Journal_1_2014_final_WEB

Volume 14
Number 1
May 2014
Published by
European
Wound Management
Association
INNOVATION,
KNOW-HOW
AND
TECHNOLOGY IN
WOUND CARE

The EWMA Journal
ISSN number: 1609-2759
Volume 14, No 1, April, 2014
The Journal of the European
Wound Management Association
Published twice a year
Editorial Board
Sue Bale, UK, Editor
Salla Seppänen, Finland
Jan Apelqvist, Sweden
Georgina Gethin, Ireland
Martin Koschnick, Germany
Rytis Rimdeika, Lithuania
José Verdú Soriano, Spain
Rita Gaspar Videira, Portugal
EWMA
Council
Gerrolt Jukema
Scientific Recorder
Salla Seppänen
President
Dubravko Huljev
Secretary
Jan Apelqvist
Immediate Past President
José Verdú Soriano
Treasurer
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2
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Severin Läuchli
COOPERATING ORGANISATIONS’ BOARD
Esther Armans Moreno, AEEVH
Christian Thyse, AFISCeP.be
Tommaso Bianchi, AISLeC
Roberto Cassino, AIUC
Ana-Maria Iuonut, AMP Romania
Aníbal Justiniano, APTFeridas
Gilbert Hämmerle, AWA
Jan Vandeputte, BEFEWO
Vladislav Hristov, BWA
Els Jonckheere, CNC
Lenka Veverková, CSLR
Ivana Vranjkovic, CWA
Arne Buss, DGfW
Bo Jørgensen, DSFS
Heidi Castrén, FWCS
Pedro Pacheco, GAIF
Sebastian Probst
EWMA JOURNAL SCIENTIFIC REVIEW PANEL
Paulo Jorge Pereira Alves, Portugal
Caroline Amery, UK
Jan Apelqvist, Sweden
Sue Bale, UK
B.E. d.Boogert-Ruimschotel, The Netherlands
Michelle Briggs, UK
Stephen Britland, UK
Mark Collier, UK
Rose Cooper, UK
Javorka Delic, Serbia
Corrado Durante, Italy
Bulent Erdogan, Turkey
Ann-Mari Fagerdahl, Sweden
Madeleine Flanagan, UK
Milada Franců, Czech Republic
Peter Franks, UK
Francisco P. García-Fernández, Spain
Elia Ricci
J. Javier Soldevilla, GNEAUPP
Georgios Vasilopoulos, HSWH
Christian Münter, ICW
Aleksandra Kuspelo, LBAA
Susan Knight, LUF
Loreta Pilipaityte, LWMA
Corinne Ward, MASC
Hunyadi János, MSKT
Suzana Nikolovska, MWMA
Linda Primmer, NATVNS
Øystein Karlsen, NIFS
Louk van Doorn, NOVW
Arkadiusz Jawień, PWMA
Severin Läuchli, SAfW (DE)
Hubert Vuagnat, SAfW (FR)
Goran D. Lazovic, SAWMA
Mária Hok, SEBINKO
Rytis Rimdeika
Magdalena Annersten Gershater, Sweden
Georgina Gethin, Ireland
Luc Gryson, Belgium
Eskild W. Henneberg, Denmark
Alison Hopkins, UK
Gabriela Hösl, Austria
Dubravko Huljev, Croatia
Arkadiusz Jawien, Poland
Gerrolt Jukema, Netherlands
Nada Kecelj, Slovenia
Klaus Kirketerp-Møller, Denmark
Zoltán Kökény, Hungary
Martin Koschnick, Germany
Knut Kröger, Germany
Severin Läuchli, Schwitzerland
Maarten J. Lubbers, Netherlands
Sylvie Meaume, France
Robert Strohal
F. Xavier Santos Heredero, SEHER
Sylvie Meaume, SFFPC
Susanne Dufva, SSIS
Jozefa Košková, SSOOR
Leonid Rubanov, STW (Belarus)
Guðbjörg Pálsdóttir, SUMS
Cedomir Vucetic, SWHS Serbia
Magnus Löndahl, SWHS Sweden
Tina Chambers, TVS
Jasmina Begić-Rahić, URuBiH
Zoya Ishkova, UWTO
Barbara E. den Boogert-Ruimschotel, V&VN
Caroline McIntosh, WMAI
Skender Zatriqi, WMAK
Nada Kecelj Leskovec, WMAS
Mustafa Deveci, WMAT
Zena Moore, Ireland
Christian Münter, Germany
Andrea Nelson, UK
Pedro L. Pancorbo-Hidalgo, Spain
Hugo Partsch, Austria
Patricia Price, UK
Sebastian Probst, Schwitzerland
Elia Ricci, Italy
Rytis Rimdeika, Lithuania
Zbigniew Rybak, Poland
Salla Seppänen, Finland
José Verdú Soriano, Spain
Robert Strohal, Austria
Richard White, UK
Carolyn Wyndham-White, Switzerland
Gerald Zöch, Austria

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6 Editorial
Make a difference
in clinical practice
Become a Member of EWMA
Science, Practice and Education
9 Prevalence of Pressure Ulcers in Hospitalized Patients in Germany
Heidi Heinhold, Andreas Westerfellhaus, Knut Kröger
17 Excess use of antibiotics in patients with non-healing ulcers
Marcus Gürgen
25 Regenerative medicine in burn wound healing:
Aiming for the perfect skin
Magda MW Ulrich
31 Promising effects of arginine-enriched oral nutritional supplements
on wound healing
Jos M.G.A. Schols
37 Efficacy of platelet-rich plasma for the treatment of chronic wounds
Vladimir N. Obolenskiy, Darya A. Ermolova, Leonid A. Laberko,
Tatiana V. Semenova
Scientific Communication
Benefits of your EWMA Membership:
n You make a difference in clinical practice within
wound management in Europe
n Right to vote and stand for EWMA Council
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Please register as a EWMA member at
WWW.EWMA.ORG
26TH CONFERENCE OF
THE EUROPEAN WOUND MANAGEMENT ASSOCIATION
EWMA 2016
11-13 MAY 2016 · BREMEN, GERMANY
In collaboration with
WUND-D.A.CH and ICW (Chronic Wounds Initiative)
4
43 Results from the world’s largest telemedicine project
Kristian Kidholm, Anne-Kirstine Dyrvig, Knud B. Yderstraede,
Birthe Dinesen, Benjamin Schnack Rasmussen
51 Nutrition and chronic wounds
José Verdú Soriano, Estrella Perdomo Pérez
54 The biofilm challenge
Maria Alhede, Morten Alhede
Innovation, know how and technolgy
60 National wound care innovation centre launched in the UK
Peter Vowden
63 Development of tools for home monitoring in wound care
Marco Romanelli, Marie Muller
66 2014 Education Activities
Ana Maria d’Auchamp
Cochrane Reviews
71 Abstracts of recent Cochrane reviews
Sally Bell-Syer
EWMA
78 EWMA Journal previous issues and other journals
80 EWMA GNEAUPP 2014 in Madrid
Javier Soldevilla Agreda, Gerrolt Jukema
84 Advocacy Activities update
Salla Seppänen
86 Christina Lindholm – Honorary Speaker at EWMA-GNEAUPP 2014
Salla Seppänen
88 EWMA’s commitment to fighting antimicrobial resistance
Salla Seppänen
90 Home Care-Wound Care
Sebastian Probst
92 Nordic Diabetic Foot Task Force: Status and Future Activities
Magnus Løndahl, Klaus Kirketerp Møller
94 Developing a Diabetic Foot Treatment Programme in Austria
Gerald Zöch, Peter Kurz, Stefan Krasnik
96 EWMA Participation in the first UEMS meeting for
European Scientific Societies
Rytis Rimdeika
99 Managing Wounds as a Team
Zena Moore
Organisations
100 EWMA Corporate Sponsors
101 Conference Calendar
102 AAWC News
Robert J. Snyder
104 EB-CLINET – Clinical Network of EB Centres and Experts
Gabriela Pohla-Gubo
106 The Korean Wound Management Society
Jong Won Rhie
108 WAWLC update
David Keast
110 EWMA Cooperating Organisations

24th Conference of the European Wound Management Association
Bilingual
English & Spanish
EWMA
n
GNEAUPP
14-16 May
2014
adrid · Spain · España
Innovation, know-how and technology in wound care
European Wound
Management Association
Asociatión Europea para
el manejo de las heridas
ewma@ewma.org
Grupo Nacional para el Estudio y Asesoramiento
en Úlceras por Presión y Heridas Crónicas
Spanish Group for the study
and advice on pressure ulcers
and chronic wounds
Grupo Nacional para el Estudio
y Asesoramiento en Úlceras
por Presión y Heridas Crónicas
fundación
sergio juán
jordán para la
Investigación y el
estudio de las
heridas crónicas
Sergio Juán Jordán Foundation
for investigation and
study on chronic wounds
Fundación Sergio Juán Jordán
para la Investigación y el Estudio
de las Heridas Crónicas
Technical Secretariat
gneaupp2014ewma@bocemtium.com
www.ewma2014.org
www.gneaupp.org

Editorial
Innovation and collaboration:
two of the leading forces that drive EWMA
Fourteen years ago, EWMA held a conference in
Stockholm, at which the partnership structure
of the EWMA Cooperating Organisations was
announced.
One of the creative minds behind this innovation
was Christina Lindholm, who for many years has been
a driving force in the EWMA Council and the EWMA
Education Committee. In 2014, we celebrate Christina
and her many contributions to EWMA at the EWMA-
GNEAUPP 2014 conference by inviting her into the
group of esteemed EWMA Honorary Speakers.
The EWMA Cooperating Organisations partnership has
grown tremendously since its inception in 2000, and today,
it includes 49 wound care associations, representing
35 European countries. Representatives from many
of these associations will meet during the 2014 EWMA
conference to elect members for the EWMA Council, discuss
aspects of wound care across Europe, and learn from
each other’s experiences during the EWMA Cooperating
Organisations Board Meeting and the Cooperating Organisations
Workshop.
In 2008, the EWMA Council formalised the first collaborations
with associations outside of Europe through
the establishment of International Partner Agreements
with the Association for the Advancement of Wound
Care (AAWC) of the U.S.A., initially, and subsequently
with the Australian Wound Management Association
(AWMA).
JOINING FORCES THROUGH JOINT
INTERNATIONAL ACTIVITIES
The number of International Partners has increased
to 11, and the initial collaborations with AAWC and
AWMA have led to publication of the “Managing
Wounds as a Team” document, which is presented on
page 99. We are proud to announce that, together, these
three major international associations have designed and
published a joint guidance document on wound care.
Furthermore, as a result of these rewarding collaborations,
a recent invitation has been extended by the
AAWC Board for EWMA to appoint a member for
the AAWC Board for 2014-2015, a position that will
be held by the EWMA Immediate Past President Jan
Apelqvist.
INNOVATION, KNOW-HOW,
AND TECHNOLOGY IN WOUND CARE
Innovation, Know-how, and Technology in Wound Care is
theme for the EWMA-GNEAUPP 2014 Madrid conference
theme. Taking place 14-16 May, the conference
will explore these topics as well as other ongo-ing
EWMA activities and projects.
The EWMA Home Care Wound Care guidance
document will also be launched at the conference. This
document has been developed in collaboration with
HomeCare Europe (www.homecareeurope.org), a new
European partner of EWMA. For more details about
this document, see page 96.
The eHealth symposium, which was a newcomer at the
EWMA 2013 conference, will run again this year. It
is being organised in collaboration with the European
Health Telematics Association (EHTEL, www.ehtel.
org). EHTEL plays a pivotal role as the focal point of
eHealth in Europe, and we look forward to EHTEL’s
contribution in developing the EWMA eHealth symposium
this year and for the EWMA 2015 London
conference, at which an extension of the collaboration
is already being planned.
We look forward to seeing many of you in Madrid and
wish you an enjoyable Spring 2014.
Yours sincerely,
Sue Bale, Editor of the EWMA Journal
Salla Seppänen, EWMA President
6
EWMA Journal 2014 vol 14 no 1

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Science, Practice and Education
Prevalence of Pressure Ulcers
in Hospitalized Patients
in Germany – Trends from 2005 to 2011
Summary
Objective: Based on the data of hospitalized people
in Germany we aimed to determine changes
in prevalence, localization of pressure ulcer (PU)
and comorbidity of the affected patients in the
period from 2005 to 2011.
Patients and Methods: Age-adjusted prevalence
and tables for gender and age distribution of pressure
ulcers separately for the principal diagnosis
and for additional diagnoses were provided from
the Federal Statistical Office. Hospitals are legally
obliged to deliver extensive data on hospital treatment,
including demographic data, diagnoses, comorbidities,
complications, and procedures to the
“Institute for the Hospital Remuneration System”
which uses the data for yearly adaptation of the
German Diagnosis Related Group System.
Results: Total number of cases hospitalized with
the principal diagnosis PU increased from 9,941
in 2005 to 12,581 in 2011 (increase of 26.5 %)
with a disproportional increase of PU grade
4 (from 46 % in 2005 to 59 % in 2001). Total
number of cases hospitalized having the additional
diagnosis PU increased from 239,760 in 2005 to
412,029 in 2011 (increase of 71.8 %) with a disproportional
of PU grade 2 (from 39 % to 47 %).
Age adjusted population based data per 100,000
inhabitants show no increase in cases with the
principal diagnosis, but cases with the additional
diagnosis does. Comparing the distribution of
PU localisation there are no relevant differences
between 2005 and 2011 with the exception of
a decrease of PUs of rare localisation (head, upper
extremity, vertebral spin) and not specified
localizations (principal diagnosis: from 25.8 % to
16.5 %, additional diagnosis from 29.1 % 18.0 %).
Patterns of comorbidity did not change in the
period from 2005 to 2011. Urinary and faecal
incontinence play a major role in those with the
principal diagnosis PU whereas fracture of femur,
heart failure and pneumonia are the most frequent
diagnoses coded with the additional diagnosis of
PU.
Conclusion: In Germany the rate of cases hospitalized
with the principal diagnosis PU did not
increase whereas the rate of PU documented in
hospitalized patients increased from 2005 to 2011.
Heidi Heinhold 1
Journalist
Andreas Westerfellhaus 2
Introduction
Pressure ulcer is a generally preventable complication
of immobility 1,2,3,4 . The awareness for
prevention of pressure ulcers (PU) and for early
detection increased in the last decades 5,6 . The
impact of these changes in awareness and in prevention
on the prevalence of PU is unclear. Data
from the National Center for Health Statistics
and the Washington State Department of Health
for the 14-year period from 1987 through 2000
found no evidence that the guidelines for the prevention
of PU have been effective in decreasing
pressure ulcer formation in the United States 4 .
As a limitation of their findings they stated that
they could not exclude a more thorough man-
ner of reporting pressure ulcer counteracting a
decrease in the absolute number of PU. It could
also be accounted for by changing demongraphics
in that, the incidence of chronic disease is increasing
along with increased age profile and thus one
would expect a similar increase in PU, but this did
not happen. So the guidelines might be effective
in decreasing PU in absolute terms. The same is
reported for Canada in a more recent study based
on the Annual Pressure Ulcer Prevalence Census
1994-2008 7 . In contrast to the somewhat constant
prevalence and incidence of PE in these countries,
an analysis of seven cross-sectional studies
reporting point PU prevalence in 225 German
Knut Kröger 3
1 for the Deutsche
Dekubitus Liga e.V.,
2 for the Deutsche
Pflegerat e.V.,
3 for the Initiative
Chronische Wunde e.V.,
Correspondence:
knut.kroeger@
helios-kliniken.de
Conflict of interest: none
EWMA Journal 2014 vol 14 no 1 9

hospital found a significant decrease when nonblanchable
erythema were excluded 8 . Prevalence
rates decreased from 6.4 % (year 2001) to 3.9 %
(year 2007) (p=0.015).
Thus we analyzed prevalence of PU based
on the federal statistic. With the introduction
of Diagnosis Related Groups (DRGs) in 2005
for reimbursement this is the most valid data
base for principal and additional diagnoses for
hospitalized patients in Germany. We aimed to
determine changes in prevalence, localization of
PU and comorbidity of the affected patients in
the period from 2005 to 2011.
Methods
The national statistic (DRG-statistic) published
by the Federal Statistical Office includes
data from all hospitals in Germany that use the
DRG-system. These hospitals treat almost 99 %
of all patients in Germany and they are legally obliged to
deliver extensive data on hospital treatment, including demographic
data, diagnoses, comorbidities, complications,
and procedures to the “Institute for the Hospital Remuneration
System” which uses the data for yearly adaptation
of the German DRG-system and transmits them to the
Federal Statistical Office 9,10 . Only some private clinics do
not participate in this system.
For 2005 to 2011 all diagnosis were coded with the
International Statistical Classification of Diseases and Related
Health Problems 10th Revision (ICD-10), which was
adapted for Germany by the German Institute for Medical
Documentation and Information (DIMDI) as ICD-10
German Modification (ICD-10-GM) version 2005 to version
2011. Pressure ulcers were coded as L89.- given all 5
digits of the code (Table 1). This code implies information
regarding the grade of the pressure ulcers (depicting the
depth) and the variety of localizations. As shown in Table 1
coding changed from 2009 to 2010.
Statistics
Age-adjusted prevalences and tables for gender and age
distribution of pressure ulcers separately for the principal
diagnosis and for additional diagnoses were provided from
the Federal Statistical Office. These data count pressure
ulcers not inpatient cases. According to its definition, each
principal diagnosis represents a single case. But, each case
could suffer from several pressure ulcers which have to be
coded. As consequence, inpatient cases could be included
Table 1: Description of pressure ulcer coding in the German version
of ICD-10 in the years 2005 to 2011.
2005 -2009 2010-2011
Fourth digit defines the grade of the pressure ulcers
L89.1- L89.0- PU Grade1
L89.2- L89.1- PU Grade2
L89.3- L89.2- PU Grade3
L89.4- L89.3- PU Grade4
L89.9- L89.9- unknown Grade
Fifth digit defines the localisation of the pressure ulcers (example grade 1)
L89.10 L89.0 PU Grade1: Head
L89.11 L89.01 PU Grade1: Upper Limb
L89.12 L89.02 PU Grade1: Spinous Process
L89.13 L89.03 PU Grade1: Iliac Crest
L89.14 L89.04 PU Grade1: Sacrum
L89.15 L89.05 PU Grade1: Ischium
L89.16 L89.06 PU Grade1: Great Trochanter
L89.17 L89.07 PU Grade1: Heel
L89.18 L89.08 PU Grade1: Other Localisation at Lower Limb
L89.19 L89.09 PU Grade1: Not Defined Localisation
Figure 1: Total number of patients hospitalized with the principal
diagnosis L89 separated by grade 1 to 4.
severalfold in the statistic on additional diagnoses. Therefore,
the distribution of patients with at least one pressure
ulcer as additional diagnoses was provided by the federal
Statistical Office additionally. Last, a single inpatient case
could be count in the statistics on principal and additional
diagnoses in parallel.
Calculations were done using Microsoft ® Excel 2003
and Microsoft ® Access 2003.
10
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
Table 2: Prevalence of patients with PU (ICD code L89.-) as principal diagnosis
and as additional diagnosis per 100,000 population in Germany.
60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 ≥ 90
Principal diagnosis pressure ulcer
Males
2005 15,3 20,1 30,3 43,2 65,9 102,5 125,7
2011 16,9 25,2 37,2 53,2 75,9 111,5 111,3
Females
2005 8,1 13,2 24,0 49,1 85,9 136,8 195,7
2011 10,7 18,6 28,4 52,8 93,6 150,4 206,5
All
2005 11,6 16,5 26,8 46,8 79,9 127,9 181,2
2011 13,7 21,8 32,5 53,0 86,8 139,3 181,9
Additional diagnosis pressure ulcer
Males
2005 364,1 560,3 956,2 1510,2 2432,7 3504,8 4028,1
2011 584,0 921,9 1435,6 2396,1 3771,3 5516,0 6133,7
Females
2005 190,5 342,1 661,3 1238,5 2259,2 3377,9 4556,9
2011 312,4 524,0 898,8 1787,4 3218,1 5162,6 6684,1
All
2005 275,8 446,2 794,8 1347,1 2311,8 3410,8 4445,7
2011 445,9 715,4 1147,7 2051,6 3429,2 5263,0 6540,8
most frequent grade (Figure 2). Its rate increased
disproportionally from 39 % in 2005
to 47 % in 2011.
In 2005 a total of 16,071,846 cases were
treated as in-patients in German hospitals.
Thus 0.062 % (9,941) was referred with PU
as principal diagnosis and 1.5 % (239,760)
had at least one additional diagnosis PU. In
2011 a total of 18.691.076 cases were treated
as full in time patients in German hospitals.
The rates of cases with PU as principal diagnosis
were 0.067 % (12,581) and that of
additional diagnosis 2.2 % (412,029).
Population based data per 100,000 inhabitants
are shown in Table 2. Locking at
this data there is no increase in cases with the
principal diagnosis PU but in cases with the
additional diagnosis.
Figure 2: Total number of patients hospitalized with the
additional diagnosis L89 separated by grade 1 to 4.
Results
Prevalence of cases with PU
Total number of cases hospitalized with the principal diagnosis
PU increased from 9,941 in 2005 to 12,581 in
2011 (increase of 26.5 %). Within this population the rate
of PU grade 4 increased disproportionally from 46 % in
2005 to 59 % in 2001 (Figure 1).
Total number of cases hospitalized for other diseases
but having the additional diagnosis PU increased from
239,760 in 2005 to 412,029 in 2011 (increase of 71,8 %).
Within this population the rate of PU grade 2 was the
Localization of PU
The most frequent localisations of PU were ischium, sacrum
and heel, but there are some specific differences between
the group of patients with PU as principal diagnosis
or as an additional diagnosis. In 10 to 59 years old patients
with the principal diagnosis PU the ischium plays a much
greater role than in patients 60 to 90 years old patients
(Figure 3). In older patients the relevance of the ischium
as most frequent localisation diminished and the sacrum
and the heel PU dominated.
These differences can not be found when a PU is coded
as an additional diagnosis. There is a consistent gradual increase
in the frequency of sacral PU with an increasing age.
Comparing the distribution of PU localization there
are no relevant differences between 2005 and 2011 with
the exception of a decrease of PUs of rare localization
(head, upper extremity, vertebral spin) and not specified
localizations. Within the cases of PU as principal diagnosis
the rate decreased from 25.8 % to 16.5 % and with in the
cases with PU as additional diagnosis the rate decreased
from 29.1 % 18.0 %
Comorbidity
The comorbidity is different between those patients with
pressure ulcer as the principal diagnosis and those with
pressure ulcer as an additional diagnosis. Urinary and faecal
incontinence play a major role in those who were referred
for treatment of the pressure ulcer (Table 2). Fracture of
EWMA Journal 2014 vol 14 no 1 11

Figure 3: Rate of PU at different
localizations separated for patients
with PU as principal (left) or additional
(right) diagnosis and for the years
2005 (upper part) and 2011
(lower part) with increasing age.
femur, heart failure and pneumonia are
the most frequent diagnoses coded with
the additional diagnosis of pressure ulcer
(Table 3). These patterns of comorbidity
did not change in the period from 2005
to 2011.
Discussion
Data from the DRG-statistic of the years
2005 to 2011 present a good overview
about the problem of pressure ulcers handled
in acute hospitals in Germany.
There is an increase in absolute numbers
of PU which in part is explained by
the aging population. After age-adjustment
the incidence rates per 100.000 inhabitants
of PU as principal diagnosis did
not increase. There is a variety of possible
interpretations that could be discussed.
One could hypothesize, that burden of PU in out of hospital
care in general remained unchanged. One can also
hypothesize, that the overall strategies in prevention of PU
failed as the rates did not decrease. We did not see a shift
towards patients suffering from lower grades of PU, thus
it can be excluded that there is trend to earlier hospitalization
of affected patients. The opposite is true as the rate
of patients admissed with PU grade 4 increased disproportionally.
This might be in indicator for an increasing
burden of PU in non-hospital settings.
The rates of PU as additional diagnosis per 100.000
inhabitants still increased after age-adjustment. Thus more
PUs were documented in the hospitals. Again there is a
variety of interpretations. As these PUs do not necessarily
developed during the period of hospitalization they could
have been acquired before hospitalization. As all hospitals
are forced to increase their awareness after publication
of the National Expert-Standard for PU Prophylaxis just
more PUs could have been documented without affecting
Table 3: Top five of the additional diagnosis coded in patients
with the principal diagnosis PU.
Order Code PU was the principal diagnosis Rate (%)
1 R15 Faecal incontinence 40,8
2 B962 Escherichia coli 32,8
3 I100 Essential Hypertension 30,4
4 R32 Urinal incontinence 26,0
5 B956 Staphylococcus aureus 22,3
the true number of PUs. An over documentation of each
discoloured skin area as PU grade 1 (or grade 0 after the
change in coding 2009) should have increased the rate of
this grade. Our data showed a dysproportional increase in
PU grade II (or grade 1 after the change in coding 2009),
which suggests that objective findings were documented.
All in all, our data do not support the results presented
from Kottner et al. 2009 who analysed the results of seven
point pressure ulcer prevalence studies conducted in 225
12
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
tice guidelines might have improved
the quality of patient care, but does not
necessarily decrease the number of PU.
Wilborn et al analysed the impact of the
National Expert Standard Pressure Ulcer
Prevention on pressure ulcer prevalence
in Germany 11 . The overall pressure ulcer
prevalence grade 2 - 4 was 4.7 %. Adjusted
for hospital departments, survey year and
individual characteristics, there was no
significant difference in the prevalence of
pressure ulcers between institutions that
refer to the National Expert Standard
Pressure Ulcer Prevention in Nursing or
those referring to other sources in developing
their local protocols (OR=1.14,
95 % CI=0.90-1.44).
Table 4: Top five of the principal diagnoses coded in patients
with the additional diagnosis PU.
Order Code PU was an additional diagnosis Rate (%)
1 S72.- Femur fracture 6,2
2 I50.- Heart insufficiency 5,8
3 J18.- Pneumonia 4,6
4 E11.- Diabetes mellitus Typ II 4,1
5 A41.- Sepsis 2,8
German hospitals and concluded that PU prevalence rates
decreased from 13.9 % (year 2001) to 7.3 % (year 2007)
(p

Science, Practice and Education
Any patient can develop a PU dependent on its individual
comorbidity, the performed procedures and the intensity
of nursing care. An American analysis on changes in the
percentage of licensed nursing staff in Pennsylvanian hospitals
between 1991 and 1997 led to the conclusion that
almost all complications are seen more often in hospitals
with fewer licensed nursing staff, in particular pressure ulcers
and pneumonia 14 . A Swedish group who examined the
problem of pressure ulcers in intensive care wards reported
that 58 % of nursing staff think lack of time was a significant
factor whenever pressure ulcer risk was not properly
evaluated or aid devices were employed either inadequately
or not at all 15 . For Germany, our analyses indicate that a
low number of full-time employees in nursing homes had
an influence on the incidence of pressure ulcers both as
primary and as secondary diagnosis 16 .
There is no predominant principal diagnosis which is
associated with a relevant number of PUs. Older people
having PU documented as an additional diagnosis in Germany
in 2005 had femur fracture in 6.9 %, heart failure
in 5.4 % and pneumonia in 5.2 % as the most frequent
principal diagnosis 4 . It remains unclear if there is a specific
risk associated with these diseases if it is just a selection of
old and immobile patients. In contrast in those presenting
with PU as the principal diagnosis the classical risk
factors faecal and urinary incontinence seem to have a
relevant impact either on the development of PU or on
the admission to hospital. These patterns of comorbidity
did not change in the period from 2005 to 2011 as we
did not expect it to change 17,18 .
Limitations
Although routine data in the electronic patient record are
frequently used for secondary purposes, there is currently
no systematic analysis of coding quality in Germany 10 .
Whether coding matches reality as a prerequisite for further
use of the data in medicine and health politics has
to be investigated in controlled trials. Thus, we cannot
estimate the rate of wrong coding of the grades or the
localizations of pressure ulcers.
In conclusion, in Germany the rate of cases hospitalized
with the principal diagnosis PU did not increase whereas
the rate of PU documented in hospitalized patients increased
from 2005 to 2011. Thus, PU is still a relevant
problem. This analysis pointed out some specific aspects
in PU localization and comorbidity that show the multidimensional
dimension of the problem.
m
Acknowledgement
We thank Referat VIII A 1 from the Federal Statistical Office
for extracting and providing the data from the DRG-Statistik.
References
1. Amlung SR, Miller WL, Bosley LM. The 1999 National Pressure Ulcer Prevalence
Survey: a benchmarking approach. Adv Skin Wound Care. 2001;14:297-301.
2. Lahmann NA, Halfens RJ, Dassen T. Pressure ulcers in German nursing homes and
acute care hospitals: prevalence, frequency, and ulcer characteristics. Ostomy
Wound Manage. 2006;52:20-33
3. Scott JR, Gibran NS, Engrav LH, Mack CD, Rivara FP. Incidence and Characteristics
of Hospitalized Patients with Pressure Ulcers: State of Washington, 1987 to 2000.
Plast. Reconstr. Surg.2006;117:630
4. Kröger K, Niebel W, Maier I, Stausberg J, Gerber V, Schwarzkopf A. Prevalence of
pressure ulcers in hospitalized patients in Germany in 2005: data from the Federal
Statistical Office. Gerontology. 2009;55:281-7.
5. Gunningberg L, Stotts NA, Idvall E. Hospital-acquired pressure ulcers in two Swedish
County Councils: cross-sectional data as the foundation for future quality improvement.Int
Wound J. 2011;8:465-73.
6. Vangilder C, Macfarlane GD, Meyer S. Results of nine international pressure ulcer
prevalence surveys: 1989 to 2005. Ostomy Wound Manage. 2008;54:40-54.
7. Vandenkerkhof EG, Friedberg E, Harrison MB. Prevalence and Risk of Pressure
Ulcers in Acute Care Following Implementation of Practice Guidelines: Annual
Pressure Ulcer Prevalence Census 1994-2008. J Healthc Qual. 2011 Jan 11. doi:
10.1111/j.1945-1474.2010.00127.x.
8. Kottner J, Wilborn D, Dassen T, Lahmann N. The trend of pressure ulcer prevalence
rates in German hospitals: results of seven cross-sectional studies. J Tissue Viability.
2009;18:36-46.
9. Mueller-Bergfort S, Fritze J. Diagnose- und Prozedurendaten im deutschen
DRG-System. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz
2007;50:1047-1054
10. Stausberg J. Quality of coding in acute inpatient care. Bundesgesundheitsblatt
Gesundheitsforschung Gesundheitsschutz. 2007;50:1039-1046.
11. Wilborn D, Grittner U, Dassen T, Kottner J. The National Expert Standard Pressure
Ulcer Prevention in Nursing and pressure ulcer prevalence in German health care
facilities: a multilevel analysis. J Clin Nurs 2010;19:3364-71.
12. Groeneveld A, Anderson M, Allen S, Bressmer S, Golberg M, Magee B, Milner M,
Young S. The prevalence of pressure ulcers in a tertiary care pediatric and adult
hospital. J Wound Ostomy Continence Nurs. 2004;31:108-120
13. Clegg A, Kring D, Plemmons J, Richbourg L. North Carolina wound nurses examine
heel pressure ulcers. J Wound Ostomy Continence Nurs. 2009;36:635-9.
14. Unruh L. Licensed nurse staffing and adverse events in hospitals. Med Care 2003;
41:142-52
15. Strand T, Lindgren M. Knowledge, attitudes and barriers towards prevention of
pressure ulcers in intensive care units: a descriptive cross-sectional study. Intensive
Crit Care Nurs 201026: 335-342
16. Kröger K, Becker R, Weiland D, Lax H, Priebel J, Maier I. Regional differences in the
incidence of inpatients with pressure ulcers in Germany. J Public Health 2012;
10.1007/s10389-012-0504-0
17. Arndt KA, Dohrendorf H, Tannen A, Braumann A, Dassen T. Prevalence of urinary
incontinence in hospitals and nursing homes: an underestimated problem. Pflege Z.
2006;59:635-638.
18. Tabali M, Kollross CM, Braumann A, Tannen A, Dassen T. Fecal incontinence – an
analysis of German clinics and nursing homes: breaking the taboo. Pflege Z.
2006;59:639-642.
14
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Science, Practice and Education
Excess use of antibiotics
in patients with non-healing ulcers
Although approximately 4 million cases of nonhealing
ulcers are diagnosed annually in Europe,
non-healing ulcers have been considered a negligible
problem in society 1 . Since there are only a few
who understand the significance of the problem,
there are very few in the health profession who
are updated in terms of evaluation, diagnosis, and
treatment of such wounds. In addition, many ulcers
are never diagnosed, a fact that reflects both a
lack of knowledge and also a low quality of care.
One problem among patients with non-healing
ulcers is an excess usage of antibiotics. As early
as 1998, Tammelin et al. reported that 60.1% of
all ulcer patients were treated with at least one
antibiotic within a six-month period. 2 However,
the indication for antibiotics was considered unfounded
in most cases.
The bacterial environment in ulcers has been
found to be more complicated than previously
assumed. Based on new knowledge about the microbiology
of non-healing ulcers, antibiotics may
not be the most effective choice as a treatment
strategy. Recently, there has been an increased focus
on the formation of so-called “biofilms” on
ulcers. Therefore, a paradigm shift in the treatment
of non-healing ulcers is needed, especially
among primary health services, to focus on better
diagnoses and treatment of the underlying cause
of the ulcer that reduces the incidence of unnecessary
antibiotic therapy.
This article presents the results from an investigation
on the use of antibiotics in ulcer patients
who were referred to the wound healing unit at
the Flekkefjord Hospital in Sørland from primary
health services.
Materials and methods
The present investigation was performed as a
prospective observational study from 1 January
2008 to 11 December 2008. The medical records
for all patients with non-healing ulcers referred
to Sørlandet Hospital Flekkefjord were obtained
from doctors in the primary health services (e.g.,
on-duty doctors, personal physicians, and nursing
home physicians). For cases that lacked the
information needed for the investigation, questionnaires
were mailed to the family doctor. Data
from 105 of a total of 110 patients were evaluated
in this investigation.
In addition to this investigation, a non-systematic
literature search was conducted in PubMed.
Results
The average age of the patients was 68.6 years (age
range: 2-98). The average age of the ulcers was 7.1
months (1-36 months). Figure 1 shows a distribution
of the ulcer diagnoses among these patients.
Figure 1: Overview of ulcer diagnoses
60 (75.1%) patients received treatment with
antibiotics before they were referred to the Wound
healing unit.
56 (53.3%) patients were treated with systemic
antibiotics and 9 (8.6%) patients were treated
with local antibiotics. Two or more antibiotic
treatments had been prescribed in 14 (13.3%)
patients.
Marcus Gürgen,
Medical Superintendent/
Department Manager,
Dept. Of Surgery, Sørlandet
Hospital HF, Flekkefjord,
Norway
Correspondence:
marcus.gurgen@sshf.no
This article was first
published in Saar,
Sept. 2012
Conflict of interest: none
venous ulcers
traumatic/postoperative wounds
pressure ulcers,
arterial ulcers
diabetic foot ulcers
hydrostatic ulcers
skin disease
cancer
ulcers caused by radiation
vasculitis
EWMA Journal 2014 vol 14 no 1 17

30
25
20
15
Figure 2:
Number of patients
treated with antibiotics
per ulcer diagnosis.
10
5
0
number of patients
per diagnosis
number treated
with antibiotics
Antibiotic treatments were administered in 78.3%
of patients with traumatic or postoperative ulcers,
66.6% of patients with venous ulcers of the legs,
36.4% of patients with pressure ulcers, and 30%
of patients with arterial ulcers (Figure 2).
A bacteriological examination was conducted in
33 (31.4%) of patients. Staphylococcus aureus was
found in 43% of these patients. Normal skin flora
was found in 13% of these patients (Figure 3).
VLU
TRAUMA / POST
PRESSURE
ARTERIAL
HYDROSTATIC
DIABETIC FOOT
CANCER
MIXED ULCER
RADIATION BURN
SKIN DISEASE
VASCULITIS
OTHER
STAPH. AUREUS
STREPTO
GRAM NEG. MIXTURE
GRAM NEG RODS
PROTEUS
Antibiotics were administered in 84.5% of the
cases in which bacteriological samples had been
taken. Dicloxacillin, which is a beta-lactamaseresistant
penicillin, was prescribed in 41% of these
cases (Figure 4).
Figure 3: Detected isolates from ulcers
PSEUDOMONAS
ENTERCOCCI
E. COLI
NORMAL SKIN FLORA
NO GROWTH
The personnel at the wound healing unit agreed
with the indication for antibiotic therapy in only
one case (0.9%). However, the Wound healing
unit identified a need for systemic antimicrobial
therapy in 6 (5.4%) patients who had not received
this treatment from primary health services. Five
of these 6 patients (83.3%) had an undiscovered
and untreated cases of either osteitis or osteomyelitis,
which is a clear indication for antibiotic
treatment.
Discussion
Microbiology of chronic ulcers
Conditions such as chronic venous insufficiency,
arterial insufficiency, and pressure over time, can
lead to the reduced reparation capacity of skin
injuries, which can lead to non-healing ulcers.
A non-healing ulcer, however, should not be regarded
as a disease, but rather as a symptom of
an underlying state. Bacteria will colonize within
the ulcer if the protective barrier of the skin is
broken. Therefore, the appearance of a chronic
ulcer depends on several factors (Table 1). These
Figure 4: Antibiotics prescribed for ulcer treatment
18
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
Table 1. Factors that enhance the risk of development of ulcer infections
Systemic factors
n Metabolic diseases, such as diabetes mellitus
n Systemic diseases, such as rheumatic diseases
n Other forms of chronic disease, such as HIV infection
n Old age
n Malnutrition / poor diet
n Alcohol / narcotics abuse
n Medicines, such as steroids, oestrogens, and vitamin K antagonists
n Smoking
Local factors
n Size of the ulcer
n Age of the ulcer
n Location of the ulcer
n Local circulation
n Necrosis
n Suppuration and maceration
n Edema
n Exposed bones or capsules
factors also contribute to the development of infections
in the ulcer. 3 As Louis Pasteur (1822-1895), the father of
modern microbiology, said: “The germ is nothing. It is the
terrain in which it is found that is everything.”
There are various hypotheses regarding the interactions
between ulcers and bacteria. The contamination–infection
continuum hypothesis is based on the fact that chronic
ulcers are contaminated or colonized by planktonics, i.e.,
free bacteria. 4 In such situations, the healing of an ulcer
takes place undisturbed, despite the fact that bacteria are
present. Critical colonization, however, occurs when microorganisms
begin to negatively affect the healing process.
In such cases, subtle signs of infection can be observed,
such as friable granulation tissue, lack of epithelial growth,
and increased suppuration. 5 Infection is present when at
least three of the following classical signs of infection have
been observed clinically:
n Redness (due to vasodilation)
n Local heat (due to vasodilation)
n Pain (due to the stimulation of nociceptive
nerve fibres by cytokines)
n Swelling (due to increased vascular permeability)
This contamination-infection continuum hypothesis
adequately explains the inflammation observed in acute
ulcers, e.g., in cases of postoperative infection.
Bacteria are always found in chronic ulcers. There are
often multiple types of bacteria observed within a single ulcer.
For example, the flora usually found in cases of venous
ulcers of the legs include Staphylococcus aureus (90.5%),
Enterococcus faecalis (71.7%), and Pseudomonas aeruginosa
(52.2%). 6 The bacterial flora found in a non-healing ulcer
change as the ulcer ages. Staphylococci and streptococci
bacteria are normally found in new ulcers, while gramnegative
mixed flora are often found in older ulcers. In
addition, different types of ulcers are influenced by different
types of bacteria. For example, a clinical infection
will develop in 60% of diabetic foot ulcers but only 20%
of venous leg ulcers that are colonized by Staphylococcus
aureus. 12 Other systemic and local factors also influence
the development of an ulcer infection.
Between 1.6 and 4.4 species of bacteria are found per
ulcer by conventional culturing methods 7 . However, molecular
biological methods suggest that even more species
of bacteria are present in the average ulcer. 8 The number
of ulcers with anaerobic bacterial growth is estimated to
be between 25% and 82%. The most common anaerobic
bacterial species are Peptostreptococcus and Prevotalla. 9,10,11
However, many ulcers heal despite the fact the presence of
these microorganisms. The presence of anaerobic bacteria
is therefore not necessarily a sign of an ulcer infection.
Recent research has indicated that the presence of bacterial
biofilm contributes to the development of chronic
ulcers. Biofilm, which is a well-known cause of periodontitis,
has also been observed in cases of infection that involve
medical implants and catheters. Studies performed
by James et al. have shown that biofilm is present in 60%
of chronic ulcers but only 6% of acute ulcers. 13 This supports
the view that biofilm probably plays an important
role in the formation of chronic ulcerations.
In contrast to planktonic, i.e., free bacteria, the bacteria in
biofilm are organized into a layer that consists of proteins,
nucleic acids, and polysaccharides. The biofilm is affixed
to the surface of the ulcer. 14 The physical properties of the
biofilm protect the bacteria against most forms of chemical,
biological, and physical stress. These properties also
protect the bacteria against antibiotics and the immune
response (e.g., neutrophil granulocytes). In addition, the
biofilm assures the maintenance of a chronic inflammation
in the ulcer. The bacteria in the biofilm release proteases.
These proteases contribute to the breakdown of growth
factors and tissue proteins that are responsible for repair
processes in the tissue. The breakdown and decomposition
products from the neutrophil granulocytes Killed by
bacteria play a role in the inhibition of the “search and
destroy” capabilities of the macrophages. This breakdown
and decomposition also leads to the destruction of tissue
EWMA Journal 2014 vol 14 no 1 19

