Keynote Speaker Abstracts

Global Health: Hope or Deterioration?

Mr. Stephen Lewis

"Mr. Lewis will address the growing disparity in the standard of health between the developed and developing countries. He will take a hard look at the emergence and re-emergence of communicable diseases, the struggle for pharmaceuticals at low cost, the absence of health professionals, the question of resources, and the overall efforts of impoverished societies to reach the admirable levels of health which characterize Canada and the United States".

Balance: Living Well and Staying Healthy

Dr. Marla Shapiro

Marla Shapiro's keynotes offer valuable "me-time" for audience members, helping them to see the things that matter in developing and maintaining a healthy lifestyle, and some of the major issues at the forefront of today's medical care. As a broadcaster and columnist she provides people with the latest medical news as well as practical advice to keep the entire family healthy, and allow them to make smart healthcare decisions. A warm, compelling and compassionate speaker, she brings this same focus to her live presentations, sharing advice and information that everyone can use in their daily lives.

A Patient's Perspective - The Evidence of Strength
"The Phoenix Factor"

Mr. John O'Leary

As the result of a childhood fire, John O'Leary was burned on 100% of his body. This was a deeply painful trauma, both physically and emotionally, and he will carry its scars for the rest of his life. However, John survived the fire and feel as if he was reborn into another existence. The transformation was unwanted and painful, yet it has also brought genuine and lasting benefits. Such can be the nature of our disasters and challenges, if we permit ourselves to accept what happened, learn its lessons, work as a team, and resolve to take flight into new life.

The lessons within the presentation won't take away pain from past events. They won't remove the scars from our past. Instead, they will serve to reveal that it is from our scars and failings that our greatest successes originate; that from the winter of our challenges will bloom the beauty of spring; that in every phoenix moment the freedom exists to choose between two opposite outcomes. The Phoenix Factor proposes not that we can avoid tough times, but that each of us can grow from them, change our direction, rise to new heights and soar in life.

Faculty Abstracts by Stream

STREAM 1: PRESSURE ULCERS

C1 - Extent of the Problem

Pressure Ulcers - Definitions and Methods: Are we all measuring the same thing?

Christina Lindholm, RN PhD Professor

Background: The aim of measuring prevalence is to obtain data on how common pressure ulcers are in a population. Prevalence figures in isolation must however be interpreted with caution, and pressure ulcer grades, locations and prevalence of preventive actions must also be considered. Risk status for the population is another factor which influences prevalence, as is exclusion of certain wards e.g. Departments of Psychiatry, Maternal Care and Paediatric units. There must also be clear definitions of the pressure ulcer aetiology, and decisions regarding these definitions of pressure ulcers should be documented prior to the study. For example, should foot ulcers in diabetics caused by pressure of shoes be classified as pressure ulcers or not? And what about incontinence lesions? It is also important to confirm that all patients in a defined population are inspected and that risk status according to a validated risk assessment instrument is described.

Method: The EPUAP prevalence form (1) was utilized in 6 studies; Stockholm xx 2 (2), Skane xx 2 (3) and Akureyri, Iceland (4) xx 2. Identical methodology and research leadership was practised in order to perform comparisons between year one and two. Figures were compared with results from a similar study in the South Atlantic islands.

Results: A total of >7000 patients were included in the six studies. Prevalence figures ranged from 8.6 to 26%. Significant decrease of pressure ulcers was noted one year after the primary study in Stockholm, whereas this effect could not be noted in the Skane studies. In Akureyri, Northern Iceland there was a slight increase of prevalence, whereas the proportion of pressure ulcers Grade 1 was 98% in the second study. In the South Atlantic islands, the prevalence was 14%, and 70% had pressure ulcers grade 3-4. In Sweden and Iceland, the most common location was heels, whereas sacrum dominated in the South Atlantic. Patients with pressure ulcers had mean risk scores<20 in all the Swedish studies, but the Icelandic population had higher mean risk scores in both studies.

Discussion: In these studies, prevalence figures varied substantially. However, scrutinizing the results revealed substantial differences in location, grades, preventive actions and risk status in the individual populations. Even if we measured identically the same things, the interpretation of the results gave rise to interesting methodological considerations. The proportion of sacral pressure ulcers, so common in the South Atlantic islands did not correspond to the Swedish and Icelandic results where the heels was the dominating location. This might be explained by the North countries being more alert to grade 1 ulcers, but also that the care routines differed significantly. The experiences gained in these studies will illustrate the risk associated with rigid interpretation of prevalence figures, but also demonstrate how they can illuminate and nuance the pressure ulcer problem if a proper instrument such as the EPUAP form is used.

References:

1. Clark, M, Bours, G, and Flour, Td. (2002). Summary report on the prevalence of pressure ulcers. EPUAP Review, 4. Access date: 2008-03-30, Available from: www.epuap.org.
2. Lindholm, C, Klang, B, Svensson, L, Kohl, E, Arnkil, A, Benner, G, Olsson, K, and Persson, C. (2007). Trycksår - signifikant minskning genom vårdprogram och utbildning. Sår. (3): 10(7).
3. Lindholm, C, Axelsson, C, Westergren, A, and Ulander, K. (2008). Trycksår i Nordöstra Skåne. Blev det någon skillnad? Jämförelse mellan 2005 och 2006. In "Klinisk Patientnära Forskning: 1654-1421:18", Högskolan i Kristianstad. Institutionen för Hälsovetenskaper, Kristianstad. p. 33. (4) Lindholm, C, Torfadottir, O, Axelsson, C, and Ulander, K. (2008). Pressure Ulcers - Prevalence and prevention at Akureyri hospital, Iceland, 2005 and 2007. In "Klinisk Patientnära Forskning: 1654-1421:11", Högskolan i Kristianstad. Institutionen för Hälsovetenskaper, Kristianstad. p. 27.

Pressure Ulcers - Trends in the Americas (North, Central and South)

Dan Berlowitz

The past 20 years have witnessed growing attention to the worldwide problem of pressure ulcers. Many countries have developed national initiatives designed to enhance the quality of care and reduce the incidence of pressure ulcers. The impact of these initiatives on care, though, is often unknown. This session will review what is known about rates of pressure ulcer incidence and prevalence in the Western hemisphere. It is expected that these results will provide insights on the possible impact of these national initiatives on improving care for patients at-risk of developing pressure ulcers.

Trends in Europe and Beyond

Michael Clark

Published data upon pressure ulcer prevalence and incidence (where available) will be presented highlighting the occurrence of pressure ulcers across different countries outside the Americas. Data will be shown from a minimum of 10 countries and will be discussed to highlight the challenges of directly comparing survey Results
across nations and over time within single care settings. The presentation will seek to use the available data to identify whether pressure ulcer occurrence is becoming rarer over time as preventative strategies are disseminated widely across health care settings. The strengths of the available data and their myriad weaknesses will be highlighted with recommendations offered for future pressure ulcer data collection.

References:

1. Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract. 2007, 13(2): 227-35. This paper sets out a method for capture of pressure ulcer prevalence data and highlights trends across five European countries.
2. Tannen A, Bours G, Halfens R, Dassen T. Comparison of pressure ulcer prevalence rates in nursing homes in the Netherlands and Germany, adjusted for population characteristics. Res Nurs Health. 2006, 29(6): 588-96 This manuscript provides direct comparison between prevalence proportions across two key European countries highlighting the need to adjust raw prevalence (and incidence) to eradicate differences between patient characteristics such as vulnerability to pressure ulcer development.
3. Clark M, Cullum N. Matching patient need for pressure sore prevention with the supply of pressure redistributing mattresses. J Adv Nurs. 1992, 17(3): 310-6. This study although quite old highlights well the challenges of using pressure ulcer prevalence data to infer changes in the quality of care allocated to people with, or at risk of pressure ulcers.

C2 - Risk Assessment

Risk Assessment: Tools, Individual Factors and Clinical Judgment

Barbara Braden

Evidence related to the predictive power of risk assessment tools and use of these tools in conjunction with nursing judgment will be summarized. Practical considerations related to use of these tools as a guide for patient care using either level of risk or risk factors identified in the various subscales will be discussed. Reflection on the use of risk assessment and protocols in special populations and in the light of the presence of additional risk factors will be included. Recent studies examining the use of risk assessment and guided protocols in programs of prevention intended to decrease the incidence of pressure ulcers will be reviewed.

References:

1. Pancorbo Hidalgo PL, Garcia Fernandez FP, Lopez Medina IM, Alvarez Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J.Adv.Nurs. 2006 Apr;54(1):94-110. This is a very good meta-analysis of validity studies on various risk assessment tools, in which multi-lingual investigators examine literature written in several languages.
2. Lynn J, West J, Hausmann S, Gifford D, Nelson R, McGann P, et al. Collaborative clinical quality improvement for pressure ulcers in nursing homes. J.Am.Geriatr.Soc. 2007 Oct;55(10):1663-1669. Anational study of involving 52 nursing homes in 39 states in the U.S. involving use of risk assessment, clinical guidelines and clinical quality improvement methods to reduce the incidence of pressure ulcers.
3. Eachempati SR, Hydo LJ, Barie PS. Factors influencing the development of decubitus ulcers in critically ill surgical patients. Crit.Care Med. 2001 Sep;29(9):1678-1682. Study of critically ill surgical patients that used multivariate analysis to determine independent predictors of ulcer formation in this high-risk population.

Should Stage 1 be Considered an Ulcer or a Risk Factor?

Lisette Schoonhoven

Besides risk assessment scales and clinical judgment, non-blanchable erythema has recently been studied as an indicator for pressure ulcer prevention. Evidence related to the use of non-blanchable erythema, as an indicator for pressure ulcer prevention will be presented. Practical considerations related to the use of non-blanchable erythema as an indicator will be discussed. The gaps in research will be addressed. Also the question whether non-blanchable erythema should be considered an ulcer, which should be prevented, or an indicator for prevention will be discussed.

References:

1. Vanderwee K, Grypdonck MH, De Bacquer D, Defloor T. The reliability of two observation methods of nonblanchable erythema, Grade 1 pressure ulcer. Appl Nurs Res 2006 Aug;19(3): 156-62. This is a very good study that discusses the difficulty of assessing non-blanchable erythema.
2. Vanderwee K., Grypdonck M., Defloor T. Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial. J Clin Nurs 2005 Aug 30;(16):325-35. This is a well performed randomized clinical trial that uses non-blanchable erythema as an indicator for prevention and discusses the pros and cons.
3. Vanderwee K, Grypdonck MH, De Bacquer D, Defloor T. Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. J Adv Nurs 2007 Jan;57(1):59-68. This is an excellent randomized clinical trial that uses non-blanchable erythema as an indicator for prevention.

How Do Pressure Ulcers Impact the Quality of Life?

Diane Langemo

Objective: Discuss approaches to assessing the impact of a pressure ulcer on quality of life.

Objective: Discuss approaches to enhancing quality of life for an individual with a pressure ulcer.

Abstract: The presence of a pressure ulcer significantly impacts an individual's quality of life in overt as well as covert ways. The manner in which this impacts on the sum total of his/her unique experiences is quality of life. How these impacts are felt and individually defined in turn impacts what, how and when care is provided. Quality of life for an individual with a pressure ulcer incorporates variables such as pain an suffering, monetary costs of health care, impact on activities of daily living, family/significant other(s), etc. Quality of life impacts physically, psychosocial, social and somatic aspects of life. Health care professionals in all clinical settings need be acutely aware of and sensitive to issues and impacts on care and quality of life and the ethical dilemmas arising in the care. Are they repositioned? How often? What about care of the pressure ulcer? The odor? The exudates? Nutrition?

References:

1. Baharestani MM (2008). Quality of life and ethical issues. In: Baranoski S, Ayello EA. Wound care essentials: practice principles, (2nd ed.). Philadelphia: Lippincott, pp. 2-17. This chapter describes the impact of a wound, including a pressure ulcer, on quality of life for the individual and caregiver(s), including ethical dilemmas.
2. Langemo DK. (2005). Quality of life and pressure ulcers: What is the impact? WOUNDS 17(1):3-7. This articles addresses the issues related to quality of life in an individual with a pressure ulcer from the framework of the 4 QoLdomains of physical, psychosocial, social and somatic.
3. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. (2000). The lived experience of having a pressure ulcer: Aqualitative study. Advances in Skin & Wound Care, 13(5):225-235. This article describes the first hand experiences of eight individuals with a Stage II, III or IV pressure ulcer.

C3 - Risk-based Prevention

Evidence-Supported Risk-based Pressure Ulcer Prevention Programs

Janet Cuddigan, PhD, RN, CWCN, CCCN

A number of pressure ulcer prevention programs have been implemented with varying degrees of success. Accurate risk identification is the cornerstone of any risk-based prevention programs. Methods of risk assessment include risk assessment tools, individual risk factors, clinical judgment and various combinations of these strategies. Where risk assessment tools are used, interventions are often based on a total score which establishes an overall level of risk. Interventions derived from this method may vary in intensity based on the level of risk, but tend to be rather general and not targeted to the specific nature of the risk. Following a comprehensive review of the literature, an evidence based protocol for pressure ulcer prevention was developed. What is unique about this protocol is the use of an intervention matrix that provides targeted interventions for each of the Braden Scale risk categories (sensory perception, activity, mobility, moisture, nutrition and friction & shear). The intensity of the interventions within each risk category is titrated according to the level of risk as defined by the Braden subscale score, thus creating an evidence-supported, risk based pressure ulcer prevention. This method has been implemented and integrated into a computerized patient information system. Hospital acquired pressure ulcer rates have decreased to less than 1% and facility acquired full thickness ulcers are a rare occurrence. Computerization of the intervention matrix facilitates continuous quality improvement strategies which link the preventive strategies utilized for each patient with patient outcomes.

References:

1. Gunningberg, L., Are patients with or at risk of pressure ulcers allocated appropriate prevention measures? International Journal Of Nursing Practice, 2005. 11(2): p. 58-67.
2. Hiser, B., et al., Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy/Wound Management, 2006. 52(2): p. 48-59.

Prevention? We are Too Busy to Do That!

EH De Laat, P. Pickkers, L. Schoonhoven, ALVerbeek, T. Feuth, T. Van Achterberg

Guidelines for pressure ulcer care can be considered a way to translate research results and clinical experience into recommendations about care procedures in clinical practice.

In two studies(1;2) we aimed to determine the effects of a hospital wide program on pressure ulcer care on the occurrence of pressure ulcers in both critically ill patients and hospitalized patients at large. The guidelines in the program work as an intermediary in the implementation process.

Considering the key-problem of failing pressure ulcer care, i.e. a lack of knowledge and accompanying skills, we chose an implementation strategy with a focus on education. This approach appeals to an intrinsic motivation to achieve optimal competence and performance. 'Problem-based learning'- and 'bottom-up' methods fit well with this approach. However, the results on change in care behavior of nurses were poor. Based on these results others strategies will be discussed(3).

References:

1. De Laat EH, Schoonhoven L, Pickkers P, Verbeek AL, Van Achterberg T. Implementation of a new policy results in a decrease of pressure ulcer frequency. Int J Qual Health Care 2006 Apr;18(2):107-12.
2. De Laat EH, Pickkers P, Schoonhoven L, Verbeek AL, Feuth T, Van Achterberg T. Guideline implementation Results
   in a decrease of pressure ulcer incidence in critically ill patients. Crit Care Med 2007 Jan 23;35:815-20.
3. Grol R, Wensing M, Eccles M. Improving patient care : the implementation of change in clinical practice / Richard Grol, Michel Wensing, Martin Eccles. Edinburgh [etc.]: Elsevier Butterworth Heinemann; 2005. The first and second references are important because these articles present implementations strategies based on the educational approach. The third reference is important because it is a recent standard work on implementation strategies.

Is Under-Nutrition a Risk Factor for Pressure Ulcers?

Mary Ellen Posthauer

Under-nutrition is often an unidentified problem associated with pressure ulcer prevention and treatment. Implementing a pressure ulcer assessment which includes nutrition factors followed by early intervention by a dietitian leads to positive outcomes. A comprehensive assessment should include implementation of aggressive strategies to support anabolic metabolism.

Relying on biochemical data to evaluate nutritional status may not be appropriate. Is low serum hepatic protein linked to the amount of dietary protein consumed? Evidence suggests serum hepatic protein levels correlate with severity of illness and do not accurately measure nutrition support.

When oral nutrition including supplementation fails to reverse under-nutrition or when oral nutrition is impossible, the short term provision of enteral nutrition should be considered. The risks and benefits must be evaluated. Nutrition assessment and treatment should be part of the interdisciplinary team approach for pressure ulcer management.

References:

1. Bergstrom N, Braden B, A prospective study of pressure ulcer risk among institutionalized elderly. J Am Geriatr Soc.1992; 40(8); 747-58.
2. Fuhrman MP, Charney P, Mueller CM, Hepatic Proteins and Nutrition Assessment. J Am Diet Assoc. 2004;104:1258-1264
3. Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, Elia M Enteral nutritional support in prevention and treatment of pressure ulcers: a systemic review and meta-analysis. Ageing Res Rev 2005; 4:422-450.

C4 - Skin Care

Skin Health: Evidence for Assessment

Keryln Carville RN PhD
Associate Professor Domiciliary Nursing
Silver Chain Nursing Association & Curtin University
Australia

Author's Name: Keryln Carville1,2

Author's Affiliations:
1Silver Chain Nursing Association, Western Australia
2Curtin University of Technology, Western Australia

Goals and Objectives: To outline the evidence for skin assessment and the methods for conducting a comprehensive assessment.

Purpose: The integument is our largest body organ and one we take largely for granted until it is compromised or injured. Assessment is the prerequisite for clinical care decisions and thus, must be evidence based.

Methods: The integument is comprised of the skin, hair and nails. The skin averages 7,600 sq cm in the average sized adult and its appearance is subject to anatomical location, health status and environmental factors. Each time one looks at another individual or oneself, one assesses either subconsciously or consciously, the skin's appearance. The ability to perform a comprehensive clinical skin assessment however, is a fundamental requirement as the outcome of assessment directs all care decisions. The presentation will examine the evidence for skin assessment.

Results: The presentation will report upon the evidence and methods for skin assessment as outlined in the literature and consensus statements. The anticipated changes in skin as individuals journey through life's milestones will be discussed.

Conclusion: Changes in the integumentary system are to be expected with aging, alterations in health status or environment influences. The skin mirrors these influences and thus evidence based assessment is required to determine the norm from the abnormal.

Differential Diagnosis: Pressure Ulcer or Incontinence Dermatitis

Mikel Gray

Both the EPUAP and NPUAP recommend differentiation of incontinence associated dermatitis (IAD) from pressure ulcers (PU). Differential diagnosis is based on visual inspection of the skin. IAD is characterized by inflammation and erythema occurring in skin folds or underneath absorptive products where skin is exposed to urine, stool, or perspiration. IAD causes erythema in persons with lighter skin tones, the erythema is more subtle in persons with darker skin tones. It may cause erosion of superficial skin layers and secondary candidiasis is common. PU are associated with ischemic tissue damage. They tend to occur over bony prominences, may be full thickness wounds and contain necrotic ticcus. IAD must be differentiated from Deep Tissue Injury, which is characterized by darker red or purplish tones, resembling a deep bruise. A pressure ulcer is suspected enever skin damage occurs over a bony prominence, or its depth extends beyond the dermis of the skin.

Skin Protection and Care

Pat Coutts

The largest organ of the body, the skin, has six functions - protection, thermal regulation, metabolism, sensation, immune processing and body image. To preserve these functions, by maintaining the integrity of the skin, is of paramount importance. A breach of this integrity can be caused by numerous factors including but not limited to aging, dryness, itching, excessive moisture caused by perspiration, trauma (skin tears), fecal or urinary incontinence and other dermatological conditions.

By developing strategies for prevention, assessing risk factors for the patient both physically and environmentally, the management of the complications can be addressed. Understanding the various categories of skin care products, their indications and contraindications will enable the care provider to make an informed decision when providing care.

Through case studies the care and protection of the skin, including shielding of the peri-wound skin will be discussed in this presentation.

Key Words: maceration, peri-wound, moisture, risk factors

References:

1. Campbell K, Woodbury MG, Whittle H, Labate T, Hoskin A. Aclinical evaluation of 3MTM No Sting Barrier Film. Ostomy Wound Management 2000;46(1):24-30. This article examines the use of a skin barrier to prevent peri-wound breakdown.
2. White RJ, Cutting KF- entitled Interventions to avoid maceration of the skin and woundbed. British Journal of Nursing 2003 Nov 1326:12(20):1186-201. This article describes various causes of maceration and some possible interventions.
3. Sibbald RG, Campbell K, Coutts P, Queen D. Intact skin - an integrity not to be lost. Ostomy Wound Mangement 2003 Jun; 49 (6):27-28,30,33. This article discusses the role of intact skin, reasons for breakdown and treatment approaches with some available products.

C5 - Staging and Grading

The EPUAP Grading System: How Accurately do Clinicians Classify Pressure Ulcers?

Tom Defloor, RN, PhD
Nursing Science, Ghent University, Belgium

Identification of tissue damage is essential in every day care as well as in research. The European Pressure Ulcer Advisory Panel (EPUAP) classifies pressure ulcers in 4 grades allowing to determine the severity of the lesion and to differentiate pressure ulcers from other lesions. This is important for determining the prevention and treatment policy.

Recent studies show that the reliability of pressure ulcer classification was low. The EPUAP formulated a new guideline on classification and differentiation (PUCLAS-2). Based on that document an education programme was developed to improve the classification skills of caregivers.

In three studies the PUCLAS-2 this programme was used as a classroom instruction and as an e-learning tool. These studies showed that the PUCLAS-2 programme improved significantly the classification skills of nurses.

Further improvement of the reliability of classification remains the focus of ongoing research.

NPUAP Pressure Ulcer Staging System

Joyce Black

Pressure ulcer staging terminology provides a shorthand means of communication about the anatomical tissue loss in a pressure ulcer. Stages can also be used to guide interventions for care. In 2007, NPUAP updated the original 4 stages of pressure ulcers in order to clarify them and attempt to reduce "staging" of other skin wounds from etiologies other than pressure. In addition, staging nomenclature was added to describe pressure ulcers that were "unstageable" and from "suspected deep tissue injury".

In the US, staging is often used to measure quality of care in all settings. In order to use pressure ulcer stages as a quality indicator the stages must be clear, distinct, reliable and valid. Implications from the updated NPUAP staging system will be discussed in this session including the impending changes in payment processes for US hospitals when full thickness pressure ulcers develop after admission.

Reliability, Validity, Similarities, and Differences in Classification Systems: Implications Worldwide

Keryln Carville RN PhD
Associate Professor Domiciliary Nursing
Silver Chain Nursing Association & Curtin University
Australia

Author's Name: Keryln Carville1,2

Author's Affiliations:
1Silver Chain Nursing Association, Western Australia
2Curtin University of Technology, Western Australia

Goals and Objectives: To outline the evidence for pressure ulcer classification systems and the worldwide implications for use.

Purpose: Pressure ulcers are a significant cause of morbidity and mortality for individuals across all health sectors. The use of pressure ulcer classification systems has their genesis in the 1960s and since then an increasing interest in their reliability, validity and utility has evolved.

Methods: "There is an immense amount of zinc rubbing but I have not met with a single observation as to whether there was a danger of bed sores" (Nightingale, 1881).

It was perhaps 100 years later before this concern of Miss Nightingale was to merit due attention with the introduction of various tools for pressure ulcer risk assessment and classification systems. The evidence for use of these tools across all health settings is however, varied. The literature and consensus statements were reviewed to ascertain the reliability, validity, similarities and differences associated with pressure classification systems.

Results: Pressure ulcers are deemed largely preventable wounds. Risk prediction tools and classification systems vary as does the evidence for their use in different settings. The presentation will outline the current evidence for use of these tools and the implications of use or lack of use worldwide.

Conclusion: The inappropriate use of pressure ulcer classification systems has the potential to compromise care outcomes and increase the risk of personal or agency litigation. Practitioners need to be able to select the most appropriate tools to guide and support clinical decisions.

C6 - Pressure, Friction, Shear

The Role of Pressure and the NPUAP ISO Initiative

Laura E. Edsberg, Ph.D

The specific role of pressure in the development of pressure ulcers is not entirely understood. The application of pressure to tissue Results
in both microstructural and mechanical changes. In vitro studies have shown that collagen fiber bundles re-align following pressure application. In animal models, changes in collagen fibril diameters have been noted; these changes were similar to those seen in tissue samples from humans with stage IV pressure ulcers. There are also mechanical changes associated with the application of pressure to tissue, which vary between tissue types. The stiffness of the tissue and the tissue's reaction to pressure are altered. The response of the tissue to the mechanical and microstructural changes, which occur as a result of pressure application, will ultimately determine whether a pressure ulcer will develop or if the tissue will adapt.

References:

1. Edsberg LE, Natiella JR, Baier RE, Earle J. Microstructural characteristics of human skin subjected to static versus cyclic pressures. J Rehabil Res Dev 2001;38(5):477-86.
2. Sanders JE, Goldstein BS. Collagen fibril diameters increase and fibril densities decrease in skin subjected to repetitive and compressive shear stresses. J Biomech 2001;34(12):1581-7.
3. Gefen A, Gefen N, Linder-Ganz E, Margulies SS. In vivo muscle stiffening under bone compression promotes deep pressure sores. J Biomech Eng 2005;127(3):512-24.

Friction and Pressure Ulcers: Proposed Methods for Early Detection

Dan Bader
School of Engineering and Materials Science, Queen Mary University of London, London, UK and
Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands

Pressure ulcers are caused by sustained loading, involving pressure, shear and/or frictional forces, in association with microenvironment factors at the patient-support interface. Indeed, it has been demonstrated that high moisture levels can increase the friction at the interface. These events can influence the acceptable levels of pressure, above which tissue breakdown can occur (1). There is a requirement for objectives measurements, which reflect the physiological response of soft tissues to loading. As an example, sweat biochemistry has been shown to be sensitive to changes in tissue viability following loading (2). An alternative approach examines the release of proinflammatory markers from epidermal cells, subjected to mechanical irritants as induced by friction. Recent studies have involved both in vitro tissue models (3) and human subjects. Results indicate an up-regulation in the localized release of cytokines in both loaded and compromised tissues. Such a strategy may inform the implementation of early detection methods.

References:

1. Chang WL, Sereig AA. Prediction of ulcer formation on the skin. Med Hypothesis 1999; 53:141-44. The paper demonstrates the relative influence of extrinsic factors, such as friction, pressure and moisture, in compromising tissue integrity at the patient-support interface.
2. Bader DL, Wang Y-N, Knight SL, Polliack AA, James T, Taylor R. Biochemical status of soft tissues subjected to sustained pressure. In Bader DLet al Current and Future Perspectives Berlin: Springer-Verlag: Berlin 2005. The paper evaluates the potential of sweat markers, such as lactate and uric acid, in assessing tissue compromise following loading and unloading periods.
3. Bronneberg D, Spiekstra SW, Cornelissen LH, Oomens CWJ, Gibbs S, Baaijens FPT, Bouten CVC. Cytokine and chemokine release upon prolonged mechanical loading of the epidermis. Exp Dermatol. 2007; 16: 567-579. Demonstrates the release of cytokines associated with damage in a tissue model, which increases with the magnitude of the applied loading.

How does Shear Force Contribute to Pressure Ulcer Formation?

Takehiko Ohura

Firstly, the two clinically important outcomes of our studies 1) relating to shear force/ pressure are demonstrated, in which a new device being able to simultaneously measure shear force/pressure is used. An external force generates a marked compression in the soft tissue near bony prominences. Residual shear force was noted in the sacral area during and after bed operations. This may cause both development and deterioration of a pressure ulcer. All the dressing materials tested proved to be effective in reducing pressure.

Secondly, the various clinical symptoms 2)3) such as DTI, an hourglass-shaped necrosis and a sandwich-shaped necrosis caused by shear force, pressure and bony prominences are shown and their mechanisms in detail are verified. Alate type of undermining develops through a combination of the three factors applied in the middle or late phase of a pressure ulcer's healing process.

References:

1. Ohura T, Takahashi M, Ohura N Jr. Influence of external forces on superficial layer and subcutis of porcine skin and effects of dressing materials: Are dressing materials beneficial for reducing pressure and shear force in tissues? Wound Repair Regen. 2008 Jan-Feb; 16(1):102-7. Epub 2007 Dec 13.
2. Ohura T, Ohura N Jr. Pathogenetic mechanisms and classification of undermining in pressure ulcers-elucidation of relationship with deep tissue injuries. WOUNDS 2006 Dec; 18(12):329-339.
3. Ohura T, Oka H., Ohura N Jr., Incidence and clinical symptoms of hourglass and sandwich-shaped tissue necrosis in stage IV pressure ulcers. WOUNDS 2007 Dec; 19(11):310-319.

C7 - Managing Mechanical Forces

Positioning and Pressure Redistribution: Evidence Based Strategies

Tom Defloor, RN, PhD
Nursing Science, Ghent University, Belgium

Repositioning is a frequently used method to prevent pressure ulcers. The repositioning regime will be influenced not only by the support surface used, but also by the body positions. By increasing the contact surface between the body and the support surface, the risk of pressure ulcer development increases.

Interface pressure measurements were conducted in healthy volunteers in different lying and sitting postures on different support surfaces. The body posture with the lowest interface pressure in supine position was the 30° semi-fowler position, in lateral position the 30° degree lateral position and in sitting position the backwards sitting position with the legs supported.

Those positions were used in three clinical trials examining different support surfaces and repositioning regimes. The combination of 30° semi-fowler position, 30° degree lateral position and a backwards sitting position with the legs supported in combination with repositioning every 4 hours on a viscoelastic mattress was the most effective strategy to prevent pressure ulcers.

Characteristics and Features of Support Surfaces and the Influence of Temperature and Moisture

Evan Call MS IM (ASM, NRM)

Recent Work by the NPUAP's Support Surface Standards Initiative (S3I) (1) has produced a series of terms and definitions important to the clinical description of patient care and interfacing with the support surface (2). Sampling of significant terms: Immersion; the distance a body sinks into a support surface, Envelopment; how well the support surface conforms to the body; Pressure redistribution replaces "pressure relief", Shear; force parallel to the plane of interest. Definitions of types of surfaces, for example: Air; a low viscosity fluid, Gel; a semi-solid, Reactive support surface; a support surface with the ability to change the patients load distribution, Active; a powered support surface. Microclimate; the accumulation of heat and humidity at the skin-support surface interface (3). An ISO committee has been convened to consider the adoption of these as well as work from the Shear Force Initiative and test methods from the S3I.

References:

1. Posthaure ME, Jordan RS, Sylvia C, and NPUAP. Support Surface Initiative: Terms, Definitions, and Patient Care. Advances in Skin & Wound Care 2006 Dec 19(9):487-489.
2. Brienza D, Who Needs Support Surface Standards? The Importance of Clear Terms, Definitions and Performance Measures. NPUAP 10th National Biennial Conference, Conference 1. 2007 Feb 9-10 San Antonio, Texas.
3. Nicholson, Graham, etal. Amethod for determining the heat transfer and water vapor permeability of patient support systems. Medical Engineering & Physics. 701-712, 1999.

Managing Mechanical Forces: Managing Shear

Makoto Takahashi, Hokkaido University, Japan

For managing shear which is the tangential component on the skin, we have to understand how shear affects, firstly. To evaluate a shear force, we can use a shear sensing instrument which can measure one or two axial tangential force. It is more difficult to recognize how shear force works in the tissue than measuring a shear force as outer force. Because effects caused by shear varies with anatomical structure, additional pressure, and mechanical/physiological characteristics of tissue. But we can surmise physical effects caused by shear in tissue from a finite element analysis, MR imaging, and an experiment of gel model. Recently, we are trying to evaluate a blood flow as physiological effect caused by shear. Managing shear aims to comprehend a total force effects not only in tissue but also in outer space including mattress, bed, and so on.

C8 - Treatment Strategies

Wound Bed Preparation and the Role of Debridement in Treating Pressure Ulcers

Mona Baharestani

Goal: To summarize best clinical practice for pressure ulcer treatment.

Objectives: 1. To discuss the evidence supporting pressure ulcer treatment strategies. 2. To examine gaps in the current pressure ulcer treatment literature, especially as it pertains to special populations such as critical care, palliative care, neonates and children.

This interactive session will methodically review the process employed by EPUAP-NPUAP in reviewing the evidence for pressure ulcer treatment strategies and the creation of international treatment recommendations. Strength of the evidence, gaps in the literature and areas of controversy, as well as treatment recommendations will discussed in such areas as pressure ulcer cleansing, debridement, pain management, dressings, biophysical agents, assessment and treatment of infection and growth factors and biologics.

Treatment Strategies: Cleansing and Dressing Ulcers

Sue Bale

Over the past 30 years a plethora of dressings and cleansing solutions has been developed to meet the different wound characteristics and requirements. In many ways access to such a wide range of choice has been positive, but one consequence has been confusion about where to use different products and how to decide which is the most effective for the different clinical situations encountered in practice. Indeed, one aspect of practice is the dilemma of whether to cleanse a wound or not. Critically appraising the evidence can be challenging, where evaluating the strength of evidence, managing conflicting evidence and sometimes a paucity of evidence exist. In addition, there is discussion and debate around whether rct evidence is the most appropriate.

Most of the larger manufacturers have products available for cleansing and dressing wounds in each of the dressing groups and this includes antiseptics, silver containing dressings. Specialist products such as biological dressings and growth factors deserve equal consideration, and present wound healing practitioners with similar challenges.

References:

1. Cochrane Collaboration (2002) Water for wound cleansing. 2002. http://www.cochrane.org/reviews/en/ab003861.html)
2. Evidence Based Nursing (2003) Review: wound cleansing with water does not differ from no cleansing or cleansing with other solutions for rates of wound infection or healing. http://ebn.bmjjournals.com/cgi/content/full/6/3/81
3. Joanna Briggs Institute (2003) Solutions, Techniques and Pressure for Wound Cleansing http://www.joannabriggs.edu.au/pdf/BPISstpwound.pdf

Infection and Inflammation Components of Pressure Ulcer Care

Nancy Parslow

Critical colonization and local wound infection present challenges for the management of pressure ulcers. Signs of critical colonization are not always obvious and require a thorough assessment by the clinician to identify indicators that may be subtle and difficult to detect.

Once identified recommendations for topical management continue to change and evolve as new evidence becomes available. Topical antibiotics which have been traditionally utilized to treat local wound infections are less advisable now due to the development of bacterial resistance. The use of antiseptics for local wound car once taboo, are now recognized as an important tool for the management of critical colonization and local wound infection. The clinician must be knowledgeable regarding the safety and appropriate use of various antiseptic agents to ensure that the desired outcomes are attained.

References:

1. Sibbald RG., Orsted HL., Coutts PM., Keast DH., Best practice recommendations for preparing the wound bed: Update 2006. Wound Care Canada. 2006; 4(1):15-29. (Provides an excellent review of current recommendations for identification and management of wound infection from the Canadian Association for Wound Care and The Registered Nurses Association of Ontario).
2. European Wound Management Association. Position Document: Identifying criteria for wound infection.[Online]. 2005 [cited Feb 28]. Available from URL: http://www.ewma.org
3. European Wound Management Association. Position Document: Management of wound infection.[Online]. 2006 [cited Feb 28]. Available from URL: http://www.ewma.org

(References 2 & 3 provide a thorough review of current research on the topic)

C9 - Closing Prevention Guideline Gaps (EPUAP / NPUAP)

Clarity and Gaps in Pressure Ulcer Prevention Evidence

Anne Witherow and Carol Dealey

The collaboration of EPUAP and NPUAP to develop international pressure ulcer guidelines is both exciting and challenging. The papers in this session will describe the methodology used for the guidelines and debate some of the practical issues that have arisen, particularly in grading the evidence. We will be seeking consensus support for the resulting strategies, in particular the use of the term 'informed clinical consensus'. In addition, using pressure redistributing equipment as an exemplar, the evidence will be discussed. In particular, the quality of evidence currently and the gaps in knowledge will be described. Delegates will be asked to debate the resulting challenges of developing guideline statements that will be of practical value to practitioners. The challenge of developing guideline statements that are both meaningful but also recognise the international context of the guidelines will also be considered.

C10 - Closing Treatment Guideline Gaps (EPUAP / NPUAP)

Treatment Guidelines: Dilemmas and Consensus Building for the Guidelines

Janet Cuddigan and Diane Langemo

Objective: Discuss approaches to closing remaining gaps in pressure ulcer treatment guidelines.

Abstract: This session will focus on literature gaps and evidentiary dilemmas in the development of the evidence-based pressure ulcer treatment guidelines. Some areas lacking solid scientific evidence that may be focused on include: specialty populations (neonatal, pediatric, bariatric, geriatric, palliative care and critical care patients), characteristics and properties to consider in selection of support surfaces, distributive justice and beneficence, respect for individual wishes, assessment and treatment of infection and use of antiseptics, etc. Issues will be presented where the research evidence does not yet provide clear guidance. The audience will be engaged in a discussion of these issues in order to guide the EPUAP-NPUAP Guideline Panel in reaching further consensus on recommendations that represent the best judgment of international clinical experts.

References:

1. Langemo DK, Cuddigan J, Baharestani MM, Ratliff CR, Posthauer ME, Black J, Garber S. (2008). Pressure ulcer guidelines: Minding the Gaps. Advances in Skin & Wound Care, in press. This article describes the process of identifying the gaps and the identified gaps in pressure ulcer prevention and treatment guidelines.
2. Shekelle P, Eccles M, Grimshaw JM, Woolf SH. (2001). When should clinical guidelines be updated? British Medical Journal 323:155-157. This article describes the criteria for determining when a clinical practice guideline needs to be updated.
3. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. (1999). Potential benefits, limitations, and harms of clinical guidelines. British Medical Journal 318(7182):527-530. This article outlines the value of clinical guidelines, including potential benefits, known limitations, and potential harms of clinical guidelines.

STREAM 2: DIABETIC FOOT ULCERS

C1 - Extent of the Problem

Diabetic Foot Ulcers: North American Perspective

Robert G. Frykberg, DPM, MPH

Diabetic foot ulcers are the most common lower extremity complication of this disease and are a major component cause in the pathway leading to both amputation as well as infection. Numerous risk factors have been identified, but the most important underlying factor that predisposes these individuals to ulceration is peripheral neuropathy including both sensorimotor and autonomic dysfunction. Unfortunately, the incidence of this complication is growing due to the increasing numbers of patients with diabetes. This presentation will discuss the determinants, distribution, and frequency of diabetic foot ulcers in North America based on available data from this continent. Commonly available treatments will also be reviewed for those therapies having evidence to support their use.

Diabetic Foot Ulcers: A European Perspective

Jan Apelqvist

The diabetic foot has been claimed to cost EC health care payers 4 billion EU annually. Based on present studies in Europe, up to 20% of total expenditure on diabetes might be attributable to the diabetic foot.

European cost-utility analysis of diabetes-related foot ulcers have shown that adequate prevention and a multidisciplinary management strategy would be highly cost-effective if reduction of incidence of ulcer or amputation by 25-42% was achieved.

The EURODIALE study and other large European cohort studies have given us a deeper understanding regarding factors related to outcome of a diabetic foot ulcer. The severity of diabetic foot ulcers at presentation is greater than previously reported (more than 50% with infection, with >50% of neuroischemic origin) and serious co morbidity increasing significantly with increasing severity of foot disease.

The influence of health care organization and reimbursement in prevention and management of the diabetic foot ulcers can not be underestimated.

C2 - Risk Assessment

Risk Assessment and Neuropathy

Andrew Boulton, MD FRCP
Manchester UK/Miami USA

Regular screening of diabetic feet, together with risk assessment are important steps in the quest to reduce amputations amongst the diabetic population. An expert panel of the American Diabetes Association met in 2008 and proposed that all patients with diabetes at least on an annual basis should be assessed for neuropathic and vascular risk factors. This screening should include the two tests of peripheral neurological function that would normally comprise 10-g monofilament assessment of pressure perception together with one other test from the following: vibration perception with a 128Hz Tuning fork, pinprick sensation or present/absence of ankle reflexes. In addition, any obvious deformity should be noted and peripheral pulses assessed together with measurement of ankle brachial indices if indicated.

Risk Assessment: Lower Extremity/Deformity

David G. Armstrong, DPM, PhD
Professor of Surgery and Associate Dean
William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science

Objective: At the end of this lecture the participant should be able to identify the key factors associated with the occurrence and recurrence of a diabetic foot wound.

Abstract: Foot wounds are now the most common diabetes-related cause of hospitalization and are a frequent precursor to amputation. Persons with diabetes have a 30-fold higher life-time risk of undergoing a lower extremity amputation compared to those without diabetes. An infected foot wound precedes about two-thirds of lower extremity amputations. and infection is surpassed only by gangrene as an indication for diabetic lower extremity amputation. Persons with diabetes have at least a 10 fold greater risk of being hospitalized for soft tissue and bone infections of the foot than persons without diabetes.

With these data as a backdrop, we will review the current state of play regarding treatment of the diabetic foot and wounds in the developed and developing world. Emphasis will be placed on specific successes and failures and perhaps a way forward toward prevention. Further information regarding this lecture including video, manuscripts and podcast (CLEARcast) is available at: www.diabeticfootonline.com.

C3 - Peripheral Arterial Disease in Diabetes

Peripheral Arterial Disease in Diabetes: Assessment and Medical Treatment

Stephan Morbach (Germany)

People with diabetes have an increased risk of atherosclerosis, and peripheral arterial disease (PAD) is approximately five times as common in the diabetic as the nondiabetic population. PAD is a contributing to the risk of diabetic ulceration. In addition, the presence of vascular insufficiency can both determine the probability of ulcer healing and affect treatment choices.

The earliest symptom of PAD is intermittent claudication. As the vascular compromise becomes more severe, claudication may progress to rest pain. Leg pain is not diagnostic for PAD, as neuropathy may also cause leg pain. Similarly, absence of claudication does not exclude PAD, as pain and local signs of ischemia may be absent in the majority of patients with concurrent diabetic neuropathy. Asking for symptoms might therefore be misleading in people diabetes and clinical examination provides an indicator of vascular status, but is not a reliable way of either excluding or diagnosing PAD. Determination of the ankle-brachial index (ABI) should therefore be considered part of a minimum vascular assessment in patients with diabetes. The limitation of its use is the presence of calcified, non-compressible vessels, which are often seen in patients with longstanding diabetes or concurrent end-stage renal disease. As vessels in the toe are less likely to calcify, toe systolic pressure can be measured in those cases and the toe brachial index can be calculated instead. Duplex ultrasonography is the imaging method of choice to further investigate the status of vascular disease in diabetic patients. Duplex scanning has the advantage of being noninvasive and requiring no contrast media but unfortunately is rather investigator dependent. Digital Subtraction Angiography (DSA) Magnetic Resonance Angiography (MRA) should be reserved for cases in which an intervention (either endovascular or traditional open surgery) is planned.

In the talk a diagnostic algorithm to be applied in diabetic foot disease will be presented. In addition, medical options for treatment of symptomatic peripheral disease in people with diabetes will be discussed based on the recent TASC II Consensus Guidelines.

Vascular Evaluation and Treatment of the Diabetic

Thomas E. Serena, MD FACS

Vascular evaluation of the diabetic is challenging. Standard screening tests can be misleading. The treatment of diabetics with PAD is also challenging: disease tends to be distributed in the tibio-peroneal arteries. Endovascular procedures are not as effective in the distal limb. Will gene therapy be the answer: "Biologic bypass?"

C4 - The Chronic Wound in Diabetes

Diabetic Foot Ulcers: What Makes a Chronic Wound Chronic?

Dr. Keith Harding

Increasing understanding of the biological responses to injury have been able to identify the complexity of the processes of tissue repair. In diabetic foot ulcers as with other chronic wounds many aberrations in this cascade can and do occur. As a consequence the potential for both diagnosing specific abnormalities occurring in individual patients and correction of those abnormalities with targeted therapy have great potential.

The traditional classification of diabetic foot ulcers into neuropathic ischaemic and neuroischaemic does not recognise the role of other factors operating at a cellular and biomechanical level that can and do influence the activity of an individual to heal their wounds. An approach to patients with diabetic foot ulcers needs to address care at three levels, namely, control of the diabetic state, control of complications in the foot caused by diabetes and control of the factors influencing healing in patients with non healing wounds.

Diabetic Foot Ulcers: Optimising Nutrition for Healing

Thomas Kwyer

Complications associated with diabetes present the clinician with a wide variety of medically challenging conditions, including foot ulcers and neuropathic osteoarthropathy (acute Charcot foot). Compromised wound healing in diabetic patients has been addressed through intense pharmacologic glycemic control, enhanced local wound care and carefully planned surgical interventions. Heretofore, nutritional interventions in diabetes have been focused on adjusting diet to optimize glycemic control. This presentation will identify some of the metabolic, mitochondrial and cell signalling events that occur in diabetes and how these reactions may be affected by nutrient-based interventions. In particular, cytokine interactions influenced by oxidative stress, metabolic abnormalities and substrate deficiencies associated with diabetes amenable to nutrient based interventions will be reviewed along with relevant pathologic changes seen in other non-diabetic conditions such as Buruli ulcer disease, (an immune deficiency associated condition), myocardial diseases (some of which are immuno-inflammatory in nature) and immune-mediated bone and joint diseases.

C5 - Infection

Diabetic Foot Ulcers: Wound Infection

Michael Edmonds

Infection, often associated with ulceration, is responsible for considerable tissue destruction in the diabetic foot. There are misunderstandings in its diagnosis and management. Infection can initially present with minimal signs. Nevertheless,it can progress rapidly and quickly reaches the point of no return . Early signs of infection include the base of the ulcer changing from pink granulation to grey tissue, increased friability of granulation tissue, increased amount of exudates, pain and odour. The microbiology is unique, involving gram positive, gram negative aerobes and anaerobes. Initially broad spectrum antibiotics should be given. Swabbing and deep tissue cultures can be used for the initial monitoring of antimicrobial treatment in diabetic foot infection. Rational, targeted, antibiotic therapy is dependent on identification of the infecting bacteria. Indications for surgical debridement include large amount of infected sloughy tissue, localised fluctuation and expression of pus, bluish or purplish discolouration and crepitus with gas in soft tissues.

Diabetic Foot: How to Assess Infection

Stephan J. Landis, MD, FRCP(C)

The clinical assessment of diabetic foot infections is a bedside skill, complemented by appropriate diagnostic radiographic and microbiological studies. In the acute setting of diabetic-related cellulitis, the age-old observation of rubor, dolor, calor and tumor still apply. However, the presentation of chronic diabetic wound infection is more subtle in nature, and requires a systematic assessment.

The wound bed paradigm focuses upon 'treating the cause' (risk factors for infection), 'assessing the wound' (wound appearance) and 'patient-related factors' (pain, loss of function). These parameters are key elements to optimal assessment of infection. All diabetic ulcers have a polymicrobial flora, which increase the risks of developing infection. NERDS and STONEES represent practical mnemonics that have considerable bedside utility in categorizing two levels of bacterial damage or infection to the superficial or deep compartments. Based upon these bedside assessments, a post-test likelihood of infection is created to subsequently influence appropriate clinical decision-making.

The Management of Osteomyelitis

William Jeffcoate

Approximately 20% of all chronic ulcers managed in specialist clinics are complicated by infection of bone. The predominant pathogen is Staphylococcus aureus but other bacteria may be involved. Approaches to management vary widely, especially with respect to the need for, and extent of, early surgery. There is also no consensus concerning antibiotic regimen, its route of administration and duration among those who advocate a primarily non-surgical approach. Such uncertainty exists because of the absence of scientific evidence, with treatment choice being based largely on clinical experience and belief. The results of large observational series indicate, however, that, the outcome is poor, irrespective of approach: with perhaps only 60% of infections eradicated in one year without surgery, and an incidence of major amputation as high as 25% in one large series in which early surgery was favoured. These results fall far short of being acceptable, and robust data are needed to compare the outcome of different management strategies and to use these as the basis for prospective studies.

C6 - Wound Assessment

Assessment of the Foot with an Established Ulcer: More than just Pattern Recognition

William Jeffcoate

Clinical practice relies largely on pattern recognition. The experienced clinician will simply look at a foot, and take the briefest of histories before deciding management strategy. It is, however, important to dissect the features which contribute to the process. These concern (i) the diagnosis of infection, (ii) peripheral arterial disease and (iii) the extent of neuropathy - all of which are addressed in other presentations. One aim of this talk is to highlight issues which present difficulty, including the diagnosis of infection, and the significance of pain. But perhaps the most neglected aspect of assessment is the need to adjust the process when a foot is reassessed at follow-up visits, and for a systematic record of the way in which the condition of the foot changes with time and in response (or not) to treatment. The assessment at follow-up visits differs from that at first presentation and must include reference to what has gone before. The challenge is to ensure that this process is documented with clarity.

Assessment of the Diabetic Foot Ulcer

Mariam Botros, DCh, and R. Gary Sibbald, MD

Early detection, assessment, and treatment of a diabetic foot ulcer can improve patient outcomes. The wound assessment starts with the documentation of the location and wound size (length, width, depth) to benchmark a potential healing trajectory with serial measurements. The probing to bone is a reliable and valid method for determining a high probability of osteomyelitis. Clinical signs can also elucidate bacterial damage in the surface compartment (critical colonization, localized or covert infection) that may be treated with topical agents. The presence of deep or surrounding tissue cellulitis requires the use of systemic agents. We also need to document the adequacy of debridement and moisture balance. The presence of excess moisture may lead to periwound maceration and the need for an absorptive dressing. The periwound callus is often indicative of increased local pressure and a hemorrhagic blister a sign of friction or shear. With appropriate assessment and treatment, many limb amputations and other complications of diabetic foot ulcers can be avoided.

C7 - Pressure Redistribution

Diabetic Foot: The Role of Abnormal Pressure

Lawrence Harkless

Goal: Summarize the evidence that abnormal pressure alone does not cause diabetic foot ulceration.

Objectives:
Participants will:

1. Assess risk factors for diabetic foot ulcers
2. Recognize the integral role that neuropathy, abnormal pressure and activity levels plays in diabetic foot ulcer formation.
3. Predict the areas likely for ulceration.

Abstract: It's important to note that abnormal pressure alone does not cause ulceration. It's important to assess risk factors for ulceration which helps in assessing patients. Risk factors for ulceration include neuropathy, deformity, history of a previous ulcer or amputation, abnormal pressure, and limited joint mobility. After evaluating patients over many years, the question arose as to whether risk factors for ulceration were cumulative, meaning that if they are, was the likelihood for ulceration worse. It was proven in a prospective study that risk factors ulcers were cumulative. If a patient has neuropathy, they were two times more likely to ulcerate. If the patient had deformity, they were 12 times more likely to ulcerate and if they had a combination of neuropathy plus deformity, plus a history of a previous ulceration or an amputation, patients were 36 times more likely to ulcerate. Previously it was felt that abnormal pressure was the primary reason that patients ulcerated. However, in a study by Masson in 1988, he performed a study where he compared patients with rheumatoid arthritis and patients with diabetes, with similar deformity. To evaluate pressure, he walked all of the subjects on an optical pedobarograph and he found that patients with diabetes ulcerated and the patients with rheumatoid arthritis never ulcerated with similar pressure. Hence, the summary that abnormal pressure alone does not cause ulceration and that neuropathy is the permissive factor in why patient's ulcerated meaning that the patient's have lost the ability to protect themselves. Several authors have also elucidated the fact that pressure alone does not cause ulceration; Lavery, Cavanaugh, Mueller and Sinacore. What was found is that the pressure time integral in ulceration, that activity level that is time related, is the biggest variable in why patients ulcerate. Following the lecture, participants should be able to predict the area's most likely to develop ulceration.

Diabetic Foot: Offloading of an Ulcer

James McGuire DPM, PT, CPed, FAPWCA
Temple University School of Podiatric Medicine
Leonard Abrams Center for Advanced Wound Care

In this presentation we will discuss management of the biomechanical and psychosocial risk factors that contribute to the development of ulcerations in the diabetic foot. Each patient's inherent skeletal structure and biomechanical function determines the forces generated in the neuropathic foot. The patient's gait and choice of footwear can either increase or decrease their risk of developing a foot wound. The problem of patient compliance and strategies to address resistant behavior will be included in the discussion. In addition to our environment, how we schedule periods of ambulation can significantly increase or decrease the stresses on the diabetic foot. Various techniques for offloading will be discussed and the available evidence supporting the decision to choose one over the other will be reviewed. Methods of off-loading presented will include total contact casting, removable cast walkers and the instant total contact cast, felted foam, offloading footwear, and the football dressing.

Diabetic Footwear: Post-healing

Robert Van Duersen

Walking is a dynamic activity resulting in an unequal pattern of loading of the feet. With diabetic foot complications a variety of factors can interfere with normal foot function which can result in increased biomechanical stresses and put the foot at risk of injuries. Special footwear is used for patients with diabetic neuropathy for prevention of plantar re-ulceration through off-loading of the at-risk foot area. Although the evidence for effectiveness of pressure relief is often limited it is possible to develop an understanding of the mechanisms by which this is achieved. Useful off-loading mechanisms include reduction of walking speed, alteration of foot rollover during gait, and transfer of load from affected areas to other areas of the foot or the lower leg. The more effective off-loading devices also appear to have a large effect on mobility. A combination of factors therefore needs to be considered for effective treatment and prevention.

C8 - Treatment of Diabetic Foot Ulcers

WBP for the Diabetic Foot: Treatment approach to local DIM

Gary Sibbald and Kevin Woo

Prior to local wound assessment, a diabetic ulcer should be classified as healable (adequate blood supply and the cause treated), nonhealable (the blood supply is inadequate) or maintenance (the wound is healable but there are patient or health care system factors preventing healing). The local management of diabetic foot ulcers is complex. The acronym DIM representing debridement, infection control and moisture balance provides an organized approach to local wound care.

For a healable wound, sharp debridement involves removal of necrotic tissue, hyperkeratotic tissue, senescent cells, and biofilms in the wound. There is some evidence to support regular sharp debridement to promote wound healing. Enzymatic, biological, and mechanical debridement in terms of their advantages and disadvantages will be discussed. Infection is common in patients with diabetic foot ulcers due to their compromised immune system. A plethora of topical antimicrobial agents (e.g. silver, chlorhexidine derivative, iodine) are available and their effectiveness on the management of superficial or local wound infection will be appraised and summarized. The superficial signs are described as NERDS while deep infection is associated with STONEES that warrant systemic antimicrobial therapies. Moisture balance is conducive to cellular activities and proliferation. The Wound dressing's moisture balance properties must be matched to the wound surface moisture content to avoid excess surface moisture or dehydration.

For the non-healable wound the paradigm changes to conservative debridement of slough, bacterial and moisture reduction.

WBP: (Wound Bed Preparation), Evidence Based Management of Diabetic Foot Ulcers

Steven R. Kravitz, DPM, FAPWCA

This presentation will discuss the evidence based management of diabetic foot ulcers relative to selected modalities that are used for wound bed preparation. Such topics as Negative Pressure Therapy, Hyperbaric Oxygen Therapy, bi-layered and single layered skin substitute, topical application of growth factors, MMP reducing therapy, wound matrix and similar topics will be reviewed with regard to the scientific evidence that supports their efficacy or demonstrates poor efficacy. The lecture will clearly demonstrate that there is limited "good" evidence for much of what is provided in clinical practice. Many treatment studies have small numbers of subjects and other therapy have no randomized trials to show "effectiveness". There are exceptions where there is good evidence with large clinical trails, but the number of therapies well supported by the evidence is relatively small. That said, there are many therapies that are used daily with good results and help many patients. The short presentation concludes with raising the question, "Have we over emphasized the need for randomized double blinded clinical trials?"

C9 - Surgical Management of Foot Ulcers

Diabetic Foot Sparing Surgeries

Robert G. Frykberg, DPM, MPH

Diabetic foot ulcers are frequently associated with underlying deformities that cause these lesions to be recalcitrant or recurrent despite the provision of therapeutic footwear. Some deformities such as Charcot arthropathy or severe hammertoes defy conservative treatment with footwear or bracing. Furthermore, foot infection with underlying osteomyelitis often requires surgery to affect a final cure. Over the last several decades numerous reconstructive or foot-sparing procedures have been recommended as effective alternatives to major or partial foot amputation in these settings. Common but useful foot sparing procedures (excluding amputations) will be discussed in relation to their most common indications. While not specific to diabetic foot disorders, performance of these relatively simple procedures can lead to rapid healing of foot ulcers and infections, correct deformities at risk of ulceration or re-ulceration, and improve the quality of life for appropriately selected patients.

Diabetic Pedal Amputation

Lee J. Sanders

Objective: Participants will: Ascertain structural and functional outcomes for ray and midfoot amputations

Abstract: Amputation of a toe, in particular the great toe, with its metatarsal head, alters weight bearing and increases the susceptibility of the foot (toes and metatarsals) to further injury. Transmetatarsal amputation provides a more favorable cosmetic result, a more durable foot and the likelihood of a better functional outcome. It is understandable that surgeons attempt to preserve as much of the foot as possible. Although this is laudable, in the long term it may not be in the patient's best interest. A deformed foot that repeatedly ulcerates and is difficult to fit in a shoe is clearly not a success. Foot structure and function following partial amputation of the foot should be carefully considered by the surgeon in the selection of procedure(s). Initial surgical intervention should be directed at resolving infection, establishing dependent drainage, excising necrotic tissues and/or repairing traumatic injuries. Ultimately however the patient needs to ambulate on the residual foot. Knowledge of lower extremity biomechanics and foot function will help the surgeon to select the most appropriate level. The goal is to preserve foot function, achieve a durable cosmetically acceptable result and to prevent major amputation of the leg.

References:

1. Sanders LJ: Ray and Transmetatarsal Amputations, Chapter 209. In Josef E. Fischer (ed.) Mastery of Surgery (2 vols.), Fifth Edition. Lippincott Williams & Wilkins. ©2007

C10 - Prevention

Diabetic Foot Care: Self Care Assessment

Lawrence Lavery

The objective of the lecture is to discuss self-care assessment to prevent foot complications. We will discuss barriers to self-inspection including poor vision, limited joint mobility and obesity. We will discuss using temperature assessment as a self-monitoring tool.

Temperature assessment has been demonstrated to reduce foot ulcers by 3-4 fold in high risk patients.

Prevention: Nursing Issues

Linda B. Haas, PhC, RN, CDE
Endocrinology Clinical Nurse Specialist
VA Puget Sound, HCS, Seattle Division

Diabetes is a chronic disease that is managed by the person with the disorder and often his/her family. This presentation will identify seven critical self-care behaviors necessary for chronic disease management. Participants will gain understanding of learning styles and how to assess learning style and appropriate approaches to different learning styles. In addition, this session will identify a Method
to assess for facilitators and barriers to self care. An example will be used where nurses and other providers can make a significant difference in assisting patients in safe foot care practices. Several resources available to providers and persons with diabetes will also be identified

STREAM 3: OSTOMY, CONTINENCE & SKIN CARE

C1 - Quality of Life Issues

Quality of Life Issues

Paula Erwin-Toth and Patricia Price

Quality of life has been defined as a subjective concept that is difficult to define. Yet the advances the development of outcome measures has resulted in a growing number of methods that are available for measuring this concept. These measures can be used as a marker of quality of care, as well as contributing to the ways in which the cost-effectiveness of interventions can be assessed.

On the individual level, qualitative approaches can help clinicians to prioritize elements of care to address patient concerns. This session will discuss conceptual issues, definition and measurement, scale development and selected research related to Quality of Life in general as well as specific considerations for persons living with a urinary or fecal diversion.

C2 - Prevention & Management of Skin Tears

Prevention of Skin Tears

Kimberly LeBlanc & Sharon Baranoski

Skin tears are traumatic wounds resulting from the separation of the epidermis from the dermis. They are an increasingly common problem health care professionals are faced with when caring for the frail elderly. These frequently seen wounds are the result of trauma to the skin from shearing, friction or blunt injury occurring at the time of transfer and/or a fall. Skin tears can cause stress to the patients and their families and are often challenging wounds for the health care professional providing care. While prevention of skin tears is the primary focus for managing this problem, health care professionals working with the elderly population must be equipped to manage and treat these difficult wounds when they occur. This presentation will focus on the classification, prevention and treatment of these often overlooked wounds.

Objectives: The learner will be able to classify skin tears according to the Payne- Martin Classification. The learner will be able to discuss interventions related to skin tear prevention and treatment

References:

1. Bank D, Nix, D, Preventing Skin Tears in a Nursing and Rehabilitation Center: An interdisciplinary effort. OWM. 2006; 52(9) 16-26.
2. Roberts MJ, Preventing AND Managing Skin Tears. JWOCN. 2007; 34(3) 256-259.
3. Jones JL, Understnading Skin Tears: the Whys and Hows. ECPN. 2007; Jan/Feb.
4. Baranoski S, Ayello E. Skin an essential organ. In Baranoski S, Ayello E, eds. Wound Care Essentials:Practice Principles. Ambler, PA: Lippincott Williams and Wilkins; 2008: 47-63.

C3 - Advanced Skin Care in Patients with Incontinence

Advanced Skin care in Patients with Incontinence

Dorothy Doughty, MN, RN, CWOCN, FAAN
Denise Nix, MS, RN, CWOCN

Objectives:

1. Distinguish between incontinence-associated dermatitis and other types of skin ulceration.
2. Describe the pathology of incontinence-associated dermatitis and implications for prevention.
3. Distinguish between irritant dermatitis and yeast dermatitis and describe appropriate management for each.

Abstract: Incontinence-associated dermatitis is a common type of skin breakdown and is associated with significant morbidity as well as increased risk for pressure ulceration. Effective prevention and management is dependent on a clear understanding of the pathologic mechanisms and the implications for differential assessment and management. Topics to be covered in this session include risk factors for IAD; current evidence regarding the relationship between IAD and pressure ulcer development; differential assessment of IAD versus other types of skin ulceration; strategies for prevention of IAD, with a strong focus on strategies to minimize incontinence episodes; and guidelines for accurate assessment and management of each of the following: mild irritant dermatitis; severe irritant dermatitis; and yeast dermatitis. Strategies for effective management of fecal incontinence will be a particular area of focus.

References:

1. Ermer-Seltun J. (2006) Assessment and management of acute or transient urinary incontinence. In Doughty D, ed. Urinary and Fecal Incontinence: Current Management Concepts, 3rd ed. Mosby Elsevier, St. Louis: 55 - 72.
2. Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. (2007). Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 34(1):45-54; quiz 55-6.
3. Junkin J and Selekof J. Prevalence of incontinence and associated skin injury in the acute care inpatient. (2007) J Wound Ostomy Continence Nurs 34 (3): 260 - 269.
4. Nix D, Seltun J. (2004) Areview of perineal skin care protocols and skin barrier product use. Ostomy Wound Manag. 50(12):59-62, 64-67.

C4 - Health Economic Evalution: Cost Effectiveness of ET Nurses for the Management of Wounds in the Community

Health Economic Evaluation: Cost Effectiveness of ET Nurses for Management of Wounds in the Community

Connie Harris and Ron Shannon

Objective: At the end of this session, the participant will: Demonstrate the direct and indirect cost-savings realized when the uniquely qualified ET Nurse is employed as part of a wound care delivery model.

Abstract: This session reports on a two year, multi-center retrospective chart audit of three models of nursing care utilizing four community nursing agencies and one specialty agency owned and operated by ET nurses. An analysis using quantitative methods evaluated healing outcomes, nursing costs and cost-effectiveness. A total of 360 chronic wounds and an additional 54 acute surgical wound charts were audited. The greater the involvement by the specialty agency, the lower the overall cost of the treatment for acute and chronic wounds, realized by a shorter time to healing and the reduction in the number of nursing visits.

The ET nurse wound specialist is a justifiable cost to any health care organization. The patients with these heavily resourced, consuming wounds require the expertise of the ET nurse who can effectively manage and control treatment costs by applying evidence-based wound care. The study was funded by the Canadian Association for Enterostomal Therapy.

Three recommended papers:

1. Harris C, Shannon R. (2008) An Innovative Enterostomal Therapy Nurse Model of Community Wound Care Delivery: A Retrospective Cost-Effectiveness Analysis. Manuscript accepted for publication in JWOCN, January 2008.
2. Arnold N, Weir D. Retrospective analysis of healing in wounds cared for by ET nurses versus staff nurses in a home setting. Journal of Wound Ostomy Continence Nurses. 1994; 21(4):156-160.
3. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB, for the Panel on Cost-Effectiveness in Health and Medicine. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA. 1996; 276:1253-58.

C5 - Assessment Tool Validation: The Experience of Validating the French Language Version of the Braden Scale

Assessment Tool Validation: The experience of validating the French language version of the Braden Scale

Barbara Braden and Diane St-Cyr

The Braden Scale was developed in the 1980's through a process of literature review and concept analysis. Validation was begun in the 1980's and continued in the 1990's(1). Diffusion of this innovation was rapid, probably due to an international group of early adopters. Multiple authors have published validation studies of the Braden Scale in a variety of languages. Pancorbo Hidalgo (2) performed a meta-analysis of validation studies published in a number of languages. Many of the translations have been done but only a few have undergone formal procedures for assuring the validity of the translations. This presentation will outline the formal procedures used to assure the linguistic validity, the temporal stability as well as the inter-rater reliability of a French version of the Braden Scale.

References:

1. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs.Res. 1998 Sep-Oct;47(5):261-269.
   This article reports detailed results of a large multi-site study of the Braden Scale and includes information on earlier studies.
2. Pancorbo Hidalgo PL, Garcia Fernandez FP, Lopez Medina IM, Alvarez Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J.Adv.Nurs. 2006 Apr;54(1):94-110.
   This is a very good meta-analysis of validity studies on various risk assessment tools, in which multi-lingual investigators examine literature written in several languages.
3. Varricchio CG, "Measurement Issues Concerning Linguistic Translations" In F. Stromberg and S.J. Olsen, Instruments for Clinical Health Care Research, Third Edition, Sudbury: Jones and Barlett Publishers. 2004, 56-63.
   This chapter describes the steps to follow to translate instruments to ensure linguistic equivalence as well as cross-cultural equivalence.
4. Vallerand RJ. Vers une méthodologie de validation trans-culturelle de questionnaires psychologiques: implications pour la recherche en langue française, Psychologie Canadienne, 1989 30(4), 210-223.
   This article outlines and describes in great details each step involved to translate and validate tools.

C6 - Assessment and Management of Peristomal Complications

Assessment and Management of Peristomal Complications

Beverly Folkedahl, Margaret Goldberg

Objectives: Participants will:
3.1 Review methods to assess and treat peristomal wound healing
3.2 Describe and explain issues that interfere with the peristomal tissue plane and methods to successfully intervene
3.3 Examine and describe the current literature regarding common peristomal complications such as Pyoderma Gangrenosum, Peristomal Varices etc.

The skin of the peristomal area is a unique surface area that is vital to the successful management of the pouching system. Measures must be taken to keep the skin healthy and intact as use of a pouching system is usually necessary whether skin is damaged or not. Therefore, the skin must be consistently monitored for complications and any interference with pouching system adherence. The goal of the successful pouching system is sustainable, predictable wear time in order to maintain healthy peristomal skin. This session will review situations that deal with the peristomal skin, including healing of the peristomal skin itself in the presence of multiple insults. Conditions that contort or reshape the surface away from pouching system adherence will be described along with interventions toward successful outcomes. There will be a description and discussion of the current literature regarding the most common peristomal complications.

References:

1. Calum Lyon, AmandaJ Smith Martin Dunitz Abdominal Stomas and their SKin Disorders 2001
2. Colwell, J: Principles of Stoma Management. In Colwell, J., Goldberg, M., Carmel, J., editors Fecal and Urinary Diversions Management Principles, St Louis Mosby, Inc 2004
3. Colwell J, Beitz J. (2007) Survey of Wound, Ostomy and Continence (WOC) Nurse Clinicians on Stomal and Peristomal Complications. A content validation study. Journal WOCN 34(1),57-69
4. Geneviève Boll et al Le point sur les stomies Editions Atlas Paris 1998
5. Rolstad, B., & Boarini, J. (1996). Principles and techniques in the use of convexity, Ostomy and Wound Management, 42(1), 24-32.

C7 - The Development of the Canadian Association of Enterostomal Therapy (CAET) Best Practice Guidelines for Fistula Management

The Development of the Canadian Association of Enterostomal Therapy (CAET) Best Practice Guidelines for Fistula Management

Jo Hoeflok, Lina Martins, and Susan Stelton

Objective:

1. To review the development process and the subsequent recommendations for the assessment and care of enterocutaneous fistulas.
2. Explain the benefits of the peer review process in the development of nursing practice recommendations.

Abstract: While Enterocutaneous Fistulas (ECF) may be a common part of nursing practice for Enterostomal Therapy Nurses (ETs), a consistent approach to assessment and management is lacking. Using the Registered Nurses Association of Ontario Best Practice Guidelines process as a template, a national working group was formed by the Canadian Association of Enterostomal Therapy. This group began a comprehensive process to develop the first recommendations for the holistic care of this patient population with challenging ECF presentations. As part of this process, a meta-analysis of the current literature was performed, leading to a set of management goals that will enable the professional nurse to provide care that improves the quality of life of adults living with an ECF in all care settings. This session will describe the process, findings and recommendations for care. These recommendations, as with any intellectual product, will be subjected to the scrutiny of other content experts through peer review.

C8 - Caring for Pediatric Patient with Epidermolysis Bullosa

Epidermolysis Bullosa

Elena Pope, MSc, FRCPC
Assistant Professor of Paediatrics, University of Toronto
Head, Section of Dermatology
Medical Director, Epidermolysis Bullosa Clinic
Hospital for Sick Children, Toronto

Louise Forest-Lalande
CHU Sainte-Justine
Montréal, Québec, Canada

Goal of the session: This session will make the participant familiar with some of the management challenges of patients with EB from birth to adulthood

Abstract: Epidermolysis bullosa (EB) is a severe inherited skin condition that poses significant management problems for practitioners. Each stage of development (from newborn period to adulthood) has unique skin care and medical challenges. A problem based approach, tailored to each developmental stage, from both physician and nursing perspective will be discussed. A multidisciplinary team approach will be presented as an ideal model of care of this complex population of patients. Special emphasis will be placed on the role played by a wound care nurse (recommend a skin care plan, act as a resource person for the families who may feel very isolated because of their child's condition and as a liaison person between the family, various hospital health care providers and community providers).

Objectives: At the end of the session the participant will be able to: Identify the medical and skin care challenges in patients with EB

References:

1. www.debra.org
2. http://ebnurse.org
3. Schober-Flores, Carol Epidermolysis bullosa: the challenges of wound care. Dermatology Nursing April 1, 2003

C9 - Addressing the Challenges of Bariatric Patients with Ostomies

Bariatric Patients and Ostomy Care

Lincoln De Souza and Susan Gallagher Camden

Abstract: As the numbers of obese individuals, and therefore patients, increase so do the numbers of individuals with ostomy surgery. Co-morbidities associated with obesity place the patient at risk for certain predictable complications. The challenge of ostomy care and the obese patient rests in the skill and planning required for physical, emotional and spiritual healing. From the onset the obese individual is at a disadvantage-preoperative planning, including finding an optimal location for stoma placement, to challenges of preventing complications during the intraoperative and postoperative phases of care are important size-sensitive considerations. Concerns regarding pain management, immobility, skin issues, embolic threats and caregiver injury increase when treating the obese patient and must be addressed.

Objectives:

1. Identify the changing demographics of obesity
2. List three comorbidities associated with obesity that influence healing
3. Discuss stoma placement in the patient with a large panniculus
4. Identify two pouching techniques appropriate for larger, heavier patients
5. Design a strategy for monitoring clinical, cost and satisfaction outcomes

References/additional reading:

1. Camden SG. Nursing care of the bariatric patient. Bariatric Nursing and Surgical Patient Care 2006;1(1):21-30.
2. Camden SG. Obesity, organizational policy and education. Bariatrics Today 2005;3:60-63.
3. Gallagher S & Gates J.. Challenges of ostomy care and obesity. Ostomy/Wound Management 2004;50(9):38-48.

C10 - Around the World with the ET Nurse

ET/WOCN Nursing Embraces the World

Janice Colwell, Elizabeth English, and Kathryn Kozell

Objective: Describe the scope of practice and value of three ET/WOCN Nursing Associations respective contributions around the world.

Abstract: 1958 marked the beginning of the practice of Enterostomal Therapy. Aperson with an ostomy, Norma Gill, was recruited by a surgeon, Rupert Turnbull to teach patients with ostomies management techniques and to serve as a role model. By 1961, a formal Enterostomal Therapy program was established, followed in the 70s by the evolution of the field as a nursing specialization. The specialty expanded in the early 80s to include wound and continence care. It is now estimated that approximately 5800 Enterostomal Therapy/Wound, Ostomy and Continence/ Stoma care nurses (ETN/WOCN/SCN) practice throughout the world providing expert, specialized health care. The Canadian Association for Enterostomal Therapy (CAET), The Wound, Ostomy and Continence Nurses Society (WOCN) and the World Council of Enterostomal Therapists (WCET) are professional nursing organizations. Their respective mission statements all share the following, "the provision of specialized, expert, high quality care for individuals with wound, ostomy or continence needs". This presentation will highlight each organization's scope of practice and valued contributions to our specialty and conclude with a vision of collaboration for the future.

References:

1. Blackley P., Future Trends in ET Nursing Internationally. In: Enterostomal therapy nursing; growth and evolution of a nursing specialty worldwide - a festschrift for Norma N Gill Thompson. Erwin Toth P., Krasner D. Baltimore MD. Halgo 1996.
2. Boarini, J, et al. Roles of the ostomy nurse specialist: historical perspective, role potential. In: Fecal and Urinary Diversions: Management Principles. Colwell, JC, Goldberg MT, Carmel JE. St. Louis: Mosby, 2004.
3. Harris C., Shannon, R. An Innovative Enterostomal Therapy Nurse Model of Community Wound Care Delivery: A Retrospective Cost-Effectiveness Analysis. Manuscript accepted for publication January 2008 in JWOCN March/April 2008.

STREAM 4: LEG ULCERS

C1 - Extent of the Problem

Leg Ulcers

Andrea Nelson, David Margolis and Keryln Carville

Chronic wounds of the leg are the most common chronic wounds world wide. The treatment of these wound varies based on diagnosis and available resources. In most countries venous leg ulcers are the prevalent, although diabetic foot ulcers likely contribute to more morbidity and mortality.

This session will provide insight into the epidemiology of these wounds worldwide as well as treatment patterns. In most cases, a team approach is often considered to be essential to assure that the proper care for individuals with leg ulcers.

This session will be didactic but time will also be allocated to provide for an interactive panel discussion.

Leg Ulcers: Australian/Asian Perspective

Keryln Carville, RN, PhD
Associate Professor Domiciliary Nursing
Silver Chain Nursing Association & Curtin University, Australia

Author's Name: Keryln Carville1,2

Author's Affiliations:
1Silver Chain Nursing Association, Western Australia
2Curtin University of Technology, Western Australia

Goals and Objectives: To outline the known prevalence of leg ulcers in Australia and Asia and to compare the attitudes, care and costs associated with living with a leg ulcer in these countries.

Purpose: Clients with leg ulcers constitute a significant care challenge and financial burden for health agencies across all sectors and most countries. Available data on the extent of the problem from an Australian and Asian perspective will be presented.

Methods: A review of the relevant literature and available health statistics was undertaken in order to determine the prevalence of leg ulcers in Australia and our neighbouring Asian countries. To date few comparisons have been made and in some Asian countries leg ulcers are deemed to be inconsequential. However, in Australia leg ulcers comprise 50% of wounds managed by community nursing services. Similarly, general practitioners are called upon to care for an increasing number of leg ulcer clients.

Results: The presentation will detail the known prevalence of leg ulcers in Australia, which is reported to be 1.1% of the population and higher in those aged over 55 years of age. Comparisons will be made with Asia in regard to prevalence and cultural attitudes associated with living with leg ulcers in these countries. The care interventions and recognised costs employed in the management of leg ulcers will also be outlined.

Conclusion: Leg ulcers are deemed to be a common wound of the elderly in Australia and Asia. It is anticipated that the societal and financial challenges will be exaggerated with the aging or our populations.

C2 - Venous Disease

Genetic Components of Venous Leg Ulcers

Paolo Zamboni, Vascular Diseases Center, University of Ferrara, Italy

Wound healing is a multi-step process involving complex pathways at cell and molecular level. This presentation demonstrates how recognition of functional gene variants, mostly single nucleotide polymorphisms (SNPs), significantly involved in wound healing and venous ulcer establishment, extraordinarily help prognosis, diagnosis and treatment of chronic wounds. We deal with on how one can manage SNPs in hemochromatosis (HFE) and coagulation factor XIII (FXIII) genes as molecular markers or prognostic tools. In this fashion, we could pave the way for strategies aimed to single out in advance categories of patients at increased risk to develop severe complications of chronic venous disorders, or to predict the healing time after surgery, compression-advanced dressing, or with their combination.

Foam Sclerotherapy of Superficial Vein Insufficiency in Patients Suffering from Leg Ulcers

Zbigniew Rybak
Department of Vascular Surgery
Wroclaw Medical University, Poland

Background: Sclerotherapy is a method of treatment that has been applied for many years for venous disorders. The effectiveness of this simple method has increased interest in its use. The sclerosing foam (SF) is a mixture of four parts oxygen to one part drug (polidokanol). The foam forms a coherent bolus that passes the blood through the vessel. About 30% to 40% of venous leg ulcers depend upon the insufficiency of either superficial or perforated veins. The possibility of eliminating insufficient veins during one outpatient treatment session has changed the policy of treatment in recent years.

Objective: The objective of the study was to assess the effectiveness of eliminating the venous reflux in incompetent superficial and perforated veins of the leg on ulcer healing in men.