Figure 5.
Ulcers on the forehead
following skin transplantation
after the removal of a basal cell
carcinoma. Several clinical
findings (e.g., hypergranulation,
absent epithelial growth,
suppuration) suggested that this
ulcer was covered by a biofilm.
as well as an increased production of pro-inflammatory cytokines.
Together, these processes contribute to the chronic
inflammatory state of the ulcer. 4
Pseudomonas aeruginosa is a microorganism whose
ability to form biofilm has been well studied. When
Pseudomonas aeruginosa is organized into a biofilm, it
releases virulence factors that are capable of eliminating
polymorphonucleated neutrophil granulocytes. Instead
of removing bacteria and tissue residues, the leukocytes
are dissolved and proteolytic enzymes are released. Some
of these enzymes are so-called metalloproteases, which
break down the extracellular matrix, including collagen
and growth factors. Together with an increase in free radicals,
the breakdown of the extracellular matrix prevents the
initiation of the normal repair processes. A high level of
harmful enzymes in combination with the breakdown of
tissue, however, stimulates the immune system and constantly
attracts new polymorphonucleated granulocytes.
The immune system is maximally stimulated, which starts
a vicious cycle that can be counteracted with antibiotics.
In such a situation, Pseudomonas aeruginosa is prepared
to “kidnap” the immune response of the host to create a
bacteria-friendly environment. The maximally stimulated
immune system brings an increased supply of blood to the
injured area, which provides the bacteria with sufficient
nutrients. Anaerobic bacteria are attracted to this site due
to the consumption of oxygen around the biofilm. An
oxygen gradient has also been demonstrated inside the
biofilm, which means that the anaerobic bacteria are able
to penetrate into deeper tissue 15,16 These observations
therefore suggest a synergistic interaction between ulcers
and bacteria that have a greater importance than the isolated
presence of any other pathogen.
A biofilm in an ulcer often appears as a membrane. Other
characteristics include hypergranulated tissue that bleeds
easily on contact, the absence of epithelial growth from
the edges, suppuration, cyanotic discoloration due to
oxygen deficiency, and a distinct odor from the ulcer site
(Figure 5).
The results from our investigation on the use of antibiotics
in patients with non-healing ulcers demonstrate that
antimicrobial medications were administered in 84.5% of
the cases in which microbiological samples had been examined.
These results also suggest that the detection of bacteria
provides an indication for antibiotic treatment. Figure
2 report the proportion of antibiotic-treated ulcers relative
to the absolute number of ulcers. For example, 66.6% of
all patients with venous ulcers of the leg (i.e., ulcus cruris
venosum; UCV) had received antibiotics. However,
venous ulcers of the leg have an inflammatory cause such
that antibiotic treatment will not be effective. There may
be either a lack of knowledge among primary care doctors
about the aetiology of venous ulcers or a misinterpretation
of the symptoms of inflammation as symptoms of infection
that causes the doctor to analyse a microbiological
sample. The current study was not designed to tease out
the reasons why a doctor may order such a bacterial test.
An investigation performed by Kirketerp-Møller et al.
showed discrepancies between ordinary cultures and genetic
analyses (i.e., peptide nuclear acid fluorized in situ
hybridization – PAN-FISH) from ulcers. 17 Conventional
laboratory methods to detect bacteria favor Staphylococcus
aureus, which may explain why Staphylococcus aureus are
observed in the majority of non-healing ulcers.
20
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
The occurrence of highly virulent organisms, such as
Pseudomonas aeruginosa, is underestimated by conventional
culturing methods. 8 Dowd et al. used genetic methods
to demonstrate that obligate anaerobes are present in 62%
of chronic ulcers. This study concluded that bacterial cultures
from ulcers rarely reflect the true bacterial population
of the ulcer.
There are several indications that conventional microbiological
methods reveal only organisms that grow
relatively rapidly and are simple to detect in the culture
medium. Importantly, biofilm cannot be detected by these
methods. 18 Therefore, better microbiological methods are
needed to understand the bacterial environment of the
ulcer. In clinical practice, samples from ulcers should be
taken only in cases in which there is an indication for
infection that could benefit from antibiotic therapy. Indications
for systemic antibiotic treatment are shown in
Table 2. As outlined in Table 2, there is a low threshold
for administering antibiotics in patients with diabetic foot
ulcers and in patients who are on immunosuppressive
medications. However, an ulcer will never be sterilized by
antibiotics. The assessment of the results provided by the
microbiologist should focus on the correct choice of antibiotic
that reduces the risk for resistant strains to develop.
Systematic reviews have not shown that antibiotics are an
effective treatment for chronic ulcers. 19,20 Clinical experience
demonstrates that ulcers treated with antibiotics
may improve over brief periods, but deteriorate after the
antibiotic has been withdrawn. The results of the current
study suggest that 13.3% of patients received repeated
“cures” with antibiotics. However, the assumption based
on current evidence is that, although the bacterial flora
within an ulcer may be reduced over a brief period during
antibiotic treatment, the polymicrobial flora return when
the medication is stopped. 8
Table 2. Indications for use of antibiotic therapy in ulcer infections
n At least 3 of the following clinical signs of infection:
– Local heat
– Redness that spreads more than 2 cm around the ulcer
– Pain
– Swelling
n Contact with bone (osteomyelitis/osteitis)
n Progression of the ulcer with the formation of satellite ulcers
n Clinical signs of infection by streptococci group A (erysipelas)
n Diabetic foot ulcers
n Patients with immunosuppression
The excess use of antibiotics in ulcer patients was studied
as early as 1998 by Tammelin et al. in Sweden. Their investigation
showed that 60.1% of patients had received
an antibiotic treatment over an observation period of 6
months. Their investigation also found resistant Staphylococcus
aureus in 12.5% of these cases. 2 The risk of developing
methicillin resistance increases with the administration
of systematic antimicrobial therapy 7.
Local antibiotic treatment of ulcers is not recommended
because of the rapid development of resistance and
the risk of allergic reactions. Nevertheless, the results of
the current study indicate that local antibiotic treatment
is widely prescribed. Several studies have suggested that
products containing silver, honey, or iodine are recommended
if local antibiotic treatment is necessary.
7,19,21, 22
Secretions from blowfly larvae have also been shown to kill
bacteria. 23 These larvae have also been used to eradicate
methicillin-resistant Staphylococcus aureus (MRSA) from
ulcers 24. Ulcer rinsing agents or bandages that contain
betaine and polyhexamide have also been shown to be
effective treatments to reduce bacteria in ulcers. 25,26
A total of 80-90% of antibiotic use takes place outside
of the hospital. 27 An English study of antibiotic use
among ulcer patients reported that more than 2 out of 3
patients with non-healing ulcers received prescriptions
for antibiotics from their family doctor over the course
of 1 year. For comparison, only 1 out of 3 patients with
other diagnoses (not related to non-healing wounds) were
prescribed antibiotics. 28 This study also showed that antibiotics
were administered over a longer period of time in
ulcer patients compared with patients without ulcers. The
practice of antibiotic prescription therefore seems to reflect
uncertainty among physicians about how to treat ulcers.
Updated Norwegian guidelines on the use of antibiotics
can be found in both hospitals and primary health services.
29,30,31,32 An article by Berild and Haug confirms that
chronic ulcers of the legs are most frequently colonized
by non-dangerous bacterial flora and that good local ulcer
treatment without antibiotics is sufficient. The guidelines
suggest that caution should be taken with respect to the
use of antibiotics in ulcers, except in diabetic ulcers of
the foot or cases of demonstrated streptococci, and indicate
that topical antibiotics are contraindicated. 30 Other
guidelines on the use of antibiotics in primary health services
describe conditions such as erysipelas, diabetic foot
ulcers, and impetigo as examples of skin and soft tissue
infections. These guidelines also caution against the use
of antibiotics. 29,31,32 However, these publications do not
mention guidelines for common types of chronic ulcers,
such as venous leg ulcers, pressure ulcers, and postopera-
EWMA Journal 2014 vol 14 no 1 21

Science, Practice and Education
tive infections. This lack of information about chronic
ulcers may contribute to the uncertainty among physicians
regarding the use of antibiotic therapy in these cases. The
National Guidelines for antibiotics issued by the Norwegian
Health Directory for primary health services, which
is assumed to be the primary reference point for doctors
who are faced with a clinical uncertainty, should therefore
provide further guidance about when the prescription of
antibiotics is contraindicated.
Conclusion
The results of the current study suggest a significant excess
use of antibiotics in patients with non-healing ulcers.
Mounting evidence suggests that the use of antibiotics
should be reduced significantly among this population
because antibiotics do not treat the underlying cause of
the ulcer. A reduction of antibiotic use among this patient
population will significantly reduce antibiotic resistance
and health care costs associated with the side effects of
antibiotics.
Although the guidelines for antibiotic use should be
updated and improved for use by doctors in the primary
health services, research suggests that the guidelines are
not read or utilized. 33 This fact argues in favour of the
creation of several specialized wound healing units in
Norway. A rapid referral of ulcer patients to specialists
will undoubtedly raise the standards in the diagnosis and
treatment of non-healing ulcers and reduce the use of
antibiotics.
The primary message
All non-healing ulcers will be influenced to various degrees by
bacteria. There is therefore no reason to take routine bacteria
samples from chronic ulcers. It is most important to find out
the underlying cause of the ulcer and focus on its treatment.
Table 1 provides an overview of the indications for antibiotic
treatment of non-healing ulcers. In such situations, bacteria
samples should be taken from the ulcer. In most cases, empirical
treatment will be necessary and narrow-spectrum antibiotics
should be utilized to the greatest possible degree. The knowledge
of the bacterial flora in different types of non-healing ulcers is
therefore highly decisive. The treatment may have to be adjusted
when resistance is determined.
References
1. Posnett J, Gottrup F, Lundgren H, et al. The resource impact of wounds on
health-care providers in Europe. J Wound Care 2009;18(4):154.
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J Wound Care 1998;7:435-7.
3. Edwards R, Harding KG. Bacteria and wound healing. Curr Opin Infect Sis
2004;17:91-6.
4. Wolcott RD, Rhoads DD. A study of biofilm-based wound management in subjects
with critical limb ischaemia. J Wound Care 2008;4:145-55.
5. Cutting K, Cert E, White RJ. Criteria for identifying wound infection – revisited.
Ostomy Wound Manage 2005;51:28-34.
6. Gjødsbol K, Christensen JJ, Karlsmark T, et al. Multiple bacterial species reside in
chronic wounds: a longitudinal study. Int Wound J 2006;3:225-31.
7. Howell-Jones RS, Wilson MJ, Hill KE, et al. A review of the microbiology, antibiotic
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8. Hill KE, Davies CE, Wilson MJ, et al. Molecular analysis of the microflora in chronic
venous leg ulceration. J Medical Microbiology 2003;52:365-69.
9. Bowler PG, Davies BJ. The microbiology of infected and noninfected leg ulcers.
Int J Dermatol 1999;38:573-578.
10. Trengrove NJ, Stacey MC, McGechie, et al.Qualitative bacteriology and leg ulcer
healing. J Wound Care 1996;5:277-80.
11. Ge Y, MacDonald D, Hait H, et al. Microbiological profile of infected diabetic foot
ulcers. Diab Med 2002;19:1032-5.
12. Schmidt K, Debus ES, Jessberger S, et al. Bacterial population of chronic crural
ulcers: is there a difference between the diabetic, the venous and the arterial ulcer?
VASA 2000;29:62-70.
13. James GA, Swogger E, Wolcott R, et al. Biofilms in chronic wounds.
Wound Repair Regen 2008;16:37-44.
14. Cooper R, Okhiria O. Biofilms, wound infection and the issue of control.
Wounds UK 2006;2:48-57.
15. Kirketerp-Møller, Gottrup F. Bacterial biofilms in chronic wounds. Ugeskr Læger
2009;171:1097.
16. Sun Y, Smith E, Wolcott R, et al. Propagation of anaerobic bacteria within
an aerobic multi-species chronic wound biofilm model.
J Wound Care 2009;18: 426-31.
17. Kirketerp-Møller K, Jensen PØ, Fazli M, et al. Distribution, organization, and ecology
of bacteria in chronic wounds. J Clinical Microbiology 2008;46:2717-22.
18. Dowd SE, Sun Y, Secor PR, et al. Survey of bacterial diversity inn chronic wounds
using pyrosequencing, DGGE, and full ribosome shotgun sequencing.
BMC Microbiol 2008;8:43.
19. O’Meara S, Al-Kurdi D, Ovington LG. Antibiotics and antiseptics for venous ulcers.
Cochrane Database Syst Rev 2008;23:CD003557.
20. O’Meara SM, Cullum NA, Majid N, et al. Systematic reviews of wound care management
(3= antimicrobial agents for chronic wounds; (4) diabetic foot ulceration.
Health Technol Assess 2000;4:1-238.
21. Percival SL, Woods E, Nutekpor M, et al. Prevalence of silver resistance in bacteria
isolated from diabetic foot ulcers and efficacy of silver containing wound dressings.
Ostomy Wound Manage 2008;54:30-40.
22. Merckoll P, Jonassen TØ, Vad ME, et al. Bacteria, biofilm and honey: a study of the
effects of honey on “planctonic” an biofilm-embedded chronic wound bacteria.
Scand J Infect Dis 2009;41:341-7.
23. Jaklic D, Lapanje A, Zupancic K, et al. Selective antimicrobial activity of maggots
against pathogenic bacteria. J Medical Microbiology 2008;57:617-25.
24. Bowling FL, Salgami EV, Boulton AJ. Larval therapy: a novel treatment in eliminating
methicillin-resistant staphylococcus aureus from diabetic foot ulcers. Diab Care
2007;30:370-1.
25. Cutting KF. Addressing the challenge of wound cleansing in the modern era.
Br J Nurs 2010;19(Suppl.):S24-S29.
26. Horrocks A. Prontosan wound irrigation and gel: management of chronic wounds.
Br J Nurs 2006;15:1224-8.
27. Leaper D. European Union antibiotic awareness day relevance for wound care
practitioners. Int Wound J 2010;7:314-5.
28. Howell-Jones RS, Price PE, Howard AJ, et al. Antibiotic prescribing for chronic skin
wounds in primary care. Wound Rep Regen 2006;14:387-93.
29. Eliassen KE, Fetveit A, Hjortdal P, et al. Nye retningslinjer for antibiotikabruk i
primærhelsetjenesten [New guidelines for antibiotic use in primary health service].
Tidsskr Nor Legeforen 2008;128:2330-34.
30. Berild D, Haug JB. Fornuftig bruk av antibiotika i sykehus. [Beneficial usage of
antibiotics in hospitals] Tidsskr Nor Legeforen 2008;128:2335-39.
31. Berild D. Hvordan få til riktigere bruk av antibiotika i allmennpraksis. [How to obtain
more correct use of antibiotics in general practice] Tidsskr Nor Lægeforen
1998;118:1172.
32. Helsedirektoratet. Nasjonale faglige retningslinjer for antibiotikabruk i primærhelsetjenesten
[The Health Directorate, National daily guidelines for antibiotic use in
the Primary Health Service]. www.helsedirektoratet.no/vp/multimedia/archive/00078/
Nasjonal_faglig_retn_78639a. (04.01.2010)
33. Treweek S, Flottorp S, Fretheim A, et al. Retningslinjer for allmennpraksis – blir de
lest og blir de brukt? [Guidelines for general practice – are they red and are they
used?] Tidsskr Nor Lægeforen 2005;125:300-3.
22
EWMA Journal 2014 vol 14 no 1

Get pressure ulcers
under control.
See you at
EWMA 14 – 16 May
Caring for foot ulcerations with a clinically approved therapy programme.
www.heelift.com
www.darco.de
www.molliter.it
e.g. Heelift® Glide
PREVENTIVE & ACUTE CARE
PREVENTIVE CARE
e.g. Claudio
e.g. WCS
e.g. OPTIMA Diab
ACUTE CARE
www.darco.de

* At smith&nephew we fully support healthcare
professionals to address the true costs of wound care.
Sponsored by Smith & Nephew Wound Management
The Wound Care Iceberg
Satellite Symposium at EWMA 2014, Thursday 15th May, 13:15-14:15, Room N104
It’s the hidden costs of wound care that affect healthcare resources the most.
At Smith & Nephew we are passionate about reducing the human and economic cost
of wounds. In the Smith & Nephew symposium, we will examine some of the real and
hidden costs involved in wound care, how they affect you, and how we can help reduce
them. We will demonstrate this with some exciting studies featuring ALLEVYN Life
advanced wound dressing and PICO negative pressure wound therapy, which show how
costs associated with nursing time and dressing changes may be decreased.
We look forward to seeing you in Madrid!
Visit us at the
Smith & Nephew
booth: 10D11
For patients. For budgets. For today.
Wound Management Smith & Nephew, Medical Ltd, 101 Hessle Road, Hull, HU3 2BN, UK
T +44 (0)1482 225181 - F +44 (0)1482 328326 - www.smith-nephew.com/wound
Trademark of Smith & Nephew
© Smith & Nephew March 2014
48467

Science, Practice and Education
Regenerative medicine
in burn wound healing:
Aiming for the perfect skin
Summary
The healing of full thickness wounds such
as burn wounds remains complicated by
hypertrophic scar formation and contraction.
The standard treatment is transplantation
with autologous split thickness skin
grafts. For extensive burns, these grafts are
widely meshed due to limited donor sites,
which often results in a poor functional and
cosmetic outcome. The application of cultured
autologous keratinocytes may enhance
wound closure and improve scars.
The first epidermal substitute, a confluent
epithelial sheet, was developed in 1979.
These cultured epidermal autografts (CEA)
have been used in burn patients with variable
success. Due to the variation in the efficacy
of CEAs, however, new strategies have
been employed. Currently, the application
of preconfluent proliferating keratinocytes is
considered a better strategy for burn wound
treatment.
In addition to improvements in epidermal
grafts, the healing outcome may improve
with the application of dermal substitutes.
Over the past several decades, several scaffolds
have been developed to mimic the dermis.
These substitutes can be supplemented
with growth factors and cells. In particular,
the application of mesenchymal stem cells
(MSCs) is thought to be a promising perspective
for cell-based tissue engineering.
Dermal substitution
Although transplantation with a meshed split thickness
autograft is the gold standard, healing of the transplanted
burn wound is not optimal and results in scar
formation, which is thought to be due to the lack of
sufficient dermal material in the thin autograft and a
delayed re-epithelialisation of the wound. The interstices
of the meshed graft especially are prone to hypertrophic
scarring. Several skin substitutes have been
explored over the past several decades to improve the
healing process. These substitutes comprise epidermal,
dermal, or full skin constructs.
Epidermal substitutes consist mainly of cultured
keratinocytes, which can be supported by a carrier
system. The main component of the dermis is the extracellular
matrix (ECM), which provides support for
different cell types and skin appendages such as hair,
sebaceous glands, and sweat glands. The ECM plays an
important role in the regulation of the different cells in
the dermis. The lack of dermal ECM in full-thickness
burn wounds is thought, therefore, to be an important
cause of scar formation. Several scaffolds have been
developed to create an environment that mimics the
dermal ECM. Many of these constructs are based on
the natural components of the dermal ECM, with collagen
as the most abundant component of the skin as
a base.
One of the first skin substitutes used in burn patients
was an acellular bilayered construct that consists
of a collagen matrix with a silicon top layer to mimic
the epidermis 1 . In addition to collagen, this scaffold
also contains chondroitin 6-sulfate, a glycosaminoglycan
(GAG), which provides more elasticity and better
tensile strength to the scaffold and protects the scaffold
against fast biodegradation. The porous structure
of the collagen/GAG scaffold allows the migration of
various cell types and structures such as blood vessels
into the substitute. This construct, which is currently
available as Integra ® , is used in a two-step procedure.
During the first operation, the burn wound is excised
and the skin substitute is applied. In a second operation
Magda MW Ulrich
MD, PhD
Association of Dutch
Burn Centres, Beverwijk,
the Netherlands
Correspondence:
mulrich@burns.nl
Conflict of interest: none
EWMA Journal 2014 vol 14 no 1 25

after revascularization of the collagen matrix, the silicon
top layer is removed and an autologous meshed split skin
autograft is applied on top of the substitute. This two-step
procedure is the main drawback of this material, which
has led to the development of a skin substitute that can
be applied in a one-step procedure where application of
the dermal substitute and the meshed split skin autograft
occurs during the same operating procedure. Matriderm ®
is one of these products. This scaffold is also composed
of porous collagen sponge, which is supplemented with
elastin hydrolysate. The elastin coating of the collagen
has been shown to improve scaffold stability and reduce
granulation tissue formation as well as fibrosis and contraction
and stimulate collagen deposition by fibroblasts 2 .
Although the take rate of the autologous meshed skin
graft was somewhat diminished, a statistically significant
improvement in scar elasticity was observed at the
3-month follow-up in patients undergoing scar reconstructive
surgery. Furthermore, although the differences did
not reach significance at the 12-month follow-up, most
patients considered the scars of the substituted sides as
better 3 . In a 12-year follow-up, a significant improvement
was observed in elasticity, especially in patients in which
a large extension of the autograft was used 4 . In this latter
study, surface roughness also was evaluated, and this
study reported that the substituted wounds were smoother
than wounds in which the standard treatment with an
autograft alone was applied. In a more recent multicentre
clinical trial, the treatment of acute burns with a skin
substitute was combined with topical negative pressure
(TNP) therapy with the aim of improving the graft take
rate. Although the latter goal was not accomplished, the
application of TNP did improve elasticity 5 .
Epidermal substitution
The first cellular substitute was the cultured epidermal
autograft (CEA), which is an in vitro cultured and differentiated
epidermis. The first clinical application of
this construct for burn wounds was performed during
the 1980s 6-8 . Although the results appeared promising at
first, problems with the use of this technique became apparent
over the years. Unpredictable take rates, the fragility
of cell sheets 9 , and long culture times quickly reduced the
enthusiasm towards this product. Blistering often occurred
due to the destruction of anchoring molecules from the
tissue culture disc during the CEA harvesting procedure.
In addition, the wounds remained open for a long period
due to the long culture time, which increased the risk of
infection and sometimes led to the inability to transplant
the cultured keratinocytes back to the patient 10 .
New methods have been developed in more recent
years. These new techniques make use of proliferating keratinocytes.
After transplantation to the wound bed, these
cells start to differentiate and form an epidermis in vivo.
This technique has the advantage that the culture times are
reduced and that anchoring molecules are not destroyed
during the process, which results in a better take rate 11 .
The cultured cells can be applied either to the wound
bed on a carrier or sprayed as a suspension 12-14 . Several
clinical studies have been performed and show promising
results. However, although these new techniques restore
most of the disadvantages of the CEAs, the product may
still be improved. For example, the culturing conditions
of keratinocytes often include animal (xenobiotic) products,
which potentially increase the risk of transmission
of animal-derived disease components such as viruses or
prions to the patient.
Cellular dermal substitutes
Although the clinical requirements for the function of
dermal substitutes have been defined, the translation of
these requirements into physical and mechano-biological
properties of scaffolds is difficult. The materials should
not only provide the correct mechanical properties of the
dermis, such as tensile strength and flexibility, but also
provide a template for cells. The materials also should create
a molecular microenvironment in which the different
cell types migrate, grow, and acquire the proper phenotype
to allow the regeneration of a new dermis.
References
1. Burke JF, Yannas IV, Quinby WC, Jr., Bondoc CC,
Jung WK. Successful use of a physiologically
acceptable artificial skin in the treatment of extensive
burn injury. Ann Surg. 1981;194(4):413-28. Epub
1981/10/01.
2. van der Veen VC, van der Wal MB, van Leeuwen MC,
Ulrich MM, Middelkoop E. Biological background of
dermal substitutes. Burns. 2010;36(3):305-21.
3. van Zuijlen PPM, Vloemans JF, van Trier AJ, Suijker
MH, van Unen E, Groenevelt F, et al. Dermal
substitution in acute burns and reconstructive
surgery: a subjective and objective long-term
follow-up. Plast Reconstr Surg. 2001;108(7):1938-
46.
4. Bloemen MC, van Leeuwen MC, van Vucht NE, van
Zuijlen PP, Middelkoop E. Dermal substitution in
acute burns and reconstructive surgery: a 12-year
follow-up. Plast Reconstr Surg. 2010;125(5):1450-9.
5. Bloemen MC, van der Wal MB, Verhaegen PD,
Nieuwenhuis MK, van Baar ME, van Zuijlen PP, et al.
Clinical effectiveness of dermal substitution in burns
by topical negative pressure: A multicenter randomized
controlled trial. Wound Repair Regen.
2012;20(6):797-805.
6. O’Connor N, Mulliken J, Banks-Schlegel S, Kehinde
O, Green H. Grafting of burns with cultured
epithelium prepared from autologous epidermal cells.
The Lancet. 1981;317(8211):75-8.
7. Gallico GG, III, O’Connor NE, Compton CC, Kehinde
O, Green H. Permanent coverage of large burn
wounds with autologous cultured human epithelium.
NEnglJMed. 1984;311(7):448-51.
8. Cuono C, Langdon R, McGuire J. Use of cultured epidermal
autografts and dermal allografts as skin
replacement after burn injury. Lancet.
1986;1(8490):1123-4.
9. Reid MJ, Currie LJ, James SE, Sharpe JR. Effect of
artificial dermal substitute, cultured keratinocytes and
split thickness skin graft on wound contraction.
WoundRepair Regen. 2007;15(6):889-96.
10. Chester DL, Balderson DS, Papini RP. A review of
keratinocyte delivery to the wound bed. JBurn Care
Rehabil. 2004;25(3):266-75.
26
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
Scaffolds such as the products Integra ® and Matriderm
® are typically based on biomolecules present in the
dermis, such as collagen, elastin, and GAGs. However,
although the clinical use of these scaffolds shows promising
results, healing is still not optimal.
To further improve the healing process, cells have been
included in the scaffolds. Several skin substitutes that use
allogeneic or autologous fibroblasts and keratinocytes (e.g.,
Tiscover ® , Apligraf ® , and OrCel ® ) have been described.
Their limited clinical use worldwide, however, is probably
due to the high expenses for production of these constructs
as well as possible immunological reactions to the allogeneic
cells and the long production time for autologous cell
constructs.
Recently, interest in the field has shifted to the use of
mesenchymal stem cells (MSC) in skin substitutes. MSCs
are thought to play an important role in tissue homeostasis
and in the facilitation of the repair of damaged tissue to
restore the function of injured organs. Over the past several
decades, stem cells have been isolated from various tissues.
Stem cells are considered to be promising for tissue engineering
purposes due to their multi-lineage differentiation
capacity as well as their immune-modulating effects.
Mesenchymal stem cells for skin
regeneration
MSCs have been shown to improve healing in different
wound models 15, 16 . The exact mechanism by which this
improvement in healing is accomplished is not known.
Initially, it was thought that MSCs were incorporated into
damaged tissues and differentiated into tissue-specific cells.
However, it is now becoming clear that these cells exert
their main therapeutic effect through paracrine actions and
their immune regulatory features, and to a lesser extent
through their incorporation into damaged tissue.
Several studies have shown that MSCs reduce fibrosis.
MSCs are able to reduce the immune response by suppressing
the activation of T cells, B cells, and natural killer cells
via a reduction in the maturation of dendritic cells. MSCs
reduce the expression levels of MHC class I and II molecules,
and they do not express co-stimulatory molecules
(CD80, CD86, and CD40) 17 . Due to these features, the
MSCs are immune privileged and therefore can be used in
an allogeneic setting, which is a major benefit that allows
MSCs to be used as an off-the-shelf product.
There remain concerns with the use of MSCs. For
example, MSCs may lose their immune suppressive and
immune privileged status during differentiation 18 . MSCs
also may differentiate into the incorrect phenotype. MSCs
also have the potential to differentiate into tumour cells
due to their high capacity for self-renewal.
Despite the criteria postulated by the International Society
for Cellular Therapy (ISCT) for defining multipotent
mesenchymal stromal or stem cells 19 , real discriminating
markers for MSCs are missing. The criteria formulated by
the ISCT state that these cells have to express a specific
CD marker pattern in which they are positive (> 95%)
for CD73, CD90, and CD105 and negative (< 2%) for
CD45, CD34, CD14 or CD11b, CD79a or CD19, and
HLA-DR. These criteria suggest that the cell isolates represent
a homogeneous cell population. The MSC populations
from various tissues, however, are a very heterogeneous
population of cells, of which only a small percentage
possess multi-lineage differentiation potential 20 . Until
proper discriminating markers have been found to identify
MSCs and other cell types, it is unknown what the different
cell types in these populations contribute to the healing
process. Currently, most papers that describe MSCs
confine their characterization of the cell population to
the different markers that have been defined by the ISCT.
Only a few studies have shown that the cell population
containing stem cells also contains alpha smooth muscle
actin (-SMA) positive cells. It is unclear whether the
MSCs themselves express -SMA or whether these cells
are differentiated myofibroblasts, which is the cell type
responsible for scar formation and fibrosis.
Recently, we have shown that MSCs migrate into the
wound during the first 10-14 days post-burn 21 . We hypothesized
that these cells contribute to scar formation.
The microenvironment created by these myofibroblast-like
11. Harris PA, Leigh IM, Navsaria HA. Pre-confluent
keratinocyte grafting: the future for cultured skin
replacements? Burns. 1998;24(7):591-3.
12. Pellegrini G, Ranno R, Stracuzzi G, Bondanza S,
Guerra L, Zambruno G, et al. The control of
epidermal stem cells (holoclones) in the treatment of
massive full-thickness burns with autologous
keratinocytes cultured on fibrin. Transplantation.
1999;68(6):868-79.
13. van den Bogaerdt AJ, Ulrich MM, van Galen MJ,
Reijnen L, Verkerk M, Pieper J, et al. Upside-down
transfer of porcine keratinocytes from a porous,
synthetic dressing to experimental full-thickness
wounds. Wound Rep Reg. 2004;12(2):225-34.
14. Navarro FA, Stoner ML, Park CS, Huertas JC, Lee
HB, Wood FM, et al. Sprayed keratinocyte suspensions
accelerate epidermal coverage in a porcine
microwound model. J Burn Care Rehabil.
2000;21(6):513-8.
15. Stoff A, Rivera AA, Sanjib Banerjee N, Moore ST,
Michael Numnum T, Espinosa-de-Los-Monteros A, et
al. Promotion of incisional wound repair by human
mesenchymal stem cell transplantation. Exp
Dermatol. 2009;18(4):362-9.
16. Rasulov MF, Vasilenko VT, Zaidenov VA, Onishchenko
NA. Cell transplantation inhibits inflammatory
reaction and stimulates repair processes in burn
wound. Bull Exp Biol Med. 2006;142(1):112-5.
17. Bassi EJ, Aita CA, Camara NO. Immune regulatory
properties of multipotent mesenchymal stromal cells:
Where do we stand? World journal of stem cells.
2011;3(1):1-8. Epub 2011/05/25.
18. Technau A, Froelich K, Hagen R, Kleinsasser N.
Adipose tissue-derived stem cells show both
immunogenic and immunosuppressive properties
after chondrogenic differentiation. Cytotherapy.
2011;13(3):310-7. Epub 2010/08/28.
19. Dominici M, Le Blanc K, Mueller I, Slaper-Cortenbach
I, Marini F, Krause D, et al. Minimal criteria for
defining multipotent mesenchymal stromal cells. The
International Society for Cellular Therapy position
statement. Cytotherapy. 2006;8(4):315-7.
EWMA Journal 2014 vol 14 no 1 27

12th Scientific Meeting of the
Diabetic Foot
Study Group
of the EASD
12-14 September 2014
Bratislava, Slovakia
Conference theme:
Advancement
of knowledge
on all aspects of
diabetic foot care
Main subjects during conference:
Epidemiology
Basic and clinical science
Diagnostics
Classification
Foot clinics
Biomechanics, Osteoarthropathy
Orthopaedic surgery
Infection
Revascularisation
Uraemia
Wound healing/outcome
www.dfsg.org
cells is distinctly different from normal dermal tissue, and
because cell function and tissue performance is largely
dependent on the cellular microenvironment, the healing
process is trapped in a vicious circle. Ideally, tissue engineering
could play an important role in the development
of a scaffold that is able to guide the stem cells into the
proper phenotype. Although various preclinical (animal)
studies have been performed and show promising results,
translation into clinical trials remains limited (reviewed
in 22 ).
Future perspectives
Despite the substantial progress in skin tissue engineering
over the past several decades, the regeneration of fully
functional skin following a burn wound still has not been
achieved. Elucidating the signals that are required to guide
the cells into the desired phenotype and away from the
myofibroblast phenotype will be useful for scaffold design.
Such scaffolds should create the microenvironment
necessary for skin regeneration instead of scar formation.
In addition to the aesthetic problems and functional
impairments due to diminished joint mobility of scars,
other problems may occur from scarring as a result of
the absence of skin appendages. For example, the lack of
sweat glands may impair the thermoregulatory function
of the skin. In addition, scars often lack hair follicles and
sebaceous glands. Hair transplantation and skin expansion
techniques have been used to restore the lack of hair follicles
in scars 23, 24 . In vitro and in vivo experiments have
shown that a tissue engineering approach may be successful
to reconstitute hair follicles 25 . The use of stem cells in
skin substitutes have also shown promising results with
respect to hair follicle induction 26 . Further research to
elucidate the mechanisms involved in the development
of sebaceous glands and sweat glands is needed to address
the lack of these structures in the healing wound. m
20. Jurgens WJ, Oedayrajsingh-Varma MJ, Helder MN, Zandiehdoulabi B, Schouten TE,
Kuik DJ, et al. Effect of tissue-harvesting site on yield of stem cells derived from
adipose tissue: implications for cell-based therapies. Cell Tissue Res.
2008;332(3):415-26.
21. van der Veen VC, Vlig M, van Milligen FJ, de Vries SI, Middelkoop E, Ulrich MM.
Stem Cells in Burn Eschar. Cell Transplant. 2012. Epub 2011/09/29.
22. Jackson WM, Nesti LJ, Tuan RS. Concise review: clinical translation of wound
healing therapies based on mesenchymal stem cells. Stem cells translational
medicine. 2012;1(1):44-50.
23. Oh SJ, Koh SH, Lee JW, Jang YC. Expanded flap and hair follicle transplantation for
reconstruction of postburn scalp alopecia. JCraniofacSurg. 2010;21(6):1737-40.
24. Gho CG, Martino Neumann HA. Donor hair follicle preservation by partial follicular
unit extraction. A method to optimize hair transplantation. JDermatologTreat.
2010;21(6):337-49.
25. Sriwiriyanont P, Lynch KA, McFarland KL, Supp DM, Boyce ST. Characterization of
hair follicle development in engineered skin substitutes. PLoSOne.
2013;8(6):e65664.
26. Liang X, Ding Y, Zhang Y, Tse HF, Lian Q. Paracrine mechanisms of Mesenchymal
Stem cell-based therapy: Current status and perspectives. Cell Transplant. 2013.