Material and method: 71 patients (93 legs) have been treated for chronic venous leg ulcers over the past ten years. The ultrasound Doppler examination confirmed truncal superficial insufficiency (in 76 legs long saphenous [ LSV ] and in17 legs short saphenous [SSV]). 8 to 10 ml of polidocanol foam was injected into the insufficient veins. The concentration of polidocanol ranged between 2% and, more frequently, 3% (79 versus 14).

The injection was given to the patient in horizontal position with the leg slightly elevated. The SF injection was guided with echo Doppler. After 10 minutes of rest following injection second class compression stockings were applied.

Results: 87% of leg ulcers healed within three months. The one injection of foam was enough to heal ulcers in 73% of patients. 9% of ulcers healed within six months and the remaining 8% within ten months.

Discussion: Insufficient superficial veins of the leg play an important role in venous hypertension and in about 30% of cases is the cause of chronic wounds. Ablation of insufficient veins with SF is a very effective and simple method of treating this confusing disease. When compared to other invasive methods of treatment sclerotherapy is low cost, does not require hospitalization or anesthesia and patients may be treated through outpatient departments.

Conclusion: For patients with venous leg ulcers coexisting with superficial vein incompetence obliteration, there is an opportunity to cure there wounds quickly, safely and without hampering their everyday activities.

C3 - Arterial Disease

Arterial Disease: Nursing Perspective

Mary Sieggreen

Objective: Participants will:
Identify the contribution of nursing in caring for patients with arterial disease.

Abstract: Peripheral arterial disease affects approximately 12% of all adults in the United States, however it is often overlooked because early physical findings are subtle and patients may not complain of symptoms until the disease is advanced. Because it can be a marker for other arterial diseases, even persons without symptoms are at an increased risk for cardiovascular and cerebral vascular mortality.

Early intervention can reduce morbidity and mortality from these diseases but risk factor management is often initiated late in the disease process. The nurse is in a unique position to assess and intervene when a patient presents with peripheral vascular disease. A significant part of the intervention includes patient education and risk management; both areas the nurse is well equipped to address. Nurses should learn to recognize the early signs of arterial disease and should be empowered to initiate risk factor modifications independently.

References:

1. NHLBI Workshop on Peripheral Arterial Disease (PAD): Developing A Public Awareness Campaign. Meeting Summary. Bethesda MD, (2003). US Department of Health and Human Services, NIH, NHLBI.
2. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHAGuidelines for the management of patients with peripheral arterial disease (Lower extremity, renal, mesenteric, and abdominal aortic): Executive Summary. A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing committee to develop guidelines for the management of patients with peripheral arterial disease). J Am Coll Cardiology (2006) 47, 1239- 1312.
3. American Society of Plastic Surgeons. Evidence-based practice guideline: chronic wounds of the lower extremity. Arlington Heights (IL): American Society of Plastic Surgeons; (2007). www.guideline.gov/summary/summary.aspx?doc_id=11513&mod e=full&ss=14
4. Sieggreen M. Arterial Ulcers, Chapter 22, in Lewis PA, Aquila A, Walsh ME (Eds) Core Curriculum for Vascular Nursing. Society for Vascular Nursing. (2007) 368-374. 2007.
5. Hopf HW, Ueno C, Asliam R, Dardik A, Fife C, Grant L, Holloway A, Iafrati MD, Misare B, Rosen N, Shapshak D, Slade JB, West J, Barbul A. Guidelines for the prevention of lower extremity arterial ulcers. Wound Rep Reg (2008) 16 175-188.
6. Vascular Disease Foundation. Risk factors for peripheral arterial disease. Available online at www.vdf.org/PAD_Frame.htm. (2008).
7. Jaffer U, Elmagrabi AW, Cameron A, Osman . Agreement of Community-Performed Ankle Brachial Pressure Incices (BPI) with Vascular Laboratory Performed Assessment. Vascular Disease Management. (2008) 5 (2)71-72.
8. Sieggreen MY, Kline RA, Sibbald G. Arterial Ulcers, Chapter 15, in Baranoski S, and Ayello, EA(Eds) Wound Care Essentials: Practice Principles: Second Edition, (2008) 317-337.
9. Sieggreen MS, Quallich SA. Assessment of the Vascular System, Chapter 51 in Black JM And Hawks JH. (Eds) Medical Surgical Nursing: Clinical Management for Positive Outcomes, Eighth Edition. Saunders Elsevier (2009) 1279-1289.

Arterial Disease: A Surgical Perspective

David L. Steed MD

Wounds cannot heal without oxygen. Intact arterial circulation facilitates oxygen delivery to the tissues. Assessment of arterial supply can be made by history and physical examination and noninvasive vascular laboratory evaluation. In cases in which the arterial circulation appears to be inadequate for healing, arteriography yields anatomic information enabling surgeons to determine if revascularization is best accomplished by angioplasty with or without stenting or bypass grafting. In general, endovascular procedures may present less risk but may not provide the same degree of improvement in blood supply and therefore may not be as desirable. Conversely, bypass surgery may offer a greater improvement in arterial circulation with a longer, more durable outcome yet may be associated with more complications. Revascularization with autogenous vein bypassing all the occlusive disease usually gives the greatest improvement in circulation.

Arterial disease: Medical and Future Perspectives

Peter Vowden
Visiting Professor of Wound Healing Research, University of Bradford
Consultant Vascular Surgeon, Bradford Teaching Hospitals, Bradford, UK

Wound ischaemia is a frequently unrecognised cause of failure or delayed wound healing and can impact on the outcome for both acute and chronic lower limb wounds. When the ischaemic process is related to correctable occlusive arterial disease restoration of distal pulsatile perfusion by either arterial surgery of endovascular radiological intervention provides the best method of management.

There are, however, a number of patients in whom such interventions are not possible. What treatment options exist in this situation? Four basic therapeutic strategies can be employed, either singularly or in combination:

1. Neurovascular intervention such as lumber sympathectomy or spinal cord stimulation
2. Systemic therapy with hyperbaric oxygen or intravenous therapy with agents such as Prostaglandins
3. Local mechanical therapy such as topical negative pressure therapy, electromagnetic stimulation, enhanced local oxygen delivery
4. Topical therapy with vaso-active growth factors or tissue engineered skin products

This session will attempted to outline the role of these, and potential future therapeutic developments, in the management of ischaemic lower limb wounds.

Learning outcome: Ischaemia is a major component in delayed wound healing. Therapeutic options when vascular reconstruction is not possible is limited but may enhance healing and improve patient outcomes.

C4 - Lymphedema

Compression Bandaging for Lymphoedema Management

Christine Moffatt

Patients suffering with lymphoedema frequently require multi-layer compression bandaging as a component of treatment. Much of the evidence about how compression works is extrapolated from research in venous disease and applied to lymphoedma. However there is relatively little research that has examined the different materials and application techniques in use. The treatment algorithms presented in this presentation provide clear clinical recommendations for a number of patient groups requiring compression. The algorithms require practitioners to consider the arterial status of the patient as well as other clinical and psychosocial issues that influence the treatment pathway. Inelastic multi-layer bandaging is required for most patient groups although elastic compression can be used in the very immobile or those with venous ulceration. The algorithm recognises the importance of maintaining stability during the transition stage of treatment before the patient enters the long term management stage that allows for the use of compression hosiery.

Lymphedema: Manual Lymphatic Drainage and Other Treatments

John Macdonald, MD

This presentation will present the essential components practiced today in the treatment of lymphedema. This treatment plan known as Complex Decongestive Physiotherapy (CDP) originally developed in Europe in the 1930`s, involves manual lymphatic massage; compression bandaging; instructed exercise: self care instruction. Clinical cases and statistical outcomes will be presented.

Obesity and Lower Extremity Lymphedema

Caroline E. Fife, MD
Associate Professor, Department of Anesthesiology, University of Texas Health Science Center, Houston, TX
Director of Clinical Research, the Memorial Hermann Center for Wound Healing and Lymphedema Management, Houston, TX

Objective: Participant will understand the way in which obesity affects the development and presentation of lymphedema

Abstract: In the USA, the prevalence of morbid obesity (body mass index greater than 40) is increasing dramatically, along with commonly cited sequelae such as diabetes. Less commonly discussed are the anatomical effects on the legs such as lymphovenous obstruction syndromes, including massive localized lymphedema (MLL). Lymphedema can cause the development of fibromas, recurrent skin infections, and limb distortion due to the deposition of excess subcutaneous tissue in response to inflammation. Adipose tissue can occlude the lymphatics, particularly in patients with lipedema, a genetically linked disease which involves the pathological accumulation of fat on the lower body. Irregularly shaped extremities preclude the wearing of compression garments. Immobility also contributes to dependent fluid collection. The net result is the increasing enlargement of the extremities of the obese individual. Unless the overarching issue of the morbid obesity is addressed, the problems for which these patients are treated will continue to recur.

C5 - Wound Assessment

Wound Assessment: Any Advances?

Raj Mani
Southampton University Hospitals Trust

The concept of wound assessment provokes images of tracing wound contours from which to measure areas, struggling impossibly to measure wound depths and confronted by a mass of mathematical operations to determine which wound size parameter is the most appropriate representative of its status. Is wound size the sole determinant of its status?

Over 20 years, there have been a large number of studies on the use of physical wound measurement as an outcome measure. Smaller but nonetheless significant numbers of report present the use of biochemical or physiological markers such as blood flow, tissue oxygen tension, pH in outcome studies. It is clear that there is no unique formula that would be globally representative of wound outcomes; this would appear to be an unmet need.

There have been some well worked up determinants of wound outcomes reported but does one size fit all?

Leg Ulcers: MEASURE Tool

David H. Keast, MSc, MD, FCFP
Centre Director, Aging Rehabilitation and Geriatric Care Research Centre
Lawson Health Research Institute, London, Ontario, Canada

Goal: The goal of the session is to describe a practical bedside approach to local wound assessment.

Objectives: By the conclusion of this session the participants will be able to apply the MEASURE mnemonic as an aid to a complete local wound assessment.

Abstract: Wound assessment must include a global approach to the patient including environmental and patient centred factors. In this session the MEASURE mnemonic will be used to examine the key components of local wound assessment. An approach using standardized terms is recommended for description of size, exudate, wound bed appearance, pain and edge characteristics including undermining. Various wound assessment tools will be described. The Leg Ulcer Measurement Tool (LUMT) is a validated tool which has been developed to quantify leg ulcer assessment and can be used to track change in wound status over time.

References:

1. Keast DH, Bowering K, Evans W, MacKean G, Burrows C, D'Souza L. Measure: Aproposed framework for developing best practice recommendations for wound assessment. Wound Rep Reg 2004;12:S1-S17
2. Woodbury MG, Houghton PE, Campbell KE, Keast DH. Development, validity, reliability and responsiveness of a new leg ulcer measurement tool. Adv Skin and Wound Care 2004;17:187-96

Leg Ulcers: Special Assessment

Marco Romanelli
Wound Healing Research Unit
Department of Dermatology, University of Pisa, Italy

Measurement of cutaneous wounds in order to detect the progression of a disease is a routine part of medical practice. Advances in both the technology of imaging and computer systems have greatly supported this process and brought it closer to the clinical area. Evaluations are in general performed on the basis of clinical experience, using very basic, low-tech equipment to make objective measurements. Non-invasive wound assessment includes the measurement of perimeter, maximum dimensions of length and width, surface area, volume and determination of tissue viability. A wound can be further described through the use of various parameters, which include the following: duration, blood flow, oxygen, hardness, inflammation, pain, and coexisting systemic factors. These parameters are clues to the definition of the cause, pathophysiology, and status of the wound, but we believe that a complete and detailed history and physical examination are also fundamental.

C6 - Inflammatory

Pyoderma Gangrenosum

Siobhan Ryan

When a patient suddenly develops a painful leg ulcer, the possibility of Pyoderma Gangrenosum is often considered. Because this is a diagnosis based on clinical features with a wide range of presentations and associated co-morbid illnesses, making the diagnosis with certainty can be difficult. A large retrospective study has indicated that the disease may be over diagnosed and a recent re-evaluation of our clinic patient referrals shows that the disease can be easily misdiagnosed. Through a review of the relevant literature and our patient population characteristics, it will be demonstrated that making the diagnosis of Pyoderma Gangrenosum can be made with more confidence.

Vasculitis and Leg Ulcers

Massimo Papi

Objectives: Participants will identify the extent of the vasculitis related leg ulcer, assess the protocol of investigation and examine the main local/systemic treatment

Abstract: Inflammatory ulcers are mainly the outcome of a vasculitic process. Vasculitis is an immunologically-mediated angiocentric inflammation, characterized by neutrophils and lymphomonocyte infiltration, fibrinoid necrosis of the vessel walls and extravasation of red cells. It may result in destruction, thrombosis or fibrosis of the vessel, reduction of tissue blood supply and ischemia. The severity of skin damage is strictly dependent on the dimension of involved vessel. To establish the vasculitic origin of a cutaneous ulcer is usually difficult when other cutaneous clinical markers are absent.

Laboratory and immunological investigation are necessary to assess associated factors and are useful to identify the potential extension of internal organs involvement and the risk of complication. Lesional skin biopsy is mandatory to confirm the diagnosis. Sistemic treatment is based on immunosuppressive, anti-inflammatory and antigranulomatous drugs. Local cure of the vasculitic ulcer has recently enriched with different products and techniques.

Vasculopathy and Leg Ulcers

Robert S. Kirsner, MD, PhD
Vice Chairman & Stiefel Laboratories Professor
Department of Dermatology & Cutaneous Surgery
University of Miami Miller School of Medicine
Miami, Florida

Avasculopathic lesion is the result of a small to medium vessel occlusion that typically occurs secondary to aberrant coagulation and results in livedo reticularis, petechiae, purpura, or ulcers. Frequently, occlusion is caused by a thrombus or embolus and may be precipitated by antibodies directed against regulators of coagulation pathways. Several conditions commonly cause small vessel disease including cryofibrinogenemia, monoclonal cryoglobulinemia and the anti-phospholipid antibody syndrome Cryofibrinogenemia is characterized by cryoprecipitation of the patients' native fibrinogen, fibrin, and fibronectin. Primary cryofibrinogenemia develops spontaneously in previously healthy individuals where as secondary cryofibrinogenemia occurs in association with an underlying infectious process, inflammatory disease, malignancy, diabetes mellitus, autoimmune collagen vascular disease, or thromboembolic disease.

Cryoglobulins are a complex of circulating immunoglobulins and proteins that precipitate in the cold. Cryoglobulinemia occurs when these complexes form thrombi and occlude vessels. By classic definition, three types of cryoglobulinemia exist. Of these one of the 3 typical causes cutaneous thrombosis. The other 2 types typically cause vasculitis.

Antiphospholipid antibody syndrome (APS) is defined by venous and/or arterial thrombosis, thrombocytopenia and recurrent fetal loss. Antiphospholipid antibodies (aPL) are immunoglobulins that are composed of IgG, IgM, or both. APS is associated with aPLs such as anticardiolipin antibodies, anti-?2 glycoprotein I antibodies, and a positive lupus anticoagulant test. APS can present as a primary disease or as a secondary illness associated with an autoimmune disorder such systemic lupus erythematosus, an underlying malignancy, or an infectious disease process.

C7 - Complex Ulcers / Surgical Management

Leg Ulcers: Care Across the Continuum

William J Ennis DO, MBA, FACOS
Professor of Surgery,
Chief Section of Wound Healing and Tissue Repair
Division of Vascular Surgery, University of Illinois Chicago

Often times caring for patients with non-healing lower extremity ulcerations requires the clinician to provide care across a number of clinical settings. In addition, the initial encounter can occur at a number of different clinical sites of care. This presentation will address the concept of the leg ulcer "life cycle" and provide the attendee with some universal guidelines applicable to all care settings. The emphasis must be on arriving at an accurate, timely initial diagnosis regardless of where in the life cycle the patient encounter occurs. The initial diagnosis will drive the therapeutic pathway and when inaccurate, will delay definitive care and prolong the life cycle. The unique aspects of each care setting will also be discussed along with limitations on time, products, equipment, and availability of clinician support. Multiple case examples will be used to emphasize the didactic points made in the lecture.

Leg Ulcers : Optimal Local Wound Care

Dr Sylvie Meaume, MD
Hôpital Charles Foix, 94 Ivry/Seine, France

A complete evaluation of the patient, the wound and the peri-wound skin are mandatory prior to determine the optimal wound care of leg ulcers. Local wound care include cleansing, debridement, periwound skin care, selection of the most appropriate dressing related to the wound bed, aspect, the margin, the peri-wound skin, control of oedema, odors, and pain at and between the dressing change. The beneficial effect of a moist wound environment has been well established for healing rate, pain relief, debridement and comfort. The specific clinical indications of different dressings depend of their physical properties and the practitioner experience, mostly based on open clinical studies. Dressings are classified according to their performance criteria. Expert opinions are determinant, mainly due to the poor level of evidence obtained with randomized control trials. Topical therapy moved from basic devices to bioengineered products or to dressings that may interact with the healing process. These new products still need efficacy and cost effectiveness studies. They represent a new generation of topical care products, progressively included in local wound care management strategies for leg ulcers.

Leg Ulcers: Surgical Approaches

Finn Gottrup
Professor of Surgery
Copenhagen Wound Healing Center,
Department of Dermatology
Bispebjerg Hospital, Copenhagen, Denmark

Introduction: Optimal conservative treatment still has a high recurrence rate.

Purpose: Improve the treatment of leg ulcers using surgical procedures.

Methods: In case of no significant progress in healing after standardised conservative treatment after 3-4 months the patients should be offered a type of surgical procedure. Principally these procedures are based on standardised ulcer surgery (wound revision/excision and split skin transplantation) and surgical treatment of chronic venous insufficiency. Surgery of the veins is performed in accordance to the findings of a preoperative Doppler scanning. In case of reflux in the perforators open surgery or SEPS (Subfasciel Endoscopic Perforator Surgery) is performed (1). All patients are treated by compression bandage postoperatively.

Results: In a material from our centre of more than 400 patients with different types of leg ulcers surgical treated as described 64% was still healed after one year undependable of type of venous insufficiency (2). The surgery and transplantation are found to be cost effective after 10-13 months dependable of type of leg ulcer. The main improvement is the spontaneous disappearance of wound pain.

Conclusion: The optimal way for treatment of leg ulcers is primarily conservative compression therapy. Surgery may, however, be an excellent alternative in non-healing leg ulcers.

References:

1. Gottrup et al. Venous Ulcer Surgery. In. Surgery in Wounds (Teot, L., Bannwell, P., Ziegler, U. eds). Springer Verlag, Heidelberg. 2004: pp. 351-360.
2. Bitsch M et al. Standardised method of surgical treatment of chronic leg ulcers. Scand J Plast Reconstr Surg Hand Surg 2005; 39: 162-169.

C8 - Venous Disease: Compression

Venous Disease: Compression Therapy

Hugo Partsch

Background:Venous disease with edema, skin changes and ulceration of the lower leg is associated with gravity.

Aim: To demonstrate that adequate compression treatment is able to counteract principle mechanisms of this disease process.

Methods: Changes of venous diameter in different body positions and hemodynamic consequences under several compression devices are described using Duplex-ultrasound, plethysmography and measurement of intravenous pressure and of interface pressure.

Results: In mobile patients the hemodanymic improvement in venous disease is mainly based on an intermittent narrowing of superficial and deep veins during walking by stiff compression systems providing adequate pressure peaks.

Conclusion: Compression therapy does not only prevent and remove leg-edema. Bandages with high working pressure are also able to reduce ambulatory venous hypertension

References: Partsch H. Compression therapy of venous ulcers. Hemodynamic effects depend on interface pressure and stiffness. EWMAJournal 2006;6:18-22

Dermatological Aspects of Venous Disease

M. Flour, Dermatology department, Univ. Hospital Leuven

In chronic venous insufficiency resulting in venous hypertension, prominent structural or functional changes occur in the veins and also in the nutritional capillary bed of the skin at the distal portion of the leg, even at the level of the calf. The same process may also damage the initial lymphatic vessels: lymphatic function might be compromised.

Not all CVI patients develop visible skin changes. Signs may include telangiectasia, reticular or varicose veins, edema, and skin changes such as pigmentation, eczema, lipodermatosclerosis and ulceration, as described in the CEAP classification of CVI. RBC extravasation, hemosiderin deposition, and endothelial cell activation represent a stimulus for continued inflammation as well as for tissue remodelling and repair. Migration of neutrophils, macrophages and lymphocytes followed by a proliferation of endothelial cells and fibroblasts presumably participate actively in tissue remodelling leading to dermal fibrosis. Apoptosis of dermal and epidermal cells results in venous leg ulcers.

C9 - Local Wound Care

Venous Disease: Local Wound Environment

M C Stacey, H Wallace
School of Surgery, University of Western Australia,
Fremantle Hospital, Western Australia

The possible causes of impaired healing in venous ulcers are factors intrinsic to the patient, factors intrinsic to the disease process and extrinsic factors that impact on the healing process.

There is an association between venous ulceration, and specific genetic polymorphisms - such as the promoter for tumour necrosis factor alpha gene (TNFA-308A), and fibroblast growth factor receptor-2. Individuals may be genetically more prone to develop wounds and may have a lesser ability to heal wounds.

The underlying cause of venous disease can be treated by compression therapy. However, little is known about what is needed at a molecular or cellular level to improve the healing in these wounds.

Extrinsic factors such as colonising bacteria may directly influence many of the cellular mechanisms that are important in wound healing. Little work has been done to accurately evaluate the role of colonising bacteria in the healing of chronic wounds.

Local Wound Care: Topical Antimicrobial Dressings

Sharon Baranoski

Chronic venous insufficiency is the most common cause of leg ulcers. They account for 70%-90% of all lower extremity ulcers. Incidence increases with age especially in those over 65. Patient with venous ulcers often have a history of having them for 5 to 10 years. Venous ulcers cause pain, limit activity of daily living and affect overall quality of life.

Our skin serves as a barrier and functions as a primary defense mechanism against infection. Certain conditions, such as, venous ulcer disease may predispose patients to infection. The nature and severity of the infection depend on the type of organism. Venous ulcers provide an ideal environment for colonization by microorganisms. Taking steps to manage infection is one of the key principles in wound bed preparation. This lecture will discuss the use of topical antimicrobials on venous ulcers.

Leg Ulcers and Natural Products for Healing

José Contreras-Ruiz

Healing of leg ulcers involves treating the underlying cause (compression for venous and revascularization for arterial), addressing patient-centered concerns, and proper wound bed preparation. A number of "natural therapies" have re-emerged in the care of patients with leg ulcers. The evidence on these therapies is building up rapidly as more research has become available in maggot debridement therapy, honey, mimosa tenuiflora (a.k. tepescohuite), among others. During this presentation, we will provide the attendee with the latest evidence on these and other therapies that are currently in use or being researched for the care of patients with leg ulcers.

Leg Ulcers and Dressing

Elia Ricci
Wound Healing Unit
St. Luca's Clinic Pecetto Torinese, ITALY

"Leg ulcers" is one of the more difficult areas of wound Care; in this location we can relieve all the different type, or etiology, of ulcers. To approach this "anatomical" type of ulcers, it is necessary considered, first of all, the diagnosis to obtain an adequate treatment; the general situation, and at the end we can start with dressings or local treatment. Dressing will be performed according the protocol of WBP and TIME to obtain conversion of a chronic wound in an acute able to heal. To dress the leg is important considered the relationship between the dressing employed and the secondary dressings or bandages. In second line we need control the exudate that, in this place, is strongly determined from life habit. Finally, to evaluate the choice of dressings in leg's ulcers, in this area, venous stasis, arteriopathy, oedema and inflammation are more common than in other parts of human body.

C10 - Complementary / Advanced Therapy

Leg Ulcers and Effects of Adjuvants

Valentina Dini, MD
Wound Healing Research Unit, Department of Dermatology
University of Pisa, Italy

Venous leg ulcers (VLUs) pose a serious clinical dilemma and an economic burden on health services. They are frequently associated with morbidity, pain and decreased quality of life in affected patients. The therapy of VLUs represents a medical challenge. Whenever possible, therapy should be causal, including compression and moist wound healing. The reasons for the lack of response to treatment of hard-to-heal VLUs have not yet been fully elucidated, although scientific and clinical research indicates that, instead of progressing through the four distinct but overlapping phases of healing (haemostasis, inflammation, proliferation and remodelling), these wounds become 'stuck' in a prolonged inflammatory phase. Vacuum Assisted Closure (V.A.C.) therapy has been successfully used in several phases of the treatment of venous leg ulcers. Positive effects of the V.A.C. therapy, such as reduction of oedema, drainage of wound exudate and acceleration of granulation tissue formation are the reasons for recommending V.A.C. therapy in order to improve the healing rate. The securing of meshed skin grafts is another indication for this type of treatment. The application of V.A.C. therapy should be based on the following criteria. In the presence of highly infected and moderately to heavily secreting ulcers a polyurethane foam should be employed with a continuous suction pressure of 125 mmHg. Because of its hydrophilic properties, the white polyvinyl alcohol foam is suitable for the support of meshed skin grafts. The compression bandage should be applied while V.A.C. therapy is in progress. Cotton bandage padding, consisting of several layers, is advisable especially in the area of the trac-pad connector to prevent pressure changes. V.A.C. therapy can be useful in hard-to-heal venous leg ulcers in order to promote a faster granulation tissue formation and decrease the costs associated with the treatment of the chronic wounds patients.

References:

1. Vuerstaek JDD et al. Anew concept in active healing of mixed or resistant venous ulcers: Vacuum assisted closure. A3 years experience. Phlebologie 55(1): 15-19, 2002.
2. McGuckin M et al. Validation of venous leg ulcer guidelines in the United States and United kingdom. Am J Surg 183(2): 132-7, 2002.

Leg Ulcers, Electrical Stimulation

Joseph McCulloch, PT, PhD, FAPTA, CWS, FACCWS

The purpose of this presentation is to present an overview of the development of electrical stimulation as a biophysical energy used to facilitate wound healing. Electrical properties of the body have been known since the 1800s and topical applications of various forms of electrical stimulation have been used for decades in the treatment of leg ulcers. This talk presents an overview of the history of therapeutic electricity and how its use has evolved to the present day. The presentation is supported by basic science and clinical research evidence of the effectiveness electrical stimulation in wound repair.

Leg Ulcers, Ultrasound and Other Modalities

Pamela E. Houghton BScPT, PhD

The purpose of this presentation is to review information that is necessary to make an informed, evidence based decision regarding the use of therapeutic modalities for treatment of chronic wounds. Physical modalities such as ultrasound, ultraviolet light, hydrotherapy, and pneumatic compression therapy have all been indicated in the treatment of chronic leg ulcers. This presentation will review clinical research evidence and proposed mechanisms of action on healing of these physical therapies with a focus on therapeutic ultrasound. Recent best practice guidelines of Registered Nurses Association of Ontario (RNAO) and Canadian Association of Wound Care (CAWC) recommend that therapeutic ultrasound to stimulate a healing of chronic leg ulcers (Level A). Meta-Analyses and clinical trials also suggest therapeutic ultrasound can significantly reduce the size of chronic leg ulcers due to venous insufficiency. Experimental research evidence suggests that ultrasound can stimulate new tissue growth, augment wound tissue strength, and/or stimulate inflammatory cell function.

STREAM 5: ACUTE WOUNDS

C1 - Burns:Classification and Treatment

Burns Classification

Allen Holloway

Many systems of classification and clinical evaluation of burns have been proposed over time. None, however, has been proven to be superior and to this date there is no "gold standard". The ultimate goal is to predict healing with no or minimal scarring, and many different "measurement" systems to provide this result have been proposed and tested. It is the goal of this presentation, in its limited time frame, to review what currently are considered the most important of these and the evidence supporting their use in the care of the burn victim.

Burns Treatment

Joel Fish

The treatment of burns has evolved significantly over the past few decades with the advent of modern wound dressings and also the availability of both biological therapies and silver based products. Burns can now be more effectively treated and our knowledge base has increased significantly with the development of these new approaches.

Burn Management: Some Common Principles in Developed and Developing Countries

Fu, Xiaobing MD
Professor, Burn Institute, the First Affiliated Hospital, The PLAGeneral Hospital,
Trauma Center of Postgraduate Medical College, P. R. China

Burn disasters are most frequently seen in modern society and their prevention and management need to be more scientific basis and technique supporting. In developed and developing countries, for truly effective burn management, the key is prevention and preparedness rather than a post hoc fire fighting type of emergency response. It has been established some principles for the scientific basis of disaster management, such as prevention, preparedness, disaster profiles, disease patterns, planning and preparation for effective multidisciplinary response, mobilization of multisectorial manpower resources, risk assessment, post-emergency phase, reconstructive phase, and the community and local/national institution involvement. These common principles can be used as the guideline to total burn care. For the emergency and initial care, the ABCs principles should be followed: For the care of outpatient burns, the first step is to remove the source of heat and to cool of wound to dissipate heat. These can be done for all of burned victims and the people. Whether topical antimicrobials and pain control are used depend on the burn area and deep. The management of blisters is varied in different burn centers and range from leaving blisters intact or to removing the blistered skin. Although early dressings serve three purposes such as to absorb drainage, to provide protection and to decrease wound pain, there is no necessary to use dressings and topical medicines in superficial partial-thickness burns. Usually, these wounds can be simply covered with a clean sheet. In some severe burns, the order of treatment is to ensure an adequate airway and ventilation for each burned victim. The prompt fluid replacement is necessary in order to counteract the loss of protein-rich fluid into interstitial tissues. Thus, the IV infusion should be set up to offer the possibility to keep enough circulation fluid. Although there are many different methods and fluid choice for resuscitation, the adequate resuscitation is the key to a better survival rate among similar groups of patients in many countries. The debridement of burn tissue can be done as early as possible, even in the stage of shock with a good circulation monitored. But it is not necessary initially in many developing countries, and it can be done within the first 5 days postburn once a patient has reached an appropriate facility. There are many choice for wound dressings and their application should be followed the principles such as simple and effective.If a patient must remain for a period before triage, the wounds can be covered with dressings impregnated with silver sulfadiazine or some other effective topical agent and gauze in place for the transfer. In the early or later stages, application of skin grafting or some other artificial skin materials, such as artificial dermis may offer the best opportunity for better future outcomes.

References:

1. David Herndon, et al. Total burn care. Elsevier Science Limited (2002)
2. New perspective in burns: shock, infection, nutrition, repair and regeneration, Z.Y. Sheng, Z.R. Guo, Eds. (Tsing Hua Press, Beijing), p2 (2005)

C2 - Burn Prevention and Education

Burn Prevention:Review of the Literature

Bishara S. Atiyeh MD, FACS
General Secretary, Mediterranean Council for Burns and Fire Disasters - MBC
Clinical Professor, Plastic and Reconstructive Surgery
American University of Beirut Medical Center, Beirut, LEBANON

Michel Costagliola, MD
Department of Plastic Surgery, University of Toulouse, Toulouse, FRANCE

Shady N. Hayek, MD
Fellow, Plastic and Reconstructive Surgery
University of Minnesota, Minneapolis, MN, USA

Burns are responsible for significant mortality and morbidity worldwide and are among the most devastating of all injuries, with outcomes spanning the spectrum from physical impairments and disabilities to emotional and mental consequences. Management of burns and their sequelae even in well-equipped, modern burn units of advanced affluent societies remains demanding and extremely costly. Undoubtedly, in most low and middle income countries LMICs with limited resources and inaccessibility to sophisticated skills and technologies, the same standard of care is obviously not possible. Unfortunately, over 90% of fatal fire-related burns occur in developing or LMICs with South-East Asia alone accounting for over half of these fire-related deaths. If burn prevention is an essential part of any integrated burn management protocol anywhere, focusing on burn prevention in LMICs rather than treatment cannot be over-emphasized where it remains the major and probably the only available way of reducing the current state of morbidity and mortality.

Like other injury mechanisms, the prevention of burns requires adequate knowledge of the epidemiological characteristics and associated risk factors, it is hence important to define clearly, the social, cultural and economic factors, which contribute to burn causation. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs) such as the United States due to sustained research on the epidemiology and risk factors, the same cannot be said of many LMICs. Many health authorities, agencies, corporations and even medical personnel in LMICs consider injury prevention to have a much lower priority than disease prevention for understandable reasons. Consequently, burns prevention programmes fail to receive the government funding that they deserve.

Prevention programmes need to be executed with patience, persistence, and precision, targeting high risk groups. Depending on the population of the country, burns prevention could be a national programme. This can ensure sufficient funds are available and lead to proper coordination of district, regional, and tertiary care centres. It could also provide for compulsory reporting of all burn admissions to a central registry, and these data could be used to evaluate strategies and prevention programmes that should be directed at behavioural and environmental changes which can be easily adopted into lifestyle. Particularly in LMICs, the emphasis in burn prevention should be by advocating change from harmful cultural practices. This needs to be done with care and sensitivity.

Key Words: Burn prevention, active prevention, passive prevention, prevention campaign

Burn Education

Richardo Roa

Chilean Experience:
In the 1950´s in Chile mortality rates for Burn patients were 10 times higher than average rates of industrialized countries. At that time it was the third highest cause of death. Realizing this, prevention and education programs became part of public health policies. In the 1960´s Chilean Society of Plastic Surgery organize a Burn Chapter that later included other health care professionals becoming Chilean Burn Association which regularly dictates courses focused on initial care of the burn victims based on Advanced Life Support course from American Burn Association throughout the country.

Non governmental organizations were also created in order to facilitate media campaigns to educate and prevent burns accidents in the house and in the work place, impacting both incidence and mortality rates, thus resulting in the same rates as other industrialized countries.

C3 - Infected Burns

Infected Burns

Luc Téot

Burns are considered as potentially infected as soon as the skin basal membrane is involved. Infection should be prevented in any second degree burns until the exact deepness has been clinically established ( uncertain before the 3rd day post burns).

Two different types of infection will occur in burns:

1. multibacterial contamination of extended surfaces of burns, when the patient is infected ( lungs, viscerae, urines, catheter). This septicaemic contamination induces a surinfection of burns, destruction of the previously positionned skin graft, deepening of the burns. Systemic antibiotherapy will be given, adapted to the biopsy cultures and antobiograms, the resistance of germs to antibiotherapy being one of the main difficulties ( multiresistant pseudomonas, acynetobacter baumanii, enterococcus)
2. local infection due to previous unappropriate local management of burns. This situation can be treated locally, by an active debridement ( mechanical repeated every two days, pulsed hydrojets, etc..) followed by application of a skin graft.

Infection control is a permanent issue in burns and a strict respect of the protocoles of prevention must be obtained.

Clinical Aspects of Diagnosis and Treatment of Infected Burns

Stephan J. Landis, MD, FRCP(C)

About 8% of all burn injuries are hospitalized, while 1 in 10 of hospitalized patients dies of his/her burns. The American Burn Association has recently published criteria for sepsis and wound infection. Local signs of burn wound infection include conversion of a partial-thickness injury to full-thickness wound, worsening cellulitis of surrounding normal tissue, eschar separation, and tissue necrosis.

Microorganisms which influence the risk of invasive disease include: MRSA, Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella spp.

Burns alter not only the innate immune character of the skin but also other arms of the immune system, including T-cell activity, levels of inflammatory cytokines, cellular chemotaxis, and phagocytosis and killing by neutrophils. The eschar is avascular, preventing immune cells and systemically administered antibiotics from being delivered to the site of infection.

Key factors that improve outcome and prevent infection include: early burn eschar excision, topical and systemic antibiotics as well as, focussed infection control measures.

Cultures from Burn Patients: The Use of Quantitative and Qualitative Cultures

Ricardo Roa

The knowledge of the bacteriological condition in wounds of burned patients allows proper planning and accurate surgical decisions in terms of procedures and the precise timing for them.

The existence of bacterias on the surface of the wound does not mean the same ones are present in deeper layers of the wound. There is a tendency to treat a positive qualitative culture result, which does not always mean the presence of a tissue infection. In most cases, this is only a superficial contamination. The antibiotic treatment of it generates a bacteriological resistance, making the overall treatment more difficult and expensive. As published in Burns magazine in 2004, where more than 5.000 cultures were analyzed, the correlation between qualitative and quantitative cultures of the burns´ wounds was only 50%. Based on clinical experiences and research, it is not recommended to use qualitative cultures in the treatment of the burned patients.

A Scientific Approach to Burn Therapy and Innovation

Robert E. Burrell, PhD
University of Alberta, Edmonton, Alberta

Important contributions to burn patient survival, based upon sound scientific approaches, include improved fluid resuscitation, improved infection control and early excision and closure. While all of these improvements have improved survival rates dramatically, the single leading cause of morbidity and mortality is still infection. Survival is further impacted if inhalation injuries are present. In the case of the burn survivor, scarring and functionality of tissue are major issues. It is these problems that drive much of the research and innovation that is occurring in the burn treatment world. To develop new approaches it is critical that the underlying principles of wound repair and regeneration are understood and that we use appropriate models to evaluate new technologies/therapies before they are used in clinically. In this talk I will compare and contrast two approaches used to evaluate new technologies and show why it is critical to use a rational scientific method.

C4 - Scarring for Surgery and Burns

Basic Research Burns: Scarring and Angiogenesis

Gus McGrouther

Skin scars vary from a fine line which is the best outcome that surgery can achieve to a variety of abnormal scars. Scarring can cause physical, cosmetic and psychosocial consequences producing significant emotional and financial costs to the patient, physician and the health-care system. This talk reviews the spectrum of abnormal scar types, and offers advice on assessment and treatment with current and potential future therapies.

It also describes the process of wound healing and highlights some of the key recent advances in this field of research. It emphasizes the importance of cell-cell and cell-matrix interactions, particularly relating to the role of cell surface adhesion molecules. Since cytokines play an important role in regulating cell function such as proliferation, migration and matrix synthesis, it is the balance of these mediators which is likely to play a key role in regulating the initiation, progression and resolution of wounds.

Scarring from Surgery and Burns: The Translational Approach

Colin Song
Associate Professor, Singapore General Hospital
President: Asia Wound Healing Association & Wound Healing Association Singapore

Basic Research in scar formation, evolution, manifestation and development especially in abnormal category has allowed greater insight into the science. Despite this the manipulation of scars remain a less than ideal state insofar as the clinical conundrum of scar contracture is concerned

In the management of abnormal scarring in surgery, a number of developments have emerged. This can be considered in the following categories:

1. Prophylaxis
2. Hypertrophic Scarring
3. True Colloids
4. Burn Scar Contractures

Prophylaxis
In surgery planning of access incisions is very much about the appreciation of lines of least tension (Langer's lines) and minimizing tension. Notwithstanding minimal access surgery. Techniques such as presuturing and suture technologies have made modern wound management that much less of a challenge insofar as prevention of normal scar sequelae.

Hypertrophic Scars
Assessment of scar modifiers using objective measures such as tissue oxygen tensiometry and colour hue match has given us some insight into natural scar behaviour. Findings of such a study will be highlighted.

Keloids
While the biochemical and molecular characterization continues to be elucidate in a multitude of studies and the work in Singapore understanding specifically dermo-epidermal kinase interactions it now remains to look at translational research efforts to see true efficacy of this difficult problem.