EWMA 2014 MADRID
VISIT US AT BOOTH N° 10B06
Flaminal ®
Your peace of mind
Flaminal ® , a total approach for every wound and
a convenient solution for you and your patient.
SYMPOSIUM on multidisciplinary wound care:
HOW TO INCREASE your added value as a wound care nurse?
15.05.14 from 15:40-16:40 in room N105/106
www.flenpharma.com I info@flenpharma.com

Wound healing has always had villains.
Now it has a hero.
EXUDATE INFECTION BIOFILM
Our breakthrough new dressing attacks the key local barriers to wound healing, even biofilm.
TWO POWERFUL TECHNOLOGIES
Our proven Hydrofiber Technology absorbs and retains excess exudate to help create an ideal
healing environment.* 1-5 And now our revolutionary new Ag+ Technology
destroys biofilm and kills infection-causing bacteria.* 6-8
See how it helps you save the day at www.convatec.com.
No dressing does more.^
*As demonstrated in vitro
^Defined as the ability to manage exudate, infection and biofilm, as demonstrated in vitro
1. Newman GR, Walker M, Hobot JA, Bowler PG, 2006. Visualisation of bacterial sequestration and bacterial activity within hydrating Hydrober wound dressings. Biomaterials; 27: 1129-1139. 2. Walker
M, Hobot JA, Newman GR, Bowler PG, 2003. Scanning electron microscopic examination of bacterial immobilization in a carboxymethyl cellulose (AQUACEL) and alginate dressing. Biomaterials;
24: 883-890. 3. Bowler PG, Jones SA, Davies BJ, Coyle E, 1999. Infection control properties of some wound dressings. J. Wound Care; 8: 499-502. 4. Walker M, Bowler PG, Cochrane CA, 2007. In vitro
studies to show sequestration of matrix metalloproteinases by silver-containing wound care products. Ostomy/Wound Management. 2007; 53: 18-25. 5. Assessment of the in vitro Physical Properties
of AQUACEL EXTRA, AQUACEL Ag EXTRA and AQUACEL Ag+ EXTRA dressings. Scientific background report. WHRIA3817 TA297, 2013, Data on file, ConvaTec Inc. 6. Physical Disruption of Biofilm by
AQUACEL® Ag+ Wound Dressing. Scientific Background Report. WHRI3850 MA232, 2013, Data on file, ConvaTec Inc. 7. Antimicrobial activity and prevention of biofilm reformation by AQUACEL Ag+
EXTRA dressing. Scientific Background Report. WHRI3857 MA236, 2013, Data on file, ConvaTec Inc. 8. Antimicrobial activity against CA-MRSA and prevention of biofilm reformation by AQUACEL Ag+
EXTRA dressing. Scientific Background Report. WHRI3875 MA239, 2013, Data on file, ConvaTec Inc.
®/ Indicates trademarks of ConvaTec Inc. ©2014 ConvaTec Inc. AP-014181-MM

Promising effects of
arginine-enriched oral nutritional
supplements on wound healing
Science, Practice and Education
Introduction
Nobody would argue against the
importance of adequate nutrition
to preserve skin and tissue viability
and to promote tissue repair processes
such as wound healing. A good
nutritional status generally reflects
a healthy condition and adequate
body power. However, there is little
scientific evidence about the relationship
between nutrition or nutritional
intervention and wound healing,
and most studies that have been
performed to date are related to the
problem of pressure ulcers (PUs). 1
This article first addresses the assumed
role of nutrients in wound
healing, and then relevant aspects of
the nutritional cycle. Finally, some
recent studies with an arginine-enriched
oral nutritional supplement in
PU healing will be described because
they represent important nutritional
research in this area.
Basic aspects of wound healing and the
assumed role of nutrients
The wound healing process involves several stages, including
phases of blood coagulation, inflammation, migration and
proliferation of defence and repair cells, remodelling of tissue
structure, and scar formation and maturation. Several endogenous
factors play an important role in promoting this process,
for example the power of the body to generate adequate inflammation
as well as the defence response to deal adequately
with the bacterial burden of the wound. Nutrients also play
a relevant and important role in this process. Carbohydrate,
protein, and fat provide the energy source (kilocalories) for the
body. The provision and consumption of adequate kilocalories
supports collagen and nitrogen synthesis and promotes
anabolism by sparing body protein from being used as an
energy source. 1
Fat
Fat is the most concentrated source of kilocalories, transports
the fat-soluble vitamins (A, D, E, K), and provides insulation
under the skin and padding to bony prominences. Moreover,
fat is an essential component of cellular membranes, which are
also important for preserving tissue viability and for wound
repair processes. Meats, eggs, dairy products, and vegetable
oils represent dietary sources of fat. 1
Jos M.G.A. Schols
Prof. MD, PhD.
Department of Family
Medicine and Department
of Health Services
Research,
Maastricht University,
Maastricht,
The Netherlands
Correspondence:
jos.schols@
maastrichtuniversity.nl
Protein and Amino Acids
Protein is composed of amino acids and is the only nutrient
containing nitrogen. Protein is important for tissue perfusion,
preservation of immune function, repair and synthesis
of enzymes involved in wound healing, cell multiplication,
and collagen and connective tissue synthesis. 2
Foods that provide all essential amino acids, such as meat,
poultry, fish, eggs, milk products, and soybeans, are considered
complete proteins. The body requires an adequate supply of
the essential amino acids plus enough nitrogen and energy to
synthesise the other amino acids. Legumes, grains, and vegetables
provide nonessential proteins.
EWMA Journal 2014 vol 14 no 1 31

During period of stress or trauma such as injury and
wound healing, certain amino acids, such as arginine and
glutamine, become conditionally essential.
L-Arginine is composed of 32% nitrogen and has been
shown to increase the concentration of hydroxyproline,
an indicator of collagen deposition and protein, at the
wound site. 3,4 Faster wound healing has been described
in non-malnourished patients with stage III-IV PUs who
received an oral nutritional supplement (ONS) containing
arginine, protein, zinc, ascorbic acid, and vitamin E. 5
Water
Water is distributed throughout the body in intracellular,
interstitial, and intravascular compartments and serves as
the transport medium for moving nutrients to the cells and
removing waste products. Fluids are solvents for minerals,
vitamins, amino acids, glucose, and other small molecules,
thus enabling them to diffuse into and out of cells. Individuals
with draining wounds, diarrhoea, elevated temperature,
or increased perspiration require additional fluids to
replace the fluid lost. 6 Water constitutes 60% of an adult’s
body. The elderly individual generally has an increase in
body fat and a decrease in lean body mass, resulting in a
decrease in the percentage of water stored. This decrease
in body water, coupled with a diminished sense of thirst,
places the elderly at particular risk for dehydration. 7 Hydration
needs are met from liquids plus the water content
of food, which accounts for 19% to 27% of the total fluid
intake of healthy adults. 8
Vitamins and Minerals
The role of micronutrients in promoting wound healing
is debatable. 1
Ascorbic acid (vitamin C), a water-soluble vitamin,
is a cofactor with iron during the hydroxylation of proline
and lysine in the production of collagen. Therefore,
a deficiency of vitamin C may prolong the healing time
and contribute to decreased resistance to infection. 9 The
required daily intake of vitamin C is achieved through
the consumption of fruits and vegetables. Mega doses of
ascorbic acid have not resulted in accelerated pressure ulcer
healing. 10
Vitamin A and Vitamin E are fat-soluble vitamins and
dietary intake of these vitamins comes from a variety of
foods. Vitamin A acts as a stimulant during the wound
healing process to increase collagen formation and promote
epithelisation. High doses of Vitamin A are not
recommended without consultation with a physician.
Vitamin E acts as an anti-oxidant and the required intake
can easily be met with food and/or a multivitamin unless
a deficiency is confirmed.
Zinc, a cofactor for collagen formation, also enhances
metabolism of protein, liberates vitamin A from storage
in the liver, and assists in immune function. Unless a deficiency
is confirmed, elemental zinc supplementation is
not recommended for individuals with wounds such as
pressure ulcers. 11,12 Copper is a mineral that is essential
for collagen cross-linking. Zinc and copper compete for
the same biding site on the albumin molecule, thus high
serum zinc levels interfere with copper metabolism and can
induce copper deficiency. 13,14 If deficiencies are suspected,
a multivitamin with minerals may be appropriate.
The nutritional cycle
Screening and assessment of nutritional status followed
by adequate nutritional intervention should be part of
the prevention and treatment plan for patients at risk for
(chronic) wounds. 1
Pressure ulcers are a representative example of such
wounds.
The ‘why’ of this statement is clearly revealed by the
literature related to PUs, which are used as an example
here. The essentials, however, also apply to other types
of wound such as chronic venous leg ulcers, arterial leg
ulcers, and diabetic foot ulcers, in which nutritional care
is additional to other disease-specific interventions.
Nutritional status and PUs
Whether a patient develops a PU depends on both extrinsic
and intrinsic factors. Important extrinsic factors
(coming from outside the patient) are pressure, friction,
and shear forces. 15
Intrinsic (patient-related) factors affect tissue viability
and therefore the tissue response to mechanical loading.
A number of intrinsic factors have been described in
the literature. An adequate nutritional status is one of the
most important intrinsic factors, and also one that can be
readily influenced. 16,17
Poor nutritional intake and poor nutritional status have
both been identified as key risk factors for pressure ulcer
development and protracted wound healing. Notwithstanding
methodological shortcomings, cross-sectional
and prospective studies suggest a fairly strong correlation
between undernutrition and pressure ulcer development.
18-21 Moreover, it appears that many acutely or
chronically ill patients and elderly patients who are at risk
of pressure ulcer development or have established pressure
ulcers suffer from undesired weight loss. 22-26
32
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
Nutrition Screening
Unless the patient has a terminal illness, undernutrition is
a reversible risk factor for pressure ulcer development and
early identification and management is therefore critical.
Individuals at risk for wounds like pressure ulcers are often
also in danger of undernutrition, so nutritional screening
should be completed in such cases. 2,27 Healthcare
organisations should have a policy on nutrition screening
and its frequency. Since individuals frequently move from
one health care setting to another, the screening results
must be documented and communicated from one care
setting to another. 2,28 Screening tools should be quick,
easy to use, validated, and reliable for the patient population
served. 29 Validated screening tools are widely used in
Europe. In a cross-sectional study by Langkamp-Henken
et al., the Mini-Nutritional Assessment (MNA) and the
MNA short form (SF) were noted to have an advantage
over the use of visceral protein when screening and assessing
nutritional status. 30,31 The MNA-SF, which was
revised to six questions and re-validated for adults 65 and
older, has 80% sensitivity and specificity and 97% positive
predictive value according to clinical status. 32 The Malnutrition
Screening Tool (MUST) has been validated in
acute care, long-term care, and the community setting,
and identifies individuals who are underweight or at risk
for undernutrition. 33
When the screening tool indicates nutritional deficits,
timely referral to the appropriate professionals is critical.
The nutrition assessment should be completed by a
registered dietician who collaborates and communicates
with other members of the healthcare team, including the
speech therapist who is responsible for screening, evaluating,
and treating swallowing problems; the occupational
therapist who works to strengthen the patient’s ability to
feed themselves; and the nursing staff, whose responsibilities
include monitoring the patient’s acceptance of nutrition.
The physician is responsible for the overall care of
the patient and ordering any treatments recommended
by the team.
Nutrition Assessment
The in-depth nutrition assessment that is performed in
individuals with a screening result that points towards
undernutrition is a methodical process of obtaining and
interpreting data in order to make decisions about the
basis of nutrition-related problems. The assessment includes
interpretation and analysis of medical, nutritional,
and biochemical data and food-medication interactions;
obtaining anthropometric measurements; and evaluation
of visual signs of poor nutrition, such as oral status, chewing/swallowing
ability, and/or diminished ability to eat
independently. 1
Diet History: The diet history includes consultation with
the patient and/or caregivers to determine the type, quantity,
and frequency of food normally consumed by the
patient. One should consider any factors that may influence
the patients’ decision about nutrition.
Nutrition-Focused Clinical Examination: The interdisciplinary
team, including the dietician, should examine the
individual for physical signs of undernutrition and protein
depletion, as evidenced by changes in the hair, skin, or
nails such as thin, dry hair, cracked lips, or brittle nails.
Individuals with missing or decayed teeth or ill-fitting
dentures often reduce their intake of protein foods that are
difficult to chew, thus restricting their caloric intake and
increasing the chance for weight loss. Moreover, individuals
with swallowing problems or dysphagia may become
dehydrated, lose weight, and develop pressure ulcers. Loss
of dexterity and/or the ability to self-feed is a risk factor
that often results in poor oral intake. All of these conditions
negatively affect wound healing.
Anthropometrics: Anthropometric measurements include
height, weight, and body mass index (BMI). Obtaining
an accurate height and weight is important, because these
values are the basis for calculating body mass index (BMI)
and caloric requirements.
Individuals should be weighed on a calibrated scale, at
the same time of the day, and wearing the same amount of
clothing. Specialty beds often are equipped with a device
to weigh an immobile individual. Significant weight loss
places an individual at increased nutritional risk and has
a negative effect on wound healing. Several studies support
the theory that unintentional weight loss of 5% in
30 days or 10% in 180 days is a predictor of mortality in
the elderly. 34-37 Moreover, an obese patient is also at risk
for PU development and healing may also be delayed in
such patients when the diet consumed is inadequate in
nutrients including protein.
Biochemical Data: Analysis of current laboratory values
is one component of the nutrition assessment, but not a
very important one. Biochemical assessment data must be
used with caution because values can be affected by hydration,
medication, and changes in metabolism. There is no
single specific laboratory test that can expressly determine
an individual’s nutritional status. Serum levels of hepatic
proteins including albumin, prealbumin (transthyretin),
and transferrin may not correlate with the clinical observation
of nutritional status. 38 In fact, studies indicate that
hepatic proteins correlate with the severity of illness rather
than with nutritional status. 39-41
EWMA Journal 2014 vol 14 no 1 33

Nutrition Intervention
Ultimately, the nutrition assessment will lead to a nutrition
diagnosis, followed by the necessary nutritional support.
Early nutrition intervention and subsequent monitoring
of the nutrition plan can reverse poor outcomes associated
with undernutrition and promote healing. Caloric,
protein, and fluid requirements should be individualised
and either increased or decreased, depending on the assessed
requirements of each patient. Furthermore it should
be determined when fortified foods and/or ONS should
be incorporated into the treatment plan. Fortified foods
include commercial products, such as cereal, soup, cookies,
or dairy products enriched with additional calories and
protein, or enriched menu items.
Of course, the nutritional intervention strategy always
tries to focus first on improving normal oral nutritional
intake. However, despite many daily efforts towards this
goal, for example by taking into account individual preferences
for foods and drinks and improving mealtime
ambiance, it is known that many patients with chronic
wounds like PUs cannot meet their nutritional demands
via normal intake only.
When normal oral intake is inadequate to promote
healing, enteral or parenteral nutrition is considered if it
is consistent with the individual’s goal. When the gut is
functioning, enteral feeding via oral nutritional supplements
in addition to the diet or total tube feeding is the
preferred route.
Research supports the theory of providing ONS to reverse
undernutrition, prevent PU occurrence, and promote
PU healing. 42-44 ONS given in addition to the regular diet
should be preferably consumed between meals so that it
does not negatively affect normal intake.
Arginine-enriched oral nutritional
supplements and pressure ulcer healing
– what’s known?
Considering nutritional intervention and the prevention of
PUs, adequate nutrition, meaning the intake of adequate
amounts of protein and energy, seems to reverse the common
underfed status of PU-prone patients and protect
against ulcer formation. 24,44 With regard to nutrition and
healing of PUs, there is a gradual accumulation of evidence
indicating that meeting the patient’s calorie and protein
requirements improves the rate of wound healing. Intake
of supplements or tube feeding with a high content of
protein has been described to improve the rate of wound
healing. 45,46,47
34
Particularly interesting are studies performed with arginine-enriched
nutritional supplements. Benati et al. tested
a PU-specific nutritional supplement that was high in energy
and protein and enriched with arginine, vitamin C,
and zinc, and found a positive effect on wound healing. 48
Subsequently, these findings were confirmed in an open
multicentre study conducted in Belgium and Luxembourg
(n=245 patients) and in a small randomised controlled trial
(n=28 patients) including several tube-fed patients. 49,50
In the CUBE study, a randomised controlled trial (n=
43 patients), van Anholt et al. observed significantly faster
wound healing in non-malnourished patients (aged between
18 and 90, with a normal BMI and no undesired
weight loss) with stage III or stage IV pressure ulcers who
received the same oral nutrition as controls, but supplemented
with arginine, protein, zinc, ascorbic acid, and
vitamin E. 5
Robust evidence for the independent role of these specific
micronutrients within a high-calorie, high-protein
oral nutritional support came recently from the large
(n=157), randomised, and controlled OligoElement Sore
Trial (OEST). In this multicentre study, Cereda and collaborators
found that, in malnourished patients with stage
III or stage IV pressure ulcers, an 8-week supplementation
with an oral formula enriched with arginine, zinc,
and antioxidants resulted in faster healing (increased by
20%) than an isocaloric-isonitrogenous control nutritional
support. 51 Both the CUBE study and the OEST trial additionally
found a positive cost effect, because in both
studies significantly fewer wound dressings were used in
the intervention group with less overall nursing time required
for dressing changes. This finding is very relevant
at a time when awareness of the costs of health care has
become increasingly important.
Arginine enriched oral nutritional
supplements and healing of other types
of chronic wounds – what’s known?
Arginine-enriched nutritional supplements may also have
a positive effect on the healing of other types of chronic
wounds, such as venous leg ulcers, arterial leg ulcers, and
diabetic foot ulcers. However, at the present time there are
only case reports on these applications. 52 Therefore, more
research in this field should be performed.
Conclusion
Nutrition is a key element in the prevention and treatment
of patients with (chronic) wounds such as pressure ulcers.
Nutritional care has to be incorporated into integrated and
multidisciplinary wound care performed by a dedicated
professional team.
m
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
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Herrlinger-Garcia KA, & Nieves C. Immune function
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32. Kaiser MJ, Bauer JM, Ramsch C, et al; MNA
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33. BAPEN (British Association of Parenteral and Enteral
Nutrition) Malnutrition Advisory Group, The MUST
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37. Murden RA, Ainslie NK. Recent weight loss is related
to short-term mortality in nursing homes. J Gen
Intern Med 1994;9:648-50.
38. Myron Johnson A, Merlini G, Sheldon J, & Ichihara K.
(2007). Clinical indications for plasma protein assays:
transthyretin (prealbumin) in inflammation and
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40. Shenkin A. Serum prealbumin: Is it a marker of
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CS. Prealbumin is not a sensitive indicator of nutrition
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42. Horn SD, Bender SA, Ferguson ML, et al. The
National Pressure Ulcer Long-term Care Study:
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43. Bergstrom N, Horn SD, Smout RJ, et al. The National
Pressure Ulcer Long-term Care Study: outcomes of
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Dequae-Merchadou L, Salles-Montaudon N, Emeriau
JP, et al. A multi-center trial of the effects of oral
nutritional supplementation in critically ill older
inpatients. Nutrition 2000;16(1):1-5.
45. Chernoff RS, Milton KY, Lipschitz DA. The effect of a
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JPEN 1992; 15: 663-8.
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impairment. Arch Gerontol Geriatr 2001; 33 (suppl
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Schols JM. Benefits of an oral nutritional supplement
on pressure lcer healing in long-term care residents.
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50. Cereda E, Gini A, Pedrolli C, Vanotti A. Diseasespecific,
versus standard, nutritional support for the
treatment of pressure ulcers in institutionalized older
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Soc. 2009 Aug;57(8):1395-402. Epub 2009 Jun 25.
51. Cereda E, Klersy C, Crespi A, D’Andrea F; OligoElement
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2013; 32 (Suppl 1): 14
52. Neyens J, Rondas A, van Leen M, Schols JMGA.
Effects of a specific arginine-enriched oral nutritional
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suppl):37.
Additional references on nutrition and
wounds in general:
A. Sobotka L. et al. (ed). Basics in clinical nutrition, 4th
edition. ESPEN Society, Galen Publishing House,
2011.
B. Romanelli et al. (ed). Science and practice management
of pressure ulcer management. Springer, 2006,
London.
EWMA Journal 2014 vol 14 no 1 35

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© Systagenix Wound Management 2013. Brands marked with ® or are trademarks of Systagenix. All other products referenced herein are acknowledged to be trademarks of their respective owners. C1685 November 2013.

Science, Practice and Education
Efficacy of platelet-rich
plasma for the treatment of
chronic wounds
Abstract
Aim: To assess the efficacy of platelet-rich
plasma for the treatment of patients with
chronic wounds of various aetiologies.
Methods. We analysed the treatment outcomes
in 81 patients with chronic wounds
of various aetiologies. For the treatment of
44 patients (experimental group), we used
platelet-rich plasma flat clot therapy starting
from phase II of the wound healing process.
The frequency of dressing changes was once
in 7 days, an interval that allowed patient
transfer to outpatient care. For the treatment
of 37 patients (control group), traditional
topical agents were used.
Results. In three patients, owing to a large
area of chronic wounds, 3-4 autodermoplastic
closures of the wound were performed;
85.4% of patients achieved complete wound
re-epithelialisation within 46.4 ± 4.3 days. In
the control group, the autodermoplastics operation
was performed in three patients, and
only 11.8% of patients achieved wound reepithelialisation
within 3 months. The mean
inpatient hospital duration was 11.0 ± 2.5
days in the experimental group and 23.1 ±
1.5 days in the control group. The mean cost
of treatment was 785.25 Euros and 1649.02
Euros per patient in the experimental and
control groups, respectively.
Conclusions. The treatment of patients with
chronic wounds using platelet-rich plasma is
safe, clinically beneficial and cost effective.
Introduction
The treatment of chronic wounds of different aetiologies
is a topical issue of modern medicine. The acceleration
of reparation processes and tissue regeneration
entails not only clinical but also economical and social
effects.
In the late 1990s, Robert E. Marx described the
method of obtaining platelet-rich plasma (PRP) and
its use as a gel in dentistry [1] . In 1994, Eduardo Anitua
demonstrated that the PRP gel helps to accelerate
bone regeneration and confirmed the presence of specific
platelet-derived growth factor receptors (PDGFs)
in the bone tissue [2] . In 2001, Russian scientists R.R.
Akhmerov and R.F. Zarudiy developed the Plasmolifting
TM technique that included the production and use
of PRP injections in dentistry and dermatocosmetology
[3,4] .
PRP is a platelet suspension in plasma derived from
human blood. The platelet concentration in PRP is
2- to 6-fold higher than that in total blood and may
reach 1000 × 10 9 /L [5] . Platelets contain growth factors
that are attracted locally to damaged progenitor
cells to stimulate their proliferative activity and
improve wound healing via autocrine and paracrine
mechanisms. Platelet growth factors include PDGF,
platelet-derived angiogenesis factor (PDAF), transforming
growth factor-b (TGFb), insulin-like growth
factor (IGF), platelet-derived endothelial cell growth
factor (PD-ECGF), epidermal growth factor (EGF),
fibroblast growth factor (FGF), thrombospondin and
osteonectin [6] .
PDGF plays a particular role in tissue reparation
and regeneration. PDGF was shown to stimulate the
proliferative, secretory and migratory activity of mesenchymal
cells [7] and is a co-factor for other growth factors
– e.g., the angiogenic vascular endothelial growth
factor (VEGF) [8] . Growth factors are released after human
platelet activation. Once activated, the platelets
release approximately 70% of their stored growth factors
within the first 10 minutes. Complete release of
platelet growth factors is accomplished within 1 hour.
Therefore, it is recommended to activate platelets immediately
before using PRP [9-11] .
Vladimir N. Obolenskiy,
PhD, Ass. Professor 1,2
Darya A. Ermolova,
PhD 2
Leonid A. Laberko,
MD, Professor 2
Tatiana V. Semenova,
PhD 2
1)
SBHI City hospital
no.13, Moscow
2)
Department of General
Surgery, Medical Faculty
of Russian National-
Research Medical
University named after
N.I. Pirogov, Moscow
Correspondence:
Vladimir N. Obolenskiy,
gkb13@mail.ru
Conflict of interest: none
EWMA Journal 2014 vol 14 no 1 37

Apart from the growth factors, activated platelets
release large amounts of substances that
contribute to primary homeostasis, including
serotonin, catecholamines, fibrinogen, fibronectin,
factor V, factor 8 (von Willebrand
factor), thromboxane A 2 and calcium [9-13] .
As a result, platelet aggregates (clots) are formed, causing
platelet stabilisation by cross-linked fibrin and sticky
glycoproteins. The fibrin matrix formed promotes normal
cell infiltration with monocytes, fibroblasts and other cells
that play an important role in wound healing.
The current use of PRP for the acceleration of bone
repair and soft tissue growth has become a true breakthrough
in dentistry, traumatology, sports medicine, cosmetology
and surgery. PRP has already proven to be useful
in tissue engineering and cellular therapy [9,10,14,15] . PRP
is most widely used for the filling of large bone defects in
maxillofacial surgery [1,11,16] . PRP can be used along with
bone material (the patient’s own or bone substitute), applied
to the implant site before the use of bone material,
placed atop of the bone material or used as a biological
membrane [6,11,16] . PRP has proven to be effective in accelerating
soft-tissue healing and epithelialisation [6] . PRP is
indicated for use in free connective tissue graft procedures,
manipulations with mucoperiosteal flaps and soft tissue
augmentation for cosmetic purposes in dentistry [17,18] .
Following the implementation of PRP therapy in dentistry,
the treatment began to be used in orthopaedics and
traumatology. PRP technology is most widely used in the
management of acute injury for the stimulation of osteogenesis
in combination with osteosynthesis and in the
treatment of arthrosis [19] . A method for the stimulation
of neoangiogenesis in the ischaemic tissues of the lower
extremities using PRP has been developed [20] .
Currently, several papers have been published on PRP
use for the management of chronic venous stasis leg ulcers
developed against the backdrop of chronic arterial or
chronic venous insufficiency. The results of these studies
allowed the conclusion that the use of PRP in the combination
treatment of stasis ulcers provides a wide range
of local therapeutic effects, improves treatment results,
enables considerable reduction of the length of treatment
and increases patient quality of life that is also of economic
importance [20-25] .
Table 1. Microbiological characteristics of the pathological focus
(day 1 of treatment)
Pathogen
Study group
n=44
Reference group
n=37
St. aureus MSSA 6 (13.6%) 6 (16.2%)
MRSA 3 (6.8%) -
Enterococcus spp. 4 (23.5%) 1 (2.7%)
Pseudomonas aeruginosa 8 (18.2%) 1 (2.7%)
Acinetobacter baumannii – 2 (5.4%)
Klebsiella pneumoniae 2 (4.5%) 2 (5.4%)
Escherichia coli 4 (9.1%) 5 (13.5%)
Proteus spp. 2 (4.5%) 7 (18.9%)
Microbial association 9 (20.5%) 8 (21.6%)
Microbial growth not revealed 6 (13.6%) 5 (13.5%)
Average bacterial load in the wound 106 106
Methods
We analysed the treatment results of 81 patients with
chronic wounds of different aetiology –namely, venous
leg ulcers (VLUs): 8 patients; ulcers of mixed aetiology
(UMEs): 20 patients; leg ulcers with underlying diabetic
foot syndrome (DFS): 20 patients; post-traumatic and
postoperative ulcerated scars and trophic ulcers (STUs):
19 patients; and decubital ulcers (DUs): 14 patients.
The exclusion criteria were as follows: suspicion of ulcer
malignisation, presence of systemic vasculitis, oncologic
condition or haematologic disorder, or low adherence
of patients to their treatment.
Following the bacteriological testing, all of the patients
were administered treatment against the main disease and
topical treatment aimed at bacterial clearance and decontamination
of the wound. The microbial landscape at
baseline is presented in Table 1.
All of the patients were divided randomly into two
groups at admission. Patients who did not meet the inclusion
and exclusion criteria were excluded from the study.
Forty-four patients in phase II of wound healing (i.e.,
the study group that included 17 men and 27 women with
an average age of 56.0 ± 3.1 years and VLU (3 patients),
UME (8 patients), DFS (12 patients), STU (14 patients)
or DU (7 patients), with an average wound area of 90.2
± 14.1 cm 2 ) received PRP flat clot applications. Different
methods for PRP preparation have been described (e.g.,
double- or single-spin centrifuge harvesting). However,
a common algorithm exists for PRP preparation that
comprises three stages: blood collection, PRP isolation
from whole blood using centrifugation and activation of
platelets contained in the PRP [26] . We used the method
described by Eduardo Anitua and BTI equipment (Spain)
to obtain PRP in the form of a gel (flat clot) [23] . The volume
of blood drawn depends on the size of the wound
and is approximately half of the wound area in cm 2 . For
example, with a wound area of approximately 100 cm 2 and
38
EWMA Journal 2014 vol 14 no 1

Science, Practice and Education
Table 2. Treatment outcomes in the study groups (n=81; p 60
Average inpatient hospital stay, days 11.0 + 2.5 23.1 + 1.5
Average cost to treat one patient, EUR 785.25 1649.02
a PRP clot thickness of about 1-2 mm, 45-50 ml of whole
blood would be required. The volume of PRP obtained on
average is 20-25% of the original volume per individual,
depending on the rheological properties of the blood of
each patient. The time from the moment of blood collection
to wound dressing was 20-30 minutes. The PRP flat
clot was covered with an atraumatic mesh dressing and
a secondary dressing on top of the former. The dressing
frequency was once in 7 days, allowing patient transition
from inpatient to outpatient care.
Thirty-seven patients in phase II of wound-healing (the
reference group that included 17 men and 20 women with
an average age of 69.5 ± 2.2 years with VLU (5 patients),
UME (12 patients), DFS (8 patients), STU (5 patients)
or DU (7 patients), with an average wound area of 79.6
± 12.3 cm 2 ) received traditional topical therapy such as
povidone-iodine gel, Olasol spray, Actovegin gel and modern
interactive wound dressing materials.
Planimetry of the wounds of all of the patients was
performed every seventh day from the time the patient was
enrolled in the study. After discharge from the hospital, all
of the patients were followed up in an outpatient setting
with a frequency of visits of once a week.
Results
The method that we used enabled us to obtain plasma
with a platelet content of approximately 338% higher than
that of whole blood. Previously, we studied the effect of
PRP on the proliferative activity of human cells in vitro
using M-22 human fibroblast cell culture (the study was
carried out jointly with the Laboratory of Cell transplantation
and Immunotyping of the Sklifosovsky Scientific
Research Institute of Emergency Medicine), and we have
confirmed the effectiveness of this method in terms of the
PRP stimulation of regeneration processes [27-29] .
At the Purulent Surgical Department of City Clinical
Hospital no. 13, we conducted a randomised controlled
study to evaluate the efficacy of PRP use for the treatment
of chronic non-healing wounds of different aetiology.
Considering the presence of wound defects mainly in
the soft tissues, we used PRP in the form of a flat, gel-like
clot. Results were evaluated over a 3-month period.
In the study group, the average number of applications
of PRP in one patient was 6.0 ± 0.6. In three patients,
the large size of the wound defect after 3- 4 applications
made the transplant free split the skin flap over the wound;
complete epithelialisation of chronic wounds was achieved
in 35 patients (85.4%) in 46.4 ± 4.3 days. The method
was not effective in five patients (1 VLU, 1 UME, and 3
STUs); full epithelialisation was achieved in one patient
within a period of more than 90 days. In the comparison
group, skin grafting was achieved in three patients, and
epithelialisation of the wound up to 3 months was attained
in only four patients (11.8%). Treatment failure – i.e., lack
of epithelialisation of the wound within a period of 90 days
– was observed in 23 patients (62.2%) in the comparison
group: 2 VLUs, 9 UMEs, 6 DFSs and 6 STUs.
The average duration of hospitalisation was 11.0 ± 2.5
days in the study group and 23.1 ± 1.5 days in the comparison
group. Importantly, the average duration of hospital
treatment was 7.5 days in patients with a high content
of platelets with grains in the plasma (300-600,000/ml)
and 12.7 days in patients with secondary (150-290,000/
ml) and low (100-130,000/ml) content of platelets on
average – i.e., the efficiency of treatment with autologous
PRP depends on the content of the functionally suitable
platelets. The average cost of treatment for one treated
patient differed by more than two fold and amounted to
(at the rates of 2012) 785.25 Euros and 1649.02 Euros
in the experimental and control groups, respectively. The
study results are presented in Table 2.
Case report
Patient P., an 18-year-old male, presented to the outpatient
department with a postoperative ulcerated scar and trophic
ulcer in the interscapular region. In 2006, he had undergone
surgical endocorrection of scoliosis using a singleplate
endocorrector that was removed in 2011 due to the
occurrence of multiple purulent fistulas. The wound defect
was corrected by plastic repair that later resulted in scar
formation and trophic ulceration. Upon primary examination,
the wound defect had dimensions of 63 × 54 mm,
and the wound bed was filled with sluggish granulations.
No microorganisms were detected in the wound before the
initiation of treatment with PRP. The PRP applications
EWMA Journal 2014 vol 14 no 1 39

Science, Practice and Education
Figure 1:
a) Ulcer appearance at baseline;
b) plasma rich in growth factors (PRGF)-membrane;
c) wound appearance after 3 weeks of treatment;
d) wound appearance after 4 weeks of treatment.
a
b
and wound dressings were carried out with 7-day intervals.
During wound dressing, the PRP clot was covered
with atraumatic Atrauman Ag silver-impregnated wound
dressing and gauze pads. The duration of treatment was
21 days and included three dressings using PRP. Treatment
resulted in complete re-epithelialisation of the ulcer by day
28 of the treatment (Fig. 1).
Discussion
PRP therapy is the preferable treatment option in patients
with chronic non-healing wounds of different aetiology
and localisation, particularly when other more conventional
therapies lack evidence of effectiveness or when radical
surgical treatment is not possible or contraindicated.
The use of PRP not only reduces the duration and
cost of treatment but also decreases the number of dressings,
shortens the inpatient hospital stay (because most
of the patients can be followed up on an outpatient basis
with intervals between dressing changes of 6-8 days) and
improves the patients’ quality of life. Notably, all of the
patients demonstrated reduced sensitivity to pain after the
PRP treatment had started.
The advantages of using an autologous PRP include
no risk of disease transmission, introduction of growth
factors and cytokines directly into the wound, restoration
of metabolic processes, neoangiogenesis, improvement of
cellular metabolism and activation of local immunity [30-32] .
m
c
d
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3. Akhmerov R.R., Zarudiy R.F., Bochkova O.I., (Korotkova),
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5. Marx R.E., DDS. Platelet-reach plasma (PRP): what is PRP
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11. Marx R.E., Carlson E.R., Eichstaedt R.M., et al. Plateletrich
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13. Marx R.E., Garg A.K. Bone Graft Physiology with Use of
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Kruglyakov P.V., Estrina M.A., Afanasiev B.V., Polyntsev
D.G. A comparative characterization of platelet lysates
obtained from different donors. // Cellular technologies in
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17. Loshkarev V.P., Bauchenkova E.V. A comparative
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24. Obolenskiy V., Ermolova D. Use of biological medications
in the treatment of chronic wounds of different etiology. //
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25. Obolenskiy V., Ermolova D. Platelet-rich plasma and
collagen preparation in treating patients with nonhealing
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26. Yurchenko M.Yu., Shumsky A.V. A review of equipment
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– 2003. – no.7. – P. 46-47.
27. Makarov M.S., Borovkova N.V., Vysochin I.V., Kobzeva
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and functional status of human platelets and its use
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28. Makarov M.S., Storozheva M.V., Konushko O.I., Borovkova
N.V., Khvatov V.B. The effect of platelet growth factor
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Borovkova N. Experimental justification for clinical use of
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Saunders. – 1991. – P.162-196.
EWMA Journal 2014 vol 14 no 1
THE EWMA
UNIVERSITY
CONFERENCE
MODEL (UCM)
in Madrid
At the EWMA-GNEAUPP 2014 Conference students of wound
management from six institutions of higher education will be attending
the UCM activities, planned to take place during the conference.
The UCM programme in Madrid offers networking opportunities between
students from many countries, a UCM Lecture as well as assignments
and workshops arranged specifically for the UCM students.
EWMA strongly encourages teaching institutions and students from
all countries to benefit from the international networking and access
to lectures by international wound management experts that the
UCM programme offers.
Participation in EWMA UCM is available to all teaching institutions
that offer wound management courses for health professionals.
Yours sincerely
Dubravko Huljev
Chair of the Education Committee
UCM Activities 2014:
Wednesday 14 th May:
08:45-09:15 Room N115: Official Welcome by the Chair of the
EWMA Education Committee
15:30-17:00 Room N115: Article Critiquing Exercise
Thursday 15 th May:
12:15-13:15 Room N115: International Practice Development
13:15-14:15 Room N115: Symposia Review
Donau Universität Krems
Austria
Lithuanian University of Health Sciences
Lithuania
Haute École de Santé
Geneva, Switzerland
University of Hertfordshire
United Kingdom
For further information about the EWMA UCM, please visit
the Education section of the EWMA website www.ewma.org
or contact the EWMA Secretariat at ewma@ewma.org
adrid · Spain
EWMA n GNEAUPP 2014
Friday 16 th May
08:00-09:30 Room N113: EWMA UCM Lecture, “Seeking and finding
the evidence” by G. McCabe
09:30-10:00 Room N113: Student Feedback Session
HUB Brussels
Belgium
Universidade Católica Portuguesa
Porto, Portugal

Leading the way
SETTING THE STANDARD FOR INNOVATION & EVIDENCE
PRO EN
PREVENTION
Can you afford the impact of not
using our proven prevention?
✔ The only dressing supported by results
of randomised controlled trials 1,2
✔ Significant reduction in pressure ulcer incidence 3,4,5,*
✔ Substantial cost savings 4,6,*
✔ Combats 4 extrinsic causes of pressure ulcers 7,8,9,*
Find out more
www.molnlycke.com/puprevention
References: 1. Kalowes P. et al. Use of a soft silicone, self-adherent, bordered foam dressing to reduce pressure ulcer formation in high risk patients: a randomized clinical trial. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore,
Maryland, United States of America. 2012. 2. Santamaria N. et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the
border trial. International Wound Journal 2013; doi: 10.1111/iwj.12101. 3. Brindle C.T. and Wegelin J.A. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. Journal of Wound Ostomy & Continence Nursing. 2012;
39(2):133-142. 4. Cherry C. and Midyette P. The Pressure Ulcer Prevention Care Bundle: a collaborative approach to preventing hospital-acquired pressure ulcers. Poster presentation at Magnet Research Day, Alabama, United States of America. 2010. 5.
Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. Journal of Wound Ostomy & Continence Nursing 2012;39(2):143-145. 6. Padula W. et al. Improving the Quality of Pressure Ulcer Care With
Prevention, A Cost-Effectiveness Analysis. Medical Care. 2011; 49(4). 7. Call, E. Pederson, J., Bill, B.Craig Oberg PhD, Martin Ferguson- Pell PhD, Wounds -2013, 25(4):94-103. 8. Call, E. Pederson, J., Bill, B. In vitro comparison of the prophylactic properties
of two leading commercially available wound dressings. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America. 2012. 9. Call, E. Black J., Clark M. ,Alves P., Brindle T., Dealey C. Santa Maria, N
International Panel Studies Creation of Guidance on Dressing Use in Prevention of Pressure Ulcers poster presentation SAWC spring 2012.
*In addition to current prevention protocols.

Scientific Communication
Results from the world’s
largest telemedicine project
– the Whole System Demonstrator
Summary
Telemedicine is highlighted as a solution to future healthcare challenges, but
currently extant research is criticized for not being sufficient and of poor quality
The Whole System Demonstrator (WSD) is the largest and most comprehensive
research project performed to date, that evaluated telemedicine effectiveness
and costs in patients with chronic diseases including lung disease, heart disease,
and diabetes. The trial was initiated in 2008 as a cluster randomized study
including 3,230 patients from 179 general practices from three regions in the
UK. The objective of the present review is to summarize the results from the
WSD based on study data published to date. Results from five publications
show that telehealth reduces mortality (odds ratio 0.54), the number of hospital
admissions during a 12-month observation period, and patient use of secondary
care. However, it is not yet clearly established which specific patient groups will
realize these benefits, nor is it known what the underlying mechanisms of these
advantageous effects are. The savings achieved by reducing hospital costs are,
at least for now, less than the extra costs incurred by using telehealth, which
increased overall net healthcare costs by 15%. There remains a strong need
to expand focused research into telemedicine technology and applications to
enhance the well-being, health outcomes, and quality-of-life of individuals in
our rapidly ageing population.
INTRODUCTION
Telemedicine is applied to a number of patient groups on a global level and,
among other applications, is used in diagnosing and treating wounds 1 . Politicians
and policy makers generally welcome telemedicine as one solution to
the challenges imposed by the changing demographics in the western world.
However, evidence regarding the clinical outcomes is scarce and more knowledge
on patient perception and the organizational and economic consequences of
telemedicine is needed.
One systematic review showed that clinical outcomes have been included in less
than 5% of over 1,300 trials studying telemedicine 2 . Another review also states
that there is a severe lack of randomized controlled studies that have focused
on telemedicine 3 . Further, it has been demonstrated that studies on telemedicine
use in general do not follow recognized standards for reporting scientific
results 4 . A Danish review comprising individuals suffering from chronic lung
disease that are treated via telemedicine underlines the need for larger studies
of higher quality 5 . Another recent review of 141 randomized studies using
tele medicine across several specialties (i.e., asthma, chronic lung disease, heart
Kristian Kidholm 1 Birthe Dinesen 2
Anne-Kirstine Dyrvig 3 Benjamin Schnack
Rasmussen 4
Knud B. Yderstraede 4
Conflict of interest:
None declared.
ICMJE formulars
from the authors are
available on request.
The article was
originally published
in Danish.
For the publication in
EWMA, journal-specific
references to
wound care have
been included.
Orig. publ; Ugeskr
Læger 2014;176:
V05130299
1 Center for Innovative
Medical Technology,
Odense University Hospital,
Odense, Denmark
2 Integrative Neuroscience
Research Group, Centre for
Senses and Motor interaction,
Institute of Medical
and Health Technology,
Faculty of Health,
Aalborg University,
Aalborg, Denmark
3 Institute of Health
Research, University of
Southern Denmark,
Odense, Denmark.
4 Department of Medical
Endocrinology and
University Centre for
Wound Healing,
Odense University Hospital
and University of Southern
Denmark, Odense,
Denmark
Correspondence:
kristian.kidholm@rsyd.dk
EWMA Journal 2014 vol 14 no 1 43

Table 1. Survey on included studies referring to Whole System Demonstrator
Reference Effect measure N Follow-up, mdr. Recruitment
Steventon et al,
2012 [8]
Use of secondary care and mortality 3,230
individuals
12 Cluster-randomization
from 179
general practices in Newham,
Kent, and Cornwall
Cartwright et al,
2013 [9]
Quality-of-life (SF-36 and EQ-5D)
Fear (Brief STAI)
Depressive symptoms (CESD-10)
1,573
individuals
12 Randomized
subgroup from [8]
Henderson et al,
2013 [10]
Costs and cost-effectiveness 965
individuals
3 (9-12 months
of the trial)
Randomized
subgroup from [8]
Hendy et al,
2012 [11]
Challenges in implementation 115
Health care
professionals
Causes for not taking part in study 22 individuals
–
Health care professionals and
leaders in Health care
Sanders et al,
2012 [12]
–
Subgroup from [8]
CESD=Centre for Epidemiological Studies Depression Scale; CHF=Coronary Heart Failure; EQ-5D=EuroQoL-5 Dimensions;
COPD=Chronic Obstructive Pulmonary Disease; SF=Short Form; STAI=State-Trait Anxiety Inventory.
disease, and hypertension) found that in only 65 of the
studies a statistically significant effect was found on primary
outcomes 6 . A further 43 studies showed significant
effects on secondary outcomes. Very few studies have addressed
the issue of telemedicine cost-effectiveness. Thus,
evidence for using telemedicine to treat individuals with
chronic diseases is weak and contradictory. In response to
this scarce and scattered evidence on telemedicine effects,
the U.K. Department of Health launched a high-quality
study of telemedicine in 2008 – the Whole System Demonstrator
(WSD). This study was planned to include 6,000
individuals and has been called the world’s largest study
of telemedicine, 7 .
Due to the large sample size and high-quality study design,
the WSD results will most likely serve as the basis
for developing and assessing telemedicine use guidelines
in the coming years. It is therefore important to create an
overview of the many WSD publications and analyses to
create a solid basis for the discussing the results and the
implications of telemedicine in chronic disease management,
including wound care. Thus the aim of this article
is to summarize the results from the WSD and to assess
the study internal validity and the consequences for the
future development of telemedicine-based health care systems
worldwide.
In the WSD, researchers from six universities evaluated
the effects of telehealth and telecare. Telehealth involves
the remote exchange of data between patients and health
care professionals to assist in diagnosing and managing
diverse diseases. The term telecare is used to describe remote,
automatic, and passive monitoring of changes in an
individual’s condition or lifestyle (including emergencies)
in order to manage the risks of independent living. In this
article we focus on the study of telehealth. The internal
validity of the WSD was assessed by means of the Risk of
Bias-tool 8 . A level of significance of 5% was used.
Aim
The aim of the WSD was to evaluate whether telehealth
for people with chronic diseases can provide cost-effective
care to improve health outcomes, maintain independence,
achieve significant gains in quality-of-life, and reduce unnecessary
acute hospital use and costs. At the same time,
the goal was to carry out a large-scale, pragmatic assessment
of the impact of a broad range of telemonitoring
technologies in the context of routine delivery of NHS
care. Table 1 describes the studies in more detail.
44
EWMA Journal 2014 vol 14 no 1

Scientific Communication
Inclusion and exclusion criteria
Inclusion
Patients >18 yrs-old suffering from at
least one of three chronic diseases:
COPD, diabetes, or CHF
Patients having cognitive limitations
took part with help from relatives
Exclusion
Non-English-speaking patients
Patients without telephone access
Comorbidity was not an exclusion criteria
Inclusion
Patients willing to take part in supplemental
questionnaires in addition to the above
criteria [8]
Exclusion
As above [8]
Inclusion
Patients willing to take part in supplemental
questionnaires in addition to the above
criteria [8]
Exclusion
Patients with cognitive limitations;
otherwise, as above criteria [8]
Patient characteristics
at study start
Telemedicine
n=1,625
Average age=70.9 yrs
Control group
n=1,605
Average age=69.7 yrs
Patients with COPD=48%
Patients with diabetes=24%
Patients with CHF=28%
Telemedicine
n=845
Average age=70.1 yrs
Control group
n=728
Average age=70.6 yrs
Telemedicine
n=534
Average age=70.0 yrs
Control group
n=431
Average age=70.1 yrs
– –
Inclusion
Patients who did not want to partake [8]
Average age=71 yrs
Randomization
The WSD was designed as a cluster-randomized study.
Every general practice (N=238) in three UK regions were
requested to take part and 179 of these (75.2%) accepted.
Randomization of the general practices was performed
centrally using an algorithm that ensured an equal distribution
according to practice size, geographic area, deprivation
index, proportion of non-white patients, and
prevalence of the major chronic diseases (i.e., chronic lung
disease, chronic heart disease, and diabetes).
Intervention
Patients in the control group were offered usual treatment,
while patients in the intervention group were additionally
offered telehealth. Telehealth includes a broad class of
technologies, but all patients had a base unit and tools to
measure weight (heart failure), pulse oximetry (COPD),
and blood glucose (diabetes). The patients performed
measurements up to 5 days per week. Questions regarding
symptoms and information concerning patient education
were forwarded to all participating individuals. Data from
these measurements were sent to monitoring centres and
handled by specially educated nurses. Each region was
supplied with different technologies and service models 9 .
Risk of bias
In existent papers on clinical and economic consequences
of telemedicine 9-11 , the randomization sequence is
described, data completeness is detailed, and results descriptions
are based on the protocol. However, patient
allocation is not hidden to investigators and statisticians,
and the patients are not blinded to their treatment group.
Clinical effects
In the study addressing use of secondary care and mortality,
the primary endpoint was the number of patients
admitted to hospital during a 12-month period 9 . Sample
size was calculated from an expected admission reduction
of 17.5%, and the study was based on registry data.
Between May 2008 and December 2009 a total of 3,230
individuals were recruited. No statistically significant differences
among patients in these two groups were found
at baseline.
The use of hospital services was generally lower in intervention
group versus control group patients (Table 2). The
number of admitted patients accordingly was found to be
Table 2. Hospital use and mortality after 12 months a
Control group
(n=1,584)
Intervention
group
(n=1,570)
Percentage
difference
(95% CI)
Admission proportion 48.2% 42.9% -10.8 (-18.0-3.7)
Mortality 8.3% 4.6% -44.5 (-65.3-23.8)
Emergency admissions/person 0.68 0.54 -20.6 (-33.8-7.4)
Elective admissions/person 0.49 0.42 -14.3 (-30.6-2.0)
Outpatient attendances/person 4.68 4.76 +1.7 (-8.3-11.8)
Emergency department visits/person 0.75 0.64 -14.7 (-28.0-1.3)
Bed days/person 5.68 4.87 -14.3 (-32.4-3.9)
DRG Tariff costs/person 2448b 2260 DKK -7.7 (-19.4-4.0)
CI=Confidence interval. a Based on [9, Table 3]. bPrice level 2009: 1 GBP=8.232 DKK.
EWMA Journal 2014 vol 14 no 1 45

10.8% lower (statistically significant) in the intervention
group, corresponding to an odds ratio of 0.82. The difference
could be ascribed to the number of patients admitted
to hospital within the first 3 months of the study period.
Correction for differences in baseline data and patient useof-services
in the 3 years before enrollment did not change
the conclusion. Overall mortality in the control group
was 8.3% and in the intervention group 4.6% which is
a statistically significant difference, corresponding to an
odds ratio of 0.5.
Effect on health-related quality-of-life
In the study examining health-related quality-of-life,
the sample size was calculated on the basis of detecting
an improvement of 0.3-fold of the standardized average
of the effect variables, and included a total of 1,650 patients
10 . Health-related quality-of-life was measured with
the Health Survey Short Form SF-36 v2. Data were
collected by personal interview at the time of baseline
measurement acquisition and also by postal questionnaires
after 4 and 12 months of enrollment. A total of 1,573
patients took part in the measurements at inclusion. After
12 months 62% returned the questionnaire.
The trial showed that patients using telemedicine had no
statistically significant better effect on quality-of-life, fear,
or depression. The authors concluded that the study did
not demonstrate any detrimental effect of using telemedicine
on patient health-related quality-of-life.
Economic effects
The purpose of the economic analysis was to estimate
the costs and cost-effectiveness of telehealth. Data from
questionnaires to patients and health professionals taking
part in the study were used 11 . The study adopted a health
and social services perspective including use of hospitals,
primary care clinics, and other sources of community care.
Concerning the costs of the intervention, the following
were assessed: Telemedicine equipment, licenses, mounting
of equipment and its maintenance, and personnel
used in the telehealth monitoring teams. The drop-out
rate from questionnaire return to investigators was 38%.
The authors estimated that the groups were comparable
overall even though there were some statistically significant
differences. For example the proportion of patients with
heart failure was higher in the usual care group whereas
the proportion of patients with COPD was higher in the
telemedicine group. Table 3 shows that the costs per patient
in the telehealth group were 15% higher compared
to the control group (during a 3-month period before
Table 3. Average costs per patient ± SEM during the period
from months 9-12 a . Numbers in 2009 GBP
Type of cost Control group Telemedicine group
Hospital costs 666.2 ± 74.9 518.7 ± 67.8
Primary care costs 244.2 ± 21.4 211.0 ± 17.1
Care home respite costs 1.5 ± 1.5 1.7 ± 1.7
Community care costs 193.0 ± 39.6 140.3 ± 29.6
Mental healthcare costs 8.4 ± 4.5 5.8 ± 2.6
Day care costs 42.7 ± 11.4 28.2 ± 9.6
Adaptations costs 1.9 ± 0.6 2.0 ± 0.5
Equipment costs 0.4 ± 0.2 0.5 ± 0.2
Medication costs 222 ± 7.4 230.4 ± 7.1
Total costs excluding telehealth
delivery and equipment
1380.3 ± 102.4 1138.6 ± 88.6
Total costs including telehealth
delivery and equipment
1389.7 ± 102.6 1596.1 ± 88.6
SEM = standard error of the mean. a Based on [11, Table 2]
the 12-month study enrollment). The main reason is that
the average annual cost per participant for the telehealth
equipment and support was £1,847 per patient for whom
cost data were available at the 12-month final follow-up.
These costs more than outweighed the savings in hospital
costs. However, none of these results were significantly
different between the two patient groups.
Two sensitivity analyses were performed on the consequences
of an 80% reduction of telehealth equipment
costs and an assumption of full utilization of equipment
capacity 11 . Both scenarios show a reduction in the costs per
patients using telehealth by 7–8%, but the costs remained
higher than in the control group. The authors calculated
the incremental costs per gained quality-adjusted life-year
to be £92,000 and concluded that telehealth is not costeffective
when used as an add-on to standard patient support
and treatment.
Organizational effects
An evaluation of the organizational factors having an impact
on telehealth implementation was performed in parallel
to the randomized study 12 , as a longitudinal case-study.
Data collection was performed by triangulating data from
interviews with health personnel and administrator, from
observations during implementation, and from document
analysis. This evaluation showed that the implementation
lessons and organizational learning amongst the trial sites
were hindered by the requirements of the randomized trial
design. An example of this includes the possible lack of
directed intervention to patients with special needs and
the lack of experienced-based adjustment during the trial
among the healthcare professionals. The full organizational
potential is thus not expected to be achieved.
46
EWMA Journal 2014 vol 14 no 1

Scientific Communication
Barriers to patient
As part of the WSD, interviews were performed with patients
who declined to participate in the intervention 13 . In
the WSD, 36.7% of invited individuals did not want to
take part after receiving a home visit and being provided
information on study goals and inclusion requirements.
Of the patients that declined to participate in the study
only 22 of 61 patients accepted to go through an interview
regarding their reasons for not taking part in the trial. The
answers obtained from the interview can be categorized
into the following:
Requirements for technical competence and operation
of equipment.
Some patients declined because they felt that they were
unable to operate equipment in a satisfactory manner. As
an example some found it difficult to get the equipment
to work and others had problems with false alarms due
to faulty readings.
Threats to identity, independence, and self-care.
Some patients felt that the required medical equipment
contributed to a feeling of morbidity, and furthermore,
thought that the equipment should be used by sicker individuals.
Some patients also found that the regular measurements
required posed a threat to their independence.
Expectations of and experienced disruptions to health
and social care services.
Some patients were quite satisfied with their current treatment
approaches and health care professionals, and they
did not want to make any changes to these arrangements.
The authors concluded that forthcoming projects related
to telemedicine must assure that intervention does not
threaten patient self-perception of independence, their
ability to use required equipment, or inadvertently cause
individuals feel sicker than they actually are. Also, time
should be spent on thoroughly introducing and clarifying
of all potential sources of uncertainty among the patients.
DISCUSSION
The WSD trial has demonstrated reduced mortality from
8.3 to 4.6% by using telemedicine to manage chronic diseases
(i.e., chronic lung disease, chronic heart disease, and
diabetes). The number of hospital admissions was reduced
by 11% during a 12-month period. Patient health-related
quality-of-life remained unchanged. The achieved savings
however, were less than the costs related to establishing
and implementing telehealth approaches, and overall costs
per patient was increased by 15%.
Central to interpreting the methodology and results of
the WSD is the choice of patient sample, which included
a heterogeneous group of individuals with either of three
chronic diseases, i.e., diabetes, chronic obstructive lung
disease, or chronic heart disease. So far, the WSD study
organizers have published the effects of telehealth on the
group as a whole (9 , and uncertainty remains on diseasespecific
outcomes within the specific patient subgroups.
Important issues have thus not yet been addressed in the
primary articles.
The WSD was criticized in a BMJ commentary 14 for not
being precise in describing the influence caused by the
sponsor (i.e., the Department of Health). Also, criticism
has been raised that the Ministry of Health presented preliminary
study data in a fairly positive manner before these
data underwent rigorous peer-review and publication. Although
the randomized design can secure the study design
internal validity, it can also be potentially problematic 15 .
There is a danger that organizational gains are overlooked
because improvements of the organization were not allowed
during the trial. A lack of blinding of information
on participating patients and healthcare professionals can
additionally lead to bias in favor of telemedicine benefits.
If an á priori expectation is that telemedicine will contribute
strongly in solving imminent demographic challenges
in the healthcare system, the results from WSD are disappointing.
The study did not show an overall reduction in
costs per patient; nor did it show cost-effectiveness of using
telemedicine. On the other hand, the study demonstrated
a health gain by a significant reduction in patient mortality
in the telemedicine group versus conventionally treated patients.
Therefore, more clinical trials are needed before we
can definitively assess the potential of telemedicine use for
special patient subgroups, and to increase our knowledge
of specific telemedicine mechanisms that govern health
outcomes. Furthermore, it is important to stress that the
technologies studied in the WSD are fairly old, having
been selected for this project in May of 2008.
The WSD thus fits nicely into the overall picture of
telemedicine that was clarified in a review from 2012 6 .
Telemedicine may have positive clinical impact, but only
rarely will it, in its current format, reduce overall healthcare
costs. Should we overtly reject the idea of telemedicine
being a possible solution for the future problems of
healthcare delivery in an increasingly elderly population?
Should we simply discount the initiatives for testing new
telemedicine solutions for people suffering from chronic
EWMA Journal 2014 vol 14 no 1 47

Scientific Communication
heart disease, chronic lung disease, diabetes, or chronic
wounds? We think not. From observing the evolution
of other kinds of technologies, it is clear that technical
development experiences often follow a “hype cycle” 16 .
That is, an initial phase that provides great expectations
of a new technology typically is followed by a period of
disillusionment when it becomes clear that not all goals
can be reached in a satisfactory manner, or as rapidly as
first envisioned. This phase is then substituted by a period
in which more accumulated knowledge and re-evaluated
approaches provide novel insight to improving the costeffectiveness,
and overall outcomes, of that technology.
In this particular scenario, we have substantiated the need
for performing more research into integrating telemedicine
into the healthcare system, including the importance of
identifying patients that will most benefit from telemedical
technology. Along these lines, a Danish study (i.e., TEL-
EKAT) showed that a group of patients with chronic lung
disease found that home monitoring was a “pseudo” setup
that had negligible impact on their perceived rehabilitative
benefits 17 . In the Southern Denmark region, we are
finalizing a study on diabetic foot ulcers that will provide
us with information on the utility of telemedicine in the
treatment and follow-up of this patient group. Ulcers of
any type would á priori seem to be an obvious target for a
telemedicine setup, and as of January 2014 telemedicine
wound treatment has been disseminated to all regions in
Denmark. We expect that this study will allow us to better
qualify the technologies that are most suitable to managing
this severe ulcer type.
As of today we have solutions that work from a technical
point of view. However, we need to adjust the whole organization
and the workflows to optimize the telemedicine
approach to improving healthcare outcomes. Furthermore,
we need to develop new technologies that minimize costs
per patient, and make sure that these cost savings (e.g.,
caused by reducing the number of readmissions) are not
completely spent on technical equipment costs.
CONCLUSION
Critically assessing the existent WSD studies shows that,
although applied telemedicine technology appears to have
a major effect on decreasing mortality, this major beneficial
effect is confounded by other less-positive results. Overall,
the implemented technology and the organization behind
telemedicine systems are not yet cost-effective. We require
a steady supply of additional studies that implement newer
telehealth technologies with well-defined patient populations.
The WSD studies contain fine examples of how to
evaluate telemedicine in a design that secures high internal
validity. We deem these approaches to be highly relevant
for the wound society members and we advocate initiating
clinical randomized studies using a comparable multidisciplinary
setup as, for example, the Model for Assessment
of Telemedicine applications – MAST 18 . m
Literature
1. Chanussot-Deprez, C. and J. Contreras-Ruiz .
Telemedicine in wound care: a review. Adv Skin
Wound Care 2013; 26(2): 78-82.
2. Hailey D, Roine R, Ohinmaa A. Systematic review of
evidence for the benefits of telemedicine. J Telemed
Telecare 2002;14(suppl 1):1-7.
3. Durrani H, Khoja S. A systematic review of the use of
telehealth in Asian countries. J Telemed Telecare
2009;15:175-81.
4. Barlow J. Building an evidence base for successful
telecare implementation – updated report of the
Evidence Working Group of the Telecare Policy
Collaborative chaired by James Barlow. http://ssia.
wlga.gov.uk/media/pdf/f/4/APPENDIX_B_CSIP_
Tele care (26. april 2013).
5. Jakobsen AS, Laursen LC, Schou L et al. Vekslende
effekt af telemedicin ved behandling af kronisk
obstruktiv lungesygdom. Ugeskr Læger
2012;174:936-42.
6. Wootton R. Twenty years of telemedicine in chronic
disease management – an evidence synthesis. J
Telemed Telecare 2012;18:211-20.
7. Bower P, Cartwright M, Hirani SP et al. A comprehensive
evaluation of the impact of telemonitoring in
patients with long-term conditions and social care
needs: protocol for the whole system demonstrator
cluster randomised trial. BMC Health Serv Res
2011;11:184.
8. JPT Higgins JPT, Green S (edt.) Cochrane Handbook
for Systematic Reviews of Interventions, version 5.1.0.
Available at: http://handbook.cochrane.org/ (3. apr
2013).
9. Steventon A, Bardsley M, Billings J et al. Whole
System Demonstrator Evaluation Team. Effect of
telehealth on use of secondary care and mortality:
findings from the Whole System Demonstrator cluster
randomised trial. BMJ 2012;344: e3874 (Published
21 June 2012).
10. Cartwright M, Hirani SP, Rixon L et al. Effect of
telehealth on quality of life and psychological
outcomes over 12 months (Whole System Demonstrator
Telehealth Questionnaire Study): nested study
of patient reported outcomes in a pragmatic, cluster
randomised controlled trial. BMJ 2013;346:f653 doi:
10.1136/bmj.f653 (Published 26 February 2013).
11. Henderson C, Knapp M, Fernández JL et al. Whole
System Demonstrator Evaluation Team. Cost
effectiveness of telehealth for patients with long term
conditions (Whole System Demonstrator telehealth
questionnaire study): nested economic evaluation in
a pragmatic, cluster randomised controlled trial. BMJ
2013;346: f1035 doi: 10.1136/bmj.f1035 (Published
22 March 2013).
12. Hendy J, Chrysanthaki T, Barlow J et al. An
organisational analysis of the implementation of
telecare and telehealth: the whole system demonstrator.
BMC Health Serv Res 2012:15:403.
13. Sanders C, Rogers A, Bowen R et al. Exploring
barriers to participation and adoption of telehealth
and telecare within the Whole System Demonstrator
Trial: a qualitative study. BMC Health Serv Res
2012;12:220.
14. Greenhalgh T. Whole System Demonstrator Trial:
policy, politics, and publication ethics. BMJ
2012;345:e5280.
15. Liu JLY, Wyatt JC. The case for randomized
controlled trials to assess the impact of clinical
information system. J Am Med Inform Assoc
2011;18:173-80.
16. O’Leary DE. Gartner’s hype cycle and information
system research issues.
Int J Account Inform Syst 2008;9:240-52.
17. Dinesen B, Huniche L, Toft E. Attitudes of COPD
patients towards tele-rehabilitation: a cross-sector
case study. Int J Enviroment Res Pub Health
2013;10:6184-98.
18. Kidholm K, Ekeland AG, Jensen LK et al. A model for
assessment of telemedicine applications: MAST. Int J
Technol Assess Health Care 2012, Jan; 28(1):44-51.
48
EWMA Journal 2014 vol 14 no 1

Vivano®
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Scientific Communication
Nutrition and chronic wounds
Series (no. 12) of Technical Documents
of the GNEAUPP (National Advisory
Group for the Study of Pressure Ulcers
and Chronic Wounds). Logroño, 2011.
This technical document was based on a
comprehensive and systematic review of
the literature. It was submitted for consensus
agreement by the National Advisory Group
for the Study of Pressure Ulcers and Chronic
Wounds (GNEAUPP). The result was a 68-page
document that included 201 bibliographic references
with two appendices of nutritional screening
tools.
The document is divided into four (4) sections:
1. Introduction. This section defines the concept
of wounds and wound variants as well as different
treatment modalities, including the concepts of
food, nutrition, and how they affect treatment.
It also defines the broader concept of malnutrition,
which is caused by unhealthy diets that may
have an excess or deficit of food energy. Thus,
malnutrition can occur in obese or underweight
individuals, and in both cases, results in deficiencies
of essential nutrients.
2. Current state of knowledge. This section reviews
current knowledge on nutrition, pressure
ulcers, and wound prevention and treatment.
The first subsection refers to epidemiology and
existing reports published in the literature on nutritional
status and chronic wounds. Specifically,
it focuses on the epidemiology of malnutrition
and wounds, and their relationship according to
wound aetiology. A distinction is made between
nutritional status and pressure ulcers (the type
of wound most referenced in the literature and
related to nutrition), and nutritional status and leg
ulcers. Here, there are few references in the literature.
This subsection concludes with an exploration
of nutritional status and wound dehiscence.
Scientific evidence, obtained primarily from observational
studies, links malnutrition directly
to pressure ulcer severity and incidence. Regarding
diabetic foot ulcers, good glycaemic control
is thought to be important in neuropathic ulcer
healing; however, little evidence exists to support
this idea. Regarding ulcers of venous aetiology,
few studies have investigated the role of nutrition
in healing. One study reported that people
with this pathology have lower levels of vitamins
A and E, carotenes, and zinc; however, to date, no
evidence has been presented to confirm that supplementation
with these micronutrients improves
healing. Regarding wound dehiscence, it is known
that this complication is 8 times more common
in vitamin C-deficient patients than in patients
with normal vitamin C levels. In addition, obese
patients are thought to have more infections and
delayed wound healing, as well as a greater incidence
of dehiscence.
The second subsection deals with the assessment,
screening, and diagnosis of malnutrition, with special
emphasis on nutritional screening and assessment
tools. A description is provided of steps to
follow in nutritional assessment, as recommended
in the guidelines of leading societies dedicated to
nutrition science. Regarding nutritional assessment
and screening, recommendations are made
about the collection of clinicometric data for the
various instruments and tools, which are validated
and based on research.
Assessment consists of two parts: nutritional
screening and the nutritional assessment itself. The
purpose of screening is to identify malnourished
individuals or those at nutritional risk. For these
individuals, a complete assessment is required.
The guidelines of the European Society for Clinical
Nutrition and Metabolism (ESPEN) for nutritional
screening recommend a series of steps that
must be considered for all hospitalised patients:
José Verdú Soriano
PhD, MSc Nurse
The University of
Alicante, Spain
Estrella Perdomo Pérez
MSc Nurse
Miller Bajo Health Center
Las Palmas, Spain
Correspondence:
pepe.verdu@ua.es
www.gneaupp.es
Conflict of interest: none
EWMA Journal 2014 vol 14 no 1 51

Scientific Communication
i. Upon admission, a simple nutritional screening
method must be used to identify patients at nutritional
risk.
ii. Patients identified as being at nutritional risk
require a complete nutritional assessment.
iii. The patient’s individual nutritional requirements
should be evaluated, and patient care and nutritional
therapy should be planned.
iv. The monitoring and definition of targeted outcomes
should be determined.
v. Finally, screening results, full assessment, planning,
and monitoring should be communicated to
the other professionals involved, especially when the
patient is transferred to the community or to another
institution.
Rasmussen et al. recommend a series of steps for assessing
nutritional risk and detecting malnutrition:
Detection: The purpose of nutritional screening
This step is to identify patients at risk of malnutrition so
that nutritional interventions can be considered. Identification
of an altered nutritional state enables the adjustment
of patient care so that nutrition can be optimized.
Assessment: the screening methodology
The screening can be performed using various available
methods. The ideal test is one that has high sensitivity (i.e.
if it tests positive in patients with the condition) and high
specificity (i.e. if it tests negative in patients without the
condition), but it is also important that the tool has a positive
predictive value (which would avoid overdiagnosis).
In short, the method used should offer the best validity
and reliability at the lowest cost possible, i.e. it should be
easy and fast to do.
EWMA values your opinion and would like to
invite all readers to participate in shaping
the organisation.
Please submit possible topics for future
conference sessions.
EWMA is also interested in receiving book reviews,
articles etc.
Please contact the EWMA Secretariat at
ewma@ewma.org
ESPEN has developed guidelines for screening tools
Screening tools should detect caloric and protein malnutrition
and/or predict the likelihood of malnutrition
developing or worsening of the patient’s condition. From
this perspective, it should meet four principles:
i. What is the patient’s current condition? Body
mass index (BMI) can provide important information
about nutritional status, although this measure
may be less useful for children, adolescents, and elderly
individuals. Weight and height can be used to
calculate BMI. Alternatively, the mid-portion of the
upper arm (between the acromion and the olecranon)
can be measured and compared with a table of
percentiles for a particular population according to
age and sex.
ii. Is the patient’s condition stable? Obtain information
about the patient’s history of weight loss by
asking the patient directly or, if possible, consulting
medical records. Unintentional weight loss greater
than 5% of total body weight over 3 months is considered
significant. This approach may be helpful
when malnutrition cannot be identified by calculating
BMI, e.g. weight loss in obese people. Furthermore,
weight loss may be predictive of subsequent
nutritional deterioration.
iii. Will the patient’s condition worsen? This question
could be answered by determining whether food intake
has recently decreased, and if so, approximately
how much and for how long. This can be confirmed
by measuring the food intake of hospitalised patients
or through use of a diet diary. If it is determined
that food intake is lower than typically required to
maintain normal weight, then weight loss will likely
occur.
iv. Will the condition of nutritional deterioration accelerate?
In addition to decreased appetite, the
patient’s nutritional requirements may increase
because of metabolic stress associated with severe
illness. For example, major surgery, sepsis, or
multiple traumas, which may be accompanied by
chronic wounds, may cause nutritional status to
worsen quickly or may result in malnutrition.
Nutritional screening tools
In recent years, various tools to assess nutritional status
have been developed, validated, and implemented, although
not all are available in Spanish. The following
tools were developed specifically for elderly people: the
Payette instrument; Nutrition Risk Score; Nutritional Risk
Index; Sadness, Cholesterol, Albumin, Loss of Weight,
52
EWMA Journal 2014 vol 14 no 1

Eating problems, Shopping and Cooking problems
(SCALES); Global Subjective Assessment; Malnutrition
Universal Screening Tool (MUST), Mini Nutritional
Assessment (MNA); and Nutrition Risk
Screening 2002 (NRS 2002).
The NRS 2002 is recommended for use in hospitals,
whereas the MUST tool is intended for general use.
The MNA is the only tool validated in Spanish.
The third subsection presents key scientific evidence
for the role of nutrition in chronic wound prevention
and treatment, examining mechanisms underlying
physiological and metabolic processes. Topics
include energy intake; protein and/or specific amino
acid intake and fatty acid intake and their potential
immunomodulatory effects; liquid intake; and
intake of micronutrients (zinc, iron, copper, alpha
lipoic acid, and vitamins A, C, K, and E). A section
focuses on nutritional interventions and their role
in wound prevention and treatment.
The conclusion highlights the important role of
nutrition in wound care, emphasising that nutritional
screening and assessment have been, thus far,
overlooked in the field of wound research. Although
substantial scientific evidence is beginning to appear
in this field, further research is needed.
3. Recommendations for clinical practice. Recommendations
are presented with the level of supporting
evidence based on the Grading of Recommendations
Assessment, Development and Evaluation
(GRADE) Working Group guidelines. Recommendations
take into account questions that clinicians
should ask such as: When should nutritional status
be assessed? Who should assess nutritional status?
How should nutritional risk be assessed? Which nutritional
interventions can prevent and treat chronic
wounds?
4. Recommendations for researchers. Recommendations
are presented to provide researchers
with guidance in fields for which further research
is needed.
This document therefore provides a broad analysis
of this topic and identifies existing gaps in knowledge
of the relationships among nutritional status,
nutritional interventions, and wound management.
m
WOUND CARE
IN THE ONE
HEALTH PERSPECTIVE
Symposium
on Veterinary
Wound Management
and Antimicrobial
Resistance
EWMA n GNEAUPP 2014 Conference
Madrid, Spain
14 May 2014 · 13:00 -17:30
n What can veterinary wound care learn from
human wound care and vice versa?
n How can modern wound care contribute to
combatting the increasingly urgent problem of
antimicrobial resistance?
These are some of the questions that will be
debated at the 1st Symposium on Veterinary
Wound Management and Antimicrobial
Resistance.
This symposium is relevant for practitioners,
researchers and other health professionals
from the veterinary and human health sectors.
We are looking forward to seeing you!
EWMA Journal 2014 vol 14 no 1

The biofilm challenge
Maria Alhede,
M.Sc., Ph.D
Morten Alhede,
M.Sc., Ph.D
Biofilm Test Facility
University of Copenhagen
Department of International
Health, Immunology
and Microbiology
Blegdamsvej 3B,
Bldg. 24.1.22,
DK-2200 Copenhagen
Denmark
http://biofilmtestfacility.
ku.dk
Correspondence:
malhede@sund.ku.dk
Conflict of interest: none
Abstract
The concept of biofilms has emerged in the
clinical setting during the last decade. Infections
involving biofilms have been documented in all
parts of the human body, and it is currently believed
that the presence of biofilm-forming bacteria
is equivalent to chronic infection. A quick
Pubmed search reveals the significance of biofilms,
as evidenced by a dramatic increase in scientific
publications on the topic, as well as in publications
concerning wounds with biofilms, which
reached 600 publications in 2013.
Judged from the number of publications, it
appears that biofilms play a significant role in
wounds. However, the impact of biofilms is often
debated, because infected wounds were also
treated before the concept of biofilms was coined.
In this short review, we will address the significance
of biofilms and their role in wounds, and
discuss the future tasks of the biofilm challenge.
Biofilms in short
Bacteria are found in at least two distinct states
– planktonic and sessile cells. Planktonic cells are
classically defined as “free flowing bacteria in suspension”
as opposed to the sessile biofilm state,
which is defined as “a structured community of
bacterial cells enclosed in a self-produced polymeric
matrix and adherent to an inert or living surface” 1 .
Figure 1. Total biofilm publications on
www.ncbi.nlm.nih.gov/pubmed/
Until the last decade, microbiologists have focused
and emphasized the planktonic state over the biofilm
state. However, the importance of the biofilm
mode of growth is becoming increasingly evident
with the availability of improved methods to study
sessile bacteria; hence the subsequent accumulation
of evidence for its widespread presence 2,3 .
Biofilms were discovered by one of the first
microbiologists, the Dutch scientist Antoine van
Leeuwenhoek, in the 1650s, but the actual breakthrough
regarding this phenomenon occurred
328 years later when Costerton and colleagues
published their work on “How Bacteria Stick” in
1978 4 . Since 1978, research on biofilm bacteria
has exploded (Figure 1).
It has now been established that most biofilmgrowing
bacteria cause chronic infections 5 , which
are characterized by persistent inflammation and
tissue damage 6 . These chronic infections, including
wound and foreign body infections, are
infections that “1) persist in spite of antibiotic
therapy and the innate and adaptive immune and
inflammatory response of the host and 2) which,
in contrast to colonization, are characterized by
the immune response and persisting pathology” 7 .
Traditionally, biofilms were considered as being attached
to a surface. However, in situ hybridization
(FISH) and confocal laser scanning microscopy
(CLSM) of different infection sites have shown
that the bacteria do not need to be attached to
surfaces to establish a chronic infection. Instead,
bacteria generate non-attached microcolonies by
aggregating with their fellow bacteria through matrix
components, and they appear to put up an
impenetrable barrier to host immune cells (e.g.,
phagocytic cells) 6,8-10 .
The challenge faced with regard to biofilms in
chronic infections lies in their significant tolerance
to treatment with antibiotics and to the host’s
immune response 11 . The antibiotic tolerance of
the biofilm has been investigated in numerous in
vitro models; these studies show that the biofilm
can withstand treatment with very high dosages of
antibiotics that are up to 1000 times the minimal
inhibitory concentration 12 .
54
EWMA Journal 2014 vol 14 no 1

Scientific Communication
As mentioned above, probably the most important trait
of the biofilm is its innate tolerance to antimicrobials and
antiseptics. Here, slow growth and matrix molecules are of
the utmost significance. The biofilm matrix is composed
of macromolecules such as proteins, extracellular DNA,
and polysaccharides. This matrix surrounding the bacteria
in the biofilm has been shown to reduce penetration and
bind protruding antibiotics 13-20 .
In addition to the matrix, it appears that the biofilm
population consists of bacteria with different physiologies,
e.g., some are dormant and some are actively growing.
With this knowledge, treatment regimens with combinations
of different antibiotics have successfully been designed
to target these different sub-populations 21 . The
administration of such combinations to patients has been
successful to some extent and seems to suppress biofilm
infection; however, in most cases, the eradication of biofilm
infections has proven impossible and the infection
recurs when treatment is stopped 22,23 .
For wound care, antiseptics are preferred over antibiotics.
In our hands, most antiseptics (including silver and
PHMB) are very effective against planktonic bacteria and
immature biofilms 24,25 . However, when applied on mature
biofilms (i.e., those older than 24 hours) with low growth
rates and a solid matrix, they can only inhibit further
growth and prevent bacteria from spreading beyond the
biofilm (unpublished observations), and do not resolve
the infection. This increasing tolerance with age has also
been reported for traditional antibiotics 26,27 .
Biofilm tolerance to the host immune response is also
characteristic of chronic infections. Polymorphonuclear
leukocytes (PMNs) are normally the first cells appearing
at the site of infection, and their role is to phagocytize
microorganisms and foreign materials 28 . Despite being
part of the acute inflammatory response, PMNs are still
seen in chronic infections often surrounding the biofilm 29 .
Investigations of P. aeruginosa biofilms have shown that
these PMNs are either paralyzed or killed (lysed) by a virulence
factor produced by P. aeruginosa, called rhamnolipids
30,31 . The lysis of PMNs causes further inflammation
and attracts additional PMNs, and this cycle contributes
to chronic P. aeruginosa infection 32 .
As mentioned, the cells of a biofilm have been shown
to be embedded in a self-produced matrix consisting of
polysaccharides, proteins, and DNA. The matrix also plays
a role in the tolerance of the biofilm by decreasing the
penetration of PMNs and antibiotics. Interestingly, DNA
released from dead PMNs has been shown to enhance
initial biofilm development, thereby enhancing the biofilm
fortress 33 .
Biofilms in wounds
Wounds are disposed to infection, as the loss of skin integrity
provides a wet, warm, and often nutrient-rich setting
that is beneficial for microbial colonization. Bacterial infections
have been shown to prevent wound healing. Data
suggest that the presence of certain bacteria (e.g., P. aeruginosa)
in these ulcers can induce ulcer enlargement and
delayed healing 34 . Recent analyses from chronic wounds
have identified the presence of biofilm-growing bacteria,
thereby explaining why these wounds persist 8,9,35 .
Publications regarding biofilms and wounds reached a total
of 600 last year. This number is impressive and indicates
that biofilms play an important role in wound healing
(Figure 2). However, it is unclear whether the delay in
wound healing is caused by bacteria present in biofilms
in the slough at the surface of the wound or if bacteria
situated deeper cause this effect 36 . Hurlow et al. concluded
from a small series of cases that the appearance of biofilms
in wounds is quite different from the slough and requires
different management strategies for its control 36 . In 2009,
Fazli et al. found that the distance of the P. aeruginosa
biofilm from the wound surface was significantly greater
than that of S. aureus biofilms, suggesting that the distribution
of the biofilms in wounds is non-random and
that important biofilms are situated deeper in the wound
bed. It was thus suggested that biofilms (i.e., P. aeruginosa)
located in the deeper regions of the wound might play a
role in arresting the wound at a stage dominated by inflammatory
processes 9 . Bjarnsholt et al. have proposed that
these biofilms keep the wound in a chronic inflammatory
state, which corresponds to findings showing that a persistent
influx of PMNs, elevated matrix metalloproteases,
and imbalances in several cytokines are found in chronic
Figure 2. Total wound biofilm publications on
www.ncbi.nlm.nih.gov/pubmed/
EWMA Journal 2014 vol 14 no 1 55

wounds 35 . Wolcott and colleagues showed in 2008 that an
intensive biofilm-based wound-care strategy significantly
improved healing frequency. The findings demonstrate
that effectively targeting bacteria in chronic wounds is
an important component of transforming ‘non-healable’
wounds into healable wounds 37 .
The challenging biofilm
From the above studies it appears that biofilms are evident
in wounds. Biofilms were also addressed in the 2013
EWMA document “Antimicrobials and Non-healing
Wounds Evidence, controversies and suggestions”. The
conclusions in the document were that further studies
elucidating the precise role of biofilms are urgently needed
since the nature of biofilms make their study very difficult
and therefore their impact a little controversial.
Diagnosing biofilm infections is extremely difficul t38 , and
therefore evaluating the impact of biofilms and novel antibiofilm
treatments is equally difficult. The difficulties in
diagnosing biofilms are in large part due to their very small
size. A recent literature study showed that biofilms that
cause inflammation rarely grow to sizes larger than 100
μm 39 . When considering that the spatial distribution of
such small biofilms is highly heterogeneous in a wound
(9,40 , one can imagine that the chance of finding and detecting
the bacteria are small. In addition to the low chance
of ‘hitting’ a biofilm when sampling from a wound, the
bacteria also need to be released from the matrix. In addition
to these difficulties, the method of detection might
also influence the diagnosis. Culturing bacteria has been
the gold standard, but many wound pathogens are very
difficult to culture (even if grown anaerobically) and persistent
cells from the biofilm might even be impossible to culture
41,42 . Molecular methods are generally more sensitive if
used with care; however, they also have their limitations 40
and the detection of 16s rRNA has also proved difficult in
non-growing biofilms (unpublished data).
Due to the above complications, in vitro biofilm studies
have widely been applied in the study of anti-biofilm treatment
strategies as an obvious alternative to clinical trials.
Such studies are much needed and yield much important
information if used with care. Until recently, such treatment
strategies have been tested on fast growing bacteria
in shaking cultures; these studies did not therefore involve
biofilm-growing bacteria. Now, the use of biofilm models
is becoming more common. The downside of in vitro
models is that it is impossible to mimic a clinical biofilm;
nevertheless, the lack or addition of host components such
as proteins and immune cells should always be considered.
Another challenge researchers should be aware of
is the false dogma stating that surface attachment per se
makes the biofilm tolerant. This is not true, because young
surface-attached biofilms still have high growth rates and
only a limited matrix shield and are therefore highly susceptible
to most antimicrobials. In our hands, biofilms
across species and models become tolerant between 20
hours and 48 hours after inoculation, but continue to
develop this tolerance 26 .
Rethinking diagnosis and treatment
Despite the above difficulties in the study of biofilms, it
appears that tolerant biofilms do impact wound healing
as they impact other chronic infections 35-37 . As suggested
for other biofilm infections, there is an urgent need to rethink
both the diagnosis and treatment strategies. Wound
expert Keith Cutting wrote a review on the challenge of
wound cleansing, in which he proposed that we need to
rethink our approach to wound cleansing: he suggested
more reflection on individual needs and thereby a reflection
of the need to use anti-biofilm treatment strategies 43 .
When studying the impact of biofilms and their treatment
in patients, it is important to combine several methods
of detection to avoid false negatives 38 . Studying the
healing of chronic wounds is further complicated by the
challenge and longevity of non-healing wounds.
As mentioned above, eradicating biofilm-forming
bacteria is almost impossible, and the best option is to
remove the infected area if possible 7 . Infected implants
and catheters can be removed, infected lungs of cystic
fibrosis patients can be explanted, and wounds can be
debrided 7,8,23,44 ; however, even in these cases, biofilms
seem to recur, and hence it is very important to find and
develop new strategies to combat bacteria in wounds.
Much research is ongoing within anti-biofilm strategies,
and a number of patents on single compounds are pending
(www.faqs.org/patents/).
In our hands, one of the most promising strategies
across all biofilm-related infections is biofilm disruption
combined with an antimicrobial agent. Biofilm disruption
and dispersal experiments suggest that biofilm tolerance
is readily reversible, whereas classic resistance due to mutations
is not 26 . Upon physical disruption the biofilm,
the bacteria inside the biofilm suddenly find themselves
outside of the protective matrix with fresh access to nutrients
and oxygen, which might induce growth. Thus, a
potential anti-biofilm strategy could be either mechanical
or enzymatic disruption of the wound biofilm. Several patent
applications are already pending on the anti-biofilm
effects of a biofilm destabilizing compound used together
with common antimicrobials in wound dressings (www.
faqs.org/patents/).
Furthermore, a good fraction of the latest wound biofilm
publications have been focused on novel treatment
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EWMA Journal 2014 vol 14 no 1