Burn Scar Contractures
The key in this real clinical conundrum remains preservation of dermis. Dermal substitutes held great promise; the clinical picture emerging is one of delayed fibrogenicity but in a more predictable location. Emphasizing therefore the dermo-epidermal interaction in control up regulation of collagenase expression while down regulation of praline hydroxylation would perceptibly control fibro genesis.

C5 - Research and Biologics in Acute Wounds

Role of Keratinocytes during Wound Healing

Marjana Tomic-Canic, PhD

The essential role of keratinocytes is to maintain the epidermal barrier. However, when the barrier is disrupted keratinocytes activate the process of epithelialization in order to restore it. Therefore, keratinocytes are among the most potent cells in their ability to respond to injury and accelerate healing and are used as highly efficacious therapy for patients. They accomplish this function by 1) releasing cytokines that recruit other cells to heal a wound, 2) releasing growth factors that stimulate collagen formation and angiogenesis, 3) by providing several types of potent skin stem cells that participate in healing and 4) by migrating into and proliferating in a wound to accelerate closure. In contrast, keratinocytes at the non-healing edge of chronic wounds show pathogenic activity of genes, such as c-myc and ?-catenin, which inhibit their migration. Such differences between acute and chronic wound keratinocytes provide the biological foundation for debridement.

The Effect of Recombinant Human Epidermal Growth Factor (rh-EGF) in Multiple Clinical Situations

Joon Pio Hong, M.D., Ph.D., M.M.M., Sang Kil Lee, Ph.D., Sun Hee Kim, M.S., Kyung Hyun Min, M.S.*, Sang Wook Lee, M.D., PhD
Department of Plastic Surgery, Asan Medical Center, Univeristy of Ulsan, Seoul, Korea

The use of growth factors in chronic wounds is not new. When combined with the right management, it may facilitate closure. Currently the use of recombinant human PDGF (platelet derived growth factor) has been considerably successful in promoting wound healing in diabetic foot ulcers. Other growth factors such as epidermal growth factors are now undergoing clinical trials.

Epidermal growth factor (EGF) was discovered in mouse salivary glands in 1962 and was the first growth factor to be described. It interacts with the EGF receptor on epidermal cells and fibroblasts. It is produced by platelets, macrophages and monocytes and its primary role is to stimulate epithelial cells to grow across the wound but also acts on fibroblasts and smooth muscle cells. EGF has been reported to significantly accelerate epidermal regeneration of partial and full thickness skin wounds in pigs, and continuous or prolonged exposure of EGF to increase tensile strength in rat skin wounds. EGF stimulates epithelialization in early human wound repair and is reported to enhance healing in chronic wounds such as diabetic foot.

This presentation will focus on epidermal growth factors in various applications such as diabetic foot, radiation induced oral mucositis and acute wound healing. Also, animal studies of epidermal growth factor combines with chitosan film will be presented focusing on possible future of chitosan's antibacterial role.

C6 - Non Healing Post Surgical and Abdominal Wounds

Non Healing Postoperative Abdominal Wounds

Prof. V. K. Shukla, Department of Surgery, Institute of Medical Sciences, Banaras Hindu University and Medical Superintendent, Sir Sundarlal Hospital, Banaras Hindu University, Varanasi, INDIA

Post operative abdominal wound is one of the common problems encountered by the surgeons. Most of these wounds are caused by infection heal by themselves and only a small percentage become chronic and non healing. These are after associated with a focus of intra-abdominal sepsis. The diagnosis is based on imaging studies including dye studies, wound culture and study of various molecular markers. The treatment depends on the cause. Several new techniques like Epidermal growth factor, in vivo transfer of EGF gene, treatment in a liquid environment using transparent vinyl chamber glued to the skin on the periphery of wound, repair by autologus tissue transfer, negative pressure wound therapy, vacuum assisted closures and angiogenic factors are being tried with good results. However the best is to prevent these wounds by using state of the art surgical techniques that will reduce the morbidity, mortality and the cost associated with these wounds.

Use of Flaps and Grafts for Post-surgical Wounds

Harold Brem, MD
Chief, Division of Wound Healing & Regenerative Medicine
New York University School of Medicine

Currently nearly all wounds can be expected to heal as measured by a decrease in area or by closure without drainage.. Skin grafts or myocutaneous flaps posses the advantage of resulting in immediate closure, however they are mostly unsuccessful in presence of infection or scar. Proper wound bed preparation includes debridement of the non-healing edge, which possess biochemical signals that impair healing. Further debridement to the base to the level of an absence of scar and infection. Growth factors and topical collagen for both wound bed preparation and permanent closure are efficacious options. Cellular therapy with keratinocytes and fibroblasts in type 1 collagen, also known as Human Skin Equivalent, accelerates closure of multiple types of wounds. In this lecture we will highlight data of which types of surgical wounds benefit from the specific biologic therapies and/or autologous grafts.

C7 - Surgical Site Infections

Infection Control Measures

Luc Téot

Surgical site infections causes delayed hospitalization, inducing high costs in term of medical outcomes. The mean rate of SSI is around 2.8% in developed countries, depending on the operated anatomical region, and the prevention protocol developed in each country. Prevention is done by limiting the risk of transmission of germs, based on a systematic hand frictions using biocid antibacterial, antifungicide and tuberculocid agents, active on HIV1, PRV, BVDV, herpes virus, rotavirus, etc.

Other policies like adapted sterilization protocols of operating rooms and clinic areas should be developed, especially when dealing with chronic wounds, where polybacterial floras are present. SSI can be superficial (60%), subcutaneous (25%) or occuring at the operated organ level (15%). Reopening the infected site is a rule, and can be followed either by "leaving open" and drain using negative pressure therapy, or drainage after extensive lavage and skin closure.

Alarge program of infection control measures should reduce the rate of SSI, which remain a real problem in most of the western hospitals, due to the increasing rate of methiresistant staphylococcus (close to 50% in some countries).

Surgical Site Infections - A European Perspective

David Leaper, Professor

Surgical site infection (SSI) causes a fifth of Healthcare Associated Infection and depends on adequate definition and post-discharge surveillance. The categorical definition of SSI used by the Centers for Disease Control (CDC) is not as useful as continuous data provided by ASEPSIS, which differentiates trivial from life-saving infections. If SSI data is collected for inter-healthcare institution comparisons, or economic analyses, it must have clear definitions and methods of data collection using trained, unbiased observers, extending for a minimum of 30 days (a year after prosthetic surgery).

The reported range of SSI in Europe varies widely from 1.5 to over 20%. SSIs after clean wound, usually day-case, surgery are underestimated as patients are increasingly allowed home before SSIs are apparent and the value of prophylactic antibiotics is controversial. The economic burden to the European Healthcare systems is likely to be between €1.4b to over €15b annually which could be preventable.

References:

1. The effects of preoperative warming on the incidence of wound infection after clean surgery. Melling AG, Ali B, Scott EM, Leaper DJ Lancet 2001; 358: 876-880.
2. Surgical site infection - a European perspective of incidence and economic burden. Leaper DJ, van Goor H, Reilly J, Petrosillo N, Geiss HK, Torres AJ, Berger A. International Wound Journal2004; 1: 247-273.
3. European Wound Management Association (EWMA) Position Documents: Identifying criteria for wound infection. London: MEP Ltd, 2005. Management of wound infection. London: MEPLtd, 2006.

Surgical Site Infections: A Nurse's View

Heather. L. Orsted

In Canada the full extent of surgical wounds care in the community is not known. Of the three million patients admitted each year to the 744 Canadian hospitals there are no accurate statistics as to how many patients have undergone surgery and what proportion of these surgical wounds experience healing failure. 75% of surgical procedures are now estimated to occur in the outpatient or ambulatory setting, and for those that do occur in the inpatient setting, postoperative length of stay is decreasing. It is estimated 47% to 84% of surgical site infections (SSIs) occur after discharge; most of these are managed entirely in the outpatient setting. With only a fraction of hospitals reporting that they perform SSI surveillance after the patient's hospital discharge a large percentage of SSI's remain unrecognized leading to an under-estimation of the SSI rates. We do know from two studies conducted in Ontario and Manitoba that the prevalence of all types of chronic wounds is between 34-37% of persons receiving community care. In Ontario, Canada (population 13 million) it is estimated that in 2002 there were approximately 6 million community nursing visits. The most common causes reported for the visits were post operative wound infection and cellulitis. Pieper reports on thirteen Home Care agencies in Michigan, that 62.4% of wounds cared for in the community were surgical wounds. The cost for caring for surgical site infections is thought to be between 1 to 10 billion dollars in direct and indirect medical costs each year.

This session will explore the significance of the problem of surgical site infections post discharge and identify strategies to integrate best practice of surgical wounds into the community setting.

Resource:
Orsted HL, McNaughton V, Whitehead C. Management and Care of Clients with Surgical Wounds in the Community. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care 4th ed. Malvern, PA: HMPCommunications.

References: CIHI http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_08jun2 005_2_e Accessed October 18 2006

Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and Economic Impact of Surgical Site Infections Diagnosed after Hospital Discharge. Emerging Infectious Diseases 2003;9(2): 196-203.

Weiss CA, Statz CL, Dahms RA, Remucal MJ, Dunn DL, Beilman GJ. Six Years of Surgical Wound Infection Surveillance at a Tertiary Care Center. ArchSurg. 1999;134:1041-1048.

Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian health-care settings. Ostomy/Wound Management. 2004;50(10):22-38

(http://www.fhs.mcmaster.ca/slru/paper/WPS0501WebAbstract.pdf accessed October 18) Pieper B, Templin TN, Dobal M, Jacox A. Wound prevalence, types, and treatments in Home care. Advances in Wound Care. 1999 Apr;12(3):117-26

Cantrell S. Help the wounded: caring for surgical sites. Healthcare Purchasing News, March, 2006

C8 - Wound Complications of Vascular Surgery

Venous Surgery and Complications

Professor Peter Vowden, MD FRCS
Consultant Vascular Surgeon and Professor of Wound Healing Research
Bradford Teaching Hospitals and University of Bradford, Bradford, UK

Chronic venous disease is common and as such has major implication for patients and health care providers. For the majority of patients superficial venous disease is unsightly but has few other long-term consequences. For others it can cause progressive skin changes and ulceration. Increasing evidence favours timed superficial surgical intervention with either conventional, endoluminal or foam sclerotherapy as a primary treatment to reduce ulcer recurrence and improve skin condition although it may not directly influence ulcer healing. Complications after treatment of superficial venous disease are uncommon, ranging in severity from life-threatening thromboembolic events, through superifical nerve damage and pain, particularly in the area of the saphenous and sural nerves, to wound infection skin pigmentation and venous flare formation.

The surgical management of deep venous disease is more challenging. Venous bypass procedures and valvular repair have a place in the selective management of some patients but have not been widely adopted as their long-term success and durability remains in question. Surgical and thrombolytic management of thrombotic disease has however been more successful and has a role in the management of deep vein thrombosis.

Arterial Surgery and its Complications

David LSteed, MD

Arterial occlusive disease is commonly seen in patients with diabetes, hypertension, hyperlipidemia, and a history of smoking. In patients with ischemic ulceration or gangrene, common comorbid conditions include atherosclerosis of the coronary, cerebral, and renal arteries; myocardial infarction, stroke, and renal dysfunction are often seen in these patients and occur more frequently in the perioperative period. Complications can be minimized by careful evaluation and screening preoperatively as well as good perioperative care. The patency rate for each revascularization procedure can be predicted, to some degree, by inflow and outflow sites, choice of conduit, and patient's preoperative status. Limb salvage, including ischemic rest pain, ulceration, or gangrene, are the strongest indications for arterial surgery.

Nursing Issues with Past Vascular Surgical Wounds

Kathryn Vowden, MSc BSc(Hons) RN
Nurse Consultant
Bradford Teaching Hospitals and University of Bradford, Bradford, UK.

Delayed or non-healing of a lower limb wounds is a potential complication for any patient with compromised peripheral arterial perfusion or significant venous disease. In such situations infection is a major concern as it may compromise any prior arterial surgery especially if a synthetic graft is present. Decision-making and appropriate treatment will affect patient outcome, pain, anxiety and hospital stay. These patients require not only effective wound care but also social and psychological support to optimise outcome and maximise their quality of life. This is particularly the case for those patients with an altered body image following amputation.

Optimising wound healing in the presence of ischaemia requires an integrated multidisciplinary approach with a focus on symptom control, the avoidance of dressing related complications and wound bed perfusion optimisation. Many factors need to be considered such as the effectiveness of revascularisation, the type of graft material used and the need for compression therapy as part of the treatment of venous or mixed lower limb ulceration. For some patients moist wound healing may not be a realistic goal and in such situations establishing mummification with hard dry eschar may represent the best treatment option. Dressing strategies for both forms of management will be outlined and supported with case examples.

C9 - Traumatic and War Wounds

Traumatic Wounds

Luis Fernando Lira

Objectives:

1. Knowing the different mechanisms of acute injuries
2. Avoid complications of these injuries
   1. Early Infection, dehiscence, necrosis, abscess.
   2. Delayed: Injury or chronic ulcer, fistula, abscess, osteomyelitis.
3. Knowing the various treatment options
4. How to choose the best option for each individual case.

Between 15 and 20% of the total killed by trauma will result from infectious complications. Of those patients who survive the first 48 hours and then die, 50% is a result of infection, and those who survive after 7 days and 75% die from infection.

Risk factors related to the type and mechanism of injury:
The record of how, when and where the trauma occurred must be carefully assessed. The amount of damaged tissue, lacerations, ischemia, necrosis, bruises, foreign bodies and pollution from the environment, must be carefully evaluated to avoid causing further damage in the initial evaluation.

Shall be checked bleeding, use clean dressings, align and immobilize bone fragments (in the case of fractures, etc.). Up to the patient to a surgical means adequate.

Soft injuries as their kind in abrasions, burns, contuses, cutting short blunt, drilling, avulsion or uprooting, crushing and / or amputation.

Knowing the origin of the injuries we have to establish the appropriate treatment to seek redress for the damage as soon as possible. The sooner will make the final closure of the wound, will be more likely to avoid drying of the tissues and limit pollution tissue trauma and additional injuries (fractures). However, we must bear in mind that injuries extensively contaminated, the best tactic to avoid infection of the tissues is precisely the closure of the same deferred. The injured by high-speed projectiles, producing a halo of injury and destruction from highest to lowest speed of the projectile, it must be considered debridement of injured tissues.

The best treatment option will always make an early surgical closure of the injury, where it can be done, looking at first instance surgical closure for the first intention, resection of injured tissues, performing adequate release of the edges and even rotation flap local, regional or distant and free flaps coupled with the implementation of this with skin grafts when he indicated for the closure of such injury .

Without power made the primary closure, must be kept clean and well-hydrated tissues to promote the closure through secondary granulation tissue and epitelización addressed. This can be done based topical treatments, dressings, supported by support teams as the VAC, Hyperbaric Oxygen Chamber, hyperthermia or others, according to the possibilities and conditions of each patient.

The fundamental aim of surgical treatment is to provide coverage and sensitivity to surfaces mainly those bearing loads, in the case of lower extremities. Recalling the first instance which is to preserve life, the role and then finally aesthetics, without forgetting that what works well is finally beautiful.

Inflammatory Cytokine, Chemokine Expression, and Quantitative Bacteriology and Wound Failure in High-Energy Penetrating War Injuries

Stojadinovic A, Hawksworth J, Gage F, Tadaki DK, Perdue PW, Forsberg JA, Davis T, Dunne JP, Denobile JW, Brown TS, Elster EA

From the Combat Wound Initiative Program; Department of Surgery, Walter Reed Army Medical Center, Washington D.C.; Uniformed Services University of Health Sciences, Bethesda, MD; Regenerative Medicine Department, Combat Casualty Care, Naval Medical Research Center, Silver Spring, MD; Department of Surgery and Orthopaedics, National Naval Medical Center, Bethesda, MD

Background: High-energy penetrating war injuries generate complex, wounds characterized by heavy polymicrobial colonization, notably Acinetobacter baumannii. The cornerstone of treatment remains aggressive repetitive debridement of necrotic tissue, foreign material and bacteria in order to achieve a moist, clean and wellvascularized wound with < 105 bacteria/gram of tissue. Despite technological advances such as vacuum assisted closure (VAC) and tangential hydrosurgery, appropriate timing of war wound closure remains subjective.

Objective: As objective criteria for defining timing of wound closure and predictors for determining wound outcome are lacking, this study evaluated serum, wound tissue and effluent biomarkers and quantitative bacteriology to determine their predictive value in war wounds.

Methods: Patients with high-energy penetrating extremity wounds sustained in combat were studied prospectively, and followed for 30 days after definitive wound closure. The primary outcome was wound failure, defined as delayed wound closure (>21 days from injury) or wound dehiscence. Surgical debridement with VAC application was repeated every 48-72 hours until wound closure. Timing of closure was at surgeon's discretion. Wound bed tissue biopsy (1 cm3), VAC effluent (5 mL), and serum (2 mL) were collected prior to each wound debridement. Effluent and serum were analyzed for relevant cytokines and chemokines, and tissue for 190 wound-healing associated genes. Effluent and tissue were cultured using traditional blood agar culture and total bacteria quantified by DNAextraction and RT-PCR for the ribosomal 16S gene sequence. Correlations between wound outcome and clinical covariates were analyzed. Analysis of variance with repeated measures was used to determine if molecular expression differed at each time point. Bayesian network classification was used to define the relationships between all of the serum and effluent cytokines and wound healing outcome.

Results: Twenty-five extremity wounds (mean size 687±873 cm3) in sixteen male patients (mean age 22 years) were investigated. Mean Injury Severity Score (ISS) was 25 ±13. The majority (92%) of the wounds were secondary to blast injury and nine (36%) of the wounds were traumatic amputations. There were eight (32%) wound failures: four (16%) with delayed closure and four (16%) dehiscence. Associated vascular injury (p=0.017), ISS>25 (p=0.004), greater wound size (p=0.016) and initial blood product resuscitation (p<0.001) correlated with wound failure. Wounds that failed had significantly increased serum pro-inflammatory cytokine and chemokine expression (IL-6, IL-10, MCP-1 and MIP-1?) and reduced anti-inflammatory IL-4 and IL-13 expression. Significant up-regulationof wound effluent inflammatory cytokines and chemokines (IL-1?, IL-6, IL-8, IL-10, MCP-1 and MIP-1?) was identified in wounds that failed to heal. Tissue gene expression from wound failures also indicated an increased pro-inflammatory state and decreased anti-inflammatory expression relative to control healed wounds. Bayesian classification defined a biomarker panel predicting successful healing with a PPV of 88% (AUC 0.80; p=0.017) and impaired healing with a PPV of 80% (0.81; p=0.014). Colonization by tissue biopsy but not VAC effluent at any point during treatment was associated with impaired healing, with Acinetobacter predominating. The majority of dehisced wounds had >105 bacteria/gram of tissue at time of wound closure (75% vs. 14%, p<0.05). Tissue biopsy and effluent 16S quantification correlated significantly with wound healing (p<0.05)

Conclusions
Inflammatory biomarkers in serum and wounds, as well as critical wound colonization are potentially predictive of acute combat wound healing. War wound failures are related to both systemic and wound inflammatory dysregulation. Aggressive control of bioburden and modulation of the inflammatory response to injury appear critical to healing outcome. Development of a personalized predictive multi-marker molecular panel for patients with complex war wounds is underway.

C10 - Plastics Reconstructive Repair

Reconstruction of Post Sternotomy Wounds

Jaime Anger, MD, Sao Paulo, Brazil

The median sternotomy was first described in 1957 as an access route for cardiac surgery. Infection and dehiscence of that incision has been associated with high indices of morbidity and mortality. The author presents the clinical experience in the treatment of this pathology in the Instituto Dante Pazzanese de Cardiiologia de Sao Paulo based in an average of 3000 cardiac surgeries per year including cardiac revascularization, pediatric, valve and heart transplant surgeries. The different treatments of the acute phase are discussed focusing the use of antibiotics and new methods as the vacuum systems. The surgical techniques for reconstructing of the sternal region are presented ranging from simple resuture of the borders to the use of different types of flaps including muscular, musculocutaneos and sub-fascial composite flaps.

Surgical Reconstruction of Pressure Sores

James Mahoney, MD, FRCS(C),
Chief, Division of Plastic Surgery, St. Michael's Hospital
Associate Professor, Department of Surgery, University of Toronto

Deep pressure sores associated with extensive soft tissue necrosis, infection and bone involvement in addition to recommended preventative and wound management require more extensive assessment. This may include radiological, nutritional, neurological, bone and soft tissue evaluation (biopsy). Surgical debridement of all compromised tissue, treatment of infection with a clean wound being managed utilizing the principles of moist wound healing can heal some of these complex wounds. Those associated with significant undermining, sinus tract formation particularly over the ischial and trochanteric prominences can remain open after local wound and patient factors have been optimized.

Surgical intervention is an option. The principles include removal or debridement of compromised tissue and bone. Soft tissue reconstruction with surrounding well vascularized tissue is performed to close the wound, obliterate dead space and improve padding or contour. In these circumstances the wound can be turned from its nonhealed state to healed with functional return in 6 - 8 weeks.

Nursing Care Related to Pressure Ulcer Reconstruction

Joyce Black

Prior to any operation on a pressure ulcer, the patient must be placed in the best condition to promote healing. Surgery on pressure ulcers in patients who are malnourished, infected and nonadherent is doomed to fail. During the operation, the patient must be well padded to prevent new ulcers from forming and hypothermia which can lead to vasoconstriction must be avoided. Following surgery, the patient is placed in a low-air loss bed or air-fluidized bed. Fecal contamination of the incisions is avoided. Shearing and stain on the incisions must be eliminated. The patient is allowed to sit on the flap over progressive periods of time until he/she can sit for 3-4 hours without signs of flap ischemia. Recurrence of ulcers is a significant complication and begins by preoperative preparation of the patient for the need for ongoing pressure redistribution practices, confirming that the seating surface is functional and developing a social network for ongoing support once in the community.

STREAM 6: COMPLEX WOUNDS

C1 - Malignant Wounds and Non-Healable Wounds

Malignant Wounds: An Overview

Dr. Patricia Grocott
King's College London, Reader in Palliative Wound Care

Malignant wounds arise from tumour infiltration of the skin and its supporting blood and lymph vessels. Tumours may be locally advanced, metastatic or recurrent. Unless treated by single or combination anti-cancer treatments there is the potential for massive skin damage. This occurs through a combination of tumour growth, loss of blood supply and consequent loss of tissue viability. The dead tissue harbours anaerobic and aerobic bacteria: the latter are the sources of the malodour and exudates commonly associated with these wounds. The mainstays of wound care are symptom management and local wound management, to optimise the quality of daily living. Local management strategies, including the selection of skin and wound care products, are determined by the condition of the wound and peri-wound skin taking into account, whenever possible, the patients' preferences. Malignant wounds present a significant challenge, and practice in this area tends to be individually constructed and ad hoc.

Non-Healable Wounds

Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Wound & Skin Care Consultant

Non-healable wounds affect a diverse subset of the population of people with wounds. There are multiple underlying etiologies, co-morbidities and risk factors.

This presentation will distinguish non-healable wounds from non-healing wounds. Clinical criteria for describing these wounds, writing goals of care and documenting will be explored.

Using a case-based approach, several commonly occurring management issues for people with non-healable wounds will be addressed including:

• Palliative wound care protocols
• Plans of care that address patient-centered concerns
• Enlisting the interprofessional team to provide holistic patient care

References:

1. Rolstad BS, Nix D. Management of wound recalcitrance and deterioration (Chapter 73). In Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: AClinical Source Book for Healthcare Professionals (4th edition). Malvern, PA: HMPCommunications, 2007. www.chronicwoundcarebook.com
2. Krasner DL, Rodeheaver GT, Sibbald RG. Interprofessional Wound Caring (Chapter 1). ). In Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: AClinical Source Book for Healthcare Professionals (4th edition). Malvern, PA: HMP Communications, 2007. www.chronicwoundcarebook.com

C2 - Principles of Palliative Care

Principles of Palliative Care

Kevin Woo

Patients with advanced cancer and other terminal disease are at high risk for developing cutaneous wounds due to cancer pathology, immobility, incontinence, malnutrition, and hypovolemia. Aholistic approach to patients requiring palliative care concentrates on the need to relieve pain and other devastating symptoms rather than the cure. The goal is to alleviate human suffering through psychosocial and emotional support and to optimize the quality of life. This presentation will delineate the several key principles of palliative care through discourses on:

1. Wound related challenges in the dying person
2. Multidimensional care: medical, emotional, social, cultural, and spiritual needs of the dying person
3. Needs of the family members
4. Provision of seamless care from home to hospital or hospice
5. Ethical and moral issues surrounding the care of the dying person
6. The use of appropriate outcome measurement to evaluate the quality of patient care.

Knowledge Transfer and Palliative Care: Can We Make a Difference with Appropriate Products?

Dr. Patricia Grocott
Reader in Palliative Wound Care
King's College London

Purpose: Three core principles underpin palliative wound care in a framework of supportive care to patients and families: 1) palliation of underlying causes; 2) symptom management; and 3) local wound management, with a key role for products. The WRAP Method
ology for evaluating dressing performance in the context of patient experiences, clinical treatment and care will be presented.

Method: The methodology is guided by the UK Medical Research Council framework for complex evaluations. It involves theorising the role of dressings relative to clinical problems, in vitro modelling and testing performance, translating in vitro performance into patient outcome measures using a clinical note-making system, evaluation studies and post market surveillance.

Results: The methodology will be demonstrated using the parameter of exudate management by high moisture loss systems

Discussion: This will centre on the rationale for the WRAPmethodology, including the quality and utility of the evidence generated.

C3 - Knowledge Transfer toward Implementation

Oral Abstract Presentations

(see Oral Abstracts section)

C4 - Unusual Infections

Leishmaniasis and Chronic Wounds

Yahya Dowlati, MD, PhD
Director, Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran

Leishmaniases are a group of diseases caused by the intracellular protozoa belonging to the genus Leishmania, which has a wide spectrum of the clinical manifestations from self-healing skin lesions to potentially life-threatening visceral infections. Cutaneous leishmaniasis (CL) is divided into Old World and New World CLas a result of differences in the epidemiology, causative organisms, vectors and reservoirs and clinical manifestations. The Old World CLwhich is the main focus of the current presentation may manifest as skin ulcers at the site of the parasites inoculation after a sand-fly bite. The ulcerative lesions are more common in zoonotic CL(ZCL), which is due to Leishmania major. The lesions are consisted of ulcers surrounded by indurated and erythematous skin. Although the ulcers are self healing in almost all cases, they may be present for months before spontaneous healing and may interfere with patient's daily activities and adversely affect his or her individual and social life. Most cases of ZCLheal within one year after the beginning of the infection with resultant scars.

HIV - Immunosuppression

Jonsson K., University of Zimbabwe, Harare, Zimbabwe

The HIV pandemic is at present estimated to affect 44 million people of whom 30 million (70%) are in sub-Saharan Africa. There is serological evidence of HIV infection in the Congo in 1959 and Uganda in 1973. (1). However, the epicenter of the pandemic is at present in southern Africa, e.g. Zimbabwe has an infection rate of 25% in the adult population. Out of the 44 million living with HIV/AIDS, 12 million (27%) have also infection with Mycobacterium tuberculosis. HIV infection is the most powerful risk factor for progression from latent TB infection to active disease. Infection with HIV and subsequent immune deficiency is affecting wound healing, resistance to bacterial and viral infections and split skin graft survival. Burn injury, trauma and sepsis are additive factors resulting in further depression of the immune system (2).

Herpes zoster scars are correlated to HIV infection in more than 90% of Zambian patients and tuberculosis of the lymph glands in more than 80%. (1) Confirmation by serological testing for HIV-1 and HIV-2 infection and CD4+/CD8+ T-lymphocyte evaluation of the immune status is necessary before treatment. Antiretroviral therapy is at present instituted in Zimbabwe when CD4+ cells are below 200/micro litre, but in the Western World at the level of 350/micro litre. Treatment with HAART (highly active antiretroviral therapy) has been shown to improve the outcome of elective surgery. (3) HIV infected abdominal surgery patients have a six fold increase in mortality and an eight fold increase in morbidity after emergency operations. Complications were recorded as wound infections, wound dehiscence and fistula formation. Biomechanical testing has shown that laparatomy wounds in HIV infected patients are weaker than in non-HIV infected individuals.

Split skin graft survival after primary excision and grafting had a graft survival of 22% recorded by planimetry in HIV infected individuals in comparison to 69% in non-HIV infected patients (4). HIV infection resulted in immune dysregulation as measured by pro-and anti-inflammatory cytokine levels. Weaker scars, delayed rate of wound healing, impaired resistance to infection and impaired split skin graft survival are features in HIV infected immunosuppressed patients, which might be reversed by ARV treatment but randomized controlled studies are lacking.

References:

1. Jönsson K, Mzezewa S. The lessons learnt from wound healing in HIV infected patients and the need for change in management. In: Chronic Wound Management. The evidence for change. Mani R, ed. Parthenon Publishing, London 2002 pp 57-72 and 185-187.
2. Mzezewa S, Jönsson K. Burns 30:670-674, 2004.
3. Foschi D et al. Br J Surg 93:1383-1389, 2006.
4. Mzezewa S, Jönsson K, et al. Br J Plast Surg 56:740-745, 2003.

Wounds as a Result of Tropical Infections

Jonsson K., University of Zimbabwe, Harare, Zimbabwe

Infections may result in soft tissue necrosis and open wounds. Tropical environment is necessary for some organisms to exist, but generally the major infections in the tropics are more related to poverty, malnutrition and nowadays immune deficiency than special tropical diseases.

Tropical pyomyositis is a deep tissue infection, which is mainly affecting people in sub tropical and tropical regions. Predisposing factors such as trauma, skin lesions, parasitosis and malnutrition used to be recorded as underlying pathology. However, today this infection has been classified by WHO as an opportunistic severe bacterial infection related to HIV infection stage III in adults and stage IV in children.

In a 5 year retrospective study of soft tissue infections in Harare, Zimbabwe, 2007 we recorded 89 patients with pyomyositis and 9 with necrotising fasciitis. The mean age for pyomyositis was 35 (SD 15) years and for necrotising fasciitis 54 (SD 19) years. Using WHO clinical criteria 97% were HIV infected and out of those 80% were in stage III. Pain, swelling and fever were the leading symptoms and all were treated by incision and drainage often after diagnostic aspiration of pus. The lower extremity (thigh, glutei, calf and foot) was affected in 66%. Staphylococcus aureaus was the most frequent isolated pathogen, in 27% and Streptococcus haemolyticus in 10%. In the necrotising fasciitis group 3/9 had HIV infection corresponding to the average rate of 25% of the Zimbabwean adult population. The deep soft tissue infection pyomyositis has changed from being an unspecific tropical infection to an opportunistic severe bacterial infection related to HIV infection stage III in adults. This was not found for necrotising fasciitis. Suppurative thyroiditis; thyroid abscess is another infection which seems to have increased in frequency as a result of the HIV pandemic and may fall in the same category as pyomyositis.

Leprosy is a chronic infection by Mycobacterium leprae, which at present is confined to tropical zones. This infection has not increased as a result of the HIV pandemic. It is an infection causing neuropathy, areas of anhidrosis, loss of fingers and toes with deep neuropathic ulcers often not different from the type seen in diabetic patients. At an assessment of the patients at the leprosy centre in Mutoko, Zimbabwe I found 28 patients living with leprosy causing disability. Two (7%) had active disease and were on medical treatment with relevant drugs from WHO. Another four patients had been referred to the tropical disease unit in Harare. Referral of the two patients on treatment had been done by nurses. This indicates lack of knowledge among doctors to recognize this disease. Lack of proper foot protection (shoes) and devises for the upper limbs to make eating possible seemed to be a problem of higher magnitude than the upper and lower extremity chronic wounds that were adequately treated. Wounds resulting from tuberculosis and fungal infections will also be discussed.

Does the Combination of Antibiotics and Hydrogels Enhance Early Wound Healing of Buruli Ulcers (BU)?

Edwin Ampadu

Background/rationale:
Buruli ulcer, a late form of skin disease caused by Mycobacterium ulcerans infection is largely a neglected health problem of the poor in remote rural areas of tropical and sub-tropical endemic countries. Since 1980, the disease incidence has been increasing and been recognized by the WHO as an emerging devastating tropical skin disease. Buruli ulcer has been reported in over 30 countries mainly in tropical and subtropical climates; in the Americas, sub-Saharan Africa, Asia and the Pacificwhich are found between the geographical locations of latitudes of 10ºN and 10ºS.

Early treatment is desirable to prevent the crippling deformities including amputation as well as reducing cost and hospital lengths of stay. The impact of BU on quality of life in patients who are predominately children and adolescents is devastating. Specific antibiotic treatment recommended by the WHO has improved treatment to an appreciable level. However, we still think we can improve on this and make it as much acceptable and accessible to patients and health care providers as possible.

Purpose: Since we do not know the mode of transmission, treatment of BU in the early stages when lesions are small in size and less invasive, is most desirable. Best practices for BU has yet to be determined and my expert knowledge from my 8 years of practice serves as basis for recommendation for further treatment combinations.

Method:

• Review of my clinical cases reveals the use of the WHO recommended guidelines for BU is not adequate for complete healing of these ulcers.
• Possible additions to the treatment plans were considered - recommended topical application of the specific Hydrogel
• Two endemic sites were selected in Ghana.
• We enrolled 15 patients into our treatment protocol. Patient demographics included: 3 males and 12 females, 7 were 15 years and younger in age and the remaining 9 were older than 15 years.
• The period of application of our combined treatment plan was 6 weeks with the average dressings being changed 3 - 5 days.
• Cases were reviewed fortnightly with documentation; wound measurement and photo taking

Buruli Ulcer patients have geographical and financial access challenges that impede their care. Atreatment plan that is easy for patients to use without daily access to health care providers was necessary to attempt solving operational challenges in wound care in developing countries. The decision was made to add a Hydrogel to antibiotics treatment to serve as enhancement to wound healing.

Results: Most patients responded very well except for two patients with very large ulcers which continued to ooze. Two patients had complete healing. Some of the observed changes in the status wound were:

• Reduced pain on application
• Marked improvement, with active granulation was estimated at 87% of total patients. This resulting in reduced wound size especially in the first two weeks of application.
• Improved and steady granulation over the period (one case, A.T had hyper granulation)

Discussion/conclusion: Patients' ulcers healed faster, and had minimal oozing than when patients were treated in the past with just antibiotics and dressing. None of the cases needed radical approach, amputations which earlier could have happened. Patients remarked that this treatment greatly reduced their pain. It is important in wound management with BU to complement standard treatment with the addition of Hydrogel. Reduction in pain and other complications like loss of limb, extensive scarring or deformities is essential for these young victims. Clinical observation as well as further research is needed to provide clinicians with the best combination of therapy plan for patients.

C5 - Molecular Clues for Chronic Wounds

Oral Abstract Presentations

(see Oral Abstracts section)

C6 - Pain, Quality of Life and Education

Reflective Nursing Practice: Learning from Practice

Sue Bale

The use of reflection and reflective practice by health professionals are indictors of mature professionals, progressing on a continuum of life long learning. Reflective practice is an active process whereby the professional can gain an understanding of how historical, social, cognitive and personal experiences have contributed to professional knowledge acquisition and practice. Reflection leads to a deeper understanding of issues and develops judgement and skills, leading to effective clinical reasoning (Kuiper and Pesut, 2004). Reflective practice has the potential to enable practitioners to develop their own and other's clinical expertise.

With respect to wound management, reflection has a particular value as evidence upon which practice should be based is often weak or at best often flawed. Using a framework for reflection, we are able to learn from our wound management practices in a structured manner. Case histories will be presented to illustrate how a structured approach to reflective practice enables learning and enhances patient care.

References:

1. Bulman, C. and Schultz, S. (2004) Reflective Practice in Nursing. Blackwell Publishing.
2. Johns, C. and Freshwater, D. (2005) Transforming Nursing through Reflective Practice Blackwell publishing.
3. Kuiper, R.A. and Pesut, D.J. (2004) Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self regulated learning theory.

C7 - Pediatric Wounds

Children do get Pressure Ulcers

Mona Baharestani

Goal: To summarize best clinical practice for pressure ulcer treatment in neonates and children.

Objectives:

1. To discuss the evidence supporting pressure ulcer prevention and treatment in children.
2. To examine gaps in the current pressure ulcer treatment literature, especially as it pertains to neonates and children.

Although there is a newly emerging awareness that acutely ill and immobilized neonates and children are at risk for pressure ulcers, a paucity of empirical data upon which to guide practice remains. In fact, most prevention and treatment measures are extrapolated from practice guidelines created for adults. Given the anatomical and physiological differences between adults and children, serious concerns arise regarding the safety, clinical efficacy and cost-effectiveness of employing protocols and products specifically designed for adults into the management of neonates and children. Evidence-based clinical practice guidelines for prevention and treatment which specifically address the unique needs of the neonatal and pediatric population are desperately needed. This session will provide an overview of the literature, as well as a blue-print for the development of an evidence-based neonatal and pediatric pressure ulcer prevention and treatment program.

Paediatric Wound Care

Louise Forest-Lalande, RN, M.Ed., ET
CHU Sainte-Justine
Consultant Manager in Nursing Sciences
Montréal, Québec, Canada

Goal of the session: This session will disseminate information specific to paediatric wound care.

It is rather unusual that wound care related to the paediatric population is discussed. We mainly address wound care in relation to the elderly, individuals with arterial or venous problems or the diabetics. However, wound care in Paediatrics presents many challenges related to the specificity of this clientele which ranges from the premature babies to the adolescents. This presentation will discuss the paediatric healing process, first reviewing the skin physiology of the premature baby who represent a new at risk clientele and whose skin particularities should be considered when presenting a wound. Secondly, we will address the topic of acute and chronic wounds in Paediatrics, giving an overview of the most common wounds observed, ranging from dehisced and burn wounds to ulcerated hemangiomas and epidermolysis bullosa wounds. Risk factors for pressure ulcers and adapted risk evaluation scales, as well as preventive and management strategies will be presented.

Objectives:At the end of the session the participant will be able to: -Identify the different types of wounds encountered in Paediatrics -Recommend products adapted to this population -Distinguish paediatric pressure wound risk factors

References:

1. AWHONN, Evidence-based clinical practice guideline, Neonatal Skin Care, 2001; 1-54.CPS, Canadian Pharmaceutical Association 32nd edition, 1997.
2. Darmstadt, G. & Dinulos J. (2000). Neonatal skin care. Paediatric Clinics of North America, 47, 757-782.
3. Lund C. & al, Neonatal Skin Care: The Scientific Basis for Practice, Neonatal Network, June 1999; 18 number 4; 15-27.
4. Forest-Lalande L. Helpful hints in Neonatology Wound Care. Wound Care Primary Intention, The Australian Journal of Wound Management, (2001) Volume 9, no 1
5. Forest-Lalande L. Wound Care in Neonatalogy/Soin de paies en néonatalogie, Wound Care Canada, Vol 2, Number 1, 2003, p. 18-20.