Scientific Communication
strategies and novel models of wound infection involving
disruption of the biofilm alone or in combination with
antimicrobial agents.
Disruption of biofilms has been demonstrated with
ultrasound waves. Although the endpoint of most studies
has been surface release from young biofilms (i.e., not
necessarily equal to a reduced infection); some studies have
managed to prove that ultrasound waves can effectively enhance
the efficacy of antimicrobials (45-50 . Clinical studies
of ultrasound wound debridement have also shown good
effects 51,52 ; however, the decrease in bacterial counts were
not significant 51 . This non-significant decrease in bacterial
burden could be explained by the difficulties in detecting
biofilms, but it has also been suggested that the positive
effect arises from a multitude of factors such as cellular
recruitment and stimulation, collagen synthesis, angiogenesis,
and fibrinolysis (53,54 . However, non-published data
from our laboratory and the recent knowledge of biofilms
in non-healing wounds has led to the hypothesis that ultrasound,
in addition to the above mentioned parameters,
aids biofilm disruption and thereby wound healing 55 .
Maggot debridement therapy of non-healing wounds
was approved in 2004 by the FDA and has been shown to
possess an antibacterial effect in combination with other
wound healing properties 56-59 . An interesting study has
recently shown that larvae actually combine physical
disruption with enzymatic destabilization of wound biofilms
60 . As mentioned in the introduction, DNA stabilizes
all biofilms. Apparently, in addition to physically grazing,
the biofilm larvae secrete DNases that degrade DNA and
thereby further weaken the biofilm structure. As with the
ultrasound, larvae also have secondary positive effects on
wound healing immunomodulation, angiogenesis, and
tissue remodelling and regeneration, and this may explain
their beneficial effects on wound healing. Another
example of combining disruption of biofilms with positive
secondary effects is negative pressure therapy 61-63 . The
authors found that negative pressure disrupted the matrix
of biofilms on porcine skin implants, making them more
susceptible to antiseptics 61 .
As observed with other biofilm infections, targeting
several factors in wound biofilms seems to be a solid strategy
worth investigating. In the case of wound healing, the
secondary effects as discussed above might even be more
pronounced and thus constitute a promising strategy.
The tasks
From the above discussion of the impact of biofilms, it is
clear that we have a number of tasks to solve. First of all,
in order to prove that biofilm plays the role it is believed
to do, we need to improve diagnostic methods. This task
is also paramount when evaluating anti-biofilm strategies
in vivo. Secondly, the study of possible treatment strategies
for biofilm infections needs to be expanded and the
in vitro models need to be aligned to simulate the wound
in the best possible way.
For these tasks to be solved, it is important that scientists,
doctors, and wound healing specialists communicate
and share their thoughts and concerns on the issue. If
we combine the knowledge of wound care professionals
and basic scientists, we can hopefully take a giant leap
towards turning non-healing wounds into healing wounds.
Such multidisciplinary communication between doctors
and biofilm researchers has contributed significantly to
the treatment of chronic lung infections in patients with
the genetic disorder cystic fibrosis 64,65 . Communication
through research journals is significant; however, it is our
experience that the most fruitful results and collaborations
come from live discussions and consensus debates at conferences.
At the EWMA conference in 2013, the topic of
biofilms was for the first time denoted in an EWMA document;
furthermore, a number of abstracts dealt with biofilms
in addition to the popular workshop. In particular,
at the workshop, we had a great discussion on the future
of biofilm research. It is our hope that even more people,
from all branches of wound care, will attend the biofilm
workshops at EWMA GNEAUPP 2014 in Madrid, so
we can discuss the best approach to finding better ways
to study, diagnose, and treat biofilm-infected wounds.m
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experience with wound biofilm and management: a
case series. Ostomy Wound Manage 55:38-49.
37. Wolcott, R. D., and D. D. Rhoads. 2008. A study of
biofilm-based wound management in subjects with
critical limb ischaemia. J Wound Care 17:145-148,
150-142, 154-145.
38. Hall-Stoodley, L., P. Stoodley, S. Kathju, N. Hoiby,
C. Moser, J. W. Costerton, A. Moter, and T.
Bjarnsholt. 2012. Towards diagnostic guidelines for
biofilm-associated infections. FEMS Immunol Med
Microbiol 65:127-145.
39. Bjarnsholt, T., M. Alhede, M. Alhede, S. R.
Eickhardt-Sorensen, C. Moser, M. Kuhl, P. O.
Jensen, and N. Hoiby. 2013. The in vivo biofilm.
Trends Microbiol.
40. Thomsen, T. R., M. S. Aasholm, V. B. Rudkjobing,
A. M. Saunders, T. Bjarnsholt, M. Givskov, K.
Kirketerp-Moller, and P. H. Nielsen. 2010. The
bacteriology of chronic venous leg ulcer examined by
culture-independent molecular methods. Wound
Repair Regen 18:38-49.
41. Zandri, G., S. Pasquaroli, C. Vignaroli, S. Talevi, E.
Manso, G. Donelli, and F. Biavasco. 2012.
Detection of viable but non-culturable staphylococci
in biofilms from central venous catheters negative on
standard microbiological assays. Clin Microbiol Infect
18:E259-261.
42. Pasquaroli, S., G. Zandri, C. Vignaroli, C. Vuotto, G.
Donelli, and F. Biavasco. 2013. Antibiotic pressure
can induce the viable but non-culturable state in
Staphylococcus aureus growing in biofilms. J
Antimicrob Chemother 68:1812-1817.
43. Cutting, K. F. 2010. Addressing the challenge of
wound cleansing in the modern era. Br J Nurs
19:S24, S26-29.
44. Rudkjobing, V. B., T. R. Thomsen, M. Alhede, K. N.
Kragh, P. H. Nielsen, U. R. Johansen, M. Givskov,
N. Hoiby, and T. Bjarnsholt. 2012. The microorganisms
in chronically infected end-stage and non-endstage
cystic fibrosis patients. FEMS immunology and
medical microbiology 65:236-244.
45. Qian, Z., P. Stoodley, and W. G. Pitt. 1996. Effect of
low-intensity ultrasound upon biofilm structure from
confocal scanning laser microscopy observation.
Biomaterials 17:1975-1980.
46. Qian, Z., R. D. Sagers, and W. G. Pitt. 1999.
Investigation of the mechanism of the bioacoustic
effect. J Biomed Mater Res 44:198-205.
47. Karau, M. J., K. E. Piper, J. M. Steckelberg, S. J.
Kavros, and R. Patel. 2010. In vitro activity of the
Qoustic Wound Therapy System against planktonic
and biofilm bacteria. Advances in skin & wound care
23:316-320.
48. Dong, Y., S. Chen, Z. Wang, N. Peng, and J. Yu.
2013. Synergy of ultrasound microbubbles and
vancomycin against Staphylococcus epidermidis
biofilm. J Antimicrob Chemother 68:816-826.
49. Nishikori, T., M. Ochi, Y. Uchio, S. Maniwa, H.
Kataoka, K. Kawasaki, K. Katsube, and M.
Kuriwaka. 2002. Effects of low-intensity pulsed
ultrasound on proliferation and chondroitin sulfate
synthesis of cultured chondrocytes embedded in
Atelocollagen gel. J Biomed Mater Res 59:201-206.
50. Nishikawa, T., A. Yoshida, A. Khanal, M. Habu, I.
Yoshioka, K. Toyoshima, T. Takehara, T. Nishihara,
K. Tachibana, and K. Tominaga. 2010. A study of
the efficacy of ultrasonic waves in removing biofilms.
Gerodontology 27:199-206.
51. Escandon, J., A. C. Vivas, R. Perez, R. Kirsner, and
S. Davis. 2012. A prospective pilot study of
ultrasound therapy effectiveness in refractory venous
leg ulcers. Int Wound J 9:570-578.
52. Maher, S. F., J. Halverson, R. Misiewicz, T.
Reckling, O. Smart, C. Benton, and D. Schoenherr.
2014. Low-frequency Ultrasound for Patients With
Lower Leg Ulcers Due to Chronic Venous Insufficiency:
A Report of Two Cases. Ostomy Wound
Manage 60:52-61.
53. Vicenti, F. A., J. L. Laus, J. M. Costa Neto, I. C.
Talieri, C. F. Campos, A. T. Jorge, A. L. Ferreira,
and A. P. Fantinatti. 2003. Effects of low-intensity
pulsed ultrasound on wound healing in corneas of
dogs following keratoplasty. Veterinary ophthalmology
6:255-263.
54. Hess, C. L., M. A. Howard, and C. E. Attinger.
2003. A review of mechanical adjuncts in wound
healing: hydrotherapy, ultrasound, negative pressure
therapy, hyperbaric oxygen, and electrostimulation.
Annals of plastic surgery 51:210-218.
55. Butcher, G., and L. Pinnuck. 2013. Wound bed
preparation: ultrasonic-assisted debridement. Br J
Nurs 22:S36, S38-43.
56. Bexfield, A., A. E. Bond, E. C. Roberts, E. Dudley, Y.
Nigam, S. Thomas, R. P. Newton, and N. A.
Ratcliffe. 2008. The antibacterial activity against
MRSA strains and other bacteria of a

BIOFILM COURSES 2014
m MADRID, SPAIN 13 MAY 2014
Full-day course in Biofilm
Learning objectives:
The importance of the bacterial biofilm mode of growth is becoming increasingly
renowned as improved methods to study sessile bacteria have become available.
The course will focus on the impact of biofilms in wounds, and implant associated
areas, as well as addressing difficulties in diagnosis and treatment.
Lectures:
n Brief introduction to bacterial biofilm and its characteristics
n Impact of biofilms in wounds and on implants
n Pitfalls and guidelines in diagnosis of biofilm infections
n Treatment strategies of biofilm infections in wounds and implants
n Future treatment strategies
m COPENHAGEN, DENMARK 4-5 JUNE 2014
2nd practical course in Biofilm Procedures
The biofilm course will introduce the participants to the topic of biofilm and its huge
impact on chronic infections. Through lectures and a full day of hands on experiments,
the participants will gain a vast understanding of biofilms and usable knowledge of how
and why to implement biofilms into their research or product portfolio.
The biofilm groups and the Biofilm Test Facility at the University of Copenhagen and
Rigshospitalet have been investigating bacterial biofilms for 15 years and are regarded
as leading pioneers in the field.
FACULTY OF HEALTH
AND MEDICAL SCIENCES
UNIVERSITY OF COPENHAGEN
For registration and more information
on both courses, please see
WWW.BIOFILMCOURSES.EU
Contact
Biofilm Course Secretariat:
EWMA Secretariat/CAP Partner
Nordre Fasanvej 113, 2.
DK-2000 Frederiksberg
Tel.: +45 70 20 03 05
info@cap-partner.eu

National wound care
innovation centre launched in
the United Kingdom
Peter Vowden,
Professor
Clinical Director,
NIHR Bradford Wound
Prevention and Treatment
Healthcare Technology
Co-operative, the United
Kingdom
Correspondence:
peter.vowden@
bthft.nhs.uk
Conflict of interest: none
In January 2013, the United Kingdom’s National
Institute for Health Research (NIHR)
established eight new Healthcare Technology
Co-operatives (HTCs) to act as centres of expertise
to focus on clinical areas or themes of high
morbidity and unmet needs of National Health
Service (NHS) patients with the aim of fostering
innovation in these areas. Working collaboratively
with industry, the HTCs aim to develop
new medical devices, healthcare technologies, or
technology-dependent interventions, which improve
patient treatment and quality of life.
The eight HTCs cover a diverse array of
clinical problems ranging from mental health to
cardiovascular disease management. One of the
key areas to benefit from the NIHR’s recognition
of unmet need was wound care, with Bradford
Teaching Hospital’s NHS Foundation Trust designated
as the host organisation for the NIHR
Wound Prevention and Treatment HTC (NIHR
WoundTec HTC).
Table 1: Strategic partners in the NIHR WoundTec HTC
Bradford Teaching Hospital’s NHS Foundation Trust,
led by Professor Peter Vowden
Specialises in: Industry links, patient focus, clinical trial delivery, clinical care,
and education.
King’s College London,
led by Dr. Patricia Grocott and Professor Glen Robert
Specialises in: Clinical data capture, identification of unmet needs, co-design
of novel medical devices with users and manufacturers, and proof-of-concept
testing.
University of Southampton, led by Professor Dan Bader
Specialises in: Sensor development, device and support system assessment,
and end-user evaluation.
University of Leeds, led by Professors A Nelson and J Nixon
Specialises in: Evidence review and clinical trial design and evaluation.
University Hospital Birmingham’s NHS Foundation Trust,
led by Dr. Carol Dealey, Lt Col Steven Jeffery, and Professor Sir Keith Porter
Specialises in: Acute and chronic wound management, clinical trial and care
evaluation, and horizon scanning.
University of Bradford, led by Professors Stephen Britland (currently at
University of Wolverhamptom) and Des Tobin
Specialises in: Laboratory and cellular research to understand the biological
action of devices.
The NIHR WoundTec HTC is led by Professor
Peter Vowden, the HTC’s Clinical Director,
and builds on an established strategic partnership
between wound care experts in King’s College
Hospital London, Queen Elizabeth II Hospital
Birmingham, and the universities of Leeds,
Bradford, Wolverhampton, and Southampton
(Table 1). Together, these experienced clinicians
and academics have a proven track record
in wound prevention and treatment, acute and
chronic wound management, patient-focused
care, patient-led device design, and clinical trial
management.
Towards cost-effective
wound care
The management and prevention of skin breakdown
is a major cost burden for health care
providers and a common area for litigation, yet
wound prevention and treatment can often be
an area of relatively unregulated clinical practice
with a poor evidence base for practice. Variation in
clinical outcome across a wide spectrum of health
care providers and within diverse national health
care systems are well recognised and have led to
the adoption of pressure ulcer prevention standards
and wound healing rates as quality indicators
for clinical care provision.
Funding constraints within all health care systems
have led to increasing recognition of cost, in
addition quality, as a driver for change in practice.
Wound care products form a major subsector of
the medical devices industry, and along with staff
costs, constitute a major cost burden for healthcare
providers. It is therefore understandable that development
of new, “advanced”, and more effective
medical devices aimed at improved wound care
provision is desirable but must be achieved within
the constraints of cost effectiveness. In order to
aid in the understanding of current wound care
60
EWMA Journal 2014 vol 14 no 1

Innovation, know how and technolgy in wound care
practice within the United Kingdom, WoundTec HTC has
commissioned, largely through funding obtained from the
wound care medical device industry, a health economic
and outcome project, which aims to assess the current
“real-life” cost and outcome of wound care delivered to
a randomly selected population within the United Kingdom.
This data will hopefully assist in informing future
wound care developments and policies.
Aim of WoundTec HTC
The successful NIHR HTC model has already raised the
profile of wound care within the United Kingdom and
now provides the opportunity for healthcare professionals
to propel forward a patient-focused, centralised, and
coordinated wound care strategy supported by relevant
research. The aim of NIHR WoundTec HTC is to be
inclusive and encourage participation; with wider input
and ideas for innovation, it is more likely to succeed in
its goal of advancing the cause and improving the quality
of life of patients with wounds, accelerating innovation,
development, adoption, and diffusion of wound-related
medical devices within healthcare systems.
WoundTec HTC is already working with patients
and staff to identify unmet needs within wound care and
translate these needs into innovations relevant to NHS
and the wider healthcare community. Wound care has
often lacked an effective voice and a logical implementation
strategy; this development will seek to rectify this by
fostering and coordinating device and system development
led by patient and clinician needs rather than being largely
industry pushed.
WoundTec HTC will:
n Identify patient and clinical needs
n Act as a platform for innovation
n Identify and develop promising concepts for medical
devices derived from an established network of
patients, clinicians, academics, and industry
n Provide theoretical, methodological, and design
expertise, as well as a clinical base to develop these
concepts into testable interventions and devices
n Offer advice on testing the feasibility, effectiveness,
cost effectiveness, and acceptability of proposed
innovations in NHS settings and various care
pathways and promote the spread of best practice
n Work with industry to foster need-driven product
innovation
Involving the end users
Securing greater patient and public involvement in healthcare
service delivery and research is a central theme of
health policy in many countries and are key areas for all
of the HTCs. A model developed by the University of
Leeds and piloted in Bradford with patients with chronic
leg ulcers demonstrated that a patient-led approach to
innovation is valuable to industry, health providers, and
higher education as it can help identify new market opportunities
(McNichol 2012, Elberse 2012).
Through adoption of these principles, NIHR Wound-
Tec HTC has already supported a number of successful
innovative grant applications, taken areas of need identified
by patients to academics, established working relationships
with industry, and established partnership arrangements
with two other NIHR HTCs (Devices for
Dignity (Sheffield) and Trauma management (Birmingham)).
Opportunities for co-operation with similarly
focused European-based national organisations utilising
the infrastructure support of pan-European groups such
as the European Wound Management Association will
allow access to additional funding streams, including Horizon
2020 for wound-related research and medical device
development. The themes for 2014 within the Horizon
2020 are outlined in Table 2 and provide scope to develop
wound-related projects.
For further information on the NIHR Wound Prevention
and Treatment HTC, visit our web site or contact
Emma Martin (e.martin@medilink.co.uk). m
Table 2: Seven themes for Horizon 2020
n Understanding health, aging, and disease
n Effective health promotion, disease prevention,
preparedness, and screening
n Improving diagnosis
n Innovative treatments and technologies
n Advancing active and healthy aging
n Integrated, suitable, citizen-centred care
n Improving health information and data exploitation,
and providing an evidence base for health policies
and regulations
References
McNichol, E. Patient-led innovation in healthcare: The value of the
‘user’ perspective. International Journal of Healthcare Management.
2012; 5(4): 216-222.
Elberse JE, Pittens CA, de Cock Buning T, Broerse JE. Patient
involvement in a scientific advisory process: setting the research
agenda for medical products. Health Policy. 2012; 107(2-3):
231-242.
EWMA Journal 2014 vol 14 no 1 61

“ An integrated part of
wound management.”
Debrisoft ®
removes debris effectively in a quick and easy way
stimulates wound healing by protecting
newly formed tissue
improves quality of life being
almost painless
2000215 0913 e

Innovation, know how and technolgy in wound care
Development of tools
for home monitoring
in wound care
Introduction
In recent years there has been an increased focus
on getting patients out of the hospital and back
into their own homes as soon as possible. To reach
these goals, technologies that enable and assist this
transfer have been developed.
In the case of wound care, some patients with
complicated hard-to-heal ulcers end up needing
hospitalisation for their condition. There are
many reasons for hospitalisation; however, some
patients who require negative pressure wound
therapy (NPWT) are hospitalised simply because
they require constant monitoring and immediate
access to wound care specialists. This means that
the total health care costs for the application of
NPWT in this particular group of patients are
relatively high despite decreasing prices of the
NPTW systems themselves. Recently, portable
NPWT systems have been developed and commercialised,
providing several advantages for the
patients such as discreteness and ease of operation.
With the ever-increasing trend to allow patients to
leave the hospital environment as soon as possible,
smaller, simpler, and more patient-friendly devices
have been developed over the last few years.
However, these devices still only offer the single
service of negative pressure on the wound and
basic vacuum control.
SWAN-iCare project
To enable monitoring and treatment of patients in
their own home environment or long term care,
the SWAN-iCare project aims to develop a Smart
Negative Pressure Device (SNPD) (Figure 1). This
device will integrate non-invasive sensors that allow
objective, continuous, real-time monitoring
of critical parameters with personalised therapy
tailored to supporting the patient’s wound condition.
In addition, the device will have the potential
to remotely release active agents to assist in
the wound healing process. To facilitate distant
monitoring and support provided by centralised
specialists to patients being cared for outside of the
hospital environment, the device will be equipped
with information and communication technologies
(ICT).
The SWAN-iCare device will:
n Collect data and monitor several wound
parameters via non-invasive integrated
micro-sensors
n Offer the opportunity to provide innovative
personalised therapy in combination with
the negative pressure wound therapy
n Allow health care providers to be remotely
aware of the patient’s condition and receive
alerts highlighting situations that require
direct actions
Target Groups for SWAN-iCare NPWT
The device is expected to be used primarily by patients
with diabetic foot ulcers (DFU) or venous
leg ulcers (VLU).
Marco Romanelli,
MD PhD
Assistant Professor
Dept. of Dermatology
University of Pisa, Italy
Marie Muller, MD
Dpt. of Diabetology
Grenoble University
Hospital, France
www.swan-icare.eu
Conflict of interest: none
Chronic ulcerative skin lesions affect approximately 1.5% of the
population and represent a considerable medical and social problem.
The patient affected by this pathology is generally geriatric
and likely to suffer from concomitant illnesses. Chronic ulcers
have different causes and can be divided into the following main
categories: vascular ulcers (venous, arterial, mixed), diabetic foot
ulcers, pressure ulcers, and ulcers of different aetiology. The above
pathologies refer to chronic and invalidating conditions that profoundly
affect the patients’ quality of life and often lead to psychological
disorders such as depression.
New treatments for these pathologies have led to improvements
in lesion management and in the quality of assistance provided by
medical and paramedical staff, but methodologies for monitoring
lesions have not kept pace with this progress.
Effective and accurate monitoring of skin lesions should be
performed by measuring the complete status and evolution of the
skin lesion in an objective, precise, and reproducible way. The
main goal of the SWAN-iCare project is to design a system that
can monitor the qualitative and quantitative evolution of a skin
lesion with an easy-to-use technological system.
EWMA Journal 2014 vol 14 no 1 63

Server
Clinical Back-end
- Data Base
- Resource Management
- Data Fusion
Mobile Application
- Smartphone
- Web Browser
Internet
Client
Client
Client
Caregiver
Outside
Healthcare
professionals
Administrator
Clinical se'ng
NPWT
Experts
Technicians
HUB
- Data Transfer
- WPAN Communication
- WWLAN Communication
Commercial Off-­‐The-­‐Shelf
Wireless Communica=on with HUB
Smart Negative Pressure Device
- User interface
- Wound Pressure Control
- WWLAN Communication (GPRS)
- Canister
- …
Medical Devices
- Infrared thermometer
- Glucometer
- Oximeter
Docking station
- Battery recharge
- Device automatic control
Wireless communica=on with HUB
Rechargeable Devices
(Contactless Energy Transfer)
Dressing
- Lipidots/Collagen Scaffolds
- pH
- CRP
- TNF-alpha
- MMPS
- Temperature matrix
- …
External Devices
- Trans Epidermal Water Loss
- Wound Surface Impedance
- Bacteria Quantification & Identification
Wearable Devices
- Insole Pressure
- Dorsiflexion
Internal Sensors
- In wound sensors
Home se'ng
64
EWMA Journal 2014 vol 14 no 1

Innovation, know how and technolgy in wound care
Only a small proportion of patients with chronic ulcers
are currently being treated by NPWT. This number is
expected to grow in the next few years as the cost of
NPWT decreases. The SWAN-iCare device will offer an
optimised NPWT treatment for chronic ulcers characterised
as “hard-to-heal”, allowing distant monitoring of
the wound healing process in specific situations where
the healing is expected to be more uncertain and more
challenging.
Expected benefits
The development of products with sensors and ICT that
allow remote monitoring of wound conditions may lead to
benefits for patients and medical support teams at numerous
different points along the patient’s treatment pathway.
The expected benefits can be summarised as follows:
Improved clinical outcomes:
n Earlier identification of wound infections and
wound deterioration, encouraging hope of a lower
amputation rate
n Better control and monitoring of exudate and compression
n Access to detailed real-time quantitative data will
contribute to evaluation of treatment effectiveness
and wound healing progress and allow for individualised
and fine-tuned treatment regimes
More efficient use of resources
n Reduced healthcare costs as a consequence of fewer
complications and faster healing
n Reduced healthcare costs as a consequence of a reduced
need for hospitalisation and fewer visits to
specialist wound centres through remote monitoring
n Reduced time spent on dressing changes during
nursing visits, allowing more time to be focused on
other medical needs
n Less potential waste of dressing materials as a result
of a reduction in “unnecessary” dressing changes
n Reduced cost to the social system and minimised loss
of productivity associated with the patient returning
to work earlier due to an improved wound management
process
Increased patient satisfaction and quality of life
n Reduced disturbance to the patient’s life and possible
reduced need for hospitalisation due to early identification
of wound deterioration and faster healing
n Personalised treatment adjusted on a daily basis to
meet each patient’s individual needs
n Patients can stay out of hospital while receiving
treatment and thus feel more comfortable while at
the same time being reassured that their condition
is being safely and remotely monitored by specialist
carers
n Less dependency on clinical visits will reduce time
and resources spent on transportation to specialist
care units
Better monitoring and documentation
n Detailed and continuous data collection on central
parameters important for wound healing will
increase the level of knowledge and competence
among the different service providers involved in
wound care
n A research dimension will be integrated into the
project to develop a deeper understanding of wound
healing through correlation and analysis of multiple
wound parameter measurements
How far are we from realising
these goals
By the end of the project period a clinically proven prototype
SNPD will have been developed. However, as with
other eHealth services, the technological development is
itself only one part of the challenge of getting these types
of systems integrated into routine care provision.
Large-scale deployment and real-market uptake requires
additional work to understand how implementation
of these ICT systems will affect current workflows
and any potential changes to the roles and responsibilities
of staff involved in service provision throughout the treatment
pathway. If this is not understood and accounted
for, implementation could be hindered simply because
organisations and staff are not ready to transform the way
routine care is being provided.
Another aspect is the business model. Clarification of
where the reimbursement of such a system is to come
from in different health care settings is a challenge that
has hampered the uptake of similar products. For patients
that end up receiving treatment and care from multiple
sectors, the impact on budget for all the different levels of
service providers will not be easy to establish. It may not
always be obvious that the ones bearing the costs are the
ones benefitting from the savings generated.
To meet these challenges, part of the project deliverables
will be to establish detailed stakeholder analysis as well
as impact and cost effectiveness analyses that will lead to
different roadmaps for adoption strategies based on the
customers’ needs and expectations.
m
PROJECT FACTS
Funding program: Seventh framework program:
Large scale Integrating project proposal –
ICT call 8 (FP7-ICT-20118)
Project period: 01.09.2012 - 01.09.2016 (4 years)
For more information see: www.swan-icare.eu/
EWMA Journal 2014 vol 14 no 1 65

2014 EDUCATION ACTIVITIES
Taking the users on board
Ana Maria d’Auchamp,
Innovation Consultant
Division Business &
Society
Danish Technological
Institute, Denmark
Correspondence:
amap@teknologisk.dk
Conflict of interest: none
Introduction
To spur and support the active involvement of
users in design and innovation processes EWMA
in collaboration with the Danish Technological
Institute are launching two training activities focusing
on user driven innovation.
The activities compromise:
n 2 day course, Autumn 2014, Copenhagen
n Workshop, EWMA conference May 2014,
Madrid
The activities can be joined independently
of each other.
BACKGROUND AND OBJECTIVES
The involvement of end users has become increasingly
important during the process of inventing
and designing new products and service delivery
models. By systematically involving end users in
innovation processes, there are good chances of
developing products and services that meet real
needs and make real impact. New products and
services that are developed by a user-driven approach
are likely to achieve rapid and widespread
market uptake and customer engagement. Despite
the increasing focus on user involvement, many
companies still lack the proper methodology for
integrating this approach into routine product and
service development procedures. The objectives of
this course are to inspire and update all industry
partners on the newest trends within user-driven
innovation processes, especially those who are involved
in critical aspects of product and service
innovation.
TARGET GROUP
The course targets clinicians and industry representatives
who want to learn more about userdriven
product design, as well as the development
and implementation of new service delivery models.
Both experienced and less-experienced employees
are invited to attend, especially those who
are involved in R&D, marketing, and/or business
development. For some modules, the group will
be divided by the level of experience.
2 day COURSE in CopenHagen
– OBJECTIVES AND PROGRAM
Title: Innovation for future healthcare:
Participation, collaboration, and value creation.
Course Objectives: The goals of the course are
to present and discuss different aspects of innovation,
from the involvement of different partners to
value creation and business model development.
Through a series of modules, participants will be
introduced to the barriers and benefits of different
approaches to product and service development,
as well as practical experience and cases. Hands-on
exercises will be used to illustrate the presented
concepts. In these exercises, the participants will
work in groups to develop concrete solutions
based on different cases from both industry and
applied R&D projects. This methodology will
allow participants to be able to lay the ground
for future work with innovation in the context
of their own company. The course is intended to
provide updates on the latest developments within
the field of user-driven innovation, and it will
also discuss subjects that are related to new trends
within the healthcare sector.
Course content: Each module will comprise of
theories, hands-on exercises, and case examples.
The course will be delivered by the Danish Technological
Institute and invited experts in wound
innovation.
Duration: 2 Days
Date: 3-4 September 2014
Place: Denmark, Copenhagen (Venue tbc.)
Registration open: 15 April 2014
Registration deadline: 15 June 2014
Registration fee: 1.995 EUR
Language: English
Maximum of 40 participants
For more information:
www.userdriveninnovationcourse.org
Entitlements: Registration fee include
course literature (compendium),
coffee breaks, and lunch
66
EWMA Journal 2014 vol 14 no 1

Innovation, know how and technolgy in wound care
2014 EDUCATION ACTIVITIES
Industry Course in Copenhagen
MODULE 1: User-driven innovation
Module 1: Introduction (for all participants)
n Rapid innovation: Participants will engage in the
product development process and try all steps of a
generic process, from user interviews to the prototype/model
building of their solution.
Module 1a: User-driven innovation –the basics (for participants
who are new to user-driven innovation)
Participants will be introduced to the following aspects of
user-driven innovation:
n What is user-driven innovation? (Basic concepts:
process and methods)
n Why should we care about user-driven innovation?
n What are the types of user-driven innovation and
their characteristics, including product design and
the development/implementation of service delivery
models?
Module 1b: User-driven innovation – new approaches
(for participants with previous practical experience in userdriven
innovation)
Participants will be presented with the newest trends
regarding user involvement:
n What are the types of user-driven innovation and
their characteristics, including product design and
the development/implementation of service delivery
models?
n How can users be involved in new approaches, such
as community-based innovation, online development
forums, and need-based focus processes, in
existing networks?
MODULE 3: Organisational and work-practice
challenges in the implementation of user-driven
innovation processes
Implementing new innovation methods into everyday
R&D can lead to the development of new work practices
and the training of employees.
n How do we integrate new innovation methods into
established work practices?
n Why must user-driven innovation be an integrated
part of corporate strategy and philosophy instead of
isolated projects?
MODULE 4: Generation of a business model
that is focused on collaboration and value creation
Opening up to new innovation methods can create new
ways to see one’s company and develop how business models
should be created for new solutions. The involvement
of external partners can help identify new ways to define
revenue structures, share expenses, and invite input to
service delivery. However, navigating the complex constellation
of private and public partners can present many
challenges.
n How do we involve partners when we are setting
up our business model? (examples from the field of
eHealth, e.g., telemedicine and exchange of patient
data)
n What tools for business model generation can have
sustainable and long-term effects?
n How can we establish collaborative innovation between
public and private sectors using telemedicine
ecosystems?
MODULE 2: From needs to value creation
One side of user-driven innovation is identifying the users’
unmet needs. However, translating these needs to ideas
that create value for the end users is another key area of
expertise that requires training and experience.
n How can unmet needs be converted into innovation?
(examples within wound care)
n Who are we creating value for in an innovation process?
n Who should be involved in the development process,
and when should it be done? (for example, end users
and industry)
MODULE 5: Trends in healthcare development:
eHealth, telemedicine, and all that jazz
New trends appearing within the healthcare sector involve
telemedicine and independent living technologies. The
traditional roles of healthcare partners are being challenged,
and the demands from users continuously change.
Therefore, it will be important to keep up with developmental
trends in order to always stay one step ahead.
n How can the industry become an active player in
creating patient empowerment for chronic patients?
n What is an example of innovation in service delivery?
(case: Telemedicine in wound care)
n What are the new trends and development paths in
the regulatory field?
EWMA Journal 2014 vol 14 no 1 67

Innovation, know how and technolgy in wound care
2014 EDUCATION ACTIVITIES
Taking the users on board
Workshop, EWMA 2014 conference, Madrid
Join the workshop on user driven innovation at the
EWMA conference in Madrid to get an introduction
to the topic of user driven innovation in product development
and get a flavour of what the 2 day course in
Copenhagen has to offer.
Title: Innovation for user value creation – Trends in collaboration,
empowerment and technological development.
Workshop objective: Join this workshop to learn more
about how different types of innovation within the healthcare
sector can answer future development challenges.
Whether this means user involvement or implementation
of new technologies and approaches to service delivery
such as assistive living technologies or eHealth, collaboration
and value creation is the key for success. The workshop
will answer questions as to why, when and how user
driven design can add value to innovation processes and
introduce different innovation models. Also the workshop
will focus on how new partnerships can create new solutions
to everyday challenges. The workshop will in addi-
Stay informed by visiting the conference website,
www.ewma2014.org, to see registration opportunities
or obtain further information about the programme.
You can also get your updates on EWMA’s
social media platforms:
tion to theoretical presentations also include case example
presented by invited experts. The workshop will also give
a short introduction to the two-day course on the same
topic offered by EWMA and the Danish Technological Institute,
September 2014. The course offers more in-depth
knowledge about the topics presented at the workshop and
will in addition to theoretical presentations also include
case examples and hands-on exercises.
The session includes contributions from Peter Vowden,
Clinical Director, NIHR Bradford Wound Prevention and
Treatment Health Care co-operative and Rod Hulme Customer
Insights Specialist, Advanced Wound Management
Smith&Nephew.
Duration: 1½ H
Date: Thursday 15 May, 08:00-09:30
Place: At the EWMA-GNEAUPP 2014 Conference in Madrid
Hosted by: Danish Technological Institute
and invited wound innovation experts
For detailed update on the workshop program
please visit www.ewma2014.org
www.facebook.com/EWMA.Wound
www.linkedin.com/company/
european-wound-management-association
The Danish Technological Institute has over 100 employees
working with healthcare innovation in various areas, such as
technology development, organisational development, user
training in new technologies, user studies, idea generation with
users (both patients and healthcare professionals), technology
foresights, and product development. These training activities
are led by the Business and Society Division, which works specifically
with user-driven innovation projects. The team of design
engineers, anthropologists, and project managers is highly experienced
in technology management, occupational health, social
science, design engineering, safety, and risk management in
emerging health technologies.
Twitter: @ewmatweet
68
EWMA Journal 2014 vol 14 no 1

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Trust Me, I’m a Doctor, The Music Group, Have I Got News For You, The
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Other confirmed keynote speakers include:
O Dr David De Berker, Consultant Dermatologist, Bristol Royal Infirmary
Dr Phil Hammond
O Professor Hylton Menz, Senior Research Fellow, National Health and Medical Research Council, Leader of the
Lower Extremity and Gait Studies Program, La Trobe University, Melbourne, Australia
O Professor Mark Nixon, Professor of Computer Vision, University of Southampton
O Dr Michael Turner, former Chief Medical Advisor to the British Horseracing Authority
O Dr David Coppini, Consultant Diabetologist, Poole Hospital
O Debbie Sharman, Consultant Podiatrist and Visiting Lecturer, University of Southampton
O Dr Tony Berendt, Deputy Medical Director, Oxford University Hospitals NHS Trust, Oxford; and Consultant
in Infectious Diseases, Bone Infection Unit, Nuffield Orthopaedic Centre, OUH, Oxford
O Professor Chris Bunker, Consultant Dermatologist, University College London Hospitals NHS Foundation
Trust and President, British Association of Dermatology
Special offer!
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Cochrane Reviews
ABSTRACTS OF RECENT
COCHRANE REVIEWS
Dressings and topical agents for
preventing pressure ulcers
Zena EH Moore, Joan Webster
Moore ZEH, Webster J. Dressings and topical agents
for preventing pressure ulcers. Cochrane Database of
Systematic Reviews 2013, Issue 8. Art. No.:
CD009362. DOI: 10.1002/14651858.CD009362.
pub2.
Copyright © 2013 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
ABSTRACT
Background: Pressure ulcers, which are localised injury
to the skin, or underlying tissue or both, occur when
people are unable to reposition themselves to relieve
pressure on bony prominences. Pressure ulcers are
often difficult to heal, painful and impact negatively on
the individual’s quality of life. The cost implications of
pressure ulcer treatment are considerable, compounding
the challenges in providing cost effective, efficient
health services. Efforts to prevent the development of
pressure ulcers have focused on nutritional support,
pressure redistributing devices, turning regimes and the
application of various topical agents and dressings
designed to maintain healthy skin, relieve pressure and
prevent shearing forces. Although products aimed at
preventing pressure ulcers are widely used, it remains
unclear which, if any, of these approaches are effective
in preventing the development of pressure ulcers.
Objectives: To evaluate the effects of dressings and
topical agents on the prevention of pressure ulcers, in
people of any age without existing pressure ulcers, but
considered to be at risk of developing a pressure ulcer,
in any healthcare setting.
Search methods: In February 2013 we searched the
following electronic databases to identify reports of relevant
randomised clinical trials (RCTs): the Cochrane
Wounds Group Specialised Register; the Cochrane
Central Register of Controlled Trials (CENTRAL)
(The Cochrane Library); Database of ABSTRACTs of
Reviews of Effects (The Cochrane Library);
Ovid MEDLINE; Ovid MEDLINE (In-Process & Other
Non-Indexed Citations); Ovid EMBASE; and EBSCO
CINAHL.
Selection criteria: We included RCTs evaluating the
use of dressings, topical agents, or topical agents with
dressings, compared with a different dressing, topical
agent, or combined topical agent and dressing, or no
intervention or standard care, with the aim of preventing
the development of a pressure ulcer.
Data collection and analysis: We assessed trials for
their appropriateness for inclusion and for their risk of
bias. This was done by two review authors working
independently, using pre-determined inclusion and
quality criteria.
Main results: Five trials (940 participants) of unclear or
high risk of bias compared a topical agent with a placebo.
Four of these trials randomised by individual and
one by cluster. When results from the five trials were
combined, the risk ratio (RR) was 0.78 (95% CI 0.47
to 1.31; P value 0.35) indicating no overall beneficial
effect of the topical agents. When the cluster randomised
trial was omitted from the analysis, use of topical
agents reduced the pressure ulcer incidence by
36%; RR 0.64 (95% CI 0.49 to 0.83; P value 0.0008).
Four trials (561 participants), all of which were of high
or unclear risk of bias, showed that dressings applied
over bony prominences reduced pressure ulcer incidence;
RR 0.21 (95% CI 0.09 to 0.51; P value
0.0006).
Authors’ conclusions: There is insufficient evidence
from RCTs to support or refute the use of topical
agents applied over bony prominences to prevent pressure
ulcers. Although the incidence of pressure ulcers
was reduced when dressings were used to protect the
skin, results were compromised by the low quality of
the included trials. These trials contained substantial
risk of bias and clinical heterogeneity (variations in
populations and interventions); consequently, results
should be interpreted as inconclusive. Further well
designed trials addressing important clinical, quality of
life and economic outcomes are justified, based on the
incidence of the problem and the high costs associated
with pressure ulcer management.
Plain language summary:
Dressings or topical agents for preventing pressure
ulcers
Pressure ulcers, sometimes known as bedsores or pressure
sores, commonly occur in people who cannot, or
find it difficult to, move themselves. Pressure ulcers are
hard to heal, so it is important to try to prevent them
from occurring in the first place. Various cream and
lotions (topical agents) have been used for this purpose;
the idea is that pressure ulcers are less likely to
occur when the skin is healthy and nourished. A number
of different types of dressings are also used to pro-
Sally Bell-Syer, MSc
Managing Editor
Cochrane Wounds Group
Department of
Health Sciences
University of York
United Kingdom
Correspondence:
sally.bell-syer@york.ac.uk
Conflict of interest: none
EWMA Journal 2014 vol 14 no 1 71

tect the skin from damage. We reviewed studies that compared
topical agents or dressings with other methods for preventing
pressure ulcers. We found nine trials that investigated these that
included 1501 people. These showed that the evidence concerning
the use of topical agents or dressings for preventing pressure
ulcers is not clear. The reason why the evidence is not clear is
because the quality of trials was low and most had manufacturer
sponsorship, which introduces potential biases, such as overestimating
the effectiveness of the product. Consequently, further
trials are needed to confirm results of this review.
Publication in The Cochrane Library Issue 9, 2013
Early versus delayed dressing removal after
primary closure of clean and clean- contaminated
surgical wounds
Clare D Toon, Rajarajan Ramamoorthy, Brian R Davidson,
Kurinchi Selvan Gurusamy
Toon CD, Ramamoorthy R, Davidson BR, Gurusamy KS. Early
versus delayed dressing removal after primary closure of clean
and clean-contaminated surgical wounds. Cochrane Database
of Systematic Reviews 2013, Issue 9. Art. No.: CD010259. DOI:
10.1002/14651858.CD010259.pub2.
Copyright © 2013 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Most surgical procedures involve a cut in the skin
that allows the surgeon to gain access to the deeper tissues or
organs. Most surgical wounds are closed fully at the end of the
procedure (primary closure). The surgeon covers the closed surgical
wound with either a dressing or adhesive tape. The dressing
can act as a physical barrier to protect the wound until the
continuity of the skin is restored (within about 48 hours) and to
absorb exudate from the wound, keeping it dry and clean, and
preventing bacterial contamination from the external environment.
Some studies have found that the moist environment
created by some dressings accelerates wound healing, although
others believe that the moist environment can be a disadvantage,
as excessive exudate can cause maceration (softening and
deterioration) of the wound and the surrounding healthy tissue.
The utility of dressing surgical wounds beyond 48 hours of
surgery is, therefore, controversial.
Objectives: To evaluate the benefits and risks of removing a
dressing covering a closed surgical incision site within 48 hours
permanently (early dressing removal) or beyond 48 hours of
surgery permanently with interim dressing changes allowed
(delayed dressing removal), on surgical site infection.
Search methods: In July 2013 we searched the following electronic
databases: The Cochrane Wounds Group Specialised
Register; The Cochrane Central Register of Controlled Trials
(CENTRAL) (The Cochrane Library); Database of ABSTRACTs of
Reviews of Effects (DARE) (The Cochrane Library); Ovid MED-
LINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations);
Ovid EMBASE; and EBSCO CINAHL. We also searched
the references of included trials to identify further potentiallyrelevant
trials.
Selection criteria: Two review authors independently identified
studies for inclusion. We included all randomised clinical trials
(RCTs) conducted with people of any age and sex, undergoing a
surgical procedure, who had their wound closed and a dressing
applied. We included only trials that compared early versus
delayed dressing removal. We excluded trials that included people
with contaminated or dirty wounds. We also excluded quasirandomised
studies, and other study designs.
Data collection and analysis: Two review authors independently
extracted data on the characteristics of the trial participants, risk
of bias in the trials and outcomes for each trial. We calculated
risk ratios (RR) with 95% confidence intervals (CI) for binary outcomes
and mean difference (MD) with 95% CI for continuous
outcomes. We used RevMan 5 software to perform these calculations.
Main results: Four trials were identified for inclusion in this
review. All the trials were at high risk of bias. Three trials provided
information for this review. Overall, this review included
280 people undergoing planned surgery. Participants were randomised
to early dressing removal (removal of the wound dressing
within the 48 hours following surgery) (n = 140) or delayed
dressing removal (continued dressing of the wound beyond 48
hours) (n = 140) in the three trials. There were no statistically
significant differences between the early dressing removal group
and delayed dressing removal group in the proportion of people
who developed superficial surgical site infection within 30 days
(RR 0.64; 95% CI 0.32 to 1.28), superficial wound dehiscence
within 30 days (RR 2.00; 95% CI 0.19 to 21.16) or serious
adverse events within 30 days (RR 0.83; 95% CI 0.28 to 2.51).
No deep wound infection or deep wound dehiscence occurred in
any of the participants in the trials that reported this outcome.
None of the trials reported quality of life. The hospital stay was
significantly shorter (MD -2.00 days; 95% CI -2.82 to -1.18) and
the total cost of treatment significantly less (MD EUR -36.00;
95% CI -59.81 to -12.19) in the early dressing removal group
than in the delayed dressing removal group in the only trial that
reported these outcomes.
Authors’ conclusions: The early removal of dressings from clean
or clean contaminated surgical wounds appears to have no detrimental
effect on outcomes. However, it should be noted that
the point estimate supporting this statement is based on very low
quality evidence from three small randomised controlled trials,
and the confidence intervals around this estimate were wide.
Early dressing removal may result in a significantly shorter hospital
stay, and significantly reduced costs, than covering the surgical
wound with wound dressings beyond the first 48 hours after
surgery, according to very low quality evidence from one small
randomised controlled trial. Further randomised controlled trials
of low risk of bias are necessary to investigate whether dressings
are necessary after 48 hours in different types of surgery and levels
of contamination and investigate whether antibiotic therapy
influences the outcome
Plain language summary:
Early versus delayed dressing removal for people with
surgical wounds
Most surgical procedures involve a cut in the skin that allows the
surgeon to gain access to the deeper tissues or organs. Most
surgical wounds are closed fully at the end of the procedure.The
surgeon covers the closed surgical wound with either a dressing
72
EWMA Journal 2014 vol 14 no 1

Cochrane Reviews
or adhesive tape.The dressing can act as a physical barrier to
protect the wound until the continuity of the skin in restored
(within about 48 hours). It can also absorb exudate from the
wound, keeping it dry and clean, and preventing bacterial contamination
from the external environment. Some studies have
found that the moist environment created by some dressings
accelerates wound healing, although others believe that it is a
disadvantage, as excessive exudate can cause softening and
deterioration of the wound and surrounding healthy tissue.
We reviewed the medical literature up to July 2013 and identified
four randomised controlled trials that investigated early (permanent
removal of dressings within 48 hours of surgery) versus
delayed removal of dressings (permanent removal of dressings
after 48 hours of surgery with interim changes of dressing
allowed) in people with surgical wounds. The levels of bias
across the studies were mostly high or unclear, i.e. flaws in the
conduct of these trials could have resulted in the production of
incorrect results. A total of 280 people undergoing planned surgery
were included in this review. One-hundred and forty people
had their dressings removed within 48 hours following surgery
and 140 people had their wounds dressed beyond 48 hours.
The choice of whether the dressing was removed early (within
48 hours) or retained for more 48 hours was made randomly by
a method similar to the toss of a coin. No significant differences
were reported between the two groups in terms of superficial
surgical site infection (infection of the wound), superficial wound
dehiscence (partial disruption of the wound that results in it reopening
at the skin surface) or the number of people experiencing
serious adverse events. There were no deep wound infections or
complete wound dehiscence (complete disruption of wound
healing, when the wound reopens completely) in the studies that
reported these complications. However, the studies were not
large enough to identify small differences in complication rates.
None of the studies reported quality of life. Participants in the
group that had early removal of dressings had significantly
shorter hospital stays and incurred significantly lower treatment
costs than those in the delayed removal of dressings group, but
these results were based on very low quality evidence from one
small randomised controlled trial. We recommend further randomised
controlled trials are performed to investigate whether
dressing of wounds beyond 48 hours after surgery is necessary,
since the current evidence is based on very low quality evidence
from three small randomised controlled trials.
Interventions for helping people adhere to compression
treatments for venous leg ulceration
Carolina D Weller, Rachelle Buchbinder, Renea V Johnston
Weller CD, Buchbinder R, Johnston RV. Interventions for helping
people adhere to compression treatments for venous leg ulceration.
Cochrane Database of Systematic Reviews 2013, Issue 9.
Art. No.: CD008378. DOI: 10.1002/14651858.CD008378.
pub2.
Copyright © 2013 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Chronic venous ulcer healing is a complex clinical
problem that requires intervention from skilled, costly, multidisciplinary
wound-care teams. Compression therapy has been
shown to help heal venous ulcers and to reduce the risk of recurrence.
It is not known which interventions help people adhere to
compression treatments.
Objectives: To assess the benefits and harms of interventions
designed to help people adhere to venous leg ulcer compression
therapy, and thus improve healing of venous leg ulcers and prevent
their recurrence after healing.
Search methods: In May 2013 we searched The Cochrane
Wounds Group Specialised Register; The Cochrane Central
Register of Controlled Trials (CENTRAL) (The Cochrane Library);
Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-
Indexed Citations); Ovid EMBASE; EBSCO CINAHL; trial registries,
and reference lists of relevant publications for published
and ongoing trials. There were no language or publication date
restrictions.
Selection criteria: We included randomised controlled trials
(RCTs) of interventions that help people with venous leg ulcers
adhere to compression treatments compared with usual care, or
no intervention, or another active intervention. Our main outcomes
were number of people with ulcers healed, recurrence,
time to complete healing, quality of life, pain, adherence to
compression therapy and number of people with adverse events.
Data collection and analysis: Two review authors independently
selected studies for inclusion, extracted data, assessed the risk of
bias of each included trial, and assessed overall quality of evidence
for the main outcomes in ‘Summary of findings’ tables.
Main results: Low quality evidence from one trial (67 participants)
indicates that, compared with home-based care, a community-based
Leg Club ® clinic that provided mechanisms for
peer-support, assistance with goal setting and social interaction
did not result in superior healing rates at three months (12/28
people healed in Leg Club clinic group versus 7/28 in homebased
care group; risk ratio (RR) 1.71, 95% confidence interval
(CI) 0.79 to 3.71); or six months (15/33 healed in Leg Club
group versus 10/34 in home-based care group; RR 1.55, 95%
CI 0.81 to 2.93); or in improved quality of life outcomes at six
months (MD 0.85 points, 95% CI -0.13 to 1.83; 0 to 10 point
scale). However, the Leg Club resulted in a statistically significant
reduction in pain at six months (MD -12.75 points, 95%
CI -24.79, -0.71; 0 to 100 point scale), although this was not
considered a clinically important difference. Time to complete
healing, recurrence of ulcers, adherence and adverse events
were not reported.
Low quality evidence from another trial (184 participants)
indicates that, compared with usual care in a wound clinic, a
community-based and nurse-led self-management programme
of six months’ duration promoting physical activity (walking and
leg exercises) and adherence to compression therapy via counselling
and behaviour modification (Lively Legs ® ) may not result
in superior healing rates at 18 months (51/92 healed in Lively
Legs group versus 41/92 in usual care group; RR 1.24 (95% CI
0.93 to 1.67)); may not result in reduced rates of recurrence of
venous leg ulcers at 18 months (32/69 with recurrence in Lively
Legs group versus 38/67 in usual care group; RR 0.82 (95% CI
0.59 to 1.14)); and may not result in superior adherence to
compression therapy at 18 months (42/92 people fully adherent
EWMA Journal 2014 vol 14 no 1 73

in Lively Legs group versus 41/92 in usual care group; RR 1.02
(95% CI 0.74 to 1.41)). Time to complete healing, quality of life,
pain and adverse events were not reported. We found no studies
that investigated other interventions to promote adherence to
compression therapy.
Authors’ conclusions: There is a paucity of trials of interventions
that promote adherence to compression therapy for venous
ulcers. Low quality evidence from two trials was identified: one
promoting adherence via socialisation and support (Leg Club ® ),
and the other promoting adherence to compression, leg exercises
and walking via counselling and behaviour modification
(Lively Legs ® ).These trials did not reveal a benefit of communitybased
clinics over usual care in terms of healing rates, prevention
of recurrence of venous leg ulcers, or quality of life. One
trial indicated a small, but possibly clinically unimportant, reduction
in pain, while adverse events were not reported. The small
number of participants may have a hidden real benefit, or an
increase in harm. Due to the lack of reliable evidence, at present
it is not possible either to recommend or discourage nurse clinic
care interventions over standard care.
Plain language summary:
Interventions for helping people adhere to compression
bandages to aid healing of venous leg ulcers
Venous leg ulcers take weeks – or months – to heal, cause distress,
and are very costly for health services. Although compression,
using bandages or stockings, helps healing and prevents
recurrence, many people do not adhere to compression therapy.
Therefore, interventions that promote the wearing of compression
should improve healing, and prevent recurrence of venous
ulcers.
We found two studies of low quality evidence, so further
studies may change the review findings.
Leg Club ® , a community-based clinic, may not significantly
improve healing of venous leg ulcers or quality of life more than
nurse home-visit care does, but probably results in less pain after
six months. Seventeen more people out of 100 were healed after
participating in Leg Club (46/100 people in Leg Club healed
compared with 29/100 people having usual home care). Leg
Club participants rated their quality of life 0.85 points better
than those receiving home care, assessed on a 10 point scale.
Leg Club participants rated their pain at six months 12.75 points
lower than the home care group, assessed on a 100 point scale.
This trial did not report whether Leg Club clinics improve adherence
to compression, time to healing, or prevent recurrence
more than home care.
Lively Legs ® , a community-based self-management programme,
may not significantly improve healing of ulcers or
decrease recurrence after 18 months any more than usual care
in a wound clinic. Ten more people out of 100 were healed at
18 months after participating in Lively Legs (55/100 Lively Legs
participants healed versus 45/100 people having usual care).
Ten fewer people out of 100 had a recurrent leg ulcer 18
months after participating in Lively Legs (47/100 Lively Legs participants
had recurrence compared with ¬57/100 people having
usual care). The same number of people adhered to compression
therapy after participating in Lively Legs (45/100 participants
in both groups). The trial did not report whether the Lively
Legs self-management programme clinics improve time to healing
of ulcers, reduce pain, or improve quality of life any more
than usual care in a wound clinic.
We found no studies investigating other potential interventions,
such as education programs. We know that compression therapy
is effective, but do not know which interventions improve adherence
to compression therapy.
Publication in The Cochrane Library Issue 10, 2013
Negative pressure wound therapy for treating
foot wounds in people with diabetes mellitus
Jo C Dumville, Robert J Hinchliffe, Nicky Cullum, Fran Game,
Nikki Stubbs, Michael Sweeting, Frank Peinemann
Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting
M, Peinemann F. Negative pressure wound therapy for treating
foot wounds in people with diabetes mellitus. Cochrane
Database of Systematic Reviews 2013, Issue 10. Art. No.:
CD010318. DOI: 10.1002/14651858.CD010318.pub2.
Copyright © 2013 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Foot wounds in people with diabetes mellitus (DM)
are a common and serious global health issue. Negative pressure
wound therapy can be used to treat these wounds and a
clear and current overview of current evidence is required to
facilitate decision-making regarding its use.
Objectives: To assess the effects of negative pressure wound
therapy compared with standard care or other adjuvant therapies
in the healing of foot wounds in people with DM.
Search methods: In July 2013, we searched the following databases
to identify reports of relevant randomised controlled trials
(RCTs): Cochrane Wounds Group Specialised Register; The
Cochrane Central Register of Controlled Trials (CENTRAL); The
Database of ABSTRACTs of Reviews of Effects (DARE); The
NHS Economic Evaluation Database; Ovid MEDLINE; Ovid
MEDLINE (In-Process & Other Non-Indexed Citations); Ovid
EMBASE; and EBSCO CINAHL.
Selection criteria: Published or unpublished RCTs that evaluate
the effects of any brand of negative pressure wound therapy in
the treatment of foot wounds in people with diabetes, irrespective
of publication date or language of publication. Particular
effort was made to identify unpublished studies.
Data collection and analysis: Two review authors independently
performed study selection, risk of bias assessment and data
extraction.
Main results: We included five studies in this review randomising
605 participants. Two studies (total of 502 participants) compared
negative pressure wound therapy with standard moist
wound dressings. The first of these was conducted in people with
DM and post-amputation wounds and reported that significantly
more people healed in the negative pressure wound therapy
group compared with the moist dressing group: (risk ratio 1.44;
95% CI 1.03 to 2.01). The second study, conducted in people
with debrided foot ulcers, also reported a statistically significant
increase in the proportion of ulcers healed in the negative pressure
wound therapy group compared with the moist dressing
group: (risk ratio 1.49; 95% CI 1.11 to 2.01). However, these
74
EWMA Journal 2014 vol 14 no 1

Cochrane Reviews
studies were noted to be at risk of performance bias, so caution
is required in their interpretation. Findings from the remaining
three studies provided limited data, as they were small, with limited
reporting, as well as being at unclear risk of bias.
Authors’ conclusions: There is some evidence to suggest that
negative pressure wound therapy is more effective in healing
post-operative foot wounds and ulcers of the foot in people with
DM compared with moist wound dressings. However, these findings
are uncertain due to the possible risk of bias in the original
studies. The limitations in current RCT evidence suggests that
further trials are required to reduce uncertainty around decision
making regarding the use of NPWT to treat foot wounds in people
with DM.
Plain language summary:
Negative pressure wound therapy for treating foot wounds in
people with diabetes mellitus
Diabetes mellitus is a common condition that leads to high
blood glucose concentrations, with around 2.8 million people
affected in the UK (approximately 4.3% of the population).
Some people with diabetes can develop ulcers on their feet.
These wounds can take a long time to heal, be painful and
become infected. Ulceration of the foot in people with diabetes
can also lead to a higher risk of amputation of parts of the foot
or leg. Generally, people with diabetes are at a higher risk of
lower-limb amputation than people without diabetes. Negative
pressure wound therapy is a wound treatment which involves
applying suction to a wound; it is used increasingly around the
world but it is not clear how effective it is. It also expensive compared
with treatments such as dressings. We found five randomised
controlled trials that compared negative pressure
wound therapy with other treatments. We found some preliminary
evidence that negative pressure wound therapy increases
the healing of foot wounds on people with diabetes compared
with other treatments. However, the findings are not conclusive
and more, better quality randomised controlled trials are
required.
Early versus delayed post-operative bathing or
showering to prevent wound complications
Clare D Toon, Sidhartha Sinha, Brian R Davidson,
Kurinchi Selvan Gurusamy
Toon CD, Sinha S, Davidson BR, Gurusamy KS. Early versus
delayed post-operative bathing or showering to prevent wound
complications. Cochrane Database of Systematic Reviews 2013,
Issue 10. Art. No.: CD010075. DOI: 10.1002/14651858.
CD010075.pub2.
Copyright © 2013 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Many people undergo surgical operations during
their life-time, which result in surgical wounds. After an operation
the incision is closed using stiches, staples, steri-strips or an
adhesive glue. Usually, towards the end of the surgical procedure
and before the patient leaves the operating theatre, the
surgeon covers the closed surgical wound using gauze and
adhesive tape or an adhesive tape containing a pad (a wound
dressing) that covers the surgical wound. There is currently no
guidance about when the wound can be made wet by post-operative
bathing or showering. Early bathing may encourage early
mobilisation of the patient, which is good after most types of
operation. Avoiding post-operative bathing or showering for two
to three days may result in accumulation of sweat and dirt on
the body. Conversely, early washing of the surgical wound may
have an adverse effect on healing, for example by irritating or
macerating the wound, and disturbing the healing environment.
Objectives: To compare the benefits (such as potential improvements
to quality of life) and harms (potentially increased woundrelated
morbidity) of early post-operative bathing or showering
(i.e. within 48 hours after surgery, the period during which epithelialisation
of the wound occurs) compared with delayed postoperative
bathing or showering (i.e. no bathing or showering for
over 48 hours after surgery) in patients with closed surgical
wounds.
Search methods: We searched The Cochrane Wounds Group
Specialised Register;The Cochrane Central Register of Controlled
Trials (CENTRAL) (The Cochrane Library); The Database
of ABSTRACTs of Reviews of Effects (DARE) (The Cochrane
Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other
Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; the
metaRegister of Controlled Trials (mRCT) and the International
Clinical Trials Registry Platform (ICTRP).
Selection criteria: We considered all randomised trials conducted
in patients who had undergone any surgical procedure
and had surgical closure of their wounds, irrespective of the
location of the wound and whether or not the wound was
dressed. We excluded trials if they included patients with contaminated,
dirty or infected wounds and those that included
open wounds. We also excluded quasi-randomised trials, cohort
studies and case-control studies.
Data collection and analysis: We extracted data on the characteristics
of the patients included in the trials, risk of bias in the
trials and outcomes from each trial. For binary outcomes, we
calculated the risk ratio (RR) with 95% confidence interval (CI).
For continuous variables we planned to calculate the mean difference
(MD), or standardised mean difference (SMD) with 95%
CI. For count data outcomes, we planned to calculate the rate
ratio (RaR) with 95% CI. We used RevMan 5 software for performing
these calculations.
Main results: Only one trial was identified for inclusion in this
review. This trial was at a high risk of bias. This trial included
857 patients undergoing minor skin excision surgery in the primary
care setting. The wounds were sutured after the excision.
Patients were randomised to early post-operative bathing (dressing
to be removed after 12 hours and normal bathing resumed)
(n = 415) or delayed post-operative bathing (dressing to be
retained for at least 48 hours before removal and resumption of
normal bathing) (n = 442). The only outcome of interest
reported in this trial was surgical site infection (SSI). There was
no statistically significant difference in the proportion of patients
who developed SSIs between the two groups (857 patients; RR
0.96; 95% CI 0.62 to 1.48). The proportions of patients who
developed SSIs were 8.5% in the early bathing group and 8.8%
in the delayed bathing group.
EWMA Journal 2014 vol 14 no 1 75

Authors’ conclusions: There is currently no conclusive evidence
available from randomised trials regarding the benefits or harms
of early versus delayed post-operative showering or bathing for
the prevention of wound complications, as the confidence intervals
around the point estimate are wide, and, therefore, a clinically
significant increase or decrease in SSI by early post-operative
bathing cannot be ruled out. We recommend running further
randomised controlled trials to compare early versus
delayed post-operative showering or bathing.
Plain language summary:
Post-operative bathing and showering to prevent wound
complications
Many people undergo surgical operations during their life-time.
After an operation the surgical wound is closed using stitches,
staples, tape (steri-strips) or an adhesive glue. Usually, towards
the end of the surgical procedure and before the person leaves
the operating theatre, the surgeon covers the closed surgical
wound using gauze and adhesive tape, or an adhesive tape containing
a pad that covers the surgical wound. This is called a
wound dressing. There is currently no guidance about when
wounds can be made wet by bathing or showering post-operatively.
Early bathing may encourage the person to move about,
which is good after most types of surgery. Avoiding post-operative
bathing or showering for two to three days may result in the
accumulation of sweat and dirt on the body, but early washing
of the wound may have a bad effect on healing by irritating the
wound and disturbing the healing environment. We reviewed all
the available evidence from the medical literature (up to July
2013) on this issue. In particular, we sought information from
randomised controlled trials, which, if conducted well, provide
the most accurate information.
We identified only one randomised controlled trial. This trial
was at high risk of bias, i.e. there were flaws in the way it was
conducted that could have given incorrect results. This trial
included 857 people undergoing minor skin operations performed
at a General Practitioner (GP) surgery. No steri-strips
were used in this trial, as the wounds were stitched. The people
running the trial used a method similar to the toss of a coin to
decide which group participants went into. One group of 415
people was advised to remove the dressing 12 hours after surgery
and then to bathe normally, while the other group of 442
people was advised to keep the dressing on for at least 48 hours
and then to bathe normally. The only outcome of interest
reported in this trial was wound infection. The authors reported
no statistically significant difference in the proportion of people
who developed wound infection in the two groups (8.5% in the
early bathing group and 8.8% in the delayed bathing group).
There is currently no conclusive evidence available from randomised
trials about the benefits, or harms, with regard to
wound complications of early or delayed post-operative showering
or bathing. We recommend further randomised controlled
trials to compare early versus delayed post-operative showering
or bathing.
Publication in The Cochrane Library Issue 12, 2013
Antibiotics and antiseptics for venous leg ulcers
Susan O’Meara, Deyaa Al-Kurdi, Yemisi Ologun,
Liza G Ovington, Marrissa Martyn-St James,
Rachel Richardson
O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG, Martyn-St
James M, Richardson R. Antibiotics and antiseptics for venous
leg ulcers. Cochrane Database of Systematic Reviews 2014,
Issue 1. Art. No.: CD003557. DOI: 10.1002/14651858.
CD003557.pub5.
Copyright © 2013 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Venous leg ulcers are a type of chronic wound
affecting up to 1% of adults in developed countries at some
point during their lives. Many of these wounds are colonised by
bacteria or show signs of clinical infection. The presence of
infection may delay ulcer healing. Two main strategies are used
to prevent and treat clinical infection in venous leg ulcers: systemic
antibiotics and topical antibiotics or antiseptics.
Objectives: The objective of this review was to determine the
effects of systemic antibiotics and topical antibiotics and antiseptics
on the healing of venous ulcers; review authors also examined
the effects of these interventions on clinical infection, bacterial
flora, bacterial resistance, ulcer recurrence, adverse
effects, patient satisfaction, health-related quality of life and
costs.
Search methods: In May 2013, for this second update, we
searched the Cochrane Wounds Group Specialised Register
(searched 24 May 2013); the Cochrane Central Register of Controlled
Trials (CENTRAL 2013, Issue 4); Ovid MEDLINE (1948
to Week 3 May 2013); Ovid MEDLINE (In-Process & Other Nonindexed
Citations, 22 May 2013); Ovid EMBASE (1980 to Week
20 2013); and EBSCO CINAHL (1982 to 17 May 2013). No
language or publication date restrictions were applied.
Selection criteria: Randomised controlled trials (RCTs) recruiting
people with venous leg ulceration, evaluating at least one systemic
antibiotic, topical antibiotic or topical antiseptic that
reported an objective assessment of wound healing (e.g. time to
complete healing, frequency of complete healing, change in
ulcer surface area) were eligible for inclusion. Selection decisions
were made by two review authors while working independently.
Data collection and analysis: Information on the characteristics
of participants, interventions and outcomes was recorded on a
standardised data extraction form. In addition, aspects of trial
methods were extracted, including randomisation, allocation
concealment, blinding of participants and outcome assessors,
incomplete outcome data and study group comparability at
baseline. Data extraction and validity assessment were conducted
by one review author and were checked by a second.
Data were pooled when appropriate.
Main results: Forty-five RCTs reporting 53 comparisons and
recruiting a total of 4486 participants were included, Many RCTs
were small, and most were at high or unclear risk of bias. Ulcer
76
EWMA Journal 2014 vol 14 no 1

Cochrane Reviews
infection status at baseline and duration of follow-up varied
across RCTs. Five RCTs reported eight comparisons of systemic
antibiotics, and the remainder evaluated topical preparations:
cadexomer iodine (11 RCTs reporting 12 comparisons); povidone-iodine
(six RCTs reporting seven comparisons); peroxidebased
preparations (four RCTs reporting four comparisons);
honey-based preparations (two RCTs reporting two comparisons);
silver-based preparations (12 RCTs reporting 13 comparisons);
other topical antibiotics (three RCTs reporting five comparisons);
and other topical antiseptics (two RCTs reporting two
comparisons). Few RCTs provided a reliable estimate of time to
healing; most reported the proportion of participants with complete
healing during the trial period.
Systemic antibiotics: More participants were healed when they
were prescribed levamisole (normally used to treat roundworm
infection) compared with placebo: risk ratio (RR) 1.31 (95% CI
1.06 to 1.62). No between-group differences were detected in
terms of complete healing for other comparisons: antibiotics
given according to antibiogram versus usual care; ciprofloxacin
versus standard care/placebo; trimethoprim versus placebo; ciprofloxacin
versus trimethoprim; and amoxicillin versus topical
povidone-iodine.
Topical antibiotics and antiseptics: Cadexomer iodine: more
participants were healed when given cadexomer iodine compared
with standard care. The pooled estimate from four RCTs
for complete healing at four to 12 weeks was RR 2.17 (95% CI
1.30 to 3.60). No between-group differences in complete healing
were detected when cadexomer iodine was compared with
the following: hydrocolloid dressing; paraffin gauze dressing;
dextranomer; and silver-impregnated dressings.
Povidone iodine: no between-group differences in complete
healing were detected when povidone-iodine was compared with
the following: hydrocolloid; moist or foam dressings according to
wound status; and growth factor. Time to healing estimates for
povidone-iodine versus dextranomer, and for povidone-iodine
versus hydrocolloid, were likely to be unreliable.
Peroxide-based preparations: four RCTs reported findings in
favour of peroxide-based preparations when compared with
usual care for surrogate healing outcomes (change in ulcer
area). There was no report of complete healing.
Honey-based preparations: no between-group difference in
time to healing or complete healing was detected for honeybased
products when compared with usual care.
Silver-based preparations: no between-group differences in
complete healing were detected when 1% silver sulphadiazine
ointment was compared with standard care/placebo and tripeptide
copper complex; or when different brands of silver-impregnated
dressings were compared; or when silver-impregnated
dressings were compared with non-antimicrobial dressings.
Other topical antibiotics: data from one RCT suggested that
more participants healed at four weeks when treated with an
enzymatic cleanser (a non-antibiotic preparation) compared with
a chloramphenicol-containing ointment (additional active ingredients
also included in the ointment): RR 0.13 (95% CI 0.02 to
0.99). No between-group differences in complete healing were
detected for framycetin sulphate ointment versus enzymatic
cleanser; chloramphenicol ointment versus framycetin sulphate
ointment; mupirocin ointment versus vehicle; and topical antibiotics
given according to antibiogram versus an herbal ointment.
Other topical antiseptics: data from one RCT suggested that
more participants receiving an antiseptic ointment (ethacridine
lactate) had responsive ulcers (defined as > 20% reduction in
area) at four weeks when compared with placebo: RR 1.45
(95% CI 1.21 to 1.73). Complete healing was not reported. No
between-group difference was detected between chlorhexidine
solution and usual care.
Authors’ conclusions: At present, no evidence is available to
support the routine use of systemic antibiotics in promoting healing
of venous leg ulcers. However, the lack of reliable evidence
means that it is not possible to recommend the discontinuation
of any of the agents reviewed. In terms of topical preparations,
some evidence supports the use of cadexomer iodine. Current
evidence does not support the routine use of honey- or silverbased
products. Further good quality research is required before
definitive conclusions can be drawn about the effectiveness of
povidone-iodine, peroxide-based preparations, ethacridine lactate,
chloramphenicol, framycetin, mupirocin, ethacridine or
chlorhexidine in healing venous leg ulceration. In light of the
increasing problem of bacterial resistance to antibiotics, current
prescribing guidelines recommend that antibacterial preparations
should be used only in cases of clinical infection, not for
bacterial colonisation.
Plain language summary:
Antibiotics and antiseptics to help healing venous leg ulcers
Venous leg ulcers are a type of wound that can take a long time
to heal. These ulcers can become infected, and this might cause
further delay to healing. Two types of treatment are available to
treat infection: systemic antibiotics (i.e. antibiotics taken by
mouth or by injection) and topical preparations (i.e. treatments
applied directly to the wound). Whether systemic or topical preparations
are used, patients will also usually have a wound dressing
and bandage over the wound. This review was undertaken to
find out whether using antibiotics and antiseptics works better
than usual care in healing venous leg ulcers, and if so, to find
out which antibiotic and antiseptic preparations are better than
others. In terms of topical preparations, some evidence is available
to support the use of cadexomer iodine (a topical agent
thought to have cleansing and antibacterial effects). Current evidence
does not support the use of honey- or silver-based products.
Further good quality research is required before definitive
conclusions can be drawn about the effectiveness of antibiotic
tablets and topical agents such as povidone-iodine, peroxidebased
products and other topical antibiotics and antiseptics in
healing venous leg ulceration.
m
EWMA Journal 2014 vol 14 no 1 77

EWMA Journal
Previous Issues
Volume 13, no 2, October 2013
Risk assessment scales for pressure ulcers in intensive care
units: A systematic review with meta-analysis
F. P. García-Fernández et al.
Pressure-time integral of elastic versus inelastic bandages
H. Partsch, G. Mosti
VERUM – A European approach for successful venous leg ulcer
healing
R. Brambilla et al.
Effect of topical haemoglobin on venous leg ulcer healing
M. Arenbergerova et al.
The effects of an arginine-enriched oral nutritional supplement
on chronic wound healing in non-malnourished patients
J. Schols et al.
Efficacy of honey gel in the treatment of chronic lower leg
ulcers
O. Tellechea et al.
Volume 13, no 1, April 2013
The Biofilm-forming capacity of staphylococcus aureus
from chronic wounds can be useful for determining Wound-Bed
Preparation methods
Y. Yarets, L. Rubanov, I. Novikova, N. Shevchenko
In vitro efficacy of various topical antimicrobial agents against
multidrug-resistant bacteria
M. Hajská, L. Slobodníková, H. Hupková, J. Koller
The mTOR inhibitors and the skin wound healing
F. Benhadou, V. del Marmol
A Review of Evidence for Negative Pressure Wound Therapy
(NPWT) use Post Spinal Surgery
R. A. Atkinson, K. J. Ousey, S. Lui, J. B. Williamson
A randomized study on the effectiveness of a new pressurerelieving
mattress overlay for the prevention of pressure ulcers
in elderly patients at risk
E. Ricci, C. Roberto, A. Ippolito, A. Bianco, M. T. Scalise
Motorcycle ride position, venous return, and symptoms of
chronic venous insufficiency
Ellie Lindsay, P. Vowden, K. Vowden, J. Megson
Archagathus – History’s first wound expert
E. Ricci
Volume 12, no 3, October 2012
Therapeutic strategies for diabetic foot ulceration
RJ Hinchliffe, JRW Brownrigg
Offloading the diabetic foot: Evidence and clinical decision
making
S.A. Bus
Soft-tissue complications during treatment of children
with congenital clubfoot
A. Baindurashvili, V. Kenis, Y. Stepanova
An evolution in Medical Tapes: From Latex to Acrylic
L. Gryson
Bacteria and fungus binding mesh in negative pressure
wound therapy – A review of the biological effects in
the wound bed
M. Malmsjö, S. Lindstedt, R. Ingemansson, L. Gustafsson
Volume 12, no 2, May 2012
A structured approach to surgical treatment in deep infection
in diabetic foot
Cedomir S Vucetic, et.al.
Endothelial progenitor cells, a unipotent stem cell, involved in
neovascularization of wound healing in diabetic foot ulcer
Jacqueline Chor Wing Tama, et.al.
Bacteriophages for the treatment of severe infections:
– a ‘new’ option for the future?
Daniel De Vos, et.al.
Developing evidence-based ways of working:
– Employing interdisciplinary team working to improve patient
outcomes in diabetic foot ulceration – our experience
Kristien Van Acker
Exploring the characteristics of a venous leg ulcer that
contribute to the emotional distress experienced by patients
Jessica Walburn, et.al.
The EWMA Journals can be downloaded free of charge from www.ewma.org
Other Journals
EWMA wishes to facilitate the exchange of information
on wound healing in a broad perspective with
this section on International Journals.
Italian
English
Finnish
Spanish
Acta Vulnologica, vol. 11, no 4, 2013
www.vulnologia.it
Gel aminoacido versus idrogel: qual è il debrider più
rapido?
Cassino R., Ippolito A. M.
Gangrena di Fournier: algoritmo di trattamento ad una
tipologia di lesione complessa
Scalise A., Tartaglione C., Bottoni M., Torresetti M.,
Gioacchini M., Pierangeli M., Grassetti L., Di Benedetto G.
Infezioni associate a ulcere da pressione. Nota I: condizioni
generali
Palazzi L., Giuliani G. C.
Trattamento dei bordi lesionali sottominati: esperienze
personali
Gallarini A.
Advances in Skin & Wound Care, vol. 27, no 3, 2014
www.aswcjournal.com
Innovative Use of Povidone-Iodine to Guide Burn Wound
Debridement and Predict the Success of Biobrane as a
Definitive Treatment for Burns
Yu Sin Lau, Peter Brooks
Human Fibroblast-like Cultures in the Presence of
Platelet-rich Plasma as a Single Growth Factor Source:
Clinical Implications
Javier Ramos-Torrecillas, et al.
Features of Pressure Ulcers in Hospitalized Older Adults
Hülya Eskiizmirli Aygör,et al.
A Hydrosurgery System (Versajet) with and without
Hydrogen Peroxide Solutions for the Debridement of
Subacute and Chronic Wounds: A Comparative Study
with Hydrodebridement
Saime Irkoren, Nazan Sivrioglu
Haava, no. 1, 2014
www.shhy.fi
Wound Care Nurse in Community
Ulla Dunder
The Model for Wound Care in Town of Heinola
Pirjo Elfvengrén, Tiina Lastikka, Maria Nevalainen
Closing of Wound is Possible to do by Several Methods
Ansa Iivanainen, Mikko Tuuliranta
Operating Safar in Kenia
Kielo Turtiainen
I Shall Treat Your Wounds Until The End – A Case Report
Arja Korhonen
How The Hand Hygienia Is Implemented In Daily Care?
Ansa Iivanainen, Piia Grek-Stjernberg, Heli Kallio, Arja
Korhonen, Tiina Pukki
The Weaknesses In Implementation of Hand Hygienia
Anne Kosonen, Sari Puhakainen
Health Promotion In The Care of Wound Patient
Eeva Häkkinen
Wound Care in Gipsy Family
Salme Annala
Discharge of Wound Patient
Piia Grek-Stjernberg
Do You Pay Attention to Feet of Wound Patient?
– A Case Report
Sirpa Arvonen
Helcos, vol. 24, no. 3, 2013
Continuous improvement plan and prevention treatment
by pressure ulcers deming cycle
Fernando Patón-Villar et al.
Nursing management on emergency wounds
R. Fernando García-Gonzalez et al.
Diversity and universality in response to patient diabetic
foot pakistani with type 2 diabetes mellitus from primary
care
Montserrat Brugada Faura et al.
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EWMA Journal 2014 vol 14 no 1