Pediatric Wounds: A Physician View

Elena Pope

Elena Pope (HSC) has developed the first epidermolysis bullosa clinic in Canada and has created an international cutaneous T-cell lymphoma pediatric network which is funded in part by the Canadian Dermatology Foundation (CDF). She has significant experience of treating wounds in children and will present a physicians view of the challenges and rewards of dealing with these wounds.

C8 - Clinical Trials

Clinical Trials

David Margolis, Andrea Nelson and Gail Woodbury

Clinical trials are essential for the proper care of patients. Not only do they provide the experience necessary to ensure our practice is appropriate but also the evidence to support the approach. The term clinical trial covers many forms of experimental designs including, the so called gold standard large multi-centre, randomized controlled trial.

This session will provide insight into the multiple perspectives necessary to develop and execute an effective clinical study. As with everyday practice, a team approach is essential to assure that the proper questions are addressed by the clinical trial. Without properly evaluating and formulating a question it is unlikely that the trial will effectively answer a question that is of benefit to the health care community or patients.

This session will provide background on the design and execution of clinical trials and emphasize the need to assure that all constituents are part of the creation of the trial. Time will also be provided for an interactive panel discussion.

C9 - Educational Outcomes

Wound Care Education in Nursing Schools

Elizabeth A. Ayello, PhD, RN, CNS-BC, WOC Nurse, FAPWCA, FAAN

What are nurses learning in their basic nursing preparation and do they feel adequately prepared to care for patients with wounds? A review of nursing textbooks (Ayello & Meaney, 2003) reveals that some nursing textbooks have very little content about pressure ulcers. In one published survey (Ayello et al, 2005) USAnurses reported that they did not feel prepared to care for patients with wounds. NPUAPhas basic pressure ulcer competencies on their website (www.npuap.org). One of the credentialing bodies for baccalaureate nursing schools in the USAhas a developed core competencies for new nurses and is in the process of revising them for 2008. As wound care experts, one of our challenges is to differentiate between basic and specialty practice. One strategy that might be helpful is to provide faculty with materials to incorporate into student learning including sample curriculum, PowerPoint, case studies, and test questions.

Wound Management Education for Doctors

Finn Gottrup
Professor of Surgery, Copenhagen Wound Healing Center
Department of Dermatology
Bispebjerg Hospital, Copenhagen, Denmark

Objective: To improve education for doctors

Methods: Establish a multi-professional organization in the health care sector and develop a standardised education for doctors.

Results: In Denmark several types of educational programs for involved staff have been created. One is for medical doctors and consists of a national educational program of 2 year after have achieved a wound relevant speciality degree. It is termed an "expert area" and named "Clinical Wound Healing". The education contains modules related to theoretical, clinical, technical and administrative competences. In the theoretical module both general aspects as the wound healing process, influencing factors, physiology of tissue perfusion and oxygenation etc. and more specialized knowledge related to involved medical specialties are covered. The clinical module contains considerations related to diagnose, treatment and follow up. This module also focuses on technical skill of the "expert doctor". This means for instance that speciality doctors from outside surgery should have assisted to at least 20 surgical procedures of the diabetic foot and 10 split skin transplantations.

Conclusion: Development of organizational models, including optimal educational programs of the different types of staff involved in wound management, will in the future improve the treatment outcome of patients suffering of problems wounds.

References:

1. Gottrup F. Optimizing wound treatment through health care structuring and professional education. Wound Rep Reg 2004; 12:129-133
2. Gottrup F. Aspecialised wound healing center concept: importance of a multidisciplinary department structure and surgical treatment facilities in the treatment of chronic wounds. Am J Surg 2004; 187:38-43S
3. Gottrup F. Management of the Diabetic Foot: Surgical and Organisational Aspects. Horm Metab Res, 2005;37, Supplement 1:69-75

C10 - Historical Journey: Wound Care Research

A Historical Perspective on the Role of Basic Science in the Development of Modern Wound Care.

Robert E. Burrell, PhD
University of Alberta, Edmonton, Alberta

Some of our modern wound treatments are linked to those from ancient societies but now with an understanding of why they work. Clinician/scientists made significant contributions around infection prevention in the 19th century. The 20th century saw the discovery of antibiotics. Winter's observations around moist wound healing expanded the role that the basic sciences would play in changing wound care. Materials scientists and polymer chemists developed a whole range of new materials for managing moisture in wounds. Biochemists and nutritionists determined the roles of various cells, molecules and nutrients in wound healing. Engineers and cell biologists developed scaffolds for use as dermal replacements and are now looking at creating artificial skin. Today nanotechnologists have altered the wound care paradigm with new materials and therapeutic delivery strategies. In this talk I will discuss the significant contributions made to wound care through basic science research over the last half century.

Historical Journey: Nursing & Wound Care Research

Christina Lindholm

In many parts of the world, wound care has been and still is delivered mainly by nurses. In some geographies the specialty that has emerged as wound care is also predominantly nurse based (e.g. Tissue Viability Nurse -UK). Nursing has, and continues, to play a very important role in the development of wound care practice both from a clinical and a research basis. This is not to say that the nurse is the only participant as wound care is and should be a truly transprofessional approach - but someone has to take the lead. Often that is the nurse. As a result much research has focused around the nursing professional both from a practice and cost perspective. This presentation will provide an overview of the nurse's role in the development of wound care practice, and will also review some of the highlights in nursing research which have truly changed clinical practice and the lives for numerous patients. Topics covered will be community clinics, quality of life, pain management and the role of the nurse as a coordinator of wound care.

A Historical Perspective on the Role of Medicine in the Development of Modern Wound Care

William Eaglstein, MD

For centuries wounds were treated by a variety of "medicaments", often seen as lotions and potions. Gauze played a dominant role in such treatment. Winter's observations, in the early 1960's, around moist wound healing opened the eyes of many with regards to wound treatment, playing a hugely changing role in the delivery of wound care. Medicine followed these important scientific findings, evolving wound care to where it is today with treatments ranging from gauze to biologicals. This new found interest has led to a brighter future with the potential for not only more effective therapies but rather preventative measures to eliminate wounds prior to their existence.

STREAM 7: GLOBAL PERSPECTIVES

C1 - Professional Education

Professional Education: A Pharmacist's View

Associate Professor, Geoff Sussman OAM

The Pharmacy profession has been directly involved in wound care for centuries. From the era of the barber surgeon/ Apothecary to the modern clinical pharmacist wound care is part of daily practice.

Historically in the development of wound dressings, bandages, sutures etc pharmacists have played a vital role with many of the major companies who produce wound products started by a pharmacist e.g. Smith of Smith & Nephew, Johnson of Johnson and Johnson.

Wound products have their standards and monographs listed in the British Pharmacopoeia and other pharmacy texts. Wound product may be better described as wound pharmaceuticals. It is just as important for the pharmacist to be trained in wound products as in medication. This will be even more important in the future as we move to the use of more pharmacologically active products.

The pharmacist is a vital member of the multidisciplinary wound care team who can contribute much to improve patient care.

It is vital that pharmacist around the world have wound care included in their undergraduate courses and that there are opportunities for post graduate training.

Professional Education: Nurses View

Karen Zulkowski

Examination of nursing textbooks shows limited space allocated to wound care. At the same time, content requirements for undergraduate nursing programs are continuously increasing while the length of programs is finitely set. Some subjects are not covered in depth during lectures, leaving critical information to be obtained by student and graduate nurses in the clinical setting.

Research by Ayello & Zulkowski has demonstrated that US nurses have a "C" level of pressure ulcer knowledge. Scores are only marginally increased with advanced educational degrees or longer times in nursing. Nurses that are certified in wound care do score significantly higher ("A") compared to non-wound care certified nurses, and nurses certified in other advanced practice fields, score significantly higher than nurses not certified in any field.

There is good news. When a facility begins to emphasize wound care, and educational opportunities are available and encouraged, staff nurse knowledge can be increased. Results from the New Jersey Hospital Association Collaborative Initiative demonstrated that as nurses' pressure ulcer related knowledge increased the incidence of pressure ulcers significantly decreased by 70%. Reducing the incidence through staff education will result in decreased cost of care and improved patient outcomes but these changes have to be policy at a facility level.

C2 - Special Consideration for Leg and Foot Ulcers

Oral Abstract Presentations

(see Oral Abstracts section)

C3 - Lymphedema

Lymphedema Wound Care from Viewpoint of a Patient

Christine Moffatt

This presentation will describe the experience of a lady with severe, bilateral phlebolymphoedema of 10 years duration. The relationship of venous disease, lymphoedema and ulceration has rarely been discussed within wound care meetings although the management challenges are complex and the impact on the patient and family are huge. The lady in this case suffered bilateral deep vein thrombosis during pregnancy. Three years later she developed severe swelling and ulceration that became circumferential and failed to respond to conservative wound care strategies. The experiences of this lady dispel many of the myths associated with lymphoedema. She experienced severe pain, described as excruciating on mobility. The quality of life issues and impact on family were her greatest issue. The case presentation will include these challenges and provide insights into how they may be addressed

Lymphoedema as a Public Health Issue

Terence J Ryan
Emeritus Professor of Dermatology
Green College, Oxford

Lymphoedema results in 33% of persons infected with Lymphatic Filariasis and in 40% of persons receiving surgery and radiotherapy for cancer There are many reports of soil irritants causing lymphoedema in the shoeless(podoconiosis) and this may be greatly underestimated.

It may deserve nomination as the commonest neglected morbidity. Contemporary emphasis on oedema control may have forgotten that, as pointed out by Kaposi and by Unna in the 19th century Elephantiasis has a decrease in Elastin fibres, only a little increase in tissue fluid but a huge increase in most other tissue components (Fibrosis, angiogenesis, and adipose tissue). Reversal of the pathology requires attention to epidermal barrier function to prevent harm done by infection and soil irritants. Venous disease must be controlled.

It is at least possible that integration of more than one system of medicine reverses the pathology better and at lesser cost than the use of Biomedical manual lymph drainage alone

Compression & Lymphstasis in the Non-Venous Chronic Wound

John MacDonald, MD

This presentation will discuss the necessity of understanding the role of lymphatic pathology and compression in the non-venous chronic wound. Lymph stasis is a major inhibitor for wound healing in the majority of non-venous chronic wounds i.e. Diabetic, infected, neuropathic, vasculitic, etc. The necessity for compression therapy therefore extends far beyond venous ulcers. Indications and safeguards will be presented.

C4 - Treatment, Adherence and Culture

Smoking Cessation

Richard Salcido

This session activity discusses the effect of smoking on wound healing, smoking cessation strategies, psychosocioeconomic issues from a historical perspective, and current health-related policy issues regarding smoking cessation programs.

C5 - Making a Difference

Oral Abstract Presentations

(see Oral Abstracts section)

C6 - Setting Up a Wound Clinic

Setting Up a Wound Clinic: Mexican Perspective

José Contreras-Ruiz

Setting up a wound clinic in a country where wound care is for the most part neglected poses particular challenges. As is widely known, the scarcity of resources available to care for patients with wounds creates a difficult environment for health care professionals aiming at improving the care of patients with chronic ulcers. In public healthcare, most of the wound care is performed either by students or residents who lack the appropriate passion and knowledge. In some places, a nurse is appointed for the task and in very rare cases a clinic is specifically dedicated to the care of this type of patients. During this presentation, we will provide you with practical information on how to move forward in setting up wound clinics where resources are not readily available, where patients pay for their care for the most part and demonstrate how is it possible to start small and develop.

C7 - Interprofessional Teams/Health Systems

Oral Abstract Presentations

(see Oral Abstracts section)

C8 - Setting Up Wound Care Societies Around the World

Setting Up A Wound Care Society: North American Perspective

Evonne Fowler

Setting up a wound clinic in a time when wound care for the most part received no real focus and was considered the bain of many practitioners' lives was in itself a challenge. But like most clinical practitioners all that is required is enthusiasm and perseverance.

Having been personally involved in the formation of the AAWCC and the SAWC provides me with the experience to talk about the trials and tribulations, but also the rewards and satisfaction. The first annual meeting took place in Long Beach, CAin 1987 bringing together scientists, physicians, nurses, other health care providers and Industry - all with a passion for wounds. Probably the most important aspect of the success of both the AAWC and the SAWC has been the work and enthusiasm of the members and support from Industry. Today the association and conference bring together over 2500 enthusiatic wound carers from around the world.

Setting Up A Wound Care Society: A European Perspective

George W. Cherry, MA, DPhil (Oxon)
Chairman, Oxford International Wound Healing Foundation

I have personally been involved in the formation of three European Wound Healing Societies - European Tissue Repair Society (ETRS), European Pressure Ulcer Advisory Panel (EPUAP) and European Wound Management Association (EWMA). All have mission statements which stress education and the dissemination of this to European countries. Oxford International Wound Healing Foundation has served as the business office to ETRS and EPUAP. ETRS was established in 1987 through an educational start up grant from Janssen, the first president being the late Charles Lapiere. An important aspect of the success of all these societies is their annual meetings which are held in various European countries. The first for ETRS was in Oxford in 1991 and was a great success with scientists, physicians and nurses attending. All of the societies established websites shortly after their inception as well as publishing specialised in house journals. ETRS has had joint meetings with wound healing societies from USA, China, Thailand and France as well as specialised Focus meetings. EPUAP was formed in 1996 with an educational start up grant from Knoll with representatives from thirteen European countries. An announcement of the foundation of the society was published in the Lancet. In addition to the annual meeting EPUAP has established an excellent pressure ulcer classification system by Tom Defloor, as well as other pressure ulcer guidelines. Probably the most important aspect of the success of these European Societies has been the work and enthusiasm of the members and support from Industry.

(www.etrs.org, www.epuap.org, www.ewma.org)

Setting Up A Wound Care Society: Australian Perspectives

Associate Professor Michael WOODWARD
President, Australian Wound Management Association

Australia has a very active community of wound care practitioners who formed state, territory and regional organisations throughout the 1970s and 1980s. In 1993 the Australian Wound Management Association (AWMA) was founded, to give a national voice to these organisations. The organisations remained autonomous - they did not become branches of AWMAbut paid a set fee to AWMAbased on their membership numbers. New members are encouraged to join their regional organisation rather than AWMAdirectly. Subsequently AWMAhas established a branch in the one territory that did not have an organisation but that branch should eventually become autonomous.

AWMAcurrently has 2,600 members and has several areas of activities and advocacy including:

• Production of national clinical practice guidelines
• Encouragement and accreditation of wound management education and training
• Holding a biennial national conference, rotating throughout the country
• Raising awareness of wounds and wound management in the community, amongst health practitioners and in government
• Agitating for a national formulary of subsidised wound products and devices
• Fostering wound and tissue repair research

The Australasian Wound and Tissue Repair Society (AWTRS) was recently established as AWMA's second branch to further foster wound research. Both AWMAand AWTRS have recently conducted a very successful conference in Darwin, Northern Territory, Australia with over 600 registrants.

Setting Up A Wound Care Society: How can Industry Help?

Willi Jung, PhD

The most important first step is to define the problem. Also, all parties involved should see the benefit:

• Researchers to describe and publicize about the subject;
• Clinicians to find better treatment strategies;
• Industry to explore new market opportunities.

Ultimately, the endeavors should lead to better treatment options for the patient.

The European Pressure Ulcer Advisory Panel (EPUAP) was founded in December 1996, following the example of the NPUAP. Pressure ulcers (PUs) were identified to be a common problem in Europe, but the scale was poorly understood and treatment regimes were vastly different. My company sponsored and the ETRS business office organized the founding meeting. It was open to clinicians and company representatives. The society has since been very active in raising the awareness of the problem. Scientific meetings are being held annually.

According to this example, the role of the industry lays in helping identify the problem, aiding with funds and logistics and bringing the right people together.

C9 - Public Health and International Wound Care

Wound Care and Public Health

Terence J. Ryan
Emeritus Professor of Dermatology
Green College Oxford

Despite rapid urbanization, much of the world is still rural, most wounds occur away from the elite centers, and most peoples are poor. Primary Health Care is a system well suited to rural communities. It is supported by the local community to address their health care needs using available resources and appropriate technology. Patients are treated in or as close to their homes as possible. Treatment should be affordable and adequate. The health care worker in the rural village should have appropriate knowledge, equipment, and transport. While delivering health care, he or she should be above all, an educator. All useful sources of knowledge should be integrated in the program to provide the principles of hygiene, including the knowledge of the traditional healer. The World Health Organisation has called for a White Paper linking Wound Healing and Lymphoedema. It will serve as a background for the production of guidelines for every level of care.

Wound and Lymphedema Care and the World Health Organization (WHO)

John Macdonald, MD

This presentation will review the recent international collaborative effort to establish an official wound/lymphedema policy for the WHO. A"White Paper" that broadly outlines the modern principles of wound and lymphedema management has been accepted by WHO. This paper and future initiatives for global education will be discussed.

How do We Make a Difference?

R Gary Sibbald, MD

There is a need to improve the lives of individuals with chronic wounds worldwide with the theme of this conference: One problem, one voice. Just as there is a need for evidence informed wound care practices, there is an evidence base for successful educational strategies and methods to change health care systems. We need to integrate the evidence informed wound care recommendations with proven educational methodologies and strategies to change health care systems. Studies of successful educational strategies that relate to improved healthcare professional performance and patient outcomes incorporate active learning strategies with a longitudinal design. Attention also has to be paid to how to change health care systems with improved communication, collaboration and manager functions. The ultimate wound care patient success also requires local champions or key opinion leaders, empowering patients and considering local customs and beliefs.

Next Steps

Luc Téot

Wound care has been slowly evoluting from an unknown area to a very active discipline. Research is stimulated by a strong concurrence, even if the development of complete EBM is still to be done. Education in wound healing had been recently developed on a larger scale, with official recognition obtained by University Diplomas and Masters. However, the image of wound healing has to be enhanced. Wounds remain frightening for medias, populations of patients with wounds being professionally and socially inactive and fewly lobbying. Patient associations and lobbies are too scarcely developed. Campaigns on the problems of healing wounds, explaining the social and economical burden have to be developed. National epidemiologic enquiries may also help to define the population target, a more visible item for politicians.

World Union consensus, already on several topics (pain at dressing change, negative pressure therapy, diagnostics, exsudation control), can be considered as a step forward in new collective initiatives in wound healing.

C10 - Cost versus Cost Effectiveness

Cost versus Cost-Effectiveness

Patricia Price
Professor of Health Sciences, Department of Wound Healing, School of Medicine, Cardiff University, UK

As we enter the 21st century it is important to reflect on the wider health context within which chronic wound care is provided. Global population changes in terms of demographics as well as advances in technology and information transfer, and the change from acute to chronic disease/health states represent additional challenges to both patients and health practitioners. Traditionally, the impact of a health intervention or a change in the method of delivering health-care, has been assessed by the 'gold standard' Method
(the Randomised Clinical Trial). However, there is a growing appreciation that this only represents part of the evaluation that should take place. Wider evaluation methods allow us to investigate the burden of an illness in terms of both financial and human costs. This presentation will focus on the distinction between studies/audits that focus on the unit cost of new technological advances and those which take a more sophisticated approach. Cost-effectiveness analysis is often used when interventions have a single and readily measurable outcome so that interventions can be compared in terms of cost per unit of outcome; whenever possible, 'natural' unit are used, e.g., number of ulcers healed. The aim of cost-effectiveness analysis is to find the least expensive of delivery for the same (or improved) impact on a population.

Cost-Effectiveness of Multidisciplinary Wound Care in Nursing Homes: APseudo-Randomized Pragmatic Cluster Trial

Geoff Sussman

Objectives: To evaluate the cost-effectiveness of a multidisciplinary wound care team in the nursing home setting from a health system perspective.

Methods: Pseudo-randomized pragmatic cluster trial with 20-week follow-up involving 342 uncomplicated leg and pressure ulcers in 176 residents located in 44 high-care nursing homes in Melbourne, Australia in 1999–2000. Twenty-one nursing homes (180 wounds in 94 residents) were assigned to the intervention arm and 23 to the control arm (162 wounds in 82 residents). Residents in the intervention arm received standardized treatment from a wound care team comprising of trained community pharmacists and nurses. Residents in the control arm received usual care.

Results: More wounds healed during the trial in the intervention arm than in the control arm (61.7% versus 52.5%, P= 0.07). ACox regression with shared frailty predicted that the chances of healing increased 73% for intervention wounds [95% confidence interval (CI) 20–150%, P= 0.003]. The mean treatment cost was $A616.4 for intervention and $A977.9 for control patients (P= 0.006). Most cost reduction was obtained from decreases in nursing time and waste disposal. The mean cost saving per wound, adjusted for baseline wound severity and random censoring, was $A277.9 (95% CI $A21.6–$A534.1).

Conclusions: Standardized treatment provided by a multidisciplinary wound care team saved costs and improved chronic wound healing in nursing homes. The main source of saving was in the cost of nursing time in applying traditional dressings and in the cost of their disposal.

Keywords: Chronic wounds, cluster trial, cost-effectiveness, multidisciplinary, nursing homes.

STREAM 8: FREE PAPERS

C1 - Infection

Wound Infection: A Nursing Perspective

Hiromi Sanada, PhD, RN, WOCN
Professor, Department of Gerontological Nursing/Wound Care Management
Division of Health Sciences and Nursing
Graduate School of Medicine
The University of Tokyo, Japan

A major concern dealing with wound infection is the difficulty in early detecting its occurrence. One reason may be due to a lack of typical clinical manifestation in chronic wounds. Previous studies attempting to improve the diagnosis of wound infection suggested a standard clinical assessment protocol which was published in the European Wound Management Association Position Document. However, a problematic situation of detecting its critical colonization status occurs since this assessment protocol relies solely on clinical signs and symptoms which are difficult to recognize in such wounds. To resolve this problem, our protocol includes the use of bioengineering devices such as thermography and ultrasonography. After detecting a wound infection or critical colonization, cleansing including the peri-wound area is usually conducted. In this session, our protocol involving the detection and management of chronic wound infection will be discussed along with our perspective in handling infected or critically colonized wounds by employing a more objective and quantitative method, specifically from a bacterial genetic view.

Wound Infection: A Medical Perspective

Martin C. Robson, MD, FACS, FRCS (Hon), FRACS (Hon)

Health is not a germ-free state. Rather it is a balance or equilibrium between the factors of host resistance and a myriad of bacteria which can be ever-present in a wound. When the equilibrium is upset in favor of the bacteria, infection can occur. This routinely occurs in soft tissue wounds when >1x106 CFUs / gm of tissue are present or when there is a tissue presence of beta hemolytic streptococci. The goal of treatment of acute wounds is to attempt to minimize the tissue level of bacteria to prevent the equilibrium from being upset. In chronic wounds, the goal is to reestablish the balance. Evidence-based guidelines for the treatment of infection in chronic wounds were published in 2006. New guidelines to prevent the impediment to acute wound healing caused by bacterial bioburden have just been completed. These guidelines provide a state-of-the art medical perspective on wound infection.

C2 - Gender Issues & the Female Professional

Gender Issues in Wound Care: Are Men with Diabetes more Likely to Develop Foot Ulcers?

Siobhan Ryan, MD, FRCPC

Diabetes appears to be more prevalent in men over the age of 50, with a more equal distribution of diabetes among men and women between 30 and 49 years of age. Accounting for these gender differences, it still appears that the incidence of diabetic foot ulcers is greater in men. Gender does not appear to be a risk factor for delayed healing, but possibly there is a gender factor that is contributing to the development of foot ulcers in men with diabetes. Are women protected? Do obesity, weight bearing and foot trauma play a more significant role in men, than in women? What is the association between cardiovascular disease, neuropathy and gender? Are women more receptive to education and the role of preventative measures related to foot care? Areview of the current literature related to gender and the development of the diabetic foot ulcer will be discussed.

Gender Issues can Make a Difference: Patients and Professionals

Moderator: Siobhan Ryan
Evonne Fowler, Elizabeth Ayello, Heather Orsted

How We Made A Difference?

Anyone can make a difference, if you think you can. It all starts with an idea of what needs to be done, the passion and commitment to get it done, and surrounding oneself with like-minded people as resources or part of the team. It's important to love what you do! Perseverance is pretty important too!

By telling our story, we hope to present an early map of the practical applications of wound care and wound caring and capture the essence of how Our Wound Care Community Effort made a difference. Our story begins at the bedside, to the classroom and to boardroom and back to the bedside. It could be anyone's story. It could be your story!

C3 - Inflammation/Anti-Inflammatories/Contact Dermatitis

A Dermatologist's View: What Topical Therapies are Beneficial and Which are Harmful

Mieke FLOUR. Univ. Hospit. Leuven, Belgium

The clinical effects of topical wound therapies are context specific: it will depend on the phase of healing the wound is in, whether the topical agent is appropriate for the actual needs of the wound, and on patients' characteristics like underlying co-morbidities, medication, or allergy towards used products.

An anticipated benefit may be directly or indirectly related to wound healing: cleansing, debriding and antiseptic agents may have a place in the early stages of wound evolution, facilitating granulation and eventual wound closure through enhancing initial wound healing events.

For some topical therapies there is a wide consensus regarding beneficial or detrimental effect on wound healing, while other substances elicit controversy due to the fact that literature is outdated by new facts and by lack of evidence from good clinical trials.

Balancing the relative advantages and known side-effects will guide the clinician opting for a specific wound care topical product.

C4 - Pain and Quality of Life

Pain and Quality of Life in Brazil: Nurses' Perspectives

Vera Lúcia Conceição de Gouveia Santos, PhD, WOCN, MSN, BSN

Learning objective:
At the end of this presentation the participants will be able to:

1. recognize the state of the art of the Brazilian Nursing scientific production related to the pain and quality of life issues, mainly in wound care area; and
2. recognize the main challenges and perspectives for Wound Care Nursing to manage the limits and problems related to pain and quality of life issues.

Brazilian nurses have a short scientific production related to pain and quality of life (QOL). After reviewing two of the most important Brazilian databases, which include post graduation thesis - USP (1997 - 2008) and CAPES (2004 to 2006) - and indexed publications (LILACS and Medline), mainly descriptive studies were found. Pain characteristics in different health conditions, including nursing diagnosis, were the most frequent. Researches on non-pharmacologic nursing interventions (therapeutic touch, breast feeding, self care programs), were also found and a few of them were randomized trials. No systematic pain assessments, with restricted use of standardized scales, low report of nursing interventions and exclusive use of pharmacological pain control are the most important challenges in pain control for nurses. This review also showed that only 3.3% out of 1759 master and doctoral thesis about QOLwere developed by nurses, related mainly to nursing work and students, cancer patients, elderly, renal and cardiac diseases among others. Studies described patients' QOLcharacteristics besides adaptation and validation of international instruments. Few papers were found about pain and QOLof patients with wounds (venous ulcers, pressure ulcers and diabetic ulcers). Systematic pain and QOLassessments besides randomized trials are still needed to spread the use of these concepts in nursing practice and to confirm the positive influence of nursing interventions to control pain and improve the QOLof patients.

C5 - Evidence, Local Wound Care

What is Evidence and the Role of Cochrane

E. Andrea Nelson and Sally Bell-Syer

Clinicians working in wound care make many types of decisions, e.g.diagnosing arteriopathy, deciding on treatments, assessing the impact of wounds. Each type of question is best answered by a particular study design.

One of the most common types of decision which clinicians make is about interventions, deciding when and for whom they should be used. These are best answered by randomised controlled trials (RCTs). They can be summarised in systematic reviews using methods to reduce bias. The Cochrane Collaboration is an internationalnot-forprofit and independent organization, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. There are 54 wounds reviews with 35 underway, and these are a rich source of data on what is known in wound care.

C6 - Education: Master Programs Around the World

Post Graduate Wound Training Monash University

Melbourne Australia Associate Professor Geoff Sussman OAM

Postgraduate studies in wound care are designed to meet the diverse needs of all health professionals with a responsibility and interest in wound care. The Graduate Certificate provides health professionals with the theoretical foundation for contemporary practices in wound care. The Graduate Diploma explores areas of specialty practice within wound care and develops the clinician's competency in specialist wound care skills. The Masters program prepares the health professional for advanced practice in wound care.

The courses have been developed in collaboration with the Wound Foundation of Australia, The National Ageing Research Institute, The University of Melbourne and La Trobe University. The course will be of particular benefit to doctors, nurses, pharmacists, podiatrists, dieticians, occupational therapists and physiotherapists. International students are able to study the Graduate Certificate in Wound Care in their home country. International students who wish to study in the Graduate Diploma or Masters course must be able to meet visa requirements to undertake the compulsory one week residential study block in Melbourne. The Master of Wound Care is offered part-time over three years. Students may exit early with a Graduate Certificate or a Graduate Diploma.

Students must attain a credit grade average (60-69%) or above, to progress from the Graduate Certificate to Graduate Diploma. To progress from the Graduate Diploma to the Master of Wound Care, students must achieve a minimum of a credit grade (60-69%) in ALLGraduate Diploma units.

University of Toronto - Canada

Heather L. Orsted

"Changing the way we educate health providers is key to achieving system change and to ensuring that health providers have the necessary knowledge and training to work effectively on interprofessional teams within the evolving health care system".1

"Interprofessional education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care".2

The Canadian Association of Wound Care and the University of Toronto have developed an evidence informed practice model of collaborative care with 6 levels of educational designs. This structure has facilitated the transfer of best clinical practices with associated knowledge, skills and attitudes at the novice to opinion leader and finally the international expert clinician through the World Union of Wound Healing Societies. 5,6 This session will allow the learner to recognize and appreciate the impact of the interprofessional educational experience provided by the University of Toronto to improve professional performance and patient care outcomes.

"No one profession, working in isolation, has the expertise to respond adequately and effectively to the complexity of many service users' needs and so to ensure that care is safe, seamless and holistic to the highest possible standard." 4

References:

1. Health Canada. Interprofessional Education for Collaborative Patient-Centred Practice. 2006. http://www.hc-sc.gc.ca/hcssss/hhr-rhs/strateg/interprof/index_e.html.
2. Centre for the Advancement of Interprofessional Education. http://www.caipe.org.uk/
3. Davis D. Taylor -Vaisey A. Two decades of Dixon: the question(s) of evaluating continuing education in the health professions. J Contin Educ Health Prof. 1997; 17(4): 207-213.
4. Canadian Interprofessional Health Collaboration. CIHC Statement on the definition and principles of Interprofessional Education. April 2007. www.cihc.ca/resources-files/CIHCStatement_IPE_Final.pdf
5. Sibbald RG Alavi A. Sibbald M. et al. Chapter 4: Effective Adult Education Principles to Improve Outcomes in Patients with Chronic Wounds in Chronic Wound Care 4, Krasner, D, Rodeheaver, G, Sibbald, RG. Health Management Publications 2007.
6. Sibbald RG, Orsted H. The international interdisciplinary wound care course at the University of Toronto: a 4-year evolution. International Wound Journal 2004; 1(1): 34-37.

Education - Master Programs around the World: University of Wales - UK

Samantha Holloway

A Postgraduate Diploma in Wound Healing and Tissue Repair was first established in 1996 by the Wound Healing Research Unit at the University of Wales College of Medicine, Wales, UK and was the first of its kind. The aim of the course is to enable individuals to explore and analyse existing and developing theories and concepts that underpin wound healing and tissue repair facilitating professional and personal growth.

Since 2000 the programme has been offered as a Masters course as part of the postgraduate studies on offer at Cardiff University. Since that time there have been in excess of 220 applicants to the programme, sixty of which have been awarded the Masters qualification. Currently there are seventy-seven students registered on the course, forty-three of which are working towards submitting their dissertations in the next 2 years. The remaining thirty-four are currently completing the taught element of the programme. This talk will provide an overview of the programme.

University of Western Ontario - Canada

Pamela Houghton

C7 - Developing World

What does the World Union of Wound Healing Societies (WUWHS) need to Contribute to Countries in the Developing World?

George W. Cherry, MA, D.Phil (Oxon)
Chairman, Oxford International Wound Healing Foundation

At the last WUWHS meeting in Paris where I was the chair of the commission for developing countries a number of initiatives were discussed. Representatives from 13 countries from the majority of regions of the world established an action plan for the next four years until 2008. The most important aspect of the early phase was to establish the extent and types of wounds and the availability of therapies in the various regions. Kent Jonsson and Salathiel Mzezawa surgeons from Zimbabwe were probably the most successful in carrying out this request. Previously Xiaobing Fu and myself published epidemiology studies of wounds in China in Wound Repair and Regeneration. Luc Teot our present president has organised training courses in Turkey and South Africa. Terence Ryan has continued his work in Africa and India as well as running a course in China. Raj Mani has edited a handbook which is available in India and has continued to foster his work with wound healing societies in India. It is imperative that the WUWHS provide seed grant money now to ensure the success in developing countries.

C8 - Pressure Ulcers

Oral Abstract Presentations

(see Oral Abstracts section)

C9 - Skin and Ostomy

Oral Abstract Presentations

(see Oral Abstracts section)

C10 - Patient Empowerment

Patient Empowerment: What can we do?

Paula Erwin-Toth

Historically the paternalistic approach to medicine and nursing was the preferred method of patient care. Patients knew only what they were told by their health care providers. Information was shared based on what clinicians believed the patient needed to know but not necessarily what the patient wanted to know. It was not unusual for treatments offered the patient were those that fell into the comfort zone of the clinician rather than the full array of current options available. There is compelling evidence to support the concepts that patients empowered with accurate and timely information and involved in the decision making process are more likely to comply with the health care regime. This session will focus on methods to empower patients to improve health care outcomes.

STREAM 9: CANADIAN PERSPECTIVES

C1 - Standardization & Regional Differences in Canadian Wound Care

Standardization and Regional Differences in Canadian Wound Care

Christine Pearson, Marie François Megie, Michelle Todruk-Orchard, Bernice Grant

Canada is a very vast country, the second largest in the world (9,984,670 sq km). Implementation of standardized, evidence based wound care has evolved in different ways across the country. This session will be presented by four clinicians representing four distinct areas across Canada. Each clinician will describe regional differences; explore projects, initiatives and challenges they have experienced when implementing standardization in their own region or area. The four speakers will demonstrate that many diverse approaches and practices can be utilized while still aspiring to accomplish best practice standards in wound care.

Objectives: Participants will examine how one Canadian region standardized wound care products and wound care algorithms for treatment. Participants will describe how one region identified and overcame barriers and challenges in implementing standardized, evidence based wound care. Participants will evaluate a provincial initiative which addresses challenges, barriers, and opportunities in attempting to standardize screening of the diabetic foot and appropriate referrals. Participants will be able to appraise the procedure presently used in Quebec to harmonize wound care.

C2 - Raising Awareness: The Impact of Prevention Programs

Raising Awareness: The Impact of Prevention Programs

Jan-Marie Morgan, Diane St.-Cyr, and Kimberly Stevenson

A challenge of the health care system is to make research evidence readily available to clinicians in order to reduce gaps between highquality evidence and practice, to diminish practice variation, and minimize lapses in patient safety (Davis 2005).

In 2004, The Canadian Association of Wound Care (CAWC) funded a study to determine the extent of pressure ulcers in Canada. It was discovered the mean prevalence rate for pressure ulcers was 26 per cent. Recognizing this as a huge health-related problem, the CAWC created a continuous quality improvement program known as the Pressure Ulcer Awareness Program (PUAP) to support a culture shift in health-care settings toward the prevention of pressure ulcers.

The PUAP is designed to promote positive practice change by bridging the gaps between evidence and bedside care. This presentation will describe a conceptual framework to enable successful implementation of research into practice in order to enhance patient outcomes The components of the Canadian pressure ulcer awareness program and it's effectiveness in creating a change in practice at the bedside will be described. Afacility's personal experience with the program and its impact on patient care will be outlined.

Objectives: At the end of this session participants will:

1. Identify key aspects to implement research evidence in practice.
2. Reflect on the effectiveness of a Canadian pressure ulcer awareness program that supports a culture shift toward the prevention of pressure ulcers
3. Recognize the impact of a pressure ulcer prevention program in a Canadian facility.

References:

1. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy/Wound Management. 2004; 50(10):22-38.
2. Orsted HL, Rosenthal S. Overview of Pilot Project. Wound Care Canada 2007: 5(1): 40-46.
3. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence-based practice: Aconceptual framework. Quality in Health Care. 1998; 7:149-158.
4. Davis D. Quality, Patient Safety and the Implementation of Best Evidence: Provinces in the Country of Knowledge Translation. 2005; 8(Sp): 128-13.
5. www.preventpressureulcers.ca

C3 - Evolution of the Canadian Association of Wound Care (CAWC)

The CAWC Model: How to Create a National Wound Care Association

Cathy Burrows, Gary Sibbald, and Cary Steinman

Objectives:

1. Describe the evolution of the CAWC
2. Discuss success of the CAWC using case studies and real examples of CAWC activities
3. Provide guidance that others can utilize to create a successful wound care association

The Canadian Association of Wound Care began with an idea that originated with a few like minded visionaries who wanted to improve wound care in Canada. Led by the vision and drive of Dr Gary Sibbald the CAWC was established 12 years ago as a national not- for-profit association. It's what happened next that has propelled the CAWC to the forefront of wound care in Canada and North America. From its dynamic annual conference to its official publication to its recently launched Pressure Ulcer Awareness Program, the CAWC has succeeded where other not for profits have failed. Using real world examples the CAWC will share its' journey from an idea to an organization that has become globally recognized.

C4 - Delivering Wound Care Education in Canada

Delivering Wound Care Education in Canada

David Keast, MSc, MD, FCFP
Centre Director, Aging Rehabilitation and Geriatric Care Research Centre
Lawson Health Research Institute
London, Ontario, Canada

Louise Forest-Lalande, RN, MEd, ET
Consultant Manager in Nursing Sciences
CHU Sainte-Justine
Montréal, Québec, Canada

Goal: The goal of the session is to describe the integrated approach to wound care education developed by the Canadian Association of Wound Care.

Objectives: By the conclusion of this session the participants will be able to appraise the Canadian approach to wound care education.

Wound care is a complex Interprofessional activity. Education programs for wound care clinicians must account for differing professional needs and regional differences. The Canadian Association of Wound Care (CAWC) has developed a layered approach based in adult education principles which works to integrate with other wound care education programs offered at the college and university level. The program, entitled the Seminar Series, integrates the Clinical Practice Guidelines developed by the Registered Nurses Association of Ontario and Best Practice articles developed by the CAWC into a three level program which includes an interactive knowledge based component, hands on workshops and integration into practice though a practice reflective exercise and is intended to provide the foundation for more advanced learning. By showcasing local wound care leaders this program adapts to regional differences. In particular the session will describe how the program has been adapted to the special education needs of Quebec clinicians.

References:

1. Kitson A, Harvey G, McCormack B, Enabling the implementation of evidence-based practice; Aconceptual framework. Quality in Health Care. 1998;7:149-158
2. Knowles M. The emergence of a theory of adult learning: andragogy.In The adult learner: ANeglected Species. 2nd ed. 1978. Gulf Publishing Company, Houston TX. P27-59
3. Davis DA, Taylor-Vaisey A, Translating guidelines into practice; Asystematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997;157:408-416
4. www.cawc.net
5. www.rnao.org

C5 - Wound Care Certification

Wound Care Certification

Heather Orsted, Susan Mills-Zorzes, and Jacqueline Fletcher

Objectives:

1. Review the pathway for the development of wound care certification and competency development
2. Describe the Canadian experience to develop a certification process for Enterostomal Therapy nurses.
3. Describe the UK position on wound care accreditation

It is important to establish a common understanding of the term "certification". Certification for the purposes of this presentation is defined as a voluntary process whose purpose is to provide recognition that a licensed professional has attained knowledge, skill, and clinical or practical experiences in a defined specialty practice. It is not a testament to broad based knowledge and skill; rather, it is recognition of advanced achievements in a particular specialty. It is not a certificate of completion given to a person who has graduated from a specialty program. It is also not institutional certification achieved by an employee upon completing an in-house continuing education program.

Wound care clinicians are calling for certification in order to show they can meet rigorous academic / clinical requirements to achieve a recognized standard in wound care practice.

However, not only is there confusion around the meaning of certification but around:

• what type of certification would best serve a particular healthcare professional, employers who want to hire them and the public at large and
• how certification programs should be developed, recognized and administered.

In the United States any professional organization may develop a program of certification for its members. There are currently five organizations offering wound care certification.

Certification for Canadian Registered Nurses is developed, recognized and administered by only one organization - the Canadian Nurses' Association (CNA). Canadian Enterostomal Therapy nurses (wound, ostomy and continence nurses) have recently achieved specialty status and the eligibility to write a certification examination under CNA.

In the UK no such organizations exist, individual institutions (both academic and clinical) offer certificates of competency for key tasks such as Doppler bandaging and sharp debridement but there are no common standards which underpin these. In Scotland a group of core competencies for specialist practice were developed but these were not widely accepted elsewhere (Finnie and Wilson). The majority of health care professionals rely on attainment of named academic awards such as a BSc (hons) Tissue Viability to justify their clinical position and knowledge however there is little standardization across this provision. A call has been made to set standards both for academic awards and certification but as yet there is no lead to take this innovative national project forward (Fletcher 2007).

References:

1. Finnie Aand Wilson ADevelopment of a tissue viability nursing competency framework. Br J Nurs. 2003 Mar;12(6 Suppl):S38-44. Review.
2. Fletcher J Acollaborative approach to education provision will help save our specialism. J Wound Care. 2007 Nov;16(10):421-3.
3. Cary, A. Data Driven Policy: The Case for Certification Research. Policy, Politics & Nursing Practice. August, 2000:1(3):165-171.
4. Rappi, L., Fleck, C., Hecker, D., Wright, K., Fredericks, C., Mrdjenovich, D. Wound Care Organizations, Program and Certifications: An Overview. Ostomy/Wound Management. November, 2007:52(11) :28-39.
5. Zulkowski K, Ayello EA, Wexler S, Certification and Education: Do They Affect Pressure Ulcer Knowledge in Nursing? Advances in Skin & Wound Care: The Journal for Prevention and Healing. January 2007;20(1):34-38.

C6 - Enabling Best Practice through the Guideline Implementation

Enabling Best Practices through Guideline Implementation

Connie Harris, RN ET MSc (candidate)
Tazim Virani, RN, MScN, PhD (candidate)

Guideline implementation has functional value in enabling best practices in health care and, therefore, an important arena for exploration and learning through shared experiences. Our presentation focuses on sharing two initiatives undertaken in Canada that focuses on 1) a province wide initiative for the implementation of the Registered Nurses' Association of Ontario (RNAO) developed nursing best practice guidelines and 2) practical application of best practices in one agency through documentation tools that serve as practice enablers to cue assessment, interventions and make documentation an efficient process. Through an interactive process, we will invite session participants to engage in a dialogue of guideline implementation concepts and analyze their use in the above mentioned initiatives. Additionally, we will discuss both what has worked and not worked in knowledge transfer activities.

Objective: Through this presentation, participants will explore and analyze concepts of guideline implementation.

Three Recommended Resources:

1. CAWC. Best Practice Recommendations Wound Care Canada 4(1):15-29, 31-43,45-55,57-71.
2. Registered Nurses' Association of Ontario. (2002). Toolkit: Implementation of clinical practice guidelines. Toronto, Canada: RNAO. All guidelines and toolkit available at www.RNAO.org.
3. Thomas, L; Cullum, N; McColl, E; Rousseau, N; Soutter, J; & Steen, N. (2002). Guidelines in professions allied to medicine. (Cochrane Review). In The Cochrane Library, Issue 3, Oxford: Update software.

C7 - Developing and Sustaining Wound Care Teams

Effective Wound Care Teams

Cathy Burrows, RN, BScN
Rob Miller, MD
Patricia Coutts RN
Mariam Botros DCh

Objectives:

1. Define the role of team members in treating chronic wounds
2. Identify characteristics of teams and their identity
3. Explore the benefits, challenges and barriers in developing a team

Chronic wounds can be challenging and very costly. It is well documented that a multidisciplinary approach to treatment improves healing outcomes, and is cost-effective. To develop a team requires more than bringing people together within a geographical boundary. Teams can be extensions of existing groups through networking, electronic communication and telehealth technology. There are many challenges and barriers that must be overcome before a team can be effective. This session will discuss the many facets of teams, their impact on wound healing, and provide an interactive team building activity to demonstrate team dynamics.

References:

1. Woo, K., RN, MSc, PhD ( c ), Alavi, A., MD, Botros, M., DCh., et al. ( 2007 ). Atransprofessional comprehensive assessment model for persons with lower extremity leg and foot ulcers. Wound Care Canada; Vol. 5(1) Supp: S 34-47
2. Krasner, D., PhD, RN, CWCN, CWS, BCLNC, FAAN, Rodeheaver, G., PhD, Sibbald, R.G., BSc, MD, FRCPC (Me/Derm), ABIM DABD Med. (2007). Interprofessional wound care. Chronic Wound Care IV: Aclinical source book for health professionals. ( Fourth Ed.). Wayne, PA. HMPCommunications
3. Mostow, E. ( 2003). Wound Healing: Amultidisciplinary approach for dermatologists. Dermatologic Clinics; 21: 371-387.

C8 - Burn-out Prevention

Preventing Burnout

Maryse Beaumier and Karen Campbell

Objectives:

1. At the end of this session the audience will summarize:
   1. A multidimensional model of job burnout and the interpersonal context of job stress.
   2. escribe research on prevention of burnout and building job engagement.

Burnout has been defined as prolonged response to chronic interpersonal and emotional job stress that results in exhaustion, cynicism and inefficiency (Maslach, Schaufeli and Leiter 2001). These three key aspects of the stress response are part of a multidimensional model. Anew aspect in burnout research is to be positive and focus on job engagement. Researchers are now looking at building engagement rather than reducing burnout. Burnout research is also looking beyond the individual response and to six key domains of work life have been identified (workload, control, reward, community, fairness and values). Researchers now are looking at the fit between the person and the domains. Best practice guidelines' for Healthy Work environment have been developed by RNAO and these will be summarized looking at the models discussed previously.

Research on preventing burnout has been limited and has focused on the individual rather than the organization. ACochran review identified limited evidence to support many of these interventions.

References:

1. Aiken, L.H., Clarke,S.P., Douglas, M.S., Sochalski, J. & Silber, J.H. (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout and Job Satisfaction. JAMA, 288 (16), p.1987-1993.
2. Maslach C, Schaufeli WB, & Leiter MP. Job Burnout. Annu Rev Psychol. 2001. 52:397-422.
3. (3) Pendry, S.P. (2007). Moral distress: Recognizing it to Retain Nurses. JAMA25(4). p. 217221.
4. Registered Nurses Association of Ontario. Healthy Work Environments Best Practice Guidelines: Collaborative Practice Among Nursing Teams. Novemberb2006. Downloaded from www.rnao.org.
5. Marine A, Ruotsalainen J, Serra C, & Verbeek J. Preventing Occupational Stress in Healthcare Workers (Review). The Cochrane Database of Systematic Reviews. 2006, Issue 4.

C9 - A Collaborative Multi-Disciplinary approach to Patient Care in our First Nation Communities

A Collaborative Multidisciplinary Approach to Patient Care in Our First Nation Communities

Sharon Rudderham & Paul Beaudin

Eskasoni is regarded as one of the most successful demonstrations of an integrated, coordinated, multi-disciplinary system of primary health care in a First Nation community. Having learned a great deal about what - and what not - to do in customizing our local primary health care system, our experiences motivated the launch of Tui'kn Initiative, which involves all five Bands in Cape Breton.

We have shifted from a model of episodic acute care to one of health promotion, disease prevention and chronic disease management. We have recruited a full complement of family physician services. We have also implemented an electronic patient record and health information system, thereby taking control of the most powerful tool in health planning. This has not been either quick or easy. It has taken us almost 10 years to grow this model of primary health care, which continues to be a fragile innovation within the context of an outdated health policy and funding environment.

C10 - Canadian Wound Care Research Initiatives

Canadian Wound Care Research Initiatives

Gail Woodbury and Laura Teague

Objective: At the end of this session, participants will recognize the importance of the cyclic relationship among clinical research, knowledge transfer, clinical practice and the generation of new research questions.

Vital exchange of information can flow among research evidence, best practice guidelines, and clinical care. This session highlights this exchange and illustrates the importance of conducting and transferring research to the bedside, using pressure ulcer research in Canada as examples. Research demonstrating the extent of the problem of pressure ulcers in health care facilities in Canada was the incentive for developing a pilot project and a national prevention campaign. Similarly, the prevalence and nosocomial rates of pressure ulcers in three sites in a large urban area (Toronto Tri-Hospital Consortium) spurred the development of prevention strategies in those sites. The data generated in this project illustrates the gaps in practice and documentation provides directions for further care initiatives. Clinicians are adept at recognizing the specific clinical needs of individual patients and their knowledge is invaluable to deriving research questions; clinical research is helpful in effecting system level change and/or policy change.

References:

1. Woodbury MG, Houghton PE. Prevalence of Pressure Ulcers in Canadian Health Care Settings. Ostomy Wound Management 2004;50(10):22-38.
2. Baumbusch JL, Kirkham SR, Khan KB, McDonald H, Semeniuk P, Tan E, Anderson JM. Pursuing common agendas: Acollaborative model for knowledge translation between research and practice in clinical settings. Research in Nursing & Health 2008; 31(2):130-40.
3. Mitton C, Adair CE, McKenzie E, Patten SB, Waye Perry B. Knowledge transfer and exchange: review and synthesis of the literature. Milbank Q.2007;5(4):729-68.

STREAM 10: RESEARCH

C1 - Biologics

Properties of Individual Cells

Adrian Barbul

Skin Substitutes

Joon Pio Hong

Since the early 1980's introduction of tissue engineered skin substitutes and cultured skin cells have slowly increased their application in various wounds. The topic skin substitutes include a variety of applications from acellular matrix, cultured epithelial autograft, composite dermal/epidermal autograft, to other cultured skin substitutes with or with out applied cell therapy. The challenges for physicians and nurses are now keeping up to the science and proper indications of these high tech up to date materials for wound healing. The need for these enhanced wound healing materials is needed as wounds become more chronic and the population is aging.

But despite these recent advances, there is no one-fits-all material to heal wounds, and one must treat each wound with customized and rational approach. Furthermore, studies are needed to verify the cost-efficiency for these new approaches.

Matrix-Dermal Components

Zee Upton

Goal: To survey new approaches to recapitulate the multi-dimensional nature of matrix-dermal interactions in order to facilitate development of effective wound therapies.

Objectives: Participants will:

1. Review key concepts on the multidimensional nature of wound healing and the interactions between matrix-dermal components
2. Appraise new approaches to study wound healing in vitro using 3-dimensional human skin equivalent models
3. Appraise new approaches to deliver growth factors and pharmacological agents to wounds using synthetic biomimetic matrices and scaffolds.

Wound healing is a complex process involving multiple temporally and spatially coordinated biochemical events and interactions between cells and their environments. This is increasingly appreciated and has led to the development of 3-dimensional (3D) human skin equivalent models which possess histological features and functional characteristics commonly observed in skin in vivo. These models and their use to study wound healing will be reviewed. At the same time advances in biomaterial design have facilitated new approaches to create 3D scaffolds that mimic the extracellular environment found in the body. These synthetic matrices and scaffolds recapitulate some of the key functions of the naturally occurring wound healing matrix fibrin to provide biological and structural support to the wound healing process. These matrices can be designed to incorporate and deliver therapeutic molecules while being remodelled by invading cells recruited from tissues surrounding the wounds. Our data on the use of matrices to incorporate growth promoting agents and their subsequent evaluation in wounds created in 3D human skin equivalent models will be presented.

C2 - Emerging Technologies

Hyperbaric Oxygen Therapy (HBOT) Applications in Wound Care

Caroline E. Fife, MD

Wounds with inadequate tissue oxygen levels will not heal despite the best wound care. HBOT necessitates the patient BREATHE 100% oxygen while inside a pressurized vessel. At 2 atmospheres absolute, an arterial pO2 of 1,400 mm Hg can be achieved, over a ten-fold increase in arterial oxygen tension. HBOT can correct wound hypoxia, enhance fibroblast replication, improve collagen synthesis, promote leukocyte killing, potentiate certain antibiotics, prevent leukocyte mediated post-ischemic reperfusion injury and induce cytokine receptors. HBOT is considered adjunctive therapy for acute thermal burns, necrotizing soft tissue infections, compromised skin grafts and flaps, crush injury, compartment syndrome osteoradionecrosis and soft tissue radionecrosis, refractory osteomyelitis and other wounds with demonstrated hypoxia. A thorough review of the data for these conditions is available in the UHMS Hyperbaric Oxygen Therapy Committee Report. (UHMS, Kensington, MD, www.uhms.org). In the U.S., "Undersea and Hyperbaric Medicine" is recognized by the ABMS as an official subspecialty.

Negative Pressure Wound Therapy

Luc Téot

One of the most striking evolution of medical devices since the last decades have been the possibility to promote granulation tissue formation over surfaces of noble tissues. The negative pressure therapy can now save lives, limbs and help to close some of the most difficult to heal wounds.

Imaginated by L.Argenta and M.Morykwas, this technique became in a short period of time a unique therapy, obtaining not only Results
but a real change in mentalities in reconstructive surgery. Based on the development of flaps twenty years ago, coverage of large skin defects is essentially structured around the VAC technique, followed by flaps or skin grafts. The development of skin substitutes and their application in combination with negative pressure therapy, leads to a renovated approach in terms of strategy of tissue reconstruction. It is now possible to spare some flap anatomical donor site areas with a simple technique, integrated into a step by step concept of wound healing.

C3 - Mediators of Inflammation

MMPs in Wound Care

Greg Schultz

Wound healing is a complex biological process that is regulated at the molecular level by cytokines, growth factors, proteases and extracellular matrix molecules. Matrix metalloproteinases (MMPs) play key roles in normal wound healing including removal of damaged extracellular matrix components, angiogenesis, migration of epithelial cells, contraction of wound matrix and remodelling of scar tissue. Multiple studies show that chronic wounds are characterized by elevated levels of inflammatory cells that secrete MMPs and other proteases (elastase and plasmin) which degrade proteins that are essential for healing. Application of the principles of Wound Bed Preparation removes the barriers to healing, including reducing inflammation and proteases, which enables healing to resume. Adjuvant therapies include dressings that reduce synthesis of proteases, reduce activities of secreted proteases in wound fluids or topical MMPinhibitors. Rapid indicators of protease activity may indicate when wound fluid proteases are elevated to damaging levels.

From Bench to Bedside: Wound Fluids and Other Games

Kelman Cohen, MD, Emeritus Professor of Surgery, Virginia Commonwealth University,
Chief Medical Officer Greystone Pharmaceuticals

Scientific strides in the past 20 years have led to application of these technologies and principles in the definition and treatment of chronic wounds. Tissue and fluid from chronic wounds serve as an example of the obstacles from transition of the data learned in the laboratory of these factors to a valid clinical product at the bedside. Unfortunately, there are many obstacles along the way from research funding, politics, protection of intellectual property, patents, regulatory hurdles, government controls on payment for products, marketing, sales force and clinical validation of the worth of the product. The road to product will be discussed with data that emanating from translational research of wound tissue and fluids to an FDAapproval to market.

C4 - Diagnostics and New Methods of Assessment

From Bench to Bedside: Advances in Diagnostics

Girish Patel

Investigational tests that are readily accessible at the bedside, which are both sensitive and specific, can greatly enhance the effectiveness of carer and enhance delivery of care. But unlike the diagnosis of a monogenic disorder, which can be diagnosed quickly and reliably by genetic testing; the diagnosis of non-healing wounds can be complex. Wound healing involves a complex interaction between epidermal and dermal cells, the extracellular matrix, controlled angiogenesis, and plasma derived proteins-all coordinated by an array of cytokines and growth factors. This dynamic process is classically, but somewhat artificially, divided into four overlapping but sequential phases: thrombus formation, inflammation, proliferation and migration, and remodelling. Perturbation of any of these processes by one or more inherited or acquired diseases can hinder healing, either alone or in combination with confounding factors such as: infection/colonisation, adverse drug reaction, nutritional deficiencies, immunosuppression, foreign body object, inflammatory disease and malignancy. It is the responsibility of the wound-healing professional at the bedside to rationalise the diagnostic possibilities and with the aid of investigational tests reach a conclusion, as well as decide on therapy.

Wound Diagnostics: The Lab on a Chip?

Raj Mani
Southampton University Hospitals Trust

The advances in 'chip' technology may be seen worldwide in the form of slimmer and more power mobile phones, credit cards, identity cards even on passports! Is it reasonable for patients to aspire for a chip that will offer accurate and reliable diagnostics with which clinicians may manage wounds? Technically, the answer in theory is yes.

In practice, this would need a clear accepted view of what make the essentials of a diagnostic matrix and an even clearer view on the 'normal' thresholds. The result of incredibly sophisticated tissue biological research has informed us about abnormal levels of certain matrix metalloprotineases (MMP2 and MMP9) in chronic wounds but data on whether every chronic wound should be tested for these are lacking. Even more lacking is guidance on simple ways of reversing some of these abnormalities to promote wound healing.

Clinical evidence suggests that oedema and infection are the most common among wound complications. Wound infection especially in acute conditions such as the diabetic foot, needs to be eliminated. To achieve this we ideally need accurate non invasive detection systems. Surface temperature has the potential to indicate underlying infection but more data are needed about this parameter. The electronic nose also offers potential that needs to be exploited.

Vascular parameters such as ABPI are straightforward and globally acceptable and could conceivably figure on a chip. We understand better these days, the role of tissue oxygen measurements and its significance to the diabetic foot team, could it figure on a chip? What is the most reliable and simplest parameter of wound outcome and does this accurately reflect the potential consequent to clinical management?

But the quest for a lab on a chip is far from being a holy grail. The advent of nanotechnology promises immeasurably small sensors that could be implanted within the wound environment permitting perhaps remote sensing of the milieu. This technological benefit would be very valuable for both clinicians and patients to monitor wound changes.

Evaluating Nitric Oxide Wound Bioactivity as A Surrogate Endpoint for Diabetic Lower Extremity Ulcer Management

Joseph V. Boykin, Jr., M.D.

Nitric oxide (NO) is a pivotal molecular target and intercellular signal for normal wound healing; deficient wound NO bioactivity is a significant contributing factor for impaired wound healing in diabetes. Growth factor/cytokine-based specialized wound treatments (SWT) for diabetic LEU patients are designed without basis for wound NO bioactivity and demonstrate only modest efficacy for wound closure (~50%). Human studies in our center measuring wound fluid nitrate and nitrite (NOx, the stable oxidation products of NO) have shown that successful wound closure in diabetic LEU patients receiving SWT is characterized by a baseline threshold value of wound fluid NOx (WFNOx) production with maximal WFNOx elevation during the first two weeks of treatment. Sub-threshold reduction of WFNOx occurs prior to wound closure. These findings allow us to identify diabetic LEU patients at risk for wound complications based on their threshold value and patterns of WFNOx production. These relationships suggest that WFNOx production may function as a surrogate endpoint for clinical diabetic LEU management.

C5 - Gene Therapy and Related Genetic Approaches

Stem Cells

Jeff Davidson

Tissue repair demands resurfacing, revascularization and the efficient restoration of connective tissue integrity and architecture. The brunt of the last task falls on the fibroblast, a cell type strongly committed to the production of extracellular matrix. Recent investigation has refined the historical concept that the bone marrow and circulating precursors can make a significant, transient contribution to wound healing during the formation of granulation tissue. Endothelial progenitor cells have a significant impact on the formation of new microcirculation. In parallel, there is mounting evidence that a subset of dermal mesenchymal cells have pluripotent properties that could contribute to the restoration and even regeneration of wound sites. The interrelationships between mesenchymal stem cells, circulating fibrocytes, and dermal progenitors are still an evolving area of investigation. Nevertheless, the manipulation of these cell types for wound healing and tissue engineering applications is a promising strategy.

C6 - Aging, Scars, and Wound Healing

The Older Adult and Wound Healing

Madhuri Reddy

With aging, many physiologic functions decline. Many of these declines are attributed to aging itself; in other words, they are considered normal, not disease-related. With the aging of the Western population, chronic wounds in the older person are becoming increasingly common. In addition, age is a risk factor for chronic wounds due to the higher prevalence of chronic diseases, the vulnerability of aging skin and tissues to ulcerate and factors that result in poor healing. Age alone is not a contraindication to any aspect of wound management. With appropriate care, older individuals benefit from wound management to the same extent as younger patients. In this session, changes in wound healing with normal aging are discussed, and an approach to managing the older adult with a chronic wound is presented from the perspective of a Geriatric Medicine specialist.

Scars

Mark WJ Ferguson

Goal: To review new therapeutic approaches to the prevention and reduction of scarring in man.

Objectives: Participants will:

• Appraise basic scientific research into the mechanisms underlying scarring
• Review the translation of these research findings into human clinical trials
• Evaluate the efficacy data from the clinical trials conducted to date

Scarring is a major clinical problem often resulting in adverse aesthetic, functional, growth or psychological sequelae. Following the discovery of scar free healing in the embryo, a number of research investigations have focussed on understanding the cellular and molecular mechanisms underlying scar free and scar forming healing. These findings have been further investigated in animal studies whereby the adult wound is pharmacologically manipulated in a number of ways to try and prevent or reduce subsequent scarring.

Following on from successful preclinical studies, a number of potential new therapeutic agents have entered human clinical trial. Predominant amongst these are human TGF 3 (Juvista), human recombinant Interleukin 10 (Prevascar) and Mannose-6-Phosphate (Juvidex). Anumber of clinical trials have been conducted in both human volunteers and patients. These have typically been within patient controls i.e. bilateral surgery on the same patient with one wound treated with drug, the other with placebo in a double blind randomised design. Further trials have focussed on patients undergoing various forms of surgery. These trials and their results will be reviewed with the focus on understanding how one establishes an optimal dose, dosing frequency and efficacy in a double blind design in a new prophylactic therapy for the subsequent improvement of scar appearance. Much of the data will focus on Juvista, Prevascar and Juvidex as these are the most advanced clinical pharmaceutical candidates.

These molecules were discovered by the author and are being developed by Renovo, a biotechnology company of which the author is the Co-founder and Chief Executive Officer.

Paradigm Shifts and Biases in Medical and Surgical Decision Making

William H. Eaglstein, M.D.

Systematic, unconscious biases such as the bias against the adoption of new therapies and multiple choices will be discussed in the context of medical and surgical decision making. Recognition of such "human" biases may help hasten as well as rational the adoption of innovative approaches.

C7 - What's New in Pharmacological Agents for Wound Healing

New pharmacological Therapies

Marco Romanelli, MD PhD
Wound Healing Research Unit, Department of Dermatology, University of Pisa, Italy

Treatments for chronic wounds include systemic and topical agents. Agood balance between these two approaches has shown to produce a synergistic effect on tissue repair in certain type of chronic wounds. Recently new drugs have been developed and introduced in the field of wound healing. There are a large number of potential interventions for inflammatory ulcers such as vasculitis or pyoderma gangrenosum. The cornerstone of treatment is corticosteroids although use of immunosuppressive agents, immunomodulatory agents, plasmapheresis, intravenous immunoglobulin, and biological agents has also been described. Prolonged and high-dosage of these drugs are often required to attain and maintain disease control, but this comes at a high price considering side effects. Safety of interventions must be considered alongside efficacy, and we have responsibility to seek treatments with lower complication rates.

Drugs Which Inhibit Wound Healing

Geoff Sussman, Associate Professor

The participants will:

1. Examine the role and actions of medication on wound healing
2. Clarify specific medications and the mechanisms by which they impair wound healing
3. Determine when medication should be administered though their use may have a negative impact on wound healing.

Many of the systemic medications used on a regular basis by patients both on prescription and freely available over the counter may impact on the healing of a wound. Amajority of patients with chronic wounds have co-morbidities often requiring multiple medications. These medications may have a negative impact on wound healing. Drugs interfere with specific phases of wound healing and will effect cells, pathways, growth factors, cytokines and other important components of the wound healing cascade. In addition some drugs will, as part of their side-effects, reduce blood flow, blood cells and organ functions critical to wound healing

Medications that have a negative impact on healing include:

• Corticosteroids
• Cytotoxic drugs
• Nicotine ( smoking )
• Anti-platelet drugs/ Anti-coagulants
• Antibiotics
• Colchicine
• NSAIDS
• Vasoconsticting Drugs
• Anti leprotic Drugs
• Anti RA Drugs
• Antiseptics
• Immuno-suppressives

Drugs with Positive Effects on Wound Healing

Tania Phillips

Objectives: To understand which drugs can facilitate the healing process

Many drugs have biological activity on endothelial cells, fibroblasts, or keratinocytes or affect collagen, growth factors, matrix metalloproteinases, or blood flow. These include recombinant growth factors, oral methylxanthines and oral flavinoids. There is evidence that systemic and topical estrogens levels influence wound healing, and can improve healing rate, collagen deposition, and wound strength, especially in the elderly. Some drugs which generally have negative effects upon healing can promote healing in certain situations (for example the use of corticosteroids and immunosuppressive agents for pyoderma gangrenosum).

New Pharmacological Therapies (Topical)

Zee Upton

Goal: To survey advances on new emerging topical wound therapies, with a particular emphasis on the use of growth factors

Objectives: Participants will:

1. Assess past and emerging wound therapies based on topical application of growth factors and pharmacological agents
2. Review key concepts on growth factor action from recent in vitro and in vivo studies and assess the impact of the wound environment on these processes
3. Appraise new approaches to deliver growth factors and pharmacological agents to wounds.

Topical administration of growth factors has displayed some potential in wound healing, but variable efficacy, high doses and costs have hampered their implementation. Moreover, this approach ignores the fact that wound repair in vivo is driven by interactions between multiple growth factors and extracellular matrix proteins. This presentation will review past and recent studies examining topical growth factors as wound therapeutics. Recent data demonstrating enhanced efficacy of growth factors when delivered in combination with extracellular matrix proteins will also be presented.These new approaches show considerable promise in vitro and in vivo, and importantly, are obtained with lower doses (ie. nanograms) of growth factors. This suggests that coupling delivery of growth factors to extracellular matrix proteins may ultimately prove to be a more effective strategy for developing a wound healing therapy. Our own progress towards clinical trial of a novel growth factor:extracellular matrix protein complex will be presented.

C8 - Angiogenesis

Angiogenesis: Current Advances

William Li

Objectives:

1. IDENTIFY the latest scientific findings in angiogenesis in wound healing and tissue repair
2. DESCRIBE mechanisms that explain how pro-angiogenic and antiangiogenic factors influence accelerated vs. delayed wound healing
3. DISCUSS new clinical strategies for therapeutic angiogenesis for commonly encountered chronic wound indications

The field of angiogenesis research, begun 4 decades ago as an inquiry into the mechanisms of tumor growth, has generated fundamental insights into the process of tissue repair, revascularizationl, and regeneration. This presentation shall provide an update on the latest information about angiogenic mechanisms in wound repair with a focus on the 'angiogenic switch' regulating both physiological and pathological new blood vessel growth. The factors governing this switching mechanism may be therapeutically manipulated to accelerate healing and potentially to drive regenerative processes, including skin, nerve, hair, muscle, and bone growth. The following clinical strategies under development for therapeutic angiogenesis will be described: protein, gene, and cellular therapy. The results of major clinical studies will be presented.

VEGF and Angiogenesis - Current Advances

David O. Bates
Professor
Microvascular Research Laboratories, Department of Physiology and Pharmacology, School of Veterinary Sciences, University of Bristol, Bristol
BS2 8EJ UK

The induction of angiogenesis following an injury requires the expression of angiogenic proteins. Vascular endothelial growth factor is the principal angiogenic factor secreted by fibroblasts, platelets and other components of wounded tissues. VEGF, however, is also expressed in normal tissues, including skin. The isoforms of VEGF that are expressed in normal tissues, however, have no angiogenic potency and can act as anti-angiogenic agents. They are generated by alternative splicing of the mRNAto form a family of antiangiogenic proteins. The control of the balance of isoforms is crucial to angiogenesis in all circumstances including wound healing. The regulation of these isoforms by growth factors such as TGF-b, IGF1, TNFa and PDGF can control the angiogenic potential of tissues in response to external injury. These mechanisms are targetable and can be modified by potential therapeutic agents. The promotion of angiogenesis in certain conditions by this modification is a novel therapeutic strategy.

C9 - Science of Wound Bed Preparation

Overview of Wound Bed Preparation and Pain

Kevin Y Woo and R. Gary Sibbald

The wound bed preparation paradigm is an organized approach to the treatment of chronic wounds. The paradigm by Sibbald et al. outlines the need to treat the cause and patient centered concerns before the components of local wound care. Wound care can be to include DIM before DIME (debridement, infection and inflammation management, moisture balance before the edge effect for advanced therapies). One of the most important components for patients is the presence of pain. Wound associated pain is complex and may be part of the cause of the wound or relate to local wound related factors. Accumulating evidence suggests that inflammatory mediators can cause peripheral sensitization leading to increased pain. The mechanism linking infection to pain remains elusive but is thought to be via Toll-like receptors (TLRs), a family of pattern recognition receptors that mediate innate immune responses to stimuli from pathogens or endogenous signals. The mechanism linking infection to pain remains elusive but is thought to be via Toll-like receptors (TLRs), a family of pattern recognition receptors that mediate innate immune responses to stimuli from pathogens or endogenous signals. Negative emotions about pain have been demonstrated to activate certain pathways, neurotransmitters (e.g. cholecystokinin) and cortical structures (e.g. anterior cigulate cortex) that participate in the modulation of pain. The pathophysiological mechanisms associated with the nociceptive and neuropathic components of wound related pain will be reviewed as a basis for treatment.

Infection and Inflammation in Wounds

Greg Schultz

Normal wound healing in skin proceeds through the sequential phases of haemostasis, inflammation, repair and remodeling. Inflammatory phase typically initiates within 24 hours of injury by migration of neutrophils chemotactically drawn into the wound, followed by macrophages, reaching a maximum within a week. In the absence of infection, inflammation resolves by two weeks after injury. Chronic inflammation, often produced by bacterial biofilms, can lead to elevated levels of proteases and reactive oxygen species (ROS) that damage proteins that are essential for healing. Tissue debridement and removal of biofilms help reduce inflammation and restore molecular balance in wound bed that enable healing to progress. Traditional culturing of swabs or biopsies detects planktonic bacteria, but does not accurately assess bacteria in biofilms. Anti-inflammatory steroids reduce inflammation but also can impair healing by reducing synthesis of collagen. More selective anti-inflammatory therapies that inhibit TNFa or IL-1 may provide better inflammation control.

Local Wound Care: An Evidence-based Approach to Product Selection

Ben Peirce, RN CWOCN

Objective: Participants will be able to describe an evidence-based approach to local wound care product selection.

Selecting products for a wound will vary between patients with wounds of the same etiology and will also vary over time for an individual patient because physical features (such as depth, wound bed appearance, and drainage amount) have to be considered to select the right treatment at the right time. Acritical basis for establishing and maintaining an effective treatment plan are consistent wound assessments. Research has shown that the best way to achieve this is through consistency in terminology and techniques employed by the assessing clinicians. Every 1-3 weeks, the clinical team should objectively compare the most current wound assessment to previous ones to ensure progress toward goals is being made. This is especially important because failure to promptly progress with a comprehensive treatment plan may be predictive of a wound with little healing potential, in which case the treatment plan would need to be revised to meet more realistic goals.

C10 - Bench to Bedside

The Role of Honey in Wound Management

Rose Cooper

Honey is an ancient wound remedy that has been re-introduced into modern practice. It is a complex, natural substance comprised of multiple components that contribute to its broad spectrum antimicrobial activity and its ability to stimulate wound healing. Although precise mechanisms of action are not yet fully elucidated, laboratory and clinical observations allow an insight into its function. In this presentation its chemical composition will be reviewed and examples of microbial inhibition in vitro will be given. Reports of the eradication of antibiotic-resistant bacteria from wounds treated with honey will also be described and ways in which honey might impact chronic inflammation will be postulated.

Objective: Participants will:

1. List the components in honey that contribute to antibacterial activity
2. Assess laboratory and clinical evidence of antibacterial activity
3. Describe means by which honey might help to resolve chronic inflammation in wounds.

Mechanisms and New Developments in Local Wound Care

Robert F. Diegelmann, Ph.D.
Professor of Biochemistry & Molecular Biology
Virginia Commonwealth University Medical Center
Richmond, Virginia USA

Objective: This presentation will explore the underlying cell biology and biological mechanisms responsible for normal as well as pathologic responses to tissue injury and highlight recent novel strategies to improve the healing response.

The process of wound healing is a carefully orchestrated series of biological processes composed of Hemostasis, Inflammation, Proliferation and Remolding that usually results in a fine line scar. To achieve an optimal outcome there are critical interactions needed among the immune system, the meschenymal components and the extracellular matrix. Normally these systems interact in a very productive and efficient manor to accomplish healing. However when there are mis-communications among these systems the healing response can be altered resulting in either fibrosis on one end of the spectrum or chronic, non-healing ulcers on the opposite end. As we have gained a better understanding of the complexities following tissue injury and repair new strategies are becoming available to optimize the wound healing response and these new developments will be discussed.

Oral Abstracts

OR001
A damage threshold for muscle under prolonged loading

Bader DL (School of Engineering, Queen Mary University of London, UK and Eindhoven Univ. of Tech.), Ceelen KK (Eindhoven University of Technology, The Netherlands), Stekelenburg A (Eindhoven University of Technology, The Netherlands), Baaijens FPT (Eindhoven University of Technology, The Netherlands), Nicolay K (Eindhoven University of Technology, The Netherlands), Oomens CWJ (Eindhoven University of Technology, The Netherlands)

Goals and Objectives
Deep-tissue injury has recently been identified as a specific category of pressure ulcer, which involves pressure-related damage initially to subcutaneous tissues under an intact skin. These wounds can seriously affect quality of life and can be associated with a variable long-term prognosis. Prevention and early detection are hampered by incomplete understanding of the underlying damage pathways. Recent in vivo experiments using MRI (magnetic resonance imaging) has revealed differences between muscle damage associated with deformation alone and that with ischaemia [1].

Purpose
The present work tests the hypothesis that tissue damage occurs in internal tissue regions associated with large tissue strains.

Method
A dedicated 2D-plane stress finite element (FE) model was developed to calculate experiment-specific internal strains in an in vivo rat model [1]. The latter involved compression applied for 2 hours via a plastic indenter to the tibialis anterior region. Following a 4-hour unloaded period, damage was assessed with T2-weighted MRI. The FE model grid was imposed on the damage maps to interpolate the damage information onto the grid. For each experiment, the calculated strain was divided into 5 categories and for each, the number of grid points with and without damage was determined.

Results
Short-term damage, present in 7 of 11 experiments, was confined to a relatively narrow region extending from the skin beneath the indenter to underlying bone. In most cases, the degree of damage increased monotonically with maximum shear strain. In those cases where damage was absent the strain parameter did not exceed 0.65.

Discussion/Conclusion
Internal strains, as determined by the dedicated models, can be correlated to the spatial profiles of damage. Establishment of a reliable threshold for strain damage can support the prevention and early detection of deep tissue injury.

[1] Stekelenburg et al. J Appl Physiol 2007; 102:2002-2011.

OR002
Development and characterization of a novel shark skin collagen-aloe vera-based substrate for wound healing applications

Shanmuganathan Seetharaman (Central Leather Research Institute and Sri Ramachandra School of Pharmacy), Shanmugasundaram Natesan (US Army Institute of Surgical Research and Central Leather Research Institute), Adhirajan Natarajan (Central Leather Research Institute), Ramyaa Lakshim T.S (Central Leather Research Institute), Mary Babu (Central Leather Research Institute)

Goals and Objectives
The major objective is to isolate shark skin collagen and develop a composite scaffold using the parenchymal gel extract of aloe vera. The developed composite substrate was analyzed for its ability to be used as a substrate to deliver doxycycline for healing burn wounds.

Purpose
The present study describes development of a scaffold using fish skin collagen-aloe vera composite and its potentials as a wound dressing. Collagen from bovine and porcine skin is extensively utilized for various biomedical applications, but due to their potential risks like bovine spongiform encepalopathy (BSE) there is a requirement for alternative collagen sources.1 Collagen from shark skin presents a better alternative.2 When used along with a glycosaminoglycan (GAG),3,4 it can play an important role in wound healing, especially effective as a carrier to deliver drugs, and acts as an excellent substrate for fibroblasts.

Method
Fish skin collagen and parenchymal gel extract were mixed in ratio 1:10 w/w (total GAG:collagen) and cast as thin scaffold, after inducing fibrillation, at a controlled temperature of 320C. The scaffold was analyzed for its functional, thermodynamic and morphologic features through FTIR, DSC and AFM, respectively. Further, the scaffold was impregnated with doxycycline-loaded chitosan microspheres, prepared by water-in-oil (w/o) emulsification process with simultaneous ionic coacervation technique, and in vitro drug-release studies were carried out using Franz finite dosage method. Efficiency of the developed dressing against standard pathogens was assessed, and the dose of doxycycline impregnated into the scaffold was accordingly fixed. In vivo evaluation was done using rat model burn wounds infected with Pseudomonas aeruginosa (107 cfu/ mL). Healing was evaluated by morphometric, histologic analysis of tissue level matrix metalloproteinase (MMP) expression

Results
The developed scaffold displayed the characteristic functionalities of collagen molecules (amide I and amide II) with small variations and exhibited excellent thermal denaturation properties. Ultrastructure of collagen fibrils in the scaffold exhibited characteristic 'D' periodicity of 67 nm and a width of 40 nm. The doxycycline-loaded chitosan microspheres impregnated into the scaffold were in size range of 200 to 225 mm with 8% total drug entrapment. In vitro studies exhibited initial burst release of 38% and controlled release for 72 hours, with maximum MIC and MBC against P. aeruginosa (98.3 μg/ml). In vivo evaluation showed that infected control and treated rats showed complete healing by 18 and 26 days, respectively. Doxycycline-treated rats showed better remodeling with faster epithelialization (14 days for treated rats against 22 days for controls). MMP-2 and MMP-9 were found to be predominantly expressed in the controls (till day 15), whereas they subsided by day 12 in the treated rats

Discussion/Conclusion
The results of the current investigation affirm the influence of infection on healing events and its response to controlled delivery of doxycycline. This seems to be the first report to show the controlled delivery of doxycycline through fish skin collagen–aloe vera dressing to control early onset of infection and the subsequent events.