EWMA
English
English
Polish
Lithuanian
Int. Journal of Lower Extremity Wounds vol. 12, no 4, 2013
http://ijlew.sagepub.com
ITranslation and Validation of the Chinese Cardiff Wound Impact
Schedule
Yao Huang, et al.
Effect of Daptomycin on Local Interleukin-6, Matrix Metalloproteinase-9,
and Metallopeptidase Inhibitor 1 in Patients With MRSA-
Infected Diabetic Foot
Andreas Ambrosch, et al.
Clinical Characteristics and Medical Costs in Patients With
Diabetic Amputation and Nondiabetic Patients With Nonacute
Amputation in Central Urban Hospitals in China
Aihong Wang, zhangrong xu, Yiming Mu, Linong Ji
Reducing Major Lower Extremity Amputations After the Introduction
of a Multidisciplinary Team for the Diabetic Foot
José Antonio Rubio, et al.
The Influence of the Length of the First Metatarsal on the Risk of
Reulceration in the Feet of Patients With Diabetes
Raúl Juan Molines-Barroso, et al.
Outcomes After 294 Transtibial Amputations With the Posterior
Myocutaneous Flap
Benjamin Jacob Brown, et al.
Journal of Wound Care, vol. 23, no 3, 2014
www.journalofwoundcare.com
Inhibition of biofilms of Pseudomonas aeruginosa by Medihoney
in vitro
R. Cooper, L. Jenkins, S. Hooper
Evaluation of two fibrous wound dressings for the management
of leg ulcers: Results of a European
randomised controlled trial (EARTH RCT)
S. Meaume, et al.
Laboratory evaluation of Drawtex Hydroconductive
Dressing with LevaFiber technology
V. Edwards-Jones, V. Vishnyakov, P. Spruce
Do ready-made compression stockings fit the anatomy of the
venous leg ulcer patient?
S. Nørregaard, S. Bermark, F. Gottrup
A clinical algorithm for wound biofilm identification
D.G. Metcalf, P. Bowler, J. Hurlow
Photographic assessment of burn size and depth: reliability
and validity
M.J. Hop, et al.
Novel materials for moist wound management: Alginate-psyllium
hybrid fibres
R. Mahsood, M. Miraftab
Leczenie Ran vol. 10, no 4, 2013
The value of clinical nutrition in the wound healing
Stanisław Kłek
Reflectance confocal microscopy – a new diagnostic method
Kamila Białek-Galas, Dorota Wielowieyska-Szybinska,
Anna Wojas-Pelc
The treatment and the nursing of decubital wounds at the unconscious
patient in the department of the intensive health care
Joanna Rudek, Anna Majda, Joanna Zalewska-Puchała
Effect of different methods of compression on blood viscosity in
patients with chronic venous disease
Monika Han, Krzysztof Paruzel, Marek Kucharzewski,
Karol Monkos, Ludmiła Słowinska-Łozynska
Wounds as the cause of death of Polish rulers
Katarzyna Wilemska-Kucharzewska, Marek Kucharzewski,
Magdalena Potempa, Paweł Jonczyk, Michał Janerka
Lietuvos chirurgija, no 2, 2014
www.chirurgija.lt
Chemoradiotherapy in the treatment of locally advanced cervical
cancer
Daukantiene L, Valuckas KP, Aleknavicius E, Pipiriene-Želviene T.
Hand-assisted laparoscopic colorectal surgery for colorectal
polyps: single institution experience
Dulskas A, Samalavicius NE, Kuma Gupta R
Treatment methods of prostate cancer recurrence after radiotherapy.
Current treatment alternatives and our clinical experience
Ulys A, Veželis A, Ivanauskas A, Snicorius M.
Clinical outcomes of 154 hand-assisted laparoscopic surgeries for
left sided colon and rectal cancer: single center experience
Dulskas A, Samalavicius NE, Kumar Gupta R, Kazanavicius D,
Petrulis K, Lunevicius R.
Early loop ileostomy closure: should we do it routinely?
Žukauskiene V, Samalavicius NE.
Transanal endoscopic microsurgery (TEM) for early rectal cancer:
single center experience
Samalavicius NE, Ambrazevicius M, Kilius A, Petrulis K.
Dutch
German
English
Scandinavian
German
NTVW vol. 9, no 2, 2014
www.ntvw.nl
Interview: Wendy Roelofs: ‘Bussineslike approache gives
solide structure to woundcare’
Interview: New chair Woundcare Platform iris van Bennekom:
‘We must look for common interest‘
Interview: Maud Curvers: ‘Make sure to choose the
right dressing afther hipsurgery’
Interview: Emmy Stoof, Paul van der Weerd: Multidisciplinary
cooperation in Care Chain to improve woundcare.
Hyperbaric oxygen and the prevention of amputation
Dirk Ubbink
Comedo Senilis
Kasia Huisman
Phlebologie, no 1, 2014
www.schattauer.de
Compression therapy during pregnancy: bane or boon?
A. Adamczyk, M. Krug, S. Schnabl, H.-M. Häfner
Thromboembolic complications and the importance of
thrombophilia in pregnancy
L. Gonser, A. Strölin
Diagnosis and treatment of venous thromboembolism
during pregnancy and the postpartum period
E. Randrianarisoa, H. Abele; B. Balletshofer
Therapy of pudendal varicosities with sclerotherapy
M. Stücker, M. Dörler
Interventional therapy of a descending ilio-femoral deep
vein thrombosis in a young women
W. Blättler, J. Largiadèr, H. Altenkämper
The recalcitrant venous leg ulcer – a never ending story?
S. W. I. Reeder, et al.
Leg venous ulcer healing process after application of
membranous dressing with silver ions
M. Kucharzewski, et al.
Wound Repair and Regeneration, vol. 22, no 1, 2014
www.wiley.com
Perspective Articles
Altered TGF-b signaling in fetal fibroblasts: What is known
about the underlying mechanisms?
Mariëlle Walraven, et al.
The use of dermal substitutes in burn surgery: Acute phase 14
Shahriar Shahrokhi, et al.
Erythropoietin, a novel repurposed drug: An innovative treatment
for wound healing in patients with diabetes mellitus
Saher Hamed, et al.
Chronic venous leg ulcer treatment: Future research needs
Gerald Lazarus, et al.
A randomized controlled trial of larval therapy for the debridement
of leg ulcers: Results of a multicenter, randomized,
controlled, open, observer blind, parallel group study
Elizabeth Mudge, et al.
Wounds (SÅR) vol. 21, no 4, 2013
www.saar.dk
Offering nationwide telemedicine wound assessment of
patients with cancer wounds
Betina Lund-Nielsen
Clothing and hygiene when healing wounds and in nursing
Maria Plaschke
Illness, normality and self-care: diabetic foot ulcers and the
logic of freedom of choice
Signe Lindgård Andersen, Vibeke Steffen
The pH of skin care products in the area of skin nuisances
and wounds
Magne Skjervheim
First experiences with Optima pH 4 gel
Bodo Günther
Wund Management, vol. 8, no 2, 2014
English abstracts are available from www.mhp-verlag.de
Zur Sauerstoffpartialdruckmessung bei chronischen
Wunden
Major-Amputationen in Deutschland
Standard für die Publikation von Fallstudien
Sich Kümmern und interdisziplinäre Zusammenarbeit –
Ein Fallbeispiel aus der Hausarztpraxis
Das ICW e. V. Wundsiegel – Zertifzierung von Wundbehandlungseinrichtungen
EWMA Journal 2014 vol 14 no 1 79

EWMA
n
GNEAUPP
adrid · Spain
14-16 May 2014
Grupo Nacional para el Estudio y Asesoramiento
en Úlceras por Presión y Heridas Crónicas
Javier Soldevilla Agreda
GNEAUPP Director
EWMA-GNEAUPP 2014
Conference in Madrid, Spain
The 24th Conference of the European Wound
Management Association (EWMA-GNEAUPP
2014) will be a historic event in many ways. The
scientific programme has expanded significantly
and will consist of varied key sessions, workshops,
lectures, full-day streams, and satellite symposia,
with scientists from Europe as well as the rest
of the world. The 2014 conference is organised
in cooperation with the Spanish Group for the
Study and Advise on Pressure Ulcers and Chronic
Wounds (GNEAUPP).
Gerrolt Jukema
EWMA Scientific Recorder
ewma@ewma.org
www.ewma2014.org
www.gneaupp.es
Expectations for this conference are high, as
more than 1,050 abstracts have been submitted,
of which 148 have been invited as oral presentations
in the free paper sessions, and 754 for poster
presentations. In total, there will be more than
320 oral presentations, and over 1,130 scientific
presentations by international key speakers, free
paper presenters, poster presenters, workshops
facilitators, and speakers in satellite symposia. A
record number of participants are expected and
the exhibition is likely to be the largest in the
history of EWMA.
PROGRAMME HIGHLIGHTS
Key sessions
• Innovation, Know-How, and Technology
• Interdisciplinary Perspectives
• Wound Care in Home Care
• Health and New Technologies
• The Infected Diabetic Foot
• Clinical Evidence
• Implementation of New Pressure Ulcer Knowledge
• Infection
• Surgical Site Infection
• Trauma Wounds
• Oxygen and Hypoxia
• Vascular Wounds
• Patient Perspectives
This year, the programme will have three simultaneous
key sessions on clinical, evidence, and
organisational topics. Furthermore, two separate
workshop streams are integrated into the
programme structure; one focused on practical
“hands on” approaches and another dedicated
to theoretical approaches. This will accommodate
both the organisational and clinical topics,
providing a better fit for the growing number of
participants and satisfying the diverse interests in
EWMA.
The conference theme, Innovation, know-how, and
technology in wound care, reflects both the technological
and organisational need for high-quality
services with the limited resources available for
wound care. Health care systems throughout Europe
must address the challenges of aging populations,
and of more people living with chronic
conditions, which have created a growing demand
for optimising wound care with the help of innovative
procedures and practises. The theme will
be reflected in the opening plenary session as well
as in a number of workshops and other sessions
throughout the conference.
In addition, a special session this year will be the
Honorary Session in which Professor Christina
Lindholm will be celebrated for her long-standing
work and achievements in wound management.
80
EWMA Journal 2014 vol 14 no 1

EWMA
MADRID
A city where you will find everything,
Madrid is home to cutting-edge facilities,
devoted professionals, and modern
infrastructure, allowing you to easily adhere
to the most demanding standards of quality.
Furthermore, you will find a booming
culture, a thriving lifestyle, and warm, friendly,
passionate people. Madrid is a thriving cosmopolitan
city in which a perfect balance has been struck between
entertainment and business. Thanks to all this, the
EWMA 2014 conference promises to be a unique
experience.
The 2014 programme will offer guest sessions from several
organisations active in thematic issues related to wound
healing and management. Guest sessions include, among
others, a joint session between the European Pressure Ulcer
Advisory Panel (EPUAP) and EWMA, as well as sessions
by the Dystrophic Epidermolysis Bullosa Research Association
(DEBRA), the European Society for Clinical
Nutrition and Metabolism (ESPEN), the European Tissue
Repair Society (ETRS), and the Ibero-Latin American
Society of Ulcers and Wounds (SILAUHE).
The full-day streams are extremely popular among EWMA
conference delegates and will offer more in-depth presentations
and discussions within particular fields of knowledge.
At the EWMA-GNEAUPP 2014 full-day symposia, the
topics will be Diabetic Foot/Pie Diabetico Day, e-Health
Day, and Veterinary Wound Healing. In addition, a Spanish
Symposium will be offered at the conference.
DIABETIC FOOT DAY/PIE DIABETICO SYMPOSIUM
A key diabetic foot activity is the 1-day symposium scheduled
for Thursday, 15 May 2014. Current diagnostic and
intervention strategies for diabetic foot ulcers and amputation
prevention in Spain, which has one of the highest
amputation rates in people with diabetes, will be presented
and discussed. Multidisciplinary care by specialized units
has proved useful in preventing major amputations in
patients with complicated foot ulcers. However, major
challenges remain in establishing this model in Spain,
and some of these obstacles will be discussed at the symposium.
The symposium also offers the opportunity to
review state-of-the-art concepts and techniques within the
field of saving the diabetic foot through achieving better
treatment outcomes and health economic savings in
multidisciplinary treatment structures, as recommended
in the international consensus guidelines. On this occasion,
central stakeholders from the International Working
Group on the Diabetic Foot (IWGDF), Spanish and international
diabetes organisations, as well as policymakers
and politicians, will participate in panel discussions and
presentations to discuss how current treatment plans are
conducted and to identify future strategies toward achieving
better standards of care for diabetic foot patients.
eHEALTH SYMPOSIUM – eHealth in wound care –
From pilot projects to routine care
More and more often, eHealth is being introduced as an
important means to solve the future challenges our health
care systems are facing. eHealth solutions are perceived as
essential tools to enable more care to be provided outside
of hospitals and to facilitate interdisciplinary collaboration
and communication across units and sectors to optimise
continuity of care. The hope is that using these technologies
will lead to responsive care of higher quality at lower
WORKSHOPS
• Russian workshops
• Debridement
• Pain Management
• Challenges in Diagnosis
• Paediatric Patients
• Nutrition
• Maggot Therapy
• Diabetic Foot Wounds
• Biofilms
• Use of Information Technology
• Skin Complications
• Pressure Redistribution Devices
• Innovation with and for User Value Creation
• Trends in Healthcare
• Clinical Photography in Wounds
• Optimising the Performance of Postural Changes
• Lawsuits for Pressure Ulcers
EWMA Journal 2014 vol 14 no 1 81

EWMA
PUBLICATIONS 2014
Document by AAWC, AWMA & EWMA:
Managing Wounds as a Team
The document provides a universal model for the
adoption of a team approach to wound care.
Publication: April 2014
EWMA Document:
Home Care-Wound Care
The document uncovers the preconditions that
are necessary to provide safe, high-quality care for
wound patients in a home care setting.
Publication: May 2014
EWMA
Study Recommendations
Study recommendations for clinical investigations
in leg ulcers and wound care. An easy-to-use
guidance document for the novice researcher in
wound care.
Publication: May 2014
82
costs. What we see now is rapid development of available
technologies with ever-increasing examples of regions and
countries where eHealth is already part of routine care.
eHealth is here to stay and will forever change the way
care is delivered.
As these changes and developments will also affect
wound care provision, EWMA finds it exceedingly important
to, for the second time, address this topic with a
full-day symposium.
The symposium will delve into current trends and developments
at the policy level, the current implementation
status of telemedicine in wound care, and recent technological
developments. The symposium will conclude with
a key session exploring the barriers and facilitators related
to large-scale implementation of eHealth and discuss the
challenges related to generating evidence on clinical effectiveness
and cost efficiency.
EWMA has invited some of Europe’s leading experts,
researchers, and experienced practitioners within the field
of eHealth and wound care to guide the audience through
these topics. The eHealth symposium at this years conference
is one of the activities that EWMA and The European
Health Telematics Association (EHTEL) have committed
to deliver as consortium partners in the EU funded project,
United4Health.
VETERINARY WOUND MANAGEMENT AND
ANTIMICROBIAL RESISTANCE SYMPOSIUM
We are proud to announce the launch of this new symposium
organised in association with the Veterinary Wound
Healing Association (VWHA). The symposium is based
on the One Health Approach and will include talks from
leading veterinary practitioners, researchers, and health
professionals with expertise in antimicrobial resistance.
The objectives of the EWMA/VWHA symposium are to
provide a unique platform from which scientists and other
experts from veterinary and human wound management
and public health can share new knowledge, to identify
interfaces between veterinary and human wound research
and management and build the capacity to draw on their
synergies, and to build an interdisciplinary, international
network with a multidimensional perspective on wound
management.
Let’s join forces in bringing together the European wound
healing community in its mission to raise awareness of
wound management and drive the wound management
agenda forward across Europe. We look forward to welcoming
you in Madrid!
m
EWMA Journal 2014 vol 14 no 1

Strong when wet 1,2
Gentle on the budget 3
Clean one-piece removal – high wet strength 1,2
High absorbency – up to 7-day wear time 1,2
Minimal dressing shrinkage – may help sustained coverage 1,4
Minimal lateral wicking – may help to reduce the risk of
peri-wound maceration 2,5 References: 1. DOF DS/10/056/R1. 2. Case Series Evaluation: The Use of DURAFIBER on Exuding Wounds. Wounds UK 2012, Vol 8, No 3.
Wound Management
Smith & Nephew
Medical Ltd
101 Hessle Road
Hull HU3 2BN
UK
T +44 (0) 1482 225181
F +44 (0) 1482 328326
Trademark of Smith & Nephew
© Smith & Nephew February 2014
48169
3. DOF DS/014/051/R. 4. DOF DS/11/187. 5. DOF DS/10/042/RI.
For patients. For budgets. For today. All references relate to in vitro testing excluding 2.

EWMA
ADVOCACY ACTIVITIES UPDATE
THE PATIENT SAFETY AND PRESSURE ULCERS PREVENTION AGENDA
Salla Seppänen,
EWMA President
and Chair of the
EWMA Advocacy Group
ewma@ewma.org
www.ewma.org
EWMA plays an important role in the continuous
effort to raise awareness about
wound prevention and effective wound
care within relevant EU institutions such as the
European Parliament and the European Commission.
Since the latest update in October 2013
about EWMA’s advocacy activities, I am happy
to announce an important achievement regarding
the Patient Safety and Pressure Ulcers prevention
agenda, which EWMA has been pursuing
in collaboration with the Eucomed Advanced
Wound Care Sector (AWCS) group.
Furthermore, EWMA has now joined the
newly initiated Joint Action on Chronic Disease
(CHRODIS-JA) programme of the European
Commission.
Multidisciplinary wound care and pressure
ulcer prevention mentioned in the European
Parliament report 1
In October 2013, the European Parliament (EP)
adopted the own-initiative report by MEP Oreste
Rossi on “Patient Safety including the prevention
and control of healthcare associated infections” 1 .
The report specifically mentions multidisciplinary
wound care and prevention of pressure ulcers, and
urges member states to implement or increase
measures to support multidisciplinary wound care
and pressure ulcer prevention.
EWMA has actively contributed to the work
process that has led to the adoption of MEP Rossi’s
own-initiative report. Earlier in 2013, a EWMA
policy paper on Patient Safety and Pressure Ulcers
(which is available for download at www.ewma.
org) was elaborated by previous EWMA President
Prof. Zena Moore, who also presented on
the Prevention of Healthcare Associated Infections
in a May 2013 workshop hosted by the EP
and MEP Rossi. Materials from this meeting are
available at www.europarl.europa.eu/document/...
T66710EN.pdf
1. This report is a reaction to the 2009 European Commission recommendation
on “Patient safety, including the prevention and control of healthcare
associated infections” and how this recommendation has been implemented
by the Member States. The full text of the repor is available at
www.europarl.europa.eu/...=EN&ring=A7-2013-0320
EWMA recognises that the adoption of the
report by the EP sends a strong signal of support
and increased awareness of these matters to the
Member States.
European Chronic Disease Collaboration
launched in January 2014
The Joint Action on Chronic Disease (CHRO-
DIS-JA) programme of the European Commission
(EC) was initiated at a kick-off meeting in
Madrid 29-30 January 2014. EWMA has been
invited to join the programme as a Collaborating
Partner Organisation, and has accepted this invitation
with the objective to advocate for increased
focus on diabetes complications, in particular diabetic
foot ulcers.
The CHRODIS-JA integrates a large number
of European health care partners, including national
authorities, European associations, and research
institutions. EWMA expects to join forces
with these other associations to advocate for actions
to improve the prevention and treatment of
the major complications of diabetes.
Continued participation in the Innovation
Partnership on Active and Healthy Ageing
EWMA continues to participate in the European
Innovation Partnership on Active and Healthy
Ageing (EIP-AHA). EWMA has been a partner
of the action group on Integrated Care since the
beginning of 2012.
Interest in the EIP-AHA has grown tremendously,
and the partnership now includes several
hundred representatives from regional development
organisations, health care authorities, research
institutions, and non-governmental associations.
Activities are divided into several working
groups, of which EWMA continues to follow
those of the Workforce Development and Care
Pathways.
During the spring of 2014, EWMA will continue
its networking activities within the EIP-
AHA. Amongst other activities, the final versions
of the two documents on “Home Care Wound
Care” and “Managing Wounds as a Team” will
be shared with the working groups. m
84
EWMA Journal 2014 vol 14 no 1

Now available –
DURAFIBER Ag with
antimicrobial silver
Strong when wet 1–3
Gentle on the budget 4
Sustained antimicrobial activity (in vitro) – for up to 7 days
against a broad spectrum of pathogens 5–7
Clean one-piece removal – high wet strength 1–3
High absorbency – up to 7-day wear time 1–3
Minimal dressing shrinkage – may help sustained coverage 1
Request a free sample at: www.tryDURAFIBERAg.com
Wound Management
Smith & Nephew
Medical Ltd
101 Hessle Road
Hull HU3 2BN
UK
T +44 (0) 1482 225181
F +44 (0) 1482 328326
Trademark of Smith & Nephew
© Smith & Nephew February 2014
48171
References: 1. DOF DS/10/060/R1. 2. OR-DOF/28. 3. DS/12/093/DOF.
4. DOF DS/014/051/R. 5. DOF 1004007. 6. DOF 1009011. 7. DOF 1009012.
For patients. For budgets. For today. All references relate to in vitro testing excluding 2.

EWMA
Christina Lindholm – Honorary Speaker at
Salla Seppänen,
EWMA President
ewma@ewma.org
www.ewma.org
Christina has inspired those
around her with her gentle,
passionate, unassuming, and yet
powerful, way of being. It is said that
in the quiet you are enabled to hear the
dreams of others. Christina exemplifies
this saying in her unique ability to listen
to those around her, enabling her to fully
understand their experiences and help
guide them through their clinical and
professional practice more effectively.
With her enormous energy, Christina
has pushed the boundaries of research
and practice, trail blazing her way towards
improving clinical practice for the
benefit of patients in Sweden and be-
yond. Indeed, Christina co-authored a ground-breaking
research paper that changed the perception of how painful
leg ulcers are for patients. Through this work, Christina
stressed the importance of clinicians understanding the
patients’ experience, thereby bringing to the fore the significance
of adopting a “human” approach to wound care.
Christina is an internationally acclaimed professor of
nursing and former research chief at the Karolinska
University Hospital in Sweden. Her PhD in 1993 comprised
five studies on leg ulcer epidemiology, treatment,
health economics, and quality of life. Her later research
has focused on wound infections, infection control, and
pressure ulcers.
In leading and influencing at an international level,
Christina has been at the centre of a broad range of international
ventures. She was the editor-in-chief of the
THIS IS THE FIFTH TIME AN HONORARY LECTURER
HAS BEEN APPOINTED BY EWMA.
previously published Swedish Wound Journal “Sår”,
a council member (and first president) of the Swedish
Association of Tissue Viabilty Nurses (SSiS), one of the
founders of the European Pressure Ulcer Advisory Panel
(EPUAP) and a member of the EWMA Council from
1994-2008. During her years in the EWMA Council,
Christina made significant contributions to the activities
and development of EWMA. In 2000, she was responsible
for a very successful EWMA Conference, held in Stockholm,
Sweden. This conference became the starting point
for the development of the EWMA Cooperating Organisations
programme. Christina played a crucial role in this
and has subsequently contributed to the development of
multidisciplinary wound management organisations in
the Balcans and the Baltic States.
In 2014, Christina is hosting another European wound
conference in Stockholm, the 17th Annual Meeting of
EPUAP held 27-29 August.
EWMA 2000 STOCKHOLM
Throughout the years, Christina has ensured a good collaboration
between EWMA and EPUAP with the objective
to promote high quality wound management. Her work
on “Stop Pressure Ulcer Day” has yielded particular success
in raising awareness of pressure ulcers and highlighting
the real difference that collaborative work can make in
achieving successful reduction in both the prevalence and
incidence of pressure ulcers.
86
EWMA Journal 2014 vol 14 no 1

EWMA n GNEAUPP 2014
Christina Lindholm is a registered nurse, PhD in
Medicine (Dermatology & Surgery), senior professor
at Sophiahemmet University, and a wound consultant
to the Karolinska University Hospital and Dalen
Geriatric hospital. She is a member of the executive
board of European Pressure Ulcer Advisory Panel
(EPUAP). Christina has published more than 70
scientific papers and 10 scientific reports on wound
management and received several scientific awards.
She has published the Scandinavian textbook on
wounds, and several chapters in national and international
textbooks. She is a well-recognised international
lecturer. Her main scientific interest is pressure
ulcers and wound microbiology.
EWMA-GNEAUPP 2014
HONORARY LECTURE THURSDAY 15 MAY, 14:30-15:10
During her long engagement in EWMA and the EWMA
Education Committee, Christina has contributed significantly
to the educational activities and has given numerous
presentations and lectures at the EWMA conferences. She
has also written the leading schoolbook “Sår” (Wounds)
that is used in all nursing education and wound education
in Sweden.
Christina is a credit to the nursing profession and an inspirational
leader. She was Director of Research and Development
in Nursing at Uppsala University Hospital, a
director of research in Caring Sciences at the Karolinska
University Hospital, and held a professorial chair at the
University of Kristianstad. Christina has supervised five
PhD students, and is presently supervising an additional
three. She is an expert nurse in the International Council
of Nurses and a consultant to the National Institute of
Health and Social Society in Sweden. In addition, she
is a member of the editorial committee of the Journal of
Wound Care and frequently reviews papers for many other
scientific journals. Christina lectures on pressure ulcers
and wound management worldwide and is currently a
professor at Högskolan Kristianstad University in Sweden.
Aristotle once wrote: “We are what we repeatedly do. Excellence,
then, is not an act, but a habit.” This quotation truly
captures the essence of Christina Lindholm. m
EPUAP 2014
17th Annual Meeting of
the European Pressure Ulcer Advisory Panel
27 -29 August 2014 · Stockholm, Sweden
PRESSURE ULCERS
FROM BIRTH
TO DEATH
Prevention, Treatment
and Rehabilitation
Organised by the European Pressure Ulcer Advisory Panel
in cooperation with
the Swedish Association of Tissue Viability Nurses SSiS
and Sophiahemmet University
www.epuap2014.org
EWMA Journal 2014 vol 14 no 1

EWMA
EWMA’s commitment to
FIGHTING
ANTIMICROBIAL RESISTANCE
Salla Seppänen,
EWMA President
ewma@ewma.org
www.ewma.org
Infection is one of the most frequent complications
in wound care. Consequently, both
antibiotics and non-antibiotic antimicrobial
agents are readily used in the treatment of wounds.
However, the remarkable healing power of antibiotics
in particular has invited widespread and
often inappropriate use. This misuse and overuse
of antibiotics has led to resistance among bacteria
and consequent treatment complications,
increased healthcare costs, and general concern
for the societal healthcare consequences.
EWMA believes that advanced modern wound
care can complement antibiotic treatment. Therefore,
we are actively advocating prudent and appropriate
use of antibiotics in wound care. We also
advocate that a clear discrimination between the
use of antibiotics and non-antibiotic antimicrobial
agents should be made.
Last year, EWMA made a sizeable contribution
to the resistance debate by publishing the position
document Antimicrobials and Non-healing
Wounds. In this document, leading wound experts
described the controversies surrounding the
use of both antibiotics and non-antibiotic antimicrobial
agents in wound management and aimed
to raise interest in how to solve these problems for
future use of antimicrobials.
However, publishing Antimicrobials and Nonhealing
Wounds is not the end of EWMA’s activities
in the field of antimicrobials. As discussed
below, EWMA is committed to ending the inappropriate
use of antibiotics and defusing the ticking
time bomb of antimicrobial resistance.
Promoting THe Appropriate use
of Antimicrobials in Wound
Management
The World Health Organisation has identified
the following key factors that contribute to the
general misuse of antimicrobials: diagnostic uncertainty,
lack of skills and failure to properly
utilise clinical guidelines. As a clinical discipline,
wound management comprises all of these factors.
Healthcare professionals need guidance and
education regarding structured management of
antimicrobial treatment in wound care. They
need to understand that, to be effective, antimicrobial
treatment should be targeted to both the
appropriate wound and the appropriate patient.
Guidelines for the management of specific wound
types do exist. However, a guidance tool with a
key focus on treatment with antibiotics and nonantibiotic
antimicrobial agents is lacking but
much sought after by health professionals.
These issues are addressed in a new EWMA
project that sets sail this year. The overall aim of
the project is to develop a clinical decision support
tool that will facilitate the appropriate use of antimicrobials
in wound management. Although it
is expected to aid in clinical decision-making, the
tool will also present an outline of identified best
practices of treatment with antibiotics and nonantibiotic
antimicrobial agents. EWMA believes
that providing this approach can reduce mistakes
in those hectic moments when decisions are made.
In support of this viewpoint, our goal is to make
the tool as hands-on as possible and to offer health
professional decision support at the bedside. The
first step is to make a ‘pocket guide’ (flowchart),
but the possibility of a software application for
smart phones and tablet computers will also be
investigated.
The One Health Approach
Focusing on antimicrobial use in humans alone is
not adequate. EWMA believes that the challenge
of antimicrobial resistance must be faced using
the One Health Approach. Only through the collaborative
effort of multiple disciplines—working
locally and globally—will there be a chance to
combat the rise and spread of antimicrobial resistance.
In support of this viewpoint, EWMA is now
working to build alliances with veterinary wound
initiatives and other interdisciplinary initiatives
concerning antimicrobial resistance.
Therefore, we are very proud to welcome you
to the Symposium on Veterinary Wound Management
and Antimicrobial Resistance, which
88
EWMA Journal 2014 vol 14 no 1

will be held at this year’s EWMA Conference in Madrid.
The symposium is a collaborative initiative between the Veterinary
Wound Healing Association and EWMA who share the
goal of promoting education and research into the scientific
basis and clinical management of wounds. The objective of the
symposium is to provide a unique platform from which scientists
and other experts in the veterinary and human wound
management disciplines, as well as public health professionals,
can share knowledge, identify interfaces and build the capacity
to draw on the synergies.
EWMA’s EU Advocacy activities related to
antimicrobial resistance
Even within the European Union, scientific policies on the use
of antimicrobial agents vary greatly and result in diverse practices
in the local healthcare systems. Thus, both political incentives
and scientific strategies are needed to stimulate changes
in practice. To facilitate change, the EU is now calling upon
its member states to develop and ensure awareness among
public and health professionals of the threat of antimicrobial
resistance and measures available to counter the problem.
In February, EWMA responded to a public consultation
regarding the use of nanosilver. The public consultation was
launched by the European Commission’s Scientific Committee
on Emerging and Newly Identified Health Risks (SCENIHR).
In the response, it was expressed that EWMA believe in the
use of non-antibiotic antimicrobial agents as the first line
of defence against topical infections and that this approach
could help save valuable antibiotics for urgent and last-resort
treatment of life-threatening conditions. However, to improve
the evidence base, large-scale clinical studies to investigate the
clinical efficacy of non-antibiotic antimicrobial agents (antiseptics),
including silver, are needed and should be encouraged
and incentivised.
EWMA is continuously contributing to the EU’s commitment
to face the challenges of antimicrobial resistance. Read
more about the advocacy activities of EWMA in this issue.
Biofilm courses
Last year, EWMA offered its first practical course on biofilm.
The cause was developed in association with the University of
Copenhagen. It was a great success; for 2014, two courses are
planned that would include even more individual hands-on
experiments in the laboratories. The biofilm courses introduce
the participants to the topic of biofilms and their huge impact
on chronic infections. Through lectures and a full day of
hands-on experiments, the participants gain an understanding
of biofilms and useable knowledge of how and why to implement
biofilms into their research or product portfolio. m
UPCOMING INITIATIVES
IN 2014 -2015
EWMA leg ulcer recommendations
The objective of this project is to produce a practical
guidance document on leg ulcer treatment, that may
be applicable within the different clinical settings for
leg ulcer treatment in Europe.
EWMA recommendations on Negative
Pressure Wound Therapy (NPWT)
These recommendations will describe the available
NPWT devices (including their application and use),
the health economic aspects of use of NPWT technology
and the eHealth perspectives on the use of
NPWT technology.
Promoting Appropriate Use of Antibiotics
and Non-Antibiotic Antimicrobial Agents
in Wound Care
The goal of this project is to develop a clinical decision
support tool. The tool will facilitate appropriate
use of antibiotics and non-antibiotic antimicrobial
agents in wound management.
Wound survey Germany
The objective of the survey will be to identify the
number and type of wounds under treatment, and
provide an estimate of the resource consumption
directly attributable to wound care at an organisational
level.
This will be carried out in collaboration with the German
Wound Organisation ICW.
Home Care-Wound Care UK
A guideline for wound care within the UK home care
services will be developed, based on the recommendations
provided by the EWMA Home Care - Wound
Care document. This will be done in collaboration
with relevant organisations in the UK.
EWMA recommendations for nurse education
The recommendations will define learning outcomes
related to the different levels of education. The
objective is to eliminate inconsistencies in wound
care education within European nurse education
programmes.
EWMA Journal 2014 vol 14 no 1 89

EWMA
Home Care-Wound Care
Sebastian Probst
Chair of the EWMA
Home Care Wound Care
Author group
ewma@ewma.org
www.ewma.org
At the EWMA-GNEAUPP 2014 Conference
in Madrid (14-16 May), EWMA
is launching a new document that will
highlight the challenges of managing and providing
modern, advanced wound care outside the
controlled clinical environment in patients’ own
homes. The Home Care-Wound Care document
will be presented at a key session on Friday 16
May, 08:00-09:30.
With this document EWMA aims to generate
critical discussion and debate regarding the
prerequisites, conditions, and knowledge/skills of
healthcare practitioners that are required to manage
wounds at home. In addition, the document
provides specific recommendations for wound care
at home. These recommendations are presented
from the organisational, patients’, and health care
professionals’ points of view.
The background for Home Care-Wound Care is
the dramatic shift in location of health care delivery
from hospital towards the home care setting
that has taken place during the past decade. Because
health economic considerations have lead to
an earlier discharge of hospitalised patients 1 , more
patients with a complex pathological picture (including
wounds) are being treated at home 2 . The
challenges of providing wound care in the home
care setting is underscored by patient chronicity:
76% of patients with chronic wounds have three
or more comorbid conditions including hypertension,
vascular disease, and arthritis and up to 46%
have diabetes 3 . Furthermore, evidence suggests
that many patients receiving health care services
at home never receive a diagnosis of wound aetiology
2,4 .
EWMA has recognised that there is a paucity
of research focusing on the subject of home care
wound care from a clinical perspective 2,4-7 . This
gap can best be illustrated by the fact that there are
no guidelines or recommendations of minimum
requirements for providing best care to patients
with wounds and their families in the home care
setting.
With this background in mind, EWMA initiated
the development of the Home Care-Wound
Care document. To provide a multi-country perspective
on the provision of home care wound
care across Europe, we collaborated with the German
Wound Association, Initiative Chronische
Wunden e.V. (ICW), and British Tissue Viability
Society (TVS), with support from the non-profit
organisation HomeCare Europe.
The authors are:
n Sebastian Probst, Zurich University of
Applied Sciences ZHAW, Department of
Health, Winterthur, Switzerland
n Salla Seppänen, Senior Lecturer, Mikkeli
University of Applied Sciences, Department
of Health Care, Mikkeli, Finland
n Veronika Gerber, Initiative Chronische
Wunden e.V, Spelle, Germany
n Georgina Gethin, Senior Lecturer, School
of Nursing & Midwifery, NUI Galway,
Galway, Ireland
n Alison Hopkins, Tissue Viability Society,
CEO Accelerate CIC, Mile End Hospital,
London, UK
n Rytis Rimdeika, Kaunas University Hospital,
Department of Plastic and Reconstructive
Surgery, Kaunas, Lithuania
m
1. Bartkowski, R., [Length of hospital stay due to DRG reimbursement].
Ther Umsch 2012; 69: 1, 15-21.
2. Bliss, D.Z., Westra, B.L., Savik, K., et al., Effectiveness of wound, ostomy
and continence-certified nurses on individual patient outcomes in home
health care. J Wound Ostomy Continence Nurs 2013; 40: 2, 135-42.
3. Friedberg, E., Harrison, M.B.,Graham, I.D., Current home care
expenditures for persons with leg ulcers. Journal wound ostomy
continence nursing 2002; 29: 4, 186-192.
4. Westra, B.L., Bliss, D.Z., Savik, K., et al., Effectiveness of wound, ostomy,
and continence nurses on agency-level wound and incontinence
outcomes in home care. J Wound Ostomy Continence Nurs 2013; 40: 1,
25-53.
5. Pieper, B., Templin, T., Dobal, M., et al., Home care nurses’ ratings of
appropriateness of wound treatments and wound healing. Journal wound
ostomy continence nursing 2002; 29: 1, 20-28.
6. Pieper, B., Templin, T., Dobal, M., et al., Wound prevalence, types, and
treatments in home care. Adv Wound Care 1999; 12: 3, 117 - 126.
7. Jorgensen, S.F., Nygaard, R.,Posnett, J., Meeting the challenges of
wound care in Danish home care. J Wound Care 2013; 22: 10, 540-5.
90
EWMA Journal 2014 vol 14 no 1

Submit your next paper to
Phlebologie
Organ der Deutschen Gesellschaft für Phlebologie
Organ der Schweizerischen Gesellschaft für
Phlebologie, Bulletin de la Société Suisse de
Phlébologie
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widmet sich die CME-zertifizierte Zeitschrift allen
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EWMA
Nordic Diabetic Foot Task Force:
Status and Future Activities
Magnus Løndahl, MD,
Consultant Endocrinologist
Department of Endocrinology
and Reproductive
Medicine
Skånes University Hospital
Sweden
Klaus Kirketerp Møller,
MD,
Orthopedic Consultant
Department of Orthopaedics,
Research Unit for
Amputations and Wounds
Hvidovre Hospital
Denmark
www.
nordicdiabeticfoot.org
Aim of the Nordic
Diabetic Foot Task Force
The Nordic Diabetic Foot (NDF) Task Force is a
network of national and international health care
clinicians with different disciplinary backgrounds
with the aim of promoting the systematic implementation
of guidelines for diabetic foot care in
Nordic countries.
Planned activities
To reach its aim, the NDF Task Force will initiate
and support various activities at the national
level that highlight the gap between recommended
guidelines and actual clinical practice for diabetic
foot care. These activities will be undertaken by
national working groups in each country. Findings
from these activities will be used to engage local
health authorities and national-level policy makers
and to push for initiatives that support the further
implementation of best practices. The NDF Task
Force will also host a biennial NDF symposium
to actively promote and support the systematic
implementation of best practices in diabetic foot
care in Nordic countries.
Network structure
The overall strategic planning and prioritization
of the NDF project will be undertaken by the
steering group of the NDF Task Force. National
working groups in each Nordic country will develop
and manage project activities (figure 1). These
groups will be composed of individuals with clinical
expertise in orthopaedic surgery, cardiovascular
Steering Group members. From left to right:
Klaus Kirketerp Møller (DK), Magnus Löndahl (SWE),
Tore Julsrud Berg (NO) and Vesa Juutilainen (FIN).
surgery, plastic surgery, general surgery, endocrinology,
and diabetology as well as wound care
specialists and podiatrists. Policy makers, health
care administrators, and industry representatives
will also be involved as dialogue partners.
Steering group meeting
The steering group met in Copenhagen on February
14, 2014. This was the first formal meeting
since the launch of the initiative at last year’s
EWMA conference. The meeting was very productive,
with members agreeing and deciding
upon how to proceed toward the establishment of
national working groups and more detailed planning
of the upcoming NDF symposium.
Figure 1. Network structure
Steering Committee
Nordic Diabetic Foot
Task Force
Organising Committee
Nordic Diabetic Foot
Symposium
Swedish
Working Group
Norwegian
Working Group
Finnish
Working Group
Danish
Working Group
92
EWMA Journal 2014 vol 14 no 1

Nordic Diabetic Foot
Symposium 2014
Establishment of national working
groups
One of the main priorities in the near future is the establishment
of national working groups. An initial step is to
map and describe the current diabetic foot care situation
in each Nordic country. Although these descriptions may
be similar across countries, they are also expected to reveal
national variations in how diabetic foot care is organised
and provided. The next step will be to develop advocacy
strategies for moving toward implementing nationwide
best practices in diabetic foot care as described by clinical
guidelines for each Nordic country.
Symposium
At the steering group meeting, a draft program was created
for the NDF symposium, which is planned for November
5-6, 2014.
Specifically, the symposium will:
1) Offer up-to-date educational information on current
best practices in various aspects of diabetic foot treatment,
and
2) Set an agenda for moving toward implementing best
practices in diabetic foot care in Nordic countries.
This symposium is a unique opportunity to gather clinicians
with different disciplinary backgrounds who have an
interest in actively developing the organisation and quality
of care for diabetic foot patients in their regions and municipalities.
Primary target groups for the symposium are:
n Representatives of multidisciplinary foot care teams
at diabetic foot centers and/or hospital units responsible
for diabetic foot treatment,
n Doctors and nurses in orthopaedic surgery, cardiovascular
surgery, plastic surgery, endocrinology, and
diabetology as well as wound care specialists and podiatrists,
n Representatives from general practice organisations,
n Policy makers and health care administrators, and
n Industry representatives.
After invitation of speakers and final revision, the program
will be announced at www.nordicdiabeticfoot.org/. Those
who sign up to receive newsletters will be notified when
the program is available.
For further information, please contact the NDF Conference
Secretariat at info@cap-partner.eu.
m
Join us to take an active role
in implementing Best Practice
Diabetic Foot Care in
the Nordic countries
5-6 November 2014 Malmö, Sweden
The program will cover a mix of;
n Traditional presentations
n Interactive session with centre presentations
based on submitted contribution
n Hands on workshops
n Meet the expert sessions
– addressing best practice treatment regimes
n Concluding panel debate defining strategies
to pursue implementation of Guidelines
Examples of topics to be covered;
n Basic pathophysiology of diabetic foot problems
n Introduction to IWGDF guidelines
n Overview of current situation of care in
the Nordic Countries
n Screening
n Diagnosing neuropathy
n Diagnosing and treating charcoot foot
n Vascular Assessment
n Debridement
n Surgery and use of flaps
n Role of Negative Pressure Wound Therapy
n Choice of dressings
n Offloading
n Amputation and rehabilitation
n Role of podiatry
n Organisation of diabetic foot teams
n Quality control and registers
n Patient education and compliance
Venue
Symposium dates
Stadionmässan, Malmö 5-6 November 2014
Workshops
Registration and information
7 November 2014 www.nordicdiabeticfoot.org
Supported by
Nordic Diabetic Foot Task Force & Symposium 2014 Sponsor:
EWMA Journal 2014 vol 14 no 1
www.nordicdiabeticfoot.org