References

1. O'Grady JE, Bordon DM. Global regulatory registration requirements for collagen-based combination products: points to consider. Adv Drug Deliv Rev 2003; 55(12):1699-1721.
2. Nomura Y, Toki S, Ishii Y, Shirai K. The physicochemical property of shark type I collagen gel and membrane. J Agric Food Chem 2000; 48(6):2028-2032.
3. Pieper JS, Hafmans T, Veerkamp JH, van Kuppevelt TH. Development of tailor-made collagen-glycosaminoglycan matrices: EDC/NHS crosslinking, and ultrastructural aspects. Biomaterials 2000; 21(6):581-593.
4. Ellis DL, Yannas IV. Recent advances in tissue synthesis in vivo by use of collagen-glycosaminoglycan copolymers. Biomaterials 1996;17(3):291-299.

OR003
Evaluation of efficacy of Canadian honeys against wound-infecting bacteria

Katrina Brudzynski (Brock University, St. Catharines, ON), Robert Lannigan (London Health Sciences Centre, London, ON)

Goals and Objectives
Honeys possessing antibacterial activity have been used as an adjunct treatment of infected wounds. A large cohort study conducted on Canadian honeys showed that they possess antibacterial activity against two standard bacterial species: gram-negative Escherichia coli (ATCC 14948) and gram-positive Bacillus subtilis (ATCC 6633). However, their activity against wound-infecting bacteria had not been adequately investigated.

Purpose
To evaluate the susceptibility of seven clinical isolates from infected wounds to Canadian honeys in vitro.

Method
The isolates included four different strains of methicillinresistant Staphylococcus aureus (MRSA), two strains of vancomycin-resistant Enterococcus faecium and Escherichia coli (VRE). A broth microdilution method was employed to establish the MIC90 for each isolate against seven honeys derived from different plant sources. Isolates were identified to genus and species and their susceptibility to antibiotics was confirmed using an automated system (Vitek R, bioMérieux R). The presence of the mecA gene, nuc gene and vanA and B genes was confirmed by polymerase chain reaction.

Results
The antibacterial assays showed that all bacterial isolates tested were susceptible to honey action. The most susceptible to honeys were two strains of MRSA (MRSA-3 and 5), and the least susceptible was E. coli from wound. The antibacterial potency of honeys against clinical isolates depended on their plant origin, with monofloral honeys (buckwheat and blueberry) reaching MIC90 values of 6.25% (v/v) to 12.5% (v/v).

Discussion/Conclusion
Canadian honeys showed efficacy against both the standard bacterial species as well as the antibiotic-resistant clinical isolates from wounds. Buckwheat and blueberry honeys were consistently the most active honeys, suggesting that their phytochemical compound(s) might influence the activity. These

Results
strongly suggest that some monofloral Canadian honeys are promising antimicrobial agents in treatment of infected wounds, including those infected with MRSA and VRE.

OR004
Manuka Honey versus Hydrogel to Deslough Venous Ulcers - A Randomised Controlled Trial

Gethin, G (Royal College of Surgeons in Ireland), Cowman, S (Royal College of Surgeons in Ireland)

Goals and Objectives
To determine if Manuka honey could deslough venous ulcers in comparison to hydrogel. To determine the % of wounds healed after 4 and 12 weeks. To quantify the effects on healing when wounds are desloughed. To determine changes in qualitative bacterial culture wound swabs over 4 weeks in both groups.

Methods
Prospective, open label, multicentre, randomised controlled trial. Randomisation via remote telephone. Wounds having > 50% area covered in slough included. Manuka Honey or Hydrogel applied once or twice weekly for 4 weeks in conjunction with compression therapy, followed by appropriate care based on clinical evaluation for next 8 weeks. Outcome measures included; % area covered in slough, wound size, healing rates, culture swab . Analysis by intention to treat . Ethical approval granted.

Results
35 males, 73 females age 24-89 years (mean 73 yrs). Baseline comparability was established. At week 4: mean wound area covered in slough reduced to 29% (honey) vs 43%(gel) (p = 0.065); the median reduction in size was 34% vs 13% (z -4.609, p = 0.001). At week 12: healing rates were : 30% (n=24) in honey group vs 21% gel (n=18) (RR 1.38, p = 0.037). A slough reduction of > 50% after 4 weeks was associated with a higher probability of healing at 12 weeks (RR 3.3, p = 0.029). Epithelization was visible earlier in honey group vs gel (p 0.042). MRSA was recorded at baseline in 16% (n=18) cases. MRSA was eradicated by week 4 in 70% (honey) vs 16% (gel) of wounds.

Conclusion
The probability of sloughy venous ulcers healing after 12 weeks is higher when wounds are effectively desloughed and when Manuka honey is used compared to control. Further clinical research is recommended to investigate the clearance of MRSA from chronic wounds when honey is used.

OR005
Slow Release of Colistin Loaded Silk Membrane for the Treatment of Wound Infection

Lars Steinstraesser (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Galina Trust (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Christopher Sleyman (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Rafael J. Hasler (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Tobias Hirsch (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Andrea Rittig (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Ole Goertz (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Michael Rheinnecker (Spintec Engineering GmbH, Aachen), Ingo Stricker (Department of Pathology, BG University Hospital Bergmannsheil, Ruhr University Bochum), Hans-Ulrich Steinau (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum), Frank Jacobsen (Dep. of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum)

Wound infections by multidrug-resistant bacteria is still a raising problem in wound care. An occlusive dressing delivering an antimicrobial agent to the wound over several days might be advantageous.

The objective of this study was to create an occlusive silk membrane (pore size of <100 nm) loaded with colistin to establish an effective antimicrobial wound dressing against Gram-negative bacteria in vitro and in vivo.

The membranes (80μm thick, pore size < 100 nm) were produced from fibroin, the silk protein. Membranes were covered with a log-scale colistin dilution (0.027 to 270 mg/ml) and a modified Microbroth Dilution assay against E. coli and P. aeruginosa was performed. A porcine wound infection model was used to demonstrate the antimicrobial activity in vivo also. 12 titanium wound chambers were implanted into pigs' flanks (n=2) and infected with P. aeruginosa. After infection, these wounds were randomized and treated with membranes containing 5 mg (n=9), 0.5 mg (n=3), 0.05 mg (n=3) of or without (n=6) colistin or no treatment (n=3) as a control. Wound fluid and tissue biopsies were collected after 2, 4 and 6 days for quantification of colony forming units (cfu).

The in vitro study demonstrated a concentration dependent antimicrobial effect against both germs showing complete elimination at the highest concentrations (270 and 27 mg/ml). All colistin membranes demonstrated lower cfu counts compared to the corresponding PBS or carrier control. Within the in vivo trial a cfu reduction of more than 3 log-scales was observed for the highest concentration after 2 days. In average the wounds' cfu quantity remained at >1000 during the whole follow-up of 6 days, apart from 3 wounds where complete bacterial clearance was observed.

Using these membranes we were able to show that slow release of a topical antimicrobial is feasible and effective with silk dressings.

OR006
The Role of Topical Negative Pressure in Wound Repair: Expression of Biochemical Markers in Wound Fluid During Wound Healing.

Chantal M.Moues (Erasmus Medical Centre Rotterdam, Department of Plastic, Reconstructive and Hand Surgery), Albert .W.Toornenenbergen (Erasmus Medical Centre Rotterdam,Department of Clinical Chemistry), Freerk Heule (Erasmus Medical Centre Rotterdam, Department of Dermatology), Wim C. Hop (Erasmus Medical Centre Rotterdam, Department of Epidemiology & Biostatistics), Steven E.R. Hovius (Erasmus Medical Centre Rotterdam, Department of Plastic, Reconstructive and Hand Surgery)

Goals and Objectives
The clinical effects of topical negative pressure therapy (TNP) on wound healing are well described in numerous articles.While the mechanism(s) of action are not completely understood, it is postulated that reduction of local and interstitial tissue edema, increased perfusion of the (peri-) wound area, changed bacterial composition and mechanical stimulation of the woundbed contribute to the clinical success.

To gain an insight into the possible changes of the microenvironment, we carried out biochemical analysis on wound fluids from TNP treated and conventional moist gauze treated wounds. We hypothesized that the continuous removal of exudate reduces accumulation of inhibitory factors and mechanically induces a new supply of interstitial wound fluid by means of negative pressure.

Purpose
Our aim was to assess if the concentrations of albumin, matrixmetalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase (TIMP-1) were different between wounds treated with TNP and conventional moist gauze therapy.

Methods
We analysed wound fluid samples of 33 wounds treated with either TNP therapy (n=15) or conventional therapy (n=18) on albumin, pro- and activated MMP-9, TIMP-1 and the ratio of total MMP-9/TIMP-1. The levels of these biochemical parameters were measured longitudinally over time (10 days after debridement) and analysed using mixed model ANOVA.

Results
Albumin levels were found to significantly increase in acute wounds compared to chronic wounds (p<0.01), however no difference could be found comparing TNP to conventional therapy. We did find, significantly lower levels of pro-MMP-9 (p<0.05) and lower total MMP-9/TIMP-1 ratio in TNP treated wounds (p<0.02) during the follow-up of 10 days.

Discussion / Conclusion
Significant differences are found between wound fluid collected from wounds treated with TNP compared to conventional moist gauze therapy. These results might suggest that TNP therapy influences the microenvironment of the wound most probably through continuous removal of exudate, reducing accumulation of inhibitory factors.

OR007
Evaluation of Continuous and Intermittent Myocardial Topical Negative Pressure

Sandra Lindstedt (Department of Cardiothoracic Surgery ), Malin Malmsjö (Department of Clinical science), Richard Ingemansson (Department of Cardiothoracic Surgery )

Objectives
Several studies have suggested that mediastinitis, when conventional wound healing techniques were used, is a strong predictor for poor long-term survival after coronary artery bypass surgery (CABG). Previously, we have showed no difference in long-term survival between CABG patients with TNP-treated mediastinitis and CABG patients without mediastinitis. This might indicate that these patients might have developed increased coronary collateral blood vessels during TNP, since the heart is in direct contact with the vacuum source during TNP treatment, and may therefore be better prepared when bypass grafts fail to work. In wound therapy intermittent negative pressure is often preferred to continuous negative pressure as tissue exposed to intermittent therapy shows twice as much granulation tissue formation than that exposed to continuous pressure after two weeks of therapy.

Purpose
The present study was designed to elucidate the differences in myocardial microvascular blood flow between continuous and intermittent TNP of -50 mmHg.

Methods
Six pigs underwent median sternotomy. Laser Doppler probes were inserted horizontally into the heart muscle in the LAD area. Measurements of microvascular blood flow were performed in normal myocardium and ischemic myocardium, during 20 minutes of countinuous and intermittent TNP at -50 mmHg.

Results
Both continuous and intermittent TNP of -50 mmHg significantly increased microvascular blood flow in the underlying myocardium: from 56.2 ± 13.1 PU before, to 132.8 ± 7.4 PU during countinous TNP application (*p < 0.05), and from 75.8 ± 12.1 PU before, to 153.6 ± 4.7 PU during intermittent TNP application (*p < 0.05).

Conclusions
No difference was found between microvascular blood flow during 20 minutes of continuous and intermittent TNP at -50 mmHg. The increase in microvascular blood flow in the myocardium might, in part account for the reduced long-term mortality in patients with TNP treated mediastinitis.

OR008
A Preliminary Analysis of the Radiationecrosis Research Registry Data (American College of Hyperbaric Medicine)

Robert Bartlett, MD, FACHM, FAPWCA (Assoc Professor of Surgery, Ohio State Univ / Corporate Medical Director, National Healing), Jeffrey A. Niezgoda, MD, FACHM, FACEP, FAPWCA (Medical Director, The Centers for Comprehensive Wound Care and Hyperbaric Oxygen Therapy,)

Objectives

1. To present the interim data analysis of the Radiation Research Registry.
2. Illustrate the benefits of Hyperbaric Oxygen Therapy in the management of patients with radionecrosis.

Purpose
Approximately 1.2 million new cases of invasive cancer will be diagnosed this year in the United States and approximately one half of these patients will receive radiation therapy as part of the management of their malignancy. Serious complications following radiation therapy occur in approximately 5 percent of those patients receiving therapeutic radiation. These complications characteristically occur after a latent period that varies from several months to several years. The etiology of delayed radiation injury is not fully understood though most would agree that endarteritis, tissue hypoxia and fibrosis are consistent findings and are certainly major contributors to pathogenesis.

Traditional medical and surgical management of Radionecrosis has been unsatisfactory. Hyperbaric Oxygen Therapy is offered as an advanced therapy to surgical and medical management in patients who have failed conservative measures. Hyperbaric oxygen therapy reverses hypoxia, induces the release of macrophage derived angiogenesis factors, and promotes angiogenesis, fibroblast proliferation and collagen synthesis in these compromised tissues. Although the Cochrane Review supports the role of hyperbaric therapy, some insurance companies still consider the therapy to be experimental.

Methods
The Radionecrosis Research Registry is designed with the goal of compiling outcome data in a very large group of patients with Radionecrosis who have been treated with hyperbaric oxygen therapy, and then comparing these results with historical controls. The study endpoints are clinical outcomes and costeffectiveness.

Participation in the Radionecrosis Research
Registry is limited to placement of the subjects' non-identifiable medical information related to their Hyperbaric treatment and disease specific symptoms of Radionecrosis into a research database (i.e., the Radionecrosis Research Registry). The use of this retrospective information for research is to analyze outcomes related to the treatment of Radionecrosis with Hyperbaric Oxygen Therapy.

Results
This is a national, ongoing study and results provided are preliminary. The interim analysis of over 1000 cases finds greater than 80% resolution or improvement in symptoms for all types of radionecrosis injury (bone and soft tissue including vaginal, proctitis, enteritis, and cerebral).

Conclusions
A current literature review finds that prior collective case experience is inadequate as most reports are limited to the outcomes of 40-60 patients. The endpoint of the registry is to compile the outcomes of over 2,000 cases. If this goal is reached, it will be the largest study of hyperbaric therapy published to date. Interim data analysis suggests excellent outcomes are achieved when hyperbaric oxygen therapy is utilized in the management of patients with radionecrosis.

OR009
Infection in Chronic Wounds Correlated to Wound Cytokine Levels. Diagnosis by the Clinician and Bacterial Bioburden.

Rachael Clark (Wound Biology Group, Cardiff University & Johnson and Johnson Wound Management, UK), Katja Hill (Wound Biology Group, Cardiff University, UK), Patricia Price (Wound Healing Research Unit, Cardiff, UK), Keith Harding (Wound Healing Research Unit, Cardiff, UK), Ryan Moseley (Wound Biology Group, Cardiff University, UK), Phil Stephens (Wound Biology Group, Cardiff University, UK), Breda Cullen (Johnson and Johnson Wound Management, UK)

Objective
This study aimed to determine whether there is a measurable biochemical host response that could provide an alternative diagnostic tool to aid a clinician's decision-making process for chronic wound infection.

Purpose
Chronic wounds fail to heal in a timely and orderly manner. A complication associated with normal wound healing is wound infection. The diagnosis of chronic wound infection can be a difficult clinical decision. Signs and symptoms used to diagnose infection can often be masked by factors relating to the host, chronic inflammation and the tissue damage associated with chronic wounds.

Methods
The study design involved collecting wound fluid from a number of chronic wounds (n=35), determining the microbial content, and measuring a variety of host factors, including cytokines, by micro-array and ELISA technology.

Results
There appeared to be no correlation between the levels of various host factors, total bioburden (in this study it ranged between 102-108 CFU/ml), and the clinical diagnosis of infection. However, a number of cytokines were found to be significantly elevated (p<0.05) in venous leg ulcer wounds assigned as infected (angiogenin, ICAM-1, L-1b, IL-4, IL-6, TNFa, TNFr2, and VEGF), by microbiological classification at a level of equal to or > 106 CFU/ml. In contrast, using the same infection classification, an additional set of cytokines (IL-2, -4, -5, 12p40, 12p70, -13, TNFr2, IP-10, IFN-g, and TGF-b1), significantly decreased (p<0.05), upon increasing bacterial bioburden levels within diabetic foot ulcer wounds.

Discussion
A differing cytokine response was observed dependent on ulcer type that may be attributed to underlying pathology, and/or the type and combination of bacteria found in these particular wounds. The results of this study suggest that measuring cytokines within chronic wounds may provide an effective and timely approach to defining the bacterial infection within a wound.

OR010
Determination of the Effects of a Myeloperoxidase (MPO) Formulation on Wounds Inoculated with Staphylococcus Aureus

Roberto Perez (University of Miami, Miller School of Medicine), Yan Rivas (University of Miami, Miller School of Medicine), Joel Gil (University of Miami, Miller School of Medicine), Jose Valdes (University of Miami, Miller School of Medicine), Sophie Becquerelle (Exoxemis, Inc ), Obsidiana Abril-Horpel (Exoxemis, Inc ), Stephen C. Davis (University of Miami, Miller School of Medicine)

As part of the normal inflammatory process, human phagocytes employ myeloperoxidase (MPO) to eliminate bacteria from wounds. Staphylococcal species have been estimated to affect over 70% of wounds due to the prevalence of the bacteria on the skin and the high incidence of resistance to antimicrobial treatments. It has been suggested that chronicity of wounds can be associated with a persistent elevation in bacterial counts, resulting in a prolonged and more intense inflammatory response. Herein, we present research conducted to investigate the ability of a MPO containing formulation to combat Staphylococcus aureus infection using a porcine partial thickness wound model.

Swine were used in the study due to the similarities of porcine skin to human skin. Deep partial thickness wounds (10 mm x 7 mm x 0.5 mm) were made on each animal using a specialized electrokeratome. Wounds (6 per treatment) were inoculated with Staphylococcus aureus. Wounds were treated with high or low concentration of MPO formulation, placebo, saline, or mupirocin, which served as a positive control. Untreated wounds served as a negative control. Treatments were applied 20 minutes after inoculation, 4 hours after initial treatment, and 24 hours after initial treatment at which time the bacteria were recovered using catalase solution and a neutralizing solution for mupirocin. Recovered bacteria were plated on mannitol salt agar using the Spiral Plater System and the Log CFU/mL determined after overnight incubation.

Treatment with the MPO formulations reduced the 8 Log CFU/mL of challenge pathogens recovered from the untreated wounds by 3 Log (p<0.01). There was no difference in the placebo, saline, or untreated groups. As expected mupirocin treatment resulted in no detectable wound bacteria. These

Results indicate that treatment with MPO formulation is effective in reducing the number of S. aureus in wounds, which may have important clinical implications.

OR011
Development of Alendronate-functionalised Hydrogels as Novel Wound Dressings for Chronic Leg Ulcers

Erin A. Rayment (Institute of Health and Biomedical Innovation), Tim R. Dargaville (Institute of Health and Biomedical Innovation), Gary K. Shooter (Institute of Health and Biomedical Innovation), Graeme A. George (Institute of Health and Biomedical Innovation), Zee Upton (Institute of Health and Biomedical Innovation)

Goals and Objectives
Chronic ulcers are an important medical issue, causing their sufferers pain, immobility and decreased quality of life. The common pathology in these chronic wounds is characterised by excessive proteolytic activity, leading to the degradation of key factors critical to the ulcer's ability to heal.

Purpose
As matrix metalloproteinases (MMPs) have been shown to have increased activity in chronic wound fluid (CWF), we hypothesised that this was directly related to an ulcer's chronic nature and that inhibition could therefore lead to an effective treatment.

Methods
To investigate this hypothesis Collagen Type I and IV zymography, specific immunoprecipitation, and an indirect enzyme-linked immunosorbant assay were used to analyse MMP levels in CWF. In addition, a specific MMP-inhibitor, sodium alendronate, was methacrylated and then copolymerised into a hydrogel system to create a wound dressing with a tethered MMP-inhibitor.

Results
The MMP characterisation studies demonstrated that MMP activity is significantly elevated in CWF compared with acute wound fluid. In particular, it appears that MMP-9 is the predominant protease responsible for matrix degradation by CWF. Furthermore, the levels of MMP-9 activity correlate with the clinical status of the wound itself. Moreover, MMP-9 can be inhibited with the bisphosphonate alendronate, in the form of a sodium salt, a functionalised analogue, and also tethered to a synthetic biocompatible hydrogel compromised of aqueous poly (2-hydroxy methacrylate) synthesised in the presence of poly(ethylene glycol).

Discussion / Conclusion
Together, these results highlight the potential use of a tethered MMP inhibitor as an improved ulcer treatment to inhibit protease activity in CWF and yet will still allow MMPs to remain active in the wound bed where they perform vital roles in the activation of growth-promoting agents and immune system regulation.

OR012
Preventing Heart Injury During Topical Negative Pressure Therapy in Cardiac Surgery

Malin Malmsjo (Department of Medicine, Lund University Hospital, Lund, Sweden), Rainer Petzina (Department of Medicine, Lund University Hospital, Lund, Sweden,), Martin Ugander (Department of Clinical Physiology, Lund University Hospital, Lund, Sweden, ), Henrik Engblom (Department of Clinical Physiology, Lund University Hospital, Lund, Sweden), Arash Mokhtari (Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden), Hakan Arheden (Department of Clinical Physiology, Lund University Hospital, Lund, Sweden), Richard Ingemansson (Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden)

Goals and Purpose
Heart rupture is a devastating complication to topical negative pressure (TNP) therapy in cardiac surgery. Also, reduced cardiac output during TNP has been reported. The present study was aimed to examine the effects of TNP therapy on the intrathoracic anatomy, in particular the heart, using magnetic resonance imaging (MRI) in a porcine sternotomy wound model.

Methods
Six pigs underwent median sternotomy followed by TNP therapy at -75, -125 and -175 mmHg. Real time MRI movies (10 images/s) were acquired in a midventricular transverse plane or a midsagittal plane during the application of TNP.

Results
TNP caused the heart to be sucked up towards the thoracic wall and alter the movement of the myocardium. In some cases, the right ventricular wall bulged into the space between the sternal edges, and the sharp edges of the sternum jutted into and deformed the anterior surface of the heart. These events were not prevented by the interposition of four layers of paraffin gauze dressing, but were hindered by the placement of a rigid barrier between the anterior portion of the heart and the inside of the thoracic wall.

Discussion / Conclusion
The current findings of altered intrathoracic anatomy during TNP may explain two potentially hazardous events associated with TNP therapy, namely risk for heart injury and reduced cardiac output. Inserting a rigid barrier over the heart is a protective measure that may be clinically practicable.

OR013
Detection of Potential Prognostic and Diagnostic Markers of Healing in Chronic Wound Fluid

Melissa Fernandez (Institute of Health and Biomedical Innovation), James Broadbent (Institute of Health and Biomedical Innovation), Dr Gary Shooter (Institute of Health and Biomedical Innovation), Prof Zee Upton (Institute of Health and Biomedical Innovation)

Purpose
Chronic venous leg ulcers are a significant cause of pain, immobility and decreased quality of life. In view of this, research has been focusing on multiple factors in the wound environment to provide information regarding the healing of ulcers. Chronic wound fluid (CWF), containing a complex mixture of proteins, is an important modulator of the wound environment, therefore we hypothesised that these proteins may be indicators of wound status and their potential to heal or otherwise. To explore this we analysed CWF using a proteomic method developed within our research program.

Methods
Pooled wound fluid samples were depleted of 6 high abundant proteins using a multiple affinity removal system column as per the manufacturer's instructions. Two fractions containing high and low abundant proteins were collected, concentrated and desalted using reverse phase resin. Each fraction was further separated using ion exchange chromatography and finally mass spectrometry was used to identify potential peptides present in CWF.

Results
Immuno-depletion resulted in the enrichment of low abundant proteins in CWF thus improving the resolution and identification of these proteins in subsequent analysis. Many of these proteins identified by mass spectrometry were acute phase proteins previously been reported to be expressed during the inflammatory stage of healing.

Discussion / Conclusion
The identification of inflammatory proteins in CWF has confirmed that the healing process appears to be stalled in the healing phase; this is one of the key characteristics of chronic wounds. Currently, further analysis is being carried out with CWF obtained from patients receiving various levels of compression treatment and is being correlated with the healing or non-healing status of these ulcers. This proteomic approach to analyse CWF has the potential to provide novel information regarding wound fluid composition and healing and may ultimately guide health care professionals when treating chronic leg ulcers.

OR014
Human Papilloma Virus E6/E7 Oncogenes Promote Mouse Ear Regeneration in the Transgenic Model: Tg-[K6b-E6/E7]

Jose Bonilla-Delgado (Cinvestav), Concepcion Valencia (IBT-UNAM), Katarzyna Oktaba (IBT-UNAM), Rodolfo Ocadiz-Delgado (Cinvestav), Giselle B. Llaguno (UAM), Arturo Luna-Andrade (Cinvestav), Patricio Gariglio (Cinvestav), Luis Covarrubias (IBTUNAM)

Goals and Objectives
To generate transgenic mice able to express E6/E7 oncogenes of Human Papillomavirus type 16 (HPV-16) under the control of a wound-inducible promotor: Tg-[K6b-E6/E7].

Purpose
To understand the role that E6/E7 oncogenes play in tissue homeostasis and wound healing through the generation of a transgenic mice capable of repairing skin without leaving a scar and with no evidence of tumor formation.

Methods
Generation of transgenic mice, BrdU labeling, Immunohistochemistry, in situ RT-PCR, TUNEL.

Results
The regeneration process observed includes the formation of hair follicles and cartilage in the regenerated tissue, without evidence of tumor formation. The increased regeneration observed in Tg-[K6b-E6/E7] correlates with an increased number of epidermal proliferating cells including those located in the borders of the wound. In concordance with the expected effects of E6 and E7 oncogenes on epidermal cells, p53 amount decreases and p16 expression increases, respectively. We observed that wound re-epithelization proceeds faster in transgenic than in wild type animals. After re-epithelization epidermal cell migration from the intact surrounding tissue appears to be a major contributor to the growing epidermis in transgenic mice. We found that there is a significantly larger number of putative epidermal stem cells in Tg-[K6b-E6/E7] than in wild type mice.

Discussion / Conclusion
The keratin 6b (K6b) is an inducible keratin expressed only after injury. When E6/E7 oncogenes are expressed under the direction of this promotor, they are able to increase the number of epidermal stem cells enhancing the process of wound healing. We propose, that the ability to efficiently regenerate skin in Tg-[K6b-E6/E7] mice is a property of an elevated number of stem cells to repair epidermis during wounding.

OR015
Development of Non-Rejectable Cultured Skin Substitute

Farshad Forouzandeh (Department of Surgery, University of British Columbia), Reza B. Jalili (Department of Surgery, University of British Columbia), Steven Boyce (Department of Surgery, University of Cincinnati), Dorothy Supp (Department of Surgery, University of Cincinnati), Aziz Ghahary (Department of Surgery, University of British Columbia)

Goals and Objectives
Any allogeneic skin substitute will be rejected by the host immune system unless an immunosuppressive agent is used to prevent this rejection. Thus, the goal of this study was to explore a new approach through which the clinical difficulties of nonhealing wounds can be improved by developing a shelf-ready skin substitute.

Purpose
Developing a non-rejectable skin substitute composed of epidermal and dermal layers equipped with local immunosuppressive factors such as Indoleamine 2, 3- Dioxygenase (IDO).

Methods
Foreskin pieces were used as source of fibroblasts and keratinocytes. Constructing IDO-recombinant Adenoviruses, we infected fibroblasts. Inoculating the IDO-treated and non IDOtreated fibroblasts and keratinocytes into the collagen GAG matrix, we developed different Cultured Skin Substitutes (CSSs). Then, we put IDO-expressing and non IDO-expressing CSS on same size skin wounds created on back of Sprague Dawley rats. Following the engraftment, we evaluated the wound closure, lymphocyte infiltration, and angiogenesis in the wounds at different time points.

Results
The finding of this study showed a significant improvement in wound closure time in wounds receiving IDO-expressing CSS compared to the other groups, with (P<0.05). In addition, the number of infiltrated CD3+ T cells, a marker of immunoreaction, was markedly less in IDO group relative to that of control group. Further, significantly more clusters of Red Blood Cells (RBCs) as well as endothelial cells were present within the grafted areas in IDO treated group.

Discussion / Conclusion
Promoting the wound closure, suppressing the immuno-reaction to the grafted skin substitute, and inducing angiogenesis are all very valuable effects and benefits of IDO expression in this novel approach for wound healing. Indeed, the finding of this study assists us in providing a prepared skin substitute as not only coverage, but also an incredible source of nutrients and cytokines for promoting wound healing and preventing the immune rejection of CSS.

OR016
Uncultured Lipoaspirate Cell Autografts for the Treatment of Diabetic Ulcers

Seung-Kyu Han (Korea University Guro Hospital), Woo-Kyung Kim (Korea University Guro Hospital)

Background
The treatment of diabetic ulcers using various types of cultured cells has garnered much interest. However, FDA approved facilities and techniques are required during the culturing process before applying cultured cells for clinical purposes. In addition to this, a long amount of time is needed for culturing. In constrast, human lipoaspirate cells are relatively easy to obtain in large quantities without cell culture.

Purpose
The purpose of this study is to present the possibility of using uncultured lipoasparate cell autografts for the treatment of diabetic ulcers.

Methods
The in vitro study was initially designed to determine the effect of lipoaspirate cell autografts on the activity of diabetic fibroblasts (n=4). Fibroblasts isolated from diabetic patients' discarded skin were expanded and co-cultured with or without autogenous lipoaspirate cells. Cell proliferation and collagen synthesis were measured. In a subsequent clinical study, 23 patients with diabetic foot ulcers were treated using the lipoaspirate cell autografts. The mean ulcer size was 5.1+1.1cm2. The progress of, and time required for, complete wound closure were assessed.

Results
One hundred to one hundred sixty thousand lipoaspirate cells were isolated per ml of aspirated adipose tissue. In the in vitro study, both cell proliferation and collagen synthesis in the lipoaspirate cell treatment group were 28 and 44 percent higher than in the control group, respectively (p < 0.05). Our clinical studies showed that complete wound healing occurred in 21 patients and clinically overt infection occurred in 2 patients. In the 21 healed wounds, 17 to 49 (mean 28.6+8.1) days were needed for complete reepithelization, and no clinical or laboratory abnormalities were noted.

Conclusion
Uncultured lipoaspirate cell autografts stimulate the activity of diabetic fibroblasts and offers a simple and effective treatment for diabetic ulcers.

OR017
The Effect of Recombinant Human Growth Factor (rh-EGF) Against Radiation Induced Dermatitis in Mice

Sang Wook Lee, MD, PhD (Asan Medical Center, Department of Radiation oncology ), Sue Young Moon, MS (Asan Medical Center, Department of Radiation oncology), Yeun Hwa Kim, MS (Asan Medical Center, Department of Plastic Surgery), Joon Pio Hong, MD, PhD, MBA (Asan Medical Center, Department of Plastic Surgery)

Goals and Objectives
To research the effect and efficacy of rh-EGF against radiated skin wounds.

Purpose
Due to the frequent skin complications from radiothrapy, the research on rh-EGF can be a wothwhile if the complication can be reduced.

Methods
Thirty nude mouse exposed to total of 45Gy on their femoral region. Six mouse were randomly assigned to one of the 5 groups; 1)control, 2) vehicle-treated and 3,4,5) rhEGF treated groups (ointment of 10ug/g, 50ug/g, 100ug/g rh-EGF each). Evaluated for 6 months and healing defined as complete epithelialization and recurrence as breakdown of the skin and were also evaluated with hitology.

Results
Initial wound showed no difference in time to achieve 100%healing. However, the recurrence rate was significant in group 1 and 2 whereas the rh-EGF treated groups did not demonstrate any recurrence except the 100ug/g treated group. Histology revealed near normal appearance in the group 4, irregular epidermal thickness in group 3, and poor definition of dermis and epidermis in groups 1,2,and 5. The collagen distributions; group1 -26.58%, group2 -23.79%, group3 -33.26%, group4 -41.36%, and group 5 -22.37%.

Discussion / Conclusion
The use of rh-EGF may have favorable results in healing against radiation dermatitis such as preventing further recurrence of wound and healing morphology close to normal mechanism as shown by histologic findings. This may rely on the fact that ionizing radiation leads to increased expression of functionally intact EGF receptors in human keratinocytes.

OR018
Using Gene Transcription Patterns to Guide the Extent of Excisional Debridment of Chronic Wounds

Marjana Tomic-Canic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Elizabeth A. Ayello (President, Ayello, Harris, & Associates, Inc.;Excelsior College, School of Nursing ), Olivera Stojdainovic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Irena Pastar (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Sasa Vukelic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Michael S. Golinko (Wound Healing Program, Columbia University College of Physicians and Surgeons), Harold Brem (Wound Healing Program, Columbia University College of Physicians and Surgeons)

Background
Debridement of non-healing wounds is integral part of standardized treatment protocol. However, currently, there is no mechanism that would allow surgeon to determine the extent of debridement needed to eliminate cells that are no longer biologically equipped to heal.

Purpose
To determine the objective parameters of debridement that may serve as a guide for clinicians for treatment option selection and evaluation effectiveness.

Methods
We studied venous ulcers before and after debridement to determine if the two edges- healing and non-healing are biologically distinct using biopsies from both the traditional stalled edge of non-healing wound to the true edge of the wound where keratinocytes are capable of migration. We performed histology and microarray analyses of each biopsy. Furthermore, we established primary cells from these biopsies and evaluated cellular responses to wounding.

Results
We found that biopsies from the nonhealing edges exhibit distinct pathogenic morphology. This morphological appearance is accompanied by characteristic transcriptional profile. The nonhealing edges have a specific, identifiable, and reproducible gene expression profile. The adjacent nonulcerated biopsies have their own distinctive reproducible gene expression profile, signifying that particular wound areas can be identified by gene expression profiling. Fibroblasts deriving from this location exhibit impaired migration in comparison to the cells from adjacent nonulcerated biopsies. Biopsies originating from postdebridement location exhibit normalization of morphology and cells deriving from this location show normal migration capacity.

Conclusions
By creating a simple color pattern, one can readily identify how far debridement should be done at the wound edge to reach the "margin of response", e.g. where keratinocytes are normal and capable of migration and function. In practical terms, clinicians may have a road map to guide debridement rather than relaying on visual assessment.

OR019
Clinical Symptoms of Deep Tissue Injuries (DTI) in Pressure Ulcers - Hourglass-shaped and Sandwich-shaped Necrosis

Takehiko Ohura (Pressure Ulcer and Wound Healing Research Center (Kojin-kai)), Norihiko Ohura Jr. (Department of Plastic and Reconstructive Surgery, Kyorin University), Sachio Kouraba (Plastic and Reconstructive Surgery, University of Hokkaido), Hiroaki Oka (Department of Plastic and Reconstructive Surgery, Kawasaki Medical School)

Background
Various clinical symptoms develop in deep tissue injuries, but there have been no detailed reports or systematic studies regarding DTI and the mechanisms of development thereof.

Purpose
Specific clinical symptoms of DTI include hourglass-shaped necrosis and a subdivision thereof known as sandwich-shaped necrosis that often develop. During the course of healing, when a pressure ulcer in the surface layers spreads or perforates into the deeper layer necrosis, clinically, a shallow ulcer that is being treated suddenly seems to change and pressure ulcers thereafter seem to worsen, thus creating a medical and nursing problems, and the importance of resolving these problems is immeasurable.

Methods
326 pressure ulcers cases were analyzed from June 2002 to June in 2006 (Stage IV) from several hospitals, and each subject was a patient who had been treated by the same interdisciplinary team from the onset of a pressure ulcer until the ulcers healed.

Results
Among the 326 Stage IV cases, hourglass-shaped necrosis was observed in 132 cases (40%) and sandwich-shaped necrosis was observed in 33 cases (10%).The existence of hourglass-shaped necrosis and sandwich-shaped necrosis can be confirmed by CTscans and ultrasonography imaging, but they could be made clearer by the verification of histolysis process of necrosis.

Discussion / Conclusion
The mechanism by which DTI and hourglass-shaped necrosis develops in pressure ulcers is investigated from a mechanical stress viewpoint. Sandwich-shaped necrosis comprises congested tissue or near-intact tissue left in the intermediate layer in the soft tissue when external force does not affect the layer. When this intermediate layer tissue necrotizes over time and necrosis spreads from the surface layer to the deep layer, it clinically appears as though it has suddenly deteriorated, thus leading to the conclusion that the patient's nursing care or treatment is poor, thus resulting in complaints of malpractice.

OR020
Coronary Blood Flow Changes Before and During Application of Myocardial Topical Negative Pressure

Sandra Lindstedt (Department of Cardiothoracic Surgery ), Malin Malmsjo (Department of Medicine), Richard Ingemansson (Department of Cardiothoracic Surgery )

Objectives
Topical negative pressure (TNP), has been shown to increase blood flow and stimulate angiogenesis. Mediastinitis after coronary artery by-pass surgery (CABG) has earlier been associated with poor long-term survival, when compared to patients who underwent CABG without mediastinitis. Over the last ten years, TNP has been introduced as an alternative treatment for patients with mediastinitis. Recently, we have showed no difference in long-term survival between CABG patients with TNP-treated mediastinitis and CABG patients without mediastinitis. During TNP treatment the heart is in direct contact with the negative pressure. We believe that these patients might have developed increased coronary collateral blood vessels during TNP, and may therefore be better prepared when bypass grafts fail to work.

Purpose
The present study was designed to elucidate if topical negative pressure, applied over the myocardium, resulted in an increase of the total amount of coronary blood flow.

Methods
Six pigs underwent sternotomy. The blood flow was measured, before and after the application of TNP, using coronary flowmeter probes. Analyses were performed before LAD occlusion (normal myocardium) and after 20 minutes of LAD occlusion (ischemic myocardium).

Results
A TNP of -50 mmHg induced an immediate, significant increase in total coronary blood flow in normal myocardium (171.3 ± 14.5 ml/min before, to 206.3 ± 17.6 ml/min after TNP application, *p < 0.05). A TNP of -50 mmHg induced a significant increase in total coronary blood flow in ischemic myocardium (133.7 ± 18.4 ml/min before, to 183.2 ± 18.9 ml/min after TNP application, *p < 0.05).

Conclusion
Myocardial TNP induced a significant increase in total coronary blood flow in normal and ischemic myocardium. It may be that the TNP stimulation of blood flow and development of collateral blood vessels in part account for the reduced long-term mortality in patients with TNP treated mediastinitis.

OR021
Animal Experimental Study Model for Pressure Ulcer by Persistence Stress in Local Ischemia-Reperfusion

Liping Jiang MPH, RN (Wenzhou Medical College, School of Nursing, Wenzhou, China), Funam Cai (Wenzhou Medical College, Wenzhou, China)

Goals and Objectives
Many factors contribute to the development of pressure ulcers. Tissue ischemia leads to damage in the epidermis and dermis. Skin tissue injury contributes to pressure ulcer development. The

Objectives
were to test this hypothesis using an animal model and to explore a safe, reliable and effective method for preventing pressure ulcers, based on the potential mechanism of pathology ischemia-reperfusion by persistence local stress on animal model in rats' skin.