EWMA
Developing a Diabetic Foot Treatment
– Progress and Perspectives
Gerald Zöch,
Professor of
plastical surgery
Peter Kurz,
CEO, Nurse
WPM Wund Pflege
Management GmbH
Stefan Krasnik
Head of Scientific
Department
WPM Wund Pflege
Management GmbH.
Nursing scientist
Correspondence:
peter.kurz@w-p-m.at
Conflict of interest: none
Introduction
A comparison of international prevalence rates
of diabetic foot issues reveals that Austria has a
tremendous need for improvement. The Austrian
amputation rate of 19/100.000 patients compared
to international levels of 3/100.000 indicates that
systemic changes are urgently needed to effectively
treat diabetic foot patients. Such changes will reduce
the risk of limb loss in individual patients. International
data also indicates that enormous cost
savings can be achieved by reducing the numbers
diabetic foot ulcers and major amputations. To reduce
the Austrian amputation rate, long-standing
members of the Austrian Wound Association have
launched a strategy with five aims, each designed
to address a specific intervention area.
Aim 1 – Prevention
Reduce the risk of diabetic foot syndrome by periodic
screening.
General practitioners currently treat 80 % of Austria’s
diabetic patients. Unfortunately, the national
health insurance company does not reimburse
physicians for the costs of performing neuropathy
and blood flow screenings. A small disease management
programme in Austria achieved a rapid
decrease in the number of diabetic foot ulcers by
paying for screening and educating practitioners.
Therefore, reimbursed screening is the first step
toward reducing the number of diabetic foot syndromes
in Austria. Based on current international
evidence, paid screening and intensive staff training
on screening methods, diagnosis, and diabetic
food treatment can reduce the diabetes foot syndrome
rate. Assuming that every major amputation
costs approximately 50.000 €, the Austrian
health system could save about 120 Mio € by
implanting proper preventive measures. 1
Aim 2 – Increase awareness
Enhance patient education regarding
“living with diabetes” and risk management
to reduce diabetic foot problems.
Despite the strong efforts of several national and
international institutions, the consequences of
diabetes are not well known in Austrian society.
To address this problem, further awareness campaigns
have to be organised.
To this end, Austria’s ministry of health recently
founded a working group focused on enhancing
patient education.
Aim 3 – Organisation of treatment
Improve the treatment of diabetic foot patients
by reorganising.
Only a few diabetes centres are established
throughout the country, making it difficult to
provide comprehensive treatment according
to international standards. The planned 2014
restructuring of the Austrian Health Care System
will also reorganise diabetic foot treatment.
Based on international projects, the treatment
should work on three levels.
n Level 1: Basic treatment of diabetic foot syndrome
by general practitioners and diabetes
nurses
n Level 2: Advanced treatment in specialised
diabetes centres by specialised staff (e.g.
wound experts, podologists, etc.)
n Level 3: Special treatment in hospitals by a
group of medical specialists
Although the screening methods are not very
time consuming, the treatment of diabetic patients
requires a special environment and trained,
qualified staff (nurses), and these are not available
throughout Austria.
Aim 4 – Education
Implement international educational curricula
to prevent diabetic foot syndrome.
There is a lack of courses specialised in handling
patients with diabetes in Austria. In addition,
podology is not defined as an Austria specialty.
For situations like this, the IWGDF (International
Working Group for Diabetic Foot) provides a curriculum
for countries with weak or no diabetic
foot treatment concepts. For the first time in
Austria, this curriculum will be implemented as
the “Diabetic Foot Care Assistant” course; it will
start in mid 2014 and provide basic information
on how to treat diabetic patients’ feet.
94
EWMA Journal 2014 vol 14 no 1

Programme in Austria
25th Conference of the
European Wound Management Association
Aim 5 – Analysing register data
Analyse nationally collected data to improve access
to information. (Austrian Impatient Quality Indicators)
Austria’s government recently announced the beginning
of a widespread analysis of standardised national data to
define and visualise quality criteria concerning several
health topics. These Austrian Inpatient Quality Indicators
(A-IQI) are designed to measure health-care quality based
on ICD and individual treatment. They enable the health
system to define and test quality against general data.
Therefore implementation of the A-IQI should provide
an objective view of quality of care concerning diabetes.
The A-IQI will facilitate evaluation of the major amputation
registry and will elucidate the lack of quality information
regarding diabetic foot treatment.
The first results should be available in 2014/15.
Discussion
After long medical discussions and intensive lobbying
work by members of AWA (Austrian Wound Association)
and the ÖDG (Austrian Society for Diabetes), the “diabetic
foot” problem has finally become a political issue in
Austria. Some very important changes have been scheduled
within the planned restructuring of the health care
system to prevent complications in patients with diabetes
and improve the treatment of diabetic feet. For four out
of five aims set out in the intervention strategy defined
by the AWA, initial steps towards improvement have been
taken. However, this is only the start. Reimbursement for
preventive services in primary care remains to be defined.
Within areas where improvement are already taking place,
AWA will continue to advocate for political and economic
support for initiatives that contribute to further improvement
of diabetic foot care in Austria.
m
EWMA 2015
LONDON · UK
13-15 MAY 2015
WOUND CARE
– SHAPING THE FUTURE
A PATIENT, PROFESSIONAL, PROVIDER
AND PAYER PERSPECTIVE
Dr Gerald Zöch will provide additional information
concerning this topic at the annual 2014 EWMA Congress
in Madrid, Spain.(15th May, 13:15-14:15, “
International perspectives on implementation”)
Literature:
(1) Apelqvist J, Ragnarson-Tennvall G, Larsson J, Persson U.: Long-term costs for foot
ulcers in diabetic patients in a multidisciplinary setting; Foot Ankle Int. 1995
Jul;16(7):388-94.
EWMA Journal 2014 vol 14 no 1
WWW.EWMA2015.ORG
WWW.EWMA.ORG
WWW.TVS.ORG.UK

EWMA
EWMA Participation in the first
UEMS meeting for European Scientific
Societies
Rytis Rimdeika,
MD, Ph.D.
Clinical Director for
Surgery, Head of Department
of Plastic and
Reconstructive Surgery
EWMA Council memeber
ewma@ewma.org
www.ewma.org
On March 1, 2014 the European Union
of Medical Specialists (UEMS) invited
EWMA to the first meeting for European
Scientific Societies. The objective was to
uncover areas and activities of mutual interest
between participating societies and the UEMS.
EWMA Council member Rytis Rimdeika represented
EWMA at the meeting. In this article, he
reports his reflections from the meeting.
European Reference Networks
From the perspective of the UEMS, the primary
objective of the meeting was to discuss a proposal
from the UEMS to establish a number of European
Reference Networks. The initiative was
presented by Dr. Andrzej Rys, Director, and Dr
Enrique Terol, Policy Officer and Directorate
General for Health and Consumers, of the European
Commission.
These networks should secure high-quality
treatment of rare diseases (defined as a prevalence
of ≤5/10,000) for all EU citizens. The establishment
of these networks is an initiative related to
the EU Directive 2011/24 on the application of
patients’ rights in cross-border healthcare. The
UEMS and the European Scientific Societies have
been requested to provide their input with respect
to this directive. Specifically, input was requested
on the identification of domains and groups of
diseases, ways to establish networks with a multidisciplinary
and multi-speciality approach, and
selection criteria for European Reference network
About the European Union of Medical Specialists
UEMS is the representative organisation of the National Associations
of Medical Specialists in Europe. The UEMS Council is working through
39 Specialist Sections and their European Boards. They address topics
related to continuing medical education and professional development,
the harmonisation of postgraduate training, and the organisation of
European examinations. Through this collaboration, the UEMS sets
the standards for high-quality healthcare practice and transmits
recommendations to the Authorities and Institutions of the EU and
the National Medical Associations.
centres. In addition to rare diseases, there is a focus
on complex and cost-intensive treatment that
requires a particular concentration of expertise.
The networks are also intended as focal points for
medical training and research, registries, information
dissemination, and evaluation. The directive
lists six basic criteria for defining reference centres,
as follows:
n Have knowledge and expertise in diagnostics,
follow up, and patient management
(documented via evidence and good
outcomes);
n Follow a multidisciplinary approach;
n Offer a high level of expertise and have the
capacity to produce good practice guidelines
and implement outcome measures and
quality control;
n Make a contribution to research;
n Organise teaching and training activities;
n Collaborate closely with centres of expertise
as well as national and international
networks.
Inclusion of wound specialists may be relevant to
some of these networks. EWMA will therefore follow
the continued work and propose involvement
wherever relevant.
Further EWMA perspectives on the
UEMS collaboration
Through this meeting, EWMA has initiated a
more formal contact with the UEMS. UEMS is
primarily composed of single-specialty sections
(e.g., surgery) and sub-speciality subdivisions
(e.g., surgical oncology). However, the organisation
also includes Multidisciplinary Joint Committees
and Thematic Federations that include
several specialities. A list of specialities and committees
can be found at the UEMS website:
www.uems.eu/about-us/medical-specialties. The
EWMA Council will discuss the opportunity to
suggest establishment of a multidisciplinary joint
committee on wounds within the UEMS organisation.
m
96
EWMA Journal 2014 vol 14 no 1

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EWMA
Managing Wounds as a Team
– Exploring the concept of a
Team Approach to Wound Care
A joint Position Document of the:
Association for the Advancement of Wound Care (AAWC) USA
Australian Wound Management Association (AWMA) Australia
European Wound Management Association (EWMA) Europe
Zena Moore
Chair of the Interdisciplinary
Document
Author group
The World Health Organisation argues that
a group of professionals who actively bring
the skills of different individuals together
with the aim of clearly addressing the health care
needs of patients and the community will strengthen
the health system and lead to improved clinical
and health-related outcomes. Indeed, a number of
systematic reviews have noted a positive impact
from the use of interdisciplinary interventions for
chronic diseases such as heart failure or mental illness,
and in individuals at risk of poor nutrition.
However, when it comes to wound care, available
evidence for the team approach is fragmented.
This project, which explores the concept of a team
approach to wound care, was conceptualised in
the context of this background.
Key Session at EWMA-GNEAUPP 2014
Conference
This spring, the author group will be busy presenting
their work and they are proud to invite you to
take part in a Key Session that is entirely focused
on the team approach to wound care, during
which the findings of the project will be presented.
The Key Session will be held on Thursday 15 May,
16:55-17:55 at the EWMA-GNEAUPP Conference
in Madrid.
In addition, the document will be presented at
several other international conferences including
ICIC 14, Brussels. Belgium; AAWC Spring, Orlando,
USA; AWMA 2014, Gold Coast, Australia;
and EFFORT 2014, London, UK. m
ewma@ewma.org
www.ewma.org
In this document, AAWC, AWMA, and EWMA
focus on the development of a universal model
for the adoption of a team approach to wound
care. To achieve this goal the document explores
existing evidence for the team approach to wound
care and discusses the barriers and facilitators for
a successful team approach to wound care.
“Managing Wounds as a Team” is for everyone
involved in wound care – from carers to decision
makers.
NOW AVAILABLE FOR FREE DOWNLOAD VIA:
WWW.JOURNALOFWOUNDCARE.COM
EWMA Journal 2014 vol 14 no 1 99

EWMA
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100
EWMA Journal 2014 vol 14 no 1

Organisations
Conference Calendar
Conferences 2014 Theme Month Days City Country
Annual Conference of the Tissue Viability Society (TVS) Apr 1-2 York United Kingdom
Spring Symposium on Advanced Wound Care and Wound
Healing Society (SAWC)
Apr 23-27 Florida USA
Deutscher Pflegekongress /Deutscher Wundkongress May 7-8 Bremen Germany
2014 Conference of the Leg Ulcer Forum May 8 Harben United Kingdom
10th National Conference of the Australian
A gold standard:
May 7-10 Queensland Australia
Wound Management Association (AWMA)
Research and clinical practice
24th Conference of the European Wound Management
May 14-16 Madrid Spain
Association (EWMA)
11th European Academy of Dermatology and Venereology
May 22-25 Belgrade Serbia
(EADV) Spring Symposium
2nd Practical Course in Biofilm Procedures
in collaboration with the
Jun 4-5 Copenhagen Denmark
University of Copenhagen
15th European Federation of National Associations of
Orthopaedics and Traumatology (EFORT) Congress
Jun 4-6 London United Kingdom
XXVI National Congress of Vascular Nursing and Wounds
Jun 5-6 Madrid Spain
(AEEVH)
2014 International Lymphoedema Framework (ILF) Conference Jun 5-7 Glasgow Scotland
17. Jahreskongress (DGfW) Jun 27-28 Bochum Germany
The 2nd International course on the Neuropathic
Osteoarthropathic Foot
Charcot Foot Course Jul 3-5 Rheine Germany
3rd Euro-Asian Forum (The Association for Wound
management in Bosnia & Herzegovina (URuBiH),
in cooperation with Doctors Chamber of Canton Sarajevo)
Traditional and Western Medicine
in the service of human well-being
Aug 18-22 Sarajevo Bosnia and
Herzegovina
17th Annual European Pressure Ulcer Advisory Panel Meeting (EPUAP) Aug 26-29 Stockholm Sweden
User Driven Innovation Course
in collaboration with the
Sep 3-4 Copenhagen Denmark
Danish Technological Institute
33rd annual meeting of the European Bone and Joint Infection Society (EBJIS) Sep 11-13 Utrecht The Netherlands
24th European Tissue Repair Society Annual Meeting (ETRS) Sep 11-13 Edinburgh Scotland
Conference on Science and Training of the Polish Wound
Sep 11-13 Mikołajki Poland
Healing Society (PWMA)
Diabetic Foot Study Group (DFSG) 2014 Sep 12-14 Bratislava Slovakia
16. Jahrestagung of the Austrian Wound Association (AWA) Sep 19-20 Graz Austria
DEBRA International Annual Congress Sep 19-21 Paris France
1st Joint Conference of the Swiss Wound Care Societies (SAfW) Sep 24-25 Biel-Benne Switzerland
2014 Lindsay Leg Club Conference Sep 24-25 Worcester UK
Rugby Club
Pisa International Diabetic Foot Courses 2014 Oct 1-4 Pisa Italy
National multidisciplinary Conference for Wound Professionals Wound Ecology Oct 7 Ede The Netherlands
(NOVW)
23rd European Academy of Dermatology and Venereology Building Bridges Oct 8-12 Amsterdam The Netherlands
(EADV) Congress
Fall Symposium on Advanced Wound Care and Wound Healing
Oct 16-18 Las Vegas USA
Society (SAWC)
II Congress for Chronic Wounds Management of the
Oct 24-25 Belgrade Serbia
Serbian Wound Healing Society (SWHS)
Conference of the Canadian Association
Action 2014:
Oct 30 Toronto Canada
of Wound Care (CAWC)
Skin Health For Canada
Nov 2
Nordic Diabetic Foot Symposium Nov 5-6 Malmö Sweden
VII Ibero-Latin American Congress about Ulcers and Wounds
Nov 5-8 Tucuman Argentina
(SILAUHE)
Annual meeting of the Danish Wound Healing Society Nov 20-21 Kolding Denmark
Conferences 2015
25th Conference of the
Wound Care – Shaping the Future May 13-15 London United Kingdom
European Wound Management Association (EWMA)
7th International Symposium on the Diabetic Foot (ISDF) May 20-23 The Hague The Netherlands
For web addresses please visit www.ewma.org
EWMA Journal 2014 vol 14 no 1 101

Organisations
AAWC NEWS
AAWC
Association for
the Advancement
of Wound Care
Robert J. Snyder,
DPM, MSc, CWS
President, AAWC
ABOUT AAWC
As the leading interprofessional
organisation in the
United States dedicated to
advancing the care of
people with and at risk for
wounds, AAWC provides
a whole year of valuable
benefits! Be sure to join us
for near daily updates and
alerts on Facebook
and LinkedIn.
www.aawconline.org
Thank you for the opportunity to provide the
readers of the EWMA journal with updated news
about the Association for the Advancement of
Wound Care (AAWC). As my term as President
comes to an end this April, I am pleased to note
that we have concentrated on the escalating epidemic
of diabetic foot complications over the last
two years. In an effort to foster amputation prevention,
two new guidelines are under development
for wound infection and diabetic foot ulcers.
We are honored to be partnered with EWMA and
the Australian Wound Management Association
(AWMA) to soon finalize a paper on the multidisciplinary
approach to wound care. Further, we
continue our partnership with Health Volunteers
Overseas (HVO) to provide wound and lymphedema
education in Haiti, Peru, Cambodia and India.
We continue to work with US-based organisations
such as National Pressure Ulcer Advisory Panel
(NPUAP) and the Alliance of Wound Care Stakeholders.
These opportunities strengthen dialogue
and cohesiveness among professional organisations
and societies involved in the wound care space.
Made possible by an unrestricted grant from Shire,
the Association for the Advancement of Wound
Care (AAWC) is pleased to award two $50,000
fellowship support grants for the 2014-2015 academic
year. The grants will provide salary and benefit
support for two (2) physician fellows (MD, DO,
DPM) who will conduct research in settings that are
dedicated to the multidisciplinary approach to
wound care. Winners will be announced at the
SAWC Spring Opening Ceremony opening
ceremony on April 24th.
Among our strategic objectives is to educate the
generalist practitioner. In coordination with AAWC’s
Corporate Advisory Panel (CAP), AAWC is developing
an “access portal” where the public can obtain
wound care accredited education. This education is
intended to help new wound care practitioners and
non-wound care specialists learn the most current,
evidence-based practices in wound care. Based on
a wound care pathway, the educational links can
be accessed at www.aawconline.org / education- forthe-generalist.
Help AAWC “WIN” the fight against
chronic wounds!
AAWC is offering this 11x17 inch patient-focused,
educational poster (shown to the left) for free from
the AAWC online store. A small shipping / handling
fee is all that is required. Order your poster today at
www.aawconline.org and help your patients “take
part” in their wound prevention and care.
Last but not least, AAWC is proud to announce a
tremendous increase in membership over the last
two years. With nearly 2300 members, our commitment
to community, collaboration and equal partnership
is still paramount. AAWC provides numerous
educational benefits to our professional and
patient/lay-caregiver members. Unique benefits
apply to both groups and can be viewed at
www.aawconline.org.
Thank you so much for allowing me to share
our current activities and projects with our
global partners.
Invitation from the
Association for the Advancement of
Wound Care (AAWC) to EWMA
The AAWC and EWMA have collaborated on
wound care activities since 2009. The most
recent collaborative activity is the elaboration
and publishing together with the Australian
Wound Management Association (AWMA) of
the document “Managing Wounds as a Team”,
which provides an update on the use of interdisciplinary
teams in wound care.
AAWC and EWMA will extend collaboration
in 2014-2015 by having a member from
EWMA’s board on the board of AAWC directors.
The EWMA Council has agreed to appoint
Jan Apelqvist, EWMA Immediate Past President
and chair of the EWMA Patient Outcome Group
for this position.
EWMA looks forward to a further year for the
collaboration with AAWC.
EWMA international
Partner Organisation
102
EWMA Journal 2014 vol 14 no 1

Organisations
EB-CLINET
– Clinical
Network of
EB Centres
and Experts
Dr. Gabriela Pohla-Gubo,
EB-CLINET project leader
Member of the Executive
Committee of DEBRA
Austria and Executive
Manager of the Academy at
the EB House Austria
www.debra.org.uk
EB-CLINET
– Clinical Network of EB Centres and Experts
Epidermolysis bullosa (EB) is a severe and rare
skin disease. EB-CLINET was launched in 2011 to
establish a clinical network of EB centres and
experts across all European countries and beyond.
Epidermolysis Bullosa (EB)
Approximately 30,000 people in Europe live with
EB. The symptoms of EB include blisters, wounds,
and scars that form not only on the skin but also on
the mucous membranes, including those of the
mouth, eyes, and gastrointestinal tract, from the
slightest mechanical stress. Complications associated
with EB include pain, itching, scarring, the fusion
of fingers and toes, tooth decay and tooth loss,
nutritional and digestive problems, and in some
cases, aggressive skin tumours. Life with EB is a tremendous
challenge for patients and their families.
The disorder does not yet have a cure.
DEBRA Austria & EB House Austria
DEBRA Austria was founded in 1995 as a patient
support group for those who suffer from EB. In
cooperation with the Department of Dermatology in
Salzburg, Austria (General Hospital, Paracelsus
Medical University), DEBRA Austria set up the EB
House Austria in November 2005 with private
donations and a one-time subsidy granted by the
Austrian government.
EB-CLINET
To date, more than 400 patients with EB from
24 countries in Europe and beyond have been diagnosed
and/or treated at the EB House Austria. The
expertise should travel, however, rather than the
patient. EB-CLINET therefore intends to strengthen
the collaboration between clinicians and medical
centres already specialised in EB. Moreover, EB-
CLINET aims to support the development of new
EB centres in countries without such services.
At present, EB-CLINET has 52 affiliated partners in
43 countries (including 25 of the 28 EU member
states, 6 additional European countries, and 12
countries from outside of Europe). By cross-linking
its partners, this network offers the opportunity to
work collaboratively on a number of projects,
including a global EB register, professional training,
and elaboration of clinical practice guidelines.
Moreover, EB-CLINET serves as an information
channel to share and exchange relevant news
about treatment or research in EB. Online information
is distributed via the website (www.eb-clinet.
org) and EB-CLINET eNews. Personal exchange is
assured through regular workshops, trainings, and
conferences, including the two EB-CLINET Conferences
in 2012 and 2013, respectively.
EWMA international
Partner Organisation
The EB House Austria is a centre for cutting-edge
medical treatment and targeted research. Its three
units (Outpatient Clinic, Research Laboratory, Academy)
meet the EU-recommended criteria for a Centre
of Expertise (CE). Operation costs continue to be
paid by private donations to DEBRA Austria.
See www.debra-austria.org and www.eb-haus.org
for more details.
Encouraging research results that relate to alleviation
and a causative cure of this disabling skin disease
are on the horizon. EB-CLINET will be able to
support the recruitment of patients for upcoming
clinical trials and provide these patients with the
chance to receive one of the treatment options.
In this way, EB-CLINET hopes to significantly
improve the quality of life for patients with EB.
EB-CLINET has 52 affiliated
partners in 43 countries
(including 25 of the
28 EU member states,
6 additional European countries,
and 12 countries from outside
of Europe)
For more details on EB-CLINET
see www.eb-clinet.org.
104
EWMA Journal 2014 vol 14 no 1

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Organisations
The Korean Wound Management Society
KWMS
Korean Wound
Management
Society
Jong Won Rhie,
MD, PhD, President
www.woundcare.or.kr
The Korean Wound Management Society was
established in 2002 at its inaugural meeting, with
a vision of integrating all realms of wound care to
become a leader in wound management. The
Society has grown to become the large organisation
that it is now, with about 1,500 diverse members
ranging from nurses and doctors to engineers,
researchers and industrial members. Medical personnel
come from diverse backgrounds and include
nurses working in acute care hospitals, home care,
intensive care units and wound care, as well as
orthopaedic surgeons, burn specialists, physicians
working in rehabilitation medicine, dermatologists
and emergency department doctors.
The Society sponsors a diverse array of academic
symposia and forums. In just the past year, the
Society held seven seminars and meetings. Doctors
Gerit D. Mulder and David G. Armstrong spoke
about diabetic foot care and management at the
annual spring seminar in March. The Honam
regional meeting assembled in April, and the
multinational participants by converting to an international
program. The Society also sponsors the
Korean Wound Academy and annual forums dealing
with pressure sores, wound dressing and wound
education. Issues and controversies regarding
patient care are discussed, and individualised care
principles and treatment algorithms are developed
at the Society’s gatherings. The Society publishes
its conference proceedings and the Journal of the
Korean Wound Management Society, a bi-monthly
issue that addresses relevant topics.
Along with the aforementioned conferences, interdisciplinary
education is one of the Korean Wound
Management Society’s main focuses. Educational
programs are based on the simple and realistic
notion that no single person can be an expert in all
components of wound care, and thus, the Society
encourages inter-professional communication.
We are also intent on spreading the most practical
knowledge to healthcare personnel; therefore, we
work on integrating evidence-based knowledge into
realistic wound management practice guidelines.
Hands-on lectures at the Korean Wound Academy
Voluntary activities at facilities for the homeless
EWMA
International Partner
Organisation
Korean Wound Academy met every Saturday from
August 31st to September 14th. In October, the
Busan regional meeting was convened and was
followed by several symposia held with industrial
support. Last but not least, the Education Symposium
was opened in November.
After its first seminar in 2003, the Society began
hosting an annual seminar, usually in the spring.
This meeting welcomes all those interested in
wound care and is planning to open its doors to
For example, the Korean Wound Academy, which is
held twice a year, provides various hands-on lectures.
These include the most basic principles, such as
methods for wound debridement and application of
negative pressure wound therapy (NPWT). Advanced
dressing materials are being introduced to medical
personnel at a rapid pace, and a large part of our
educational program focuses on adequate incorporation
of new dressing materials into wound care. These
academies are open to all wound care personnel.
106
EWMA Journal 2014 vol 14 no 1

Collaboration with nursing groups is also an important
aspect of the Society’s mission. The WOCN (Wound, Ostomy,
Continence Nurse) group is very active in Korea, their
motto being “Place your care in the hands of an expert.” The
Society is working to provide continuous educational courses
for WOCNs, standardise wound care procedures and issue
certificates for these courses.
Although the quality of wound care has greatly improved
thanks to the many dedicated medical personnel and continued
educational opportunities available to them, there are
still many in need. The Society has an outreach program in
which members make charity visits to those in need of wound
care that are unable to reach adequate medical help. In collaboration
with nursing groups, we visit local prisons and
facilities for the homeless and supply care for many minor
wounds.
This is how life feels
to people with EB.
Their skin is as fragile as a butterfly’s
wing. They have Epidermolysis Bullosa,
a painful and currently incurable skin
blistering condition.
www.debra-international.org
Journal of the
Korean Wound
Management Society
We are currently welcoming international communication
and collaboration. Approximately 40 members participated
in the 4th Congress of the World Union of Wound Healing
Societies (WUWHS) in September, 2012, and 13 members
participated as stream planners. Most members actively participate
in associated conferences and congresses internationally.
One of the Society’s many plans is to host the Congress
of the WUWHS in the near future.
Through these conferences, educational meetings, and collaborations,
the Society aims to provide standardised guidelines
for the care of all types of wounds. Universal prevention
and treatment guidelines are introduced, but the Society also
wishes to provide realistic practice guidelines for different situations.
For instance, care of a patient in the intensive care
unit cannot be the same as care at the home of a financially
compromised, bedridden, paraplegic patient, but each
should receive adequate management based on the same
universal principles.
Wounds are inevitable and may be found anywhere there are
people. However, through its educational and academic programs,
the Society hopes to decrease the incidence of
wounds and enable medical personnel to effectively manage
each wound based on evidence-based treatment algorithms
in order to significantly improve the quality of life for humankind.
m
EWMA Journal 2014 vol 14 no 1
International.

Organisations
UPDATE
WAWLC
World Alliance
for Wound and
Lymphoedema
Care
David Keast
President of WAWLC
www.WAWLC.org
EWMA international
Partner Organisation
The World Alliance for Wound and Lymphoedema
Care (WAWLC) continues the hard work on
advancing sustainable prevention and care of
wounds & lymphoedema in settings with limited
resources.
The annual executive board meeting of the
WAWLC took place in Geneva in November 2013.
The coordination and organisation of future initiatives
and activities of the WALWC were discussed at
the meeting.
Development of a dressing kit
Since 2012 the World Alliance for Wound and Lymphoedema
Care (WAWLC) has been in the process
of developing a dressing kit for use in limited
resource settings. This kit will be a dynamic tool
and help in providing the basic equipment for
standardised wound treatment of patients in emergency
situations.
The first step in elaborating this kit was a Delphi
like consultation launched at the end of 2012. As a
second step, the material from this consultation
was discussed by field and scientific experts during
a WAWLC Workshop at the EWMA Conference in
May 2013 in Copenhagen. Here it was discussed
what minimum material is needed to constitute a
standard wound kit.
WAWLC Workshop at EWMA-GNEAUPP 2014
During the EWMA-GNEAUPP Conference in
Madrid, the third step will be elaborated at a
WAWLC workshop where a revised standard kit will
be presented for debate and input.
This workshop will bring together experts in wound
care and actors of humanitarian contexts. Bringing
together these different experiences should help to
define the rest of the essential wound care material
that is needed to finalise the standard wound kit.
A list of the material decided on during the two first
steps will be circulated before the workshop.
The workshop will take place on
Wednesday 14 May 2014 at 16:45 -19:10.
Annual WAWLC Symposium at CAWC,
Toronto October 2014
A final consolidation of the dressing kit will be presented
at the annual WAWLC Symposium which
will take place at the Canadian Association of
Wound Care (CAWC) Conference from October 30
- November 2, 2014 in Toronto, Canada. The final
version of the dressing kit will be circulated to
wound care companies in order to have their proposal
on concrete products to be included in the kit.
Wound Course in West Africa
In 2014, a course on Chronic Wounds will be held
in Cameroon in cooperation between the Faculty of
Medicine and Biomedical Scienes at Yaoundé University,
Cameroon and the Geneva University Hospital
(HUG), Switzerland. The course includes both
theory and practice and is intended for doctors and
nurses as post-graduate training.
Since 2002, Médecins Sans Frontières (MSF), Switzerland,
has supported the BU programme of the
district hospital, Akonolinga in Cameroon. This projects
falls within the now more than 30 years old
fruitful exchanges between Yaoundé’s University
and the HUG.
Clinic in Leogane, Haiti
On 25th of January – 1st of February 2014, Heather
Hettrick from Nova South eastern University
(NSU) in Fort Lauderdale and Robyn Bjork from the
International Lymphedema & Wound Care Training
Institute were in Leogane, Haiti, where they provided
training and logistical support for clinical staff,
under the direction of WAWLC Secretariat Dr. John
Macdonald. The treatment results were impressive.
Dr. John Macdonald has actively pursued the reopening
of the lymphedema treatment branch of
the Lymphatic Filariasis (LF) Clinic at the St. Croix
Hospital in Leogane, Haiti. This vision is one step
away from full realization. The next steps include
procuring funding for the clinic, which will serve as
an epicenter for training and treatment of
lymphedema secondary to LF.
m
INFO ON WAWLC
WAWLC started as a working group in 2007 and was
officially launched as a global partnership in 2009.
Read more about WAWLC and current projects on the website:
www.wawlc.org.
108
EWMA Journal 2014 vol 14 no 1

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Cooperating Organisations
AEEVH
Spanish Association of Vascular Nursing and Wounds
www.aeevh.es
AFIScep.be
French Nurses’ Association in Stoma Therapy, Wound
Healing and Wounds
www.afiscep.be
AISLeC
Italian Nurses’ Cutaneous Wounds Association
www.aislec.it
AIUC
Italian Association for the study of Cutaneous Ulcers
www.aiuc.it
AMP Romania
Wound Management Association Romania
www.ampromania.ro
APTFeridas
Portuguese Association for the Treatment of Wounds
www.aptferidas.com
AWA
Austrian Wound Association
www.a-w-a.at
BEFEWO
Belgian Federation of Woundcare
www.befewo.org
BWA
Bulgarian Wound Association
www.woundbulgaria.org
CNC
Clinical Nursing Consulting – Wondzorg
www.wondzorg.be
CSLR
Czech Wound Management Society
www.cslr.cz
Danish Wound
Healing Society
CWA
Croatian Wound Association
www.huzr.hr
DGfW
German Wound Healing Society
www.dgfw.de
DSFS
Danish Wound Healing Society
www.saar.dk
FWCS
Finnish Wound Care Society
www.suomenhaavanhoitoyhdistys.fi
GAIF
Associated Group of Research in Wounds
www.gaif.net
GNEAUPP
National Advisory Group for the Study of Pressure
Ulcers and Chronic Wounds
www.gneaupp.org
HSWH
Hellenic Society of Wound Healing and Chronic Ulcers
www.hswh.gr
ICW
Chronic Wounds Initiative
www.ic-wunden.de
LBAA
Latvian Wound Treating Organisation
LUF
The Leg Ulcer Forum
www.legulcerforum.org
LWMA
Lithuanian Wound Management Association
www.lzga.lt
MASC
Maltese Association of Skin and Wound Care
www.mwcf.madv.org.mt/
International Partner Organisations
Associated Organisations
110
AWMA
Australian Wound Management Association
www.awma.com.au
AAWC
Association for the Advancement
of Wound Care
www.aawconline.org
CAWC
Canadian Association of Wound Care
www.cawc.net
Debra International
Dystrophic Epidermolysis Bullosa
Research Association
www.debra.org.uk
EFORT
European Federation of National Associations
of Orthopaedics and Traumatology
www.efort.org
ILF
International Lymphoedema
Framework
www.lympho.org
KWMS
Korean Wound Management Society
www.woundcare.or.kr/eng
NZWCS
New Zealand Wound Care Society
www.nzwcs.org.nz
SILAUHE
Iberolatinoamerican Society of
Ulcers and Wounds
www.silauhe.org
SOBENFeE
Brazilian Wound Management
Association
www.sobenfee.org.br
WAWLC
World Alliance for Wound and
Lymphedema Care
www.wawlc.org
Leg Club
Lindsay Leg Club Foundation
www.legclub.org
LSN
The Lymphoedema
Support Network
www.lymphoedema.org/lsn
EWMA Journal 2014 vol 14 no 1

Organisations
MSKT
Hungarian Wound Care Society
www.euuzlet.hu/mskt/
MWMA
Macedonian Wound Management Association
NATVNS
National Association of Tissue Viability Nurses, Scotland
NIFS
Norwegian Wound Healing Association
www.nifs-saar.no
NOVW
Dutch Organisation of Wound Care Nurses
www.novw.org
PWMA
Polish Wound Management Association
www.ptlr.pl
SAfW
Swiss Association for Wound Care (German section)
www.safw.ch
SAfW
Swiss Association for Wound Care (French section)
www.safw-romande.ch
SAWMA
Serbian Advanced Wound Management Association
www.lecenjerana.com
SEBINKO
Hungarian Association for the Improvement in Care of
Chronic Wounds and Incontinentia
www.sebinko.hu
SEHER
The Spanish Society of Wounds
www.sociedadespanolaheridas.es
SFFPC
The French and Francophone Society
f Wounds and Wound Healing
www.sffpc.org
SSiS
Swedish Wound Care Nurses Association
www.sarsjukskoterskor.se
SSOOR
Slovak Wound Care Association
www.ssoor.sk
STW Belarus
Society for the Treatment of Wounds
(Gomel, Belarus)
www.burnplast.gomel.by
SUMS
Icelandic Wound Healing Society
www.sums-is.org
SWHS
Serbian Wound Healing Society
www.lecenjerana.com
SWHS
Swedish Wound Healing Society
www.sarlakning.se
TVS
Tissue Viability Society
www.tvs.org.uk
URuBiH
Association for Wound Management
of Bosnia and Herzegovina
www.urubih.ba
UWTO
Ukrainian Wound Treatment Organisation
www.uwto.org.ua
V&VN
Decubitus and Wound Consultants, Netherlands
www.venvn.nl
WMAI
Wound Management Association of Ireland
www.wmai.ie
WMAK
Wound Management Association of Kosova
WMAS
Wound Management Association Slovenia
www.dors.si
WMAT
Wound Management Association Turkey
www.yaradernegi.net
Other Collaborators
ETRS
DFSG
Diabetic Foot Study Group
www.dfsg.org
EADV
European Academy of Dermatology and Venereology
www.eadv.org
EPUAP
European Pressure Ulcer Advisory Panel
www.epuap.org
ETRS
European Tissue Repair Society
www.etrs.org
Eucomed
Eucomed Advanced Wound Care Sector Group
www.eucomed.org
Home Care Europe
ICC
International Compression Club
www.icc-compressionclub.com
MSF
Médecins Sans Frontières
www.msf.org
WUWHS
The World Union of Wound Healing Societies
www.wuwhs.org
For more information about
EWMA’s Cooperating Organisations
please visit www.ewma.org
EWMA Journal 2014 vol 14 no 1 111

6 Editorial
Science, Practice and Education
9 Prevalence of Pressure Ulcers in Hospitalized Patients in Germany
Heidi Heinhold, Andreas Westerfellhaus, Knut Kröger
17 Excess use of antibiotics in patients with non-healing ulcers
Marcus Gürgen
25 Regenerative medicine in burn wound healing:
Aiming for the perfect skin
Magda MW Ulrich
31 Promising effects of arginine-enriched oral nutritional supplements
on wound healing
Jos M.G.A. Schols
37 Efficacy of platelet-rich plasma for the treatment of chronic wounds
Vladimir N. Obolenskiy, Darya A. Ermolova, Leonid A. Laberko,
Tatiana V. Semenova
Scientific Communication
43 Results from the world’s largest telemedicine project
Kristian Kidholm, Anne-Kirstine Dyrvig, Knud B. Yderstraede,
Birthe Dinesen, Benjamin Schnack Rasmussen
51 Nutrition and chronic wounds
José Verdú Soriano, Estrella Perdomo Pérez
54 The biofilm challenge
Maria Alhede, Morten Alhede
Innovation, know how and technolgy
60 National wound care innovation centre launched in the UK
Peter Vowden
63 Development of tools for home monitoring in wound care
Marco Romanelli, Marie Muller
66 2014 Education Activities
Ana Maria d’Auchamp
A KCI Company
A KCI Company
Cochrane Reviews
71 Abstracts of recent Cochrane reviews
Sally Bell-Syer
EWMA
78 EWMA Journal previous issues and other journals
80 EWMA GNEAUPP 2014 in Madrid
Javier Soldevilla Agreda, Gerrolt Jukema
84 Advocacy Activities update
Salla Seppänen
86 Christina Lindholm – Honorary Speaker at EWMA-GNEAUPP 2014
Salla Seppänen
88 EWMA’s commitment to fighting antimicrobial resistance
Salla Seppänen
90 Home Care-Wound Care
Sebastian Probst
92 Nordic Diabetic Foot Task Force: Status and Future Activities
Magnus Løndahl, Klaus Kirketerp Møller
94 Developing a Diabetic Foot Treatment Programme in Austria
Gerald Zöch, Peter Kurz, Stefan Krasnik
96 EWMA Participation in the first UEMS meeting for
European Scientific Societies
Rytis Rimdeika
99 Managing Wounds as a Team
Zena Moore
Organisations
PROTECTING PEOPLE, CARING FOR NATURE
100 EWMA Corporate Sponsors
101 Conference Calendar
102 AAWC News
Robert J. Snyder
104 EB-CLINET – Clinical Network of EB Centres and Experts
Gabriela Pohla-Gubo
106 The Korean Wound Management Society
Jong Won Rhie
108 WAWLC update
David Keast
110 EWMA Cooperating Organisations