Purpose
The purpose of this research is to to test the theory of pathology ischemia-reperfusion mechanisms applied to pressure ulcers, using an animal model.

Methods
An animal pressure ulcer model was established as follows: rats were randomly divided into three groups in terms of time and pressure, the control group, pressure for 2 hours group and reperfusion groups. The skin tissue's pathology and physiology changes were studied after applying pressure to the rat's skin.

Results
Both injury degrees and pressure time in local skin lead to ulcers. In the skin tissue of subcutaneous and muscle, there were histopathologic alterations. The subcutaneous tissue had pathology changes. These fibroproliferative alterations may produce significant deformations and alterations in the pressure group and ischemia reperfusion group. The plasma of ET- 1¸MDA¸LDH, SOD and NO were measured which SOD and the content of NO were significantly lower while ET- 1¸MDA¸LDH were significantly higher in reperfusion group compare to normal control group.

Discussion / Conclusion
The pathological and physiological alterations from persistent pressure on skin may give rise to important mechanism in ischemia-reperfusion. This result will help to understand the mechanism of pressure ulcer and reveal the value for the clinical applications. Health care providers need to be involved in preventing and treating these problematic wounds.

OR022
Effect of Vitamin C on the Random Flap Survival in the Rat

Chan Yeong Heo (Seoul Natinal University Hospital)

Goals and Objectives
Vitamin C acts as a antioxidants and as free radical scavengers in biological systems. The objectives of this study was to examine whether the administation of vitamin C could improve the skin flap survival.

Methods
Sprague-Dawley rats(n=40) were divided into 4 groups (n=10); normal saline, vitamin C 200mg/day, vitamin C 500mg/day; vitamin C 1000mg/day were injected subcutaenously to each group (n=10). A classic caudally based random flap (2x7cm) was elevated on the dorsum of rats and then sutured to its normal position. On the 3rd, 7th, 14days postoperatively each animal was evaluated for percentage area of flap survival by paper template technique, thereafter rats were sacrificed and we obatained tissue from the distal ends of the flap.

Results
1) The experimental group treated with vitamin C revealed an increased rate of skin flap survival compared with the control group(p<0.005). 2) There was correlation of vitamin C dosage with flap survival rate (Spearman's correlation coefficient=0.971). 3) The biopsy of the control group showed extensive atrophy and necrosis. However, new capillary proliferation and collagen deposition was noted in the vitamin C 200mg and 500mg treated group. In the vitamin 1000mg group, microscopic findings were very alike compared with normal rat skin texture.

Discussion / Conclusion
Vitamin C supplement increased survival rate of random pattern flap in rat skin flap model and flap survival was correlative with vitamin C dosage.

OR023
Effect of Collagenase Ointment on Healing of Partial and Full Thickness Porcine Wounds

Namrata Barai (Healthpoint, Ltd.), Michael Law (Healthpoint, Ltd.), Larry Perry (Pluris Research, Inc.), Dale Telgenhoff (Healthpoint, Ltd.), Duncan Aust (Healthpoint, Ltd.)

Collagenase ointment is efficacious as a debriding agent. Additionally, clinical studies indicate that it may also have a role in wound healing. In the current work we have evaluated the effect of the collagenase ointment in the healing of partial and full thickness wounds in the pig. In separate studies, partial thickness (0.8 mm deep) and full thickness wounds (20 mm diameter) were created on the backs of young female Yorkshire pigs. The full thickness wounds were contaminated with a mixture of S. aureus, P. aeruginosa, and fusobacterium spp. for 15 minutes before applying the treatments, which were: collagenase ointment, petrolatum (vehicle), moist dressing, or air exposed with no treatment applied. In the partial thickness wounding studies after eight days of treatment, 85% of collagenase treated wounds had completely re-epithelialized when compared to 10% of petrolatum treated wounds and 0% of the moist dressing or untreated wounds. Histological assessment of the wound tissue also showed that at four days post wounding collagenase treated wounds were significantly less inflamed with less neutrophil infiltration than both moist control and untreated wounds. In the full thickness study it was observed that rate of wound closure in the collagenase treated wounds was significantly improved when compared to moist dressing for the entire duration of the study (21 days), and was significantly better than petrolatum on days 4 and 6 post wounding. On day 21, the epidermis in the collagenase treated wounds is better developed as indicated by much deeper rete ridges into the dermis when compared to petrolatum, suggesting an enhanced quality of the healed wound. The above results demonstrate that collagenase ointment improves quality and rate of re-epithelialization in both partial and full thickness porcine wounds.

OR025
The Split Thickness Skin Graft Donor Site: Have We Found The Perfect Dressing?

Patricia Terrill (Peninsula Health; Department of Surgery, Monash University), Ray Goh (Peninsula Health), Michael Bailey (Department of Epidemiology and Preventitive Medicine, Monash University)

Goals and Objectives
The optimal dressing for the split thickness skin graft (SSG) donor site has not yet been found. Alginate dressings have been used for many years to dress donor sites. They require a secondary absorbent dressing which is not waterproof, will frequently leak blood and are often difficult to remove. Polyurethrane film dressings have also been used routinely with excellent healing rates, are waterproof, but highly prone to leakage.

Methods
A prospective, randomized controlled trial comparing two dressings, a new absorbent form of a Polyurethrane Film dressing, Tegaderm Absorbent (3M) and Kaltostat Alginate (Convatec) on the SSG donor site of 40 patients.

Results
Application of the absorbent film was significantly easier than the alginate (89% Vs 27% very easy), as was ease of removal (84% Vs 11% very easy) (p<0.0001). Median pain scores on Day 1 and 2 postoperatively and on dressing removal were significantly less for absorbent film (0,0,0) when compared to alginate (2,3,3) (p<0.01). On removal of the dressings at the first assessment, 79% of absorbent film donor sites were completely healed compared to 16% of alginate donor sites (p<0.001). A significantly greater median area was healed for absorbent film (100%) compared to alginate (89%) (p<0.0001). The mean time to complete healing was also significantly faster for absorbent film than for alginate (14 Vs 21 days) (p<0.0001). Leakage rates were reduced by 48% for absorbent film, with no leakages in the smaller donor sites. Absorbent film dressings were significantly more convenient for the patient to manage and bathe with. At one month post surgery, the Vancouver scar score showed the absorbent film donor sites to be less red, flatter, softer and less itchy.

Conclusion
Absorbent film dressings significantly reduced donor site pain and significantly improved rates of healing and ease of management especially in small donor sites.

OR026
Factors Related to Long Term Outcome and Recurrence of Ulcers in Diabetic Patients with a Previously Healed Foot Ulcer

Jan Apelqvist (Dept Endocrinology, Malmo University Hospital, Sweden), Magnus Eneroth (Dept Ortpedics, Malmo, Sweden), Jan Larsson (Depr Ortopedics, Lund, Sweden), P Nyberg (Dept Vascular SurgeryMalmo, Swede), J Thorne (Dept Surgery, Helsingborg, Sweden)

Goals and Objectives
To evaluate the recurrence of foot ulcer as well as cumulative amputation and mortality rates in diabetic patients with previous foot ulcer.

Purpose
The short term prognosis of foot ulcer in diabetic subjects is good if treated early with a multi factorial approach. There is limited information regarding long term outcome and factors related to recurrence of foot ulcer after healing of an initial ulcer.

Methods
1,610 consecutive diabetic patients admitted with new foot ulcers were followed to outcome in a multidisciplinary system according to a standardised preset protocol .Out of these patients 1,262 survived and healed either primarily (80%) or with amputation (minor/major 10/10%). Out of these patients 1229 very consecutively followed according to a standardised protocol with registration of new foot ulcer, amputation, comorbidity and mortality. Clinical examination was performed at regular visits and new ulcers were treated by the foot care team

Results
After 1,3, 5 yrs of observation 34 %, 61% and 70 % of the patients had developed a new foot ulcer. Occurrence of new ulcers were more common in patients with a previous amputation. Both cumulative mortality and amputation rate were higher among patients healed with a previous amputation (p<0.001). Data were analysed with regard to occurrence of a foot new ulcer within 2 year of observation.

Discussion / Conclusion
More than 30 %of diabetic patients with a previous foot ulcer developed an new a ulcer within one year of observation. The cumulative mortality and amputation rate during 5 years was substantial indicating importance of recognizing diabetic foot ulcer as a sign of multiple cardiovascular disease and the need for life long surveillance of the diabetic foot at risk

OR027
The Effect of Self-management Education on Foot Care Status and Metabolic Control in Diabetic Patients

Sedigheh Soheilikhah (Shahid Sadoughi University of Medical Sciences), Parichehr Kafaee (Shahid Sadoughi University of Medical Sciences), Maryam Rashidi (Shahid Sadoughi University of Medical Sciences), Hosein Ali Sadeghian (Shahid Sadoughi University of Medical Sciences), Mohammad Afkhami-Ardekani (Shahid Sadoughi University of Medical Sciences), Seid Mohammad Mohammady (Shahid Sadoughi University of Medical Sciences), Maryam Salami (Shahid Sadoughi University of Medical Sciences)

Goals and Objectives
Demonstrate the role of self management education in diabetic foot care and optimize glycemic control by patients' education.

Purpose
Improve foot care status and glycemic control in diabetic patients by a self management education program

Methods
In this Quasi-Experimental study 30 patients referred to Yazd Diabetes Research Center were randomly selected. Level of foot self care was assessed by pre-test questionnaire. Diabetic foot condition assessed by United Kingdom Screening Score (UKSS) and Semmes-weinstein monofilament, ABI and TBI index and toe pressure. After that patients educated by a specialist face to face about foot self care including washed feet, dried between toes, checked feet, inspected shoes, used moisture cream, cut their toenails straight across and wear slippers. Patients followed for 3 months and visited four weekly. After 3 months post-test was completed. Pre and post test questionnaire were scored to identify effect of education. Glycemic control measured by glycated hemoglobin (HbA1c) at baseline and after 3 months.

Results
30 subjects (12 male, 18 female) with mean age 54.24±9.48 years were assessed. Peripheral neuropathy was diagnosed in 30% by monofilament and 37% by UKSS and vasculopathy (abnormal toe brachial index [TBI<0.6]) in 20.6% of patients. There was a significant increase in the foot self-care behavior over the course of the study according to scoring (baseline 22.03±5.41, 3 months 42.1±6.85; P =0.0001). Significant differences were noted in glycemic control as reflected by hemoglobin A1c values, with a significantly higher proportion of patients having better control at 3 months (P=0.03).

Discussion/Conclusion
These findings indicate that educating patients about foot self care may encourage routine foot care and can be vitally important to prevent of diabetic foot ulcer.

OR028
Diabetic Neuropathic Ulcer: Collaboration, Is this the solution?

Margaret Ryan (Central Bayside Community Health Services)

Goals and Objectives
The anecdotal experience within the community health setting gained through the perspective of a community health nurse suggests that it is a relatively new perspective that health ojectives achieve better outcomes when researching within a collaborative environment

Purpose
This case study will illustrate the importance and benefits of professional collaboration in the management of a chronic Insulin Dependent Diabetes Type 2 neuropathic ulcer in the community setting. The paper will explore the involvement of key stakeholders including the diabetes nurse educator / wound consultant, podiatrist, general practitioner and orthic specialist with a focus on the need and expectation to achieve a healed wound.

Methods
The emphasis was on a holistic approach encompassing the significance of communication and networking between all key stakeholders, the result of which, was a collaborative approach to assessment, care planning and wound management.

Results
The outcome resulted in a healed wound and improved quality of life for the client. Furthermore, the result encapsulates the significance of the enhanced understanding of the roles and expertise of key stakeholders involved in the management of a chronic neuropathic ulcer.

Discussion / Conclusion
The issues to be discussed include the interplay between the public and private health sectors in 'off-loading' pressure, the multifaceted role of the diabetes nurse educator/wound consultant and the association between optimal glycaemic control and wound healing.

OR029
Identifying Risk Factors for Foot Ulceration in Individuals with Chronic Kidney Disease (CKD)

Ms Amy Freeman (The Royal Melbourne Hospital), Ms Nicoletta Frescos (La Trobe University), Ms Kerry May (The Royal Melbourne Hospital), Dr Paul Wraight (The Royal Melbourne Hospital )

Background
Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This study was designed to investigate risk factors for foot ulceration in individuals with CKD who do not have diabetes.

Objectives

1. To identify the foot ulcer risk factors most prevalent in individuals with CKD
2. To establish this group as high risk
3. To assist in the future development of guidelines for this population

Methods
One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (1) Control: neither diabetes nor CKD, (2) diabetes alone, (3) both diabetes and CKD, (4) CKD alone. All participants were assessed for past/current foot ulceration, peripheral neuropathy, vascular insufficiency, foot deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.

Results
Participants with CKD alone had no statistically significant differences in risk factor presentation to the group with diabetes alone. For those with CKD alone 36% displayed peripheral neuropathy, 20% displayed vascular insufficiency, and 24% copresented with LOPS and deformity. Participants with coexisting diabetes and CKD presented most frequently with past/current foot ulcers, peripheral neuropathy, and vascular insufficiency, all significantly more frequent in this group than in controls (p<0.05). Eight of the total of ten participants found to have a past/current foot ulcer were in end stage kidney disease.

Discussion / Conclusion
Individuals with CKD who do not have diabetes frequently display risk factors for foot ulceration. The prevalence of risk factors may be similar to that of persons with diabetes, a population widely acknowledged as "high risk" of foot ulceration. Individuals with both diabetes and CKD are at greatest risk of foot ulcer development and risk increases with progression to end stage kidney disease. Risk assessment and patient awareness strategies should be extended to include all patients with CKD focusing on vascular insufficiency, peripheral neuropathy and foot deformity.

OR030
Are Clinical Charcteristics Predictive of a Nontraumatic Lower Extremity Amputation in a Diabetic Population

Pip Rutherford (Hawke's Bay District Health Board)

Goals and Objectives
To evaluate if data collected, will predict lower extremity amputation (LEA), identify characteristics that predict nontraumatic LEA in the diabetic population, and investigate if these can be ranked in order of importance.

Purpose
To retrospectively correlate LEA in a diabetic population with clinical findings, to identify and validate early predictors of LEA to improve patient outcomes, reduce costs, and enhance realistic clinical goal-setting,

Methods
Data collected over a six year period stratified 150 diabetic adults (and 291 limbs) with lower extremity wounds, attending a Diabetes Ulcer Clinic, into two groups. The case group had a LEA and the control group did not have a LEA . Clinical variables and demographic data included: previous amputation, gender, diabetes type, peripheral neuropathy symptoms, peripheral perception to monofilament, biothesiometry, rest pain, intermittent claudication, ankle brachial index, glycaemic control, hypertension, evidence of pressure, and wound aetiology. The data were analysed using a Cox proportional hazards regression model in addition to collation of data from Microsoft Excel

Results
Over the study period there were 41 amputations in 291 limbs from 150 people. The only variable predictive of LEA was previous amputation (p = 0.028). Sample size was too small to demonstrate significance for any other variable. Some associations between clinical variables were found with LEA, rest pain, biothesiometry, ankle brachial index, hyperglycaemia, hypertension and wound aetiology, but these were found not to be statistically significant.

Discussion / Conclusion
This study shows that previous amputation was the only significant predictor of LEA in this sample. A larger population than currently exists in Hawke's Bay is required to identify predictors of LEA. This project has shown this methodology is feasible and suggests approach could be expanded into a multicentred study

OR031
Factors Related to Short Term Outcome of Neuroischemic/Ischemic Foot Ulcer in Diabetic Patients With and Without Angioplasty

Jan Apelqvist (Dept Endocrinology, Malmo University Hospital, Sweden), Magnus Eneroth (Dept Ortpedics, Malmo, Sweden), Jan Larsson (Depr Ortopedics, Lund, Sweden), P Nyberg (Dept Vascular SurgeryMalmo, Swede), J Thorne (Dept Surgery, Helsingborg, Sweden)

Goals and Objectives
To identify factors related to outcome and possibility for vascular intervention in consecutively presenting diabetic patients with foot ulcer and severe peripheral vascular disease.

Purpose
Peripheral vascular disease is an important limiting factor for healing in neuroischemic or ischemic diabetic foot ulcer. Non invasive vascular testing have been shown to predict probability for healing. Few studies evaluates outcome in neuroischemic or ischemic foot ulcers irrespective of vascular intervention

Methods
Diabetic patients with a foot ulcer (Wagner gr 1-5) admitted to a multidisciplinary foot centre with a systolic toe pressure <45 mmHg or ankle pressure < 80 mmHg were prospectively included and followed according to a preset programme with regard to angiography, PTA, reconstructive vascular surgery and all patients received medical treatment ( metabolic control ,oedema, pain), infection, off loading, wound treatment and continuous follow up until healing irrespective of type of vascular intervention.

Results
Out of 1145 patients ( age 75 yrs, 61% males, 68% with insulin) 39% healed primarily,13% with minor, 11% with major amputation, 28% died unhealed, 7% unhealed and 1% drop out . The most common indication among those without angiography (29%) were short life expectancy (< 6mths), bedridden, extent of tissue loss. PTA or reconstructive vascular surgery following angiography were done in 63% of patients. 11% of patients had any complication after angiography.

Factors related outcome in relation to intervention was analysed in a regression model.

Discussion / Conclusion
More than 80% of surviving patients with neuroischemic or ischemic ulcer healed without a major amputation. Most important factors related to outcome irrespective of intervention was extent of comorbidity and type of ulcer.

OR032
Retrospective Study of the Use of a Padded Hind Foot Dressing for Heel and Ankle Wounds: Efficacy, Cost Effectiveness, and Quality of Life

Noreen Campbell RN, BScN, MA, IIWCC (Foot and Leg Ulcer Clinic, Vancouver Island Health Authority, ), Caroline Quartly BSc. MD. FRCP(C) (Foot and Leg Ulcer Clinic, Vancouver Island Health Authority), Peter Dryden MD, FRCSC (Foot and Leg Ulcer Clinic, Vancouver Island Health Authority), Donna Campbell RN, IIWCC (Foot and Leg Ulcer Clinic, Vancouver Island Health Authority)

Ankle and heel ulcers associated with arterial occlusive disease have reported 50% risk of major amputation. Heel pressures (Fscan) with a padded hind foot dressing (PHD) indicate reduced peak focal pressure and increased surface, factors that improve tissue perfusion. Data was collected to determine PHD (1) efficacy, (2) cost efficiency, and (3) QoL issues. A retrospective review of medical records by alphabetical order randomly assigned heel or ankle wounds of patients with absent palpable pedal pulses to PHD (30). The Control group (30) had standard wound care with any other dressing, gauze to advanced products. Dressing combinations of PHD and compression were excluded.

Results
PHD findings were closure (29/30, p <0.0059), weeks treatment (491, p<0.0093), and number of dressings (886, p<0.0001) with control data - closure (21/30), weeks treatment (800) and dressings (2538). Dressing and nurse visit cost efficiency ratio was 2.93 favoring PHD ($142,797, control $418,136) or nearly a third of the cost. Dressing costs: PHD $6.17 and control range $2-15.50 (average used) ranging from gauze to modern heel dressings. Nurse visit cost was $155. Age, immobility, diabetes, wound size, and ulcer stage influence on closure were not significant. Amputations involved tendon/capsule (1) and bone exposure (2). Slow wound progress was associated with depression or anxiety. Pain contributed to de-conditioning of control patients but was reported to be less with PHD with ability to maintain sitting and daily activity walking. Amputation (3) and lost patients (6) was higher in control compared to one lost for PHD.

Treatment of ankle and heel ulcers with the PHD is safe, effective, and cost efficient. Quality of life improvement identified: pain management, mobility, and exudate management. Given the serious consequences of heel ulcers this dressing has been successfully used by patients with previous heel ulcers to prevent reoccurrence.

OR033
Induction of VEGF and b-FGF Release by Electro Neurostimulation in Diabetic Polyneuropathy

M Bevilacqua (Endocrinology and Diabetes Unit, Department of Medicine, L. Sacco Hospital, Milan, Italy), LJ Dominguez (Geriatric Unit, Department of Internal Medicine, University of Palermo, Italy), M Barrella (LORENZ Research Center, Department of Medicine, L. Sacco University Hospital, Milan, Italy), R Toscano (LORENZ Research Center, Department of Medicine, L. Sacco University Hospital, Milan, Italy), M Barbagallo (Geriatric Unit, Department of Internal Medicine, University of Palermo, Italy)

Goals and Objectives
Pharmacological treatment for diabetic polyneuropathy (DP) has shown limited benefit; FREMS electro-neurostimulation has shown positive results in pain control and peripheral nerve conduction velocity increase.

Purpose
To investigate the effects of FREMS vs. transcutaneous electrical nerve stimulation (TENS) on the release of vascular endothelial growth factor (VEGF) and basic Fibroblastic Growth Factor (b- FGF) in diabetic and non diabetic subjects.

Methods
A total of 20 subjects, 10 non diabetic (6 women; mean age 37±5 years) and 10 type 2 diabetic subjects with DP (5 women; mean age 52±6 years), underwent TENS followed by an interval without stimulation, and then FREMS over the forearm volar surface. Blood samples for plasma VEGF and b-FGF measurements were obtained from the contra-lateral arm.

Results
We observed a significant increase in VEGF during FREMS in both non diabetic and diabetic subjects, with a maximal response from 23.5 ±21.1 to 89.4±80.2 pg/ml (+280.4%) and from 11.4±3.9 to 59.0±22.1 pg/ml (+ 417.5%), respectively (p<0.0001 vs. basal).

No changes in VEGF were observed during TENS.

A significant increase in plasma b-FGF was also visible during FREMS in both non diabetic and diabetic subjects, with a maximal response from 0.6±0.2 to 2.3±0.7 pg/ml (+283.3%) and from 0.5±0.2 to 1.4±0.5 pg/ml (+180.0%), respectively (p<0.0001 vs. basal). Differently from VEGF, similar changes in b-FGF were observed during TENS in both non diabetic and diabetic subjects, with a maximal response to 2.0±1.0 pg/ml (+233.3%) and to 1.2±0.5 pg/ml (+140.0%), respectively (p<0.0001 vs basal).

Discussion / Conclusion
VEGF and b-FGF release during FREMS may help explain the positive effects on nerve conduction velocity in DP, possibly mediated by favorable effects on microangiopathy. The effects of FREMS in diabetic wound care could be investigated because of the role of VEGF and b-FGF in tissue repair.

OR034
Comparison of Callus Characteristics in Diabetic and Non-diabetic Subjects Using Physiological Parameters

Makoto Oe (Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences an), Kaoru Nishide (Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences an), Hiromi Sanada (Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences an), Miho Oba (Department of Gerontological Nursing/Wound Care Management, Division of Health Sciences an), Yumiko Ohashi (University of Tokyo Hospital, Japan), Kimie Wakui (University of Tokyo Hospital, Japan), Takashi Kadowaki (Department of Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Japan)

Goals and Objectives
In diabetic patients, callus forms due to repetitive mechanical stress, finally resulting in an ulcer. However, ulcer does not develop in non-diabetic subjects. The callus characteristics of diabetic patients remain unclear.

Purpose
The purpose of this study was to investigate callus characteristics of diabetic patients using physiological parameters.

Methods
Participants were 30 diabetic outpatients with callus and 30 ageand sex-matched non-diabetic subjects with callus. Callus inspection was performed by 2 wound ostomy continence nurses and 1 diabetes nurse. Callus inflammation was assessed by ultrasonography and thermography as physiological parameters. Callus dryness was assessed by hydration using a corneometer. To compare each parameter between diabetic and non-diabetic subjects, Mann-Whitney and Fisher's exact probability tests were used. This study was approved by the Ethical Committee of the University of Tokyo. Informed consent was obtained from all participants.

Results
There were 63 calluses in diabetic subjects and 94 calluses in non-diabetic subjects. Number of calluses per subject tended to be smaller in diabetic subjects than in non-diabetic subject (P=0.063). Calluses were located only on one foot in diabetic subjects, although calluses were located on both feet in nondiabetic subjects (P=0.011). Visual inspection revealed callus inflammation in neither diabetic nor non-diabetic subjects. However, callus inflammation was found in 10% of calluses in diabetic subjects and no calluses in non-diabetic subjects using physiological parameters (P=0.014). Skin hydration of callus was significantly lower among diabetic subjects than among nondiabetic subjects (P=0.000).

Discussion / Conclusion
This is first time that calluses have been evaluated using physiological parameters. In this study, callus inflammation was found using physiological parameters, despite not being apparent on visual inspection. Physiological parameters might be useful to detect high-risk callus. Callus in diabetic patients displays signs of inflammation and low skin hydration, suggesting risk of ulcer development.

OR035
Evaluation of Health-Care Utilization and Costs for Hospitalizations and Surgical Procedures in Patients with Diabetic Foot Ulcers Treated with Negative Pressure Wound Therapy Using Open Cell Foam Versus Advanced Moist Wound Therapy

Vickie Driver, DPM (Boston Medical Center, Boston, MA), Charles Andersen, MD (Madigan Army Hospital, Tacoma, WA), Charu Taneja, MPH (Policy Analysis Inc., Brookline, MA), Gerry Oster, Phd (Policy Analysis Inc., Brookline, MA)

Background
A multicenter randomized clinical trial (RCT) recently assessed efficacy and safety of negative pressure wound therapy using open cell foam (NPWT/OCF) as delivered by V.A.C.® Therapy (KCI USA, San Antonio, TX) versus advanced moist wound therapy (AMWT) in adult patients with diabetic foot ulcers (DFUs).* NPWT/OCF was reported to be as safe as and more efficacious than AMWT (predominately hydrogels and alginates).

Purpose
We evaluated healthcare utilization and costs for hospitalizations and surgical procedures between patients randomized to VAC (n=169) versus AMWT (n=166) in the above RCT.

Methods
Study subjects were followed from randomization until two weeks following wound closure or end of active treatment, whichever occurred first. We focused attention on use of all acute inpatient services, including wound-related surgical procedures performed during the RCT. Unit costs (expressed in 2007 dollars) were assigned to these services using secondary data sources. Mean estimated total costs were determined by dividing total inpatient costs by total number of randomized and treated patients for each study arm.

Results
There were 35/169 (21%) admissions to acute care hospitals among NPWT/OCF patients compared to 53/166 (32%) admissions among AMWT patients. There was a statistically significant difference between the average number of admissions per patient: NPWT/OCF patients, 0.21; AMWT, 0.32; (p=0.047). During active treatment phase, there were fewer amputations in NPWT/OCF group (6 vs 11 for AMWT). Mean estimated total costs of inpatient services were $4,964 (95% CI: $2,986, $6,962) for NPWT/OCF and $7,833 ($5,553, $10,223) for AMWT, for a difference of $2,869 per studied patient.

Conclusions
During the active treatment phase of this RCT, patients with DFUs treated with NPWT/OCF had fewer hospital admissions and fewer amputations, resulting in lower costs related to hospitalizations and surgical procedures compared to patients treated with AMWT.

*Blume et al. Diabetes Care. E-pub 27 Dec 2007.

OR036
Efficacy And Safety Of A Novel Super- Oxidized Solution (SOS) In Managing Post- Surgical Lesions Of The Diabetic Foot: A Prospective, Randomized Clinical Trial.

Alberto Piaggesi (Diabetic Foot Section, Dept. Endocrinology and Metabolism, University of Pisa, Italy), Chiara Goretti (Diabetic Foot Section, Dept. Endocrinology and Metabolism, University of Pisa, Italy), Sabrina Mazzurco (Diabetic Foot Section, Dept. Endocrinology and Metabolism, University of Pisa, Italy), Alessia Scatena (Diabetic Foot Section, Dept. Endocrinology and Metabolism, University of Pisa, Italy), Anna Tedeschi (Diabetic Foot Section, Dept. Endocrinology and Metabolism, University of Pisa, Italy), Loredana Rizzo (Diabetic Foot Section, Dept. Endocrinology and Metabolism, University of Pisa, Italy)

Goals and Objectives
It has been recently suggested that SOS could be a useful topical therapy for wide postsurgical lesions in infected diabetic feet.

Purpose
To evaluate the efficacy and safety of SOS in the management of infected lesions of the diabetic foot after surgical debridement.

Methods
All the diabetic patients with post-surgical infected lesion > 5 cm2, an ankle-brachial pressure index >0.9 and the presence of at least two arteries in the ankle attending our foot clinic during 2006 were screened for the study. Patients who fulfil the study entry criteria have been randomized to receive local SOS treatment; (Group A = 20 pts) or standard local treatment with povidone iodine (Group B = 19 pts), in addition of metabolic control, systemic antibiotics and offloading. At baseline and at weekly controls area of lesions, clinical signs of infection, microbiological sampling, new debridement procedures and adverse events were recorded blindly to the local treatment. Endpoints at week 24 included healing rate, healing time, time for lesions' sterilization, number of debridements and of adverse events.

Results
85% of Group A patients healed in 24 weeks compared to 53% of group B ones (p<.01); healing time was 10.5±1.3 wks in Group A vs 16.5±1.7 wks in Group B (p<.01), time for sterilization was 5.5± 2.1 wks in Group A compared to 16.2±6.6 wks in Group B (p<.01), further debridement procedures were carried out in 3 patients of group A and in 9 of group B (p<.05), no differences were observed in the adverse events occurrence (2 in group A vs 3 in Group B).

Discussion / Conclusion
SOS local treatment proved to be as safe as and more effective than povidone iodine in the management of wide post-surgical infected lesions of the diabetic foot.

OR037
The Effectiveness of Negative Pressure Wound Therapy (NPWT) using Open Cell Foam (OCF) in the Treatment of Diabetic Foot Ulcers in an Outpatient Setting

Caroline E. Fife (Intellicure Research Consortium), Vickie R. Driver (Boston Medical Center)

Goals and Objectives
Evaluate role of negative pressure wound therapy using opencell foam (NPWT/OCF) delivered by V.A.C.® Therapy* in the treatment of diabetic foot ulcers (DFUs) in an outpatient setting.

Purpose
Identify significant healing factors in NPWT/OCF and non- NPWT treated DFUs and determine whether NPWT/OCF improved healing rates. Compare healing outcomes for DFUs treated with hyperbaric oxygen therapy (HBOT) compared to those treated with HBOT and NPWT/OCF.

Methods
Analysis from 1,331 DFUs was conducted from 16,438 outpatient visits. DFUs treated less than 7 days were not considered in this study. NPWT/OCF was used in 35 Wagner Grade II ulcers (5.3%) and 24 Grade III ulcers (6.2%). The data was assessed for reduction in area and volume. HBOT data was considered in the analysis. Statistical significance was assessed as p≤0.05 and marginally significant at >0.05 but ≤0.10. Data were analyzed using SPSS.

Results
The data indicated that NPWT/OCF use increased as wound area increased over 2 cm2 and wound depth increased over 0.3 cm. The rate of wound depth reduction for NPWT was 1.13 cm/100 days compared to 0.6/100 days for non-NPWT (p<0.001). DFUs treated with both HBOT and NPWT/OCF had a larger overall mean maximum volume closure than HBOTtreated ulcers for Wagner Grades II (6.98 cm3, 2.22 cm3) and III (26.81 cm3, 3.27 cm3) categories.

Discussion / Conclusion
NPW/OCF had a significant positive effect on volume and percent volume closing. HBOT and NPWT-treated ulcers had a larger mean maximum volume closure than HBOT-treated ulcers in both Wagner Grade categories.

*Vacuum Assisted Closure®, KCI USA, San Antonio, TX

OR038
PKC Modulating Agents in the Treatment of Diabetic Foot Ulcers: Results of a Phase I Study

Braude E (HealOr Ltd.), Halevy-Hachem O (HealOr Ltd.), Ben-Hamo M (HealOr Ltd.), Solomonik I (HealOr Ltd.), Braiman-Wiksman L (HealOr Ltd.), Tennenbaum T (HealOr Ltd.)

Protein Kinase C is a family of serine/threonine kinases playing a role in skin physiology and various skin pathologies. HealOr has developed an effective drug (HO/03/03) consisting of PKC modulating agents. HO/03/03 is a combination of a novel PKCdelta activator and a classical PKCalpha inhibitor. Following successful completion of pre-clinical trials in normal and diabetic animal models, HealOr has conducted a phase I clinical trial in non-healing DFU patients in three medical centers in Israel.

Primary objectives were safety and efficacy of HO/03/03 on DFUs. Secondary objectives were time to heal and rate of healing.

Following a screening period of two weeks, enrolled patients were treated topically with HO/03/03 once daily. Patients' ulcers were assessed weekly by a physician, wound size planimetry was done weekly by Visitrack® and ulcers photography was done three times a week.

Nineteen diabetic patients were screened, four patients failed screening, fifteen patients were enrolled to HO/03/03 treatment.

No toxicity or drug related adverse events were reported.

All treated wounds demonstrated a positive healing response with re-epithelialization, granulation tissue formation and dermal regeneration. Ten patients had their wounds closed with mean closure time of 61 days where closure of wounds was observed between 3-14 weeks, four patients were withdrawn due to wound infection and one patient dropped out of the trial.

In 9/10 subjects, wound closure was related to reduction in wound size of more than 50% at 4 weeks; two of the healed subjects had healed at 4 weeks. Accordingly, four patients which did not heal had less than 50% decrease in wound size after four weeks of treatment. No wound recurrence was observed with a follow-up of 6 months.

Trial results suggest HO/03/03 as a future novel drug for Diabetic Foot Ulcer patients.

OR039
Chronic Leg Ulceration and its Relationship with Sociodemographic Factors.

CJ Moffatt (CRICP, Thames Valley University, London), PJ Franks (CRICP, Thames Valley University, London), DC Doherty (CRICP, Thames Valley University, London)

Goals and Objectives
There is only anecdotal evidence that patients suffering from leg ulceration are socially isolated and have deficits in their sociodemographic status.

Purpose
To determine whether sociodemograhic factors are associated with the presence of chronic leg ulceration.

Methods
A case control design was used matching patients (cases) from a geographic region with age/gender matched controls drawn from general practitioner lists from the same area. Paired analysis was undertaken using conditional logistic regression with results expressed as odds ratios (OR) and 95% confidence intervals (95%CI).

Results
In all 113 patients were identified and matched with the same number of controls.The patients had a mean(sd) age of 76 (13) years with 72 (64%) being women. The ulcer had been present for a median of 8 months (range 0.8 to 144), and 29 /100 (29%) patients had an area of ulceration larger than 10 cm2 (range 0.5 to 171.5 cm2). Being black increased the risk of leg ulceration eight fold (95%CI 1.8 to 34.7, p<0.001) compared to the white population. There was a gradient with social class, with ulcer patients more likely to come from social class IV and V (OR=2.8, 95%CI 1.2 to 2.2, p=0.015). Never having married (OR=3.0, 1.1 to 7.7, p=0.025 ), living in rented housing (p<0.001) and having a mobility deficit (p<0.001) more often occurred in the ulcer patients, whilst living with a spouse was protective (OR=0.5, 95%CI 0.2 to 0.99, p=0.048). Patients with ulceration experienced significantly poorer social support than their controls for all sub scales of the MOS social support questionnaire (all p<0.05).

Discussion / Conclusion
Chronic leg ulceration is associated with poorer socio-economic status, and factors which relate to social isolation. At present it is not possible to determine whether these associations are causative or a consequence of the ulceration.

OR040
Early Skin Changes in Chronic Venous Disease Assessed by High Frequency Ultrasound

A.I. Volikova (Fremantle Hospital, Fremantle, WA), H.J. Wallace (University of Western Australia, School of Surgery and Pathology), J. Edwards (University of Western Australia, Shool of Surgery and Pathology), S.E. Hoskin (Fremantle Hospital, Fremantle, Western Australia), L. Linacre (Fremantle Hospital, Fremantle, Western Australia), G. Brunt (Fremantle Hospital, Fremantle, Western Australia), M.C.Stacey (University of Western Australia, School of Surgery and Pathology)

Goals and Objectives
Reliable quantitative methods to detect early changes of chronic venous disease or to assess the impact of compression therapy are not readily available. To date we have relied on gross appearances of changes such as oedema, pigmentation, induration and ulceration. High frequency ultrasound (HFU) can be used to measure dermal thickness, which increases with oedema, and Resistive Index (RI), a measure of resistance to blood flow.

Purpose
1. Assess dermal thickness and RI in patients with chronic venous leg ulcers (CVLU), in age-matched controls and in patients with skin changes following deep venous thrombosis (DVT). 2. Determine the impact of compression therapy on these parameters in patients with CVLU.

Methods
18 patients with (CVLU), 18 age matched controls and 19 patients with previous DVT and evidence of oedema or skin changes (without ulceration), entered the study. CVLU patients were treated with compression therapy and reassessed after 1, 3 and 5 weeks.

Results
Prior to compression therapy, dermal thickness in patients with CVLU (median: 0.26 cm), was significantly greater than in normal subjects (median 0.14 cm, p=0.0001, Mann-Whitney test), and also significantly higher than in the post DVT group (median 0.22cm, p=0.0063). There was a significant decrease in skin thickness in the CVLU group over the first 3 weeks of compression therapy (Wilcoxon test). The RI of the post-DVT group (median: 0.96) was significantly higher than in controls (median 0.80, p=0.0063), whereas the RI of the CVLU group before compression (median: 0.72) was significantly lower than the controls (p=0.05). There were no significant changes in RI in the CVLU group with compression therapy.

Discussion / Conclusion
Dermal thickness provides an objective measurement of early skin changes in patients with chronic venous disease. These measurements may guide the use of compression stockings following DVT.

OR041
Electrical Neurostimulation for the Treatment of Non-Healing Wounds of Arterial Origin in Technically Inoperable Patients

E Ricci (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy), F Moffa (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy), R Cassino (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy), E Tonini (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy), S Ferrero (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy), M Gonella (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy), P Amione (Critical Wounds Unit. St'Lucas Clinic, Pecetto Torinese, Turin, Italy)

Goals and Objectives
Wound treatment in patients with arterial occlusive disease (AOD) still remains one of the most difficult operations. AOD treatments are well coded and aimed at achieving revascularisation, the crucial point for tissue repair. Sometimes patients are technically inoperable and delaying amputation is the only result, if pain is well controlled. In these cases vasoactive drugs are used, first of all prostaglandins, the last ditch before amputation. Another alternative could be Hyperbaric Oxygen Therapy which requires repeated cycles. Nevertheless, in many patients neither revascularisation nor prostaglandin therapy can be performed.

Purpose
The primary end point was to reduce the amputation rate with electrical neurostimulation treatment (FREMSTM, Lorenz Biotech). Secondary clinical success was to improve symptoms measured by Visual Analogue Scale (VAS).

Methods
A total of 166 patients (87 women; mean age 80.0±12.2 years) with wounds caused by AOD, technically inoperable and with problems with the administration of prostaglandins, were analyzed. Patients with neuropathy were excluded. Fifty nine (35%) patients were treated with FREMS for 10 consecutive twice-daily sessions within two weeks. The others were analyzed as control group.

Results
In a one-month period, the amputation rate was reduced from 52.34% to 30.51% (controls vs. FREMS, p=0.0187). The reduction was mostly in minor amputation rate (13.07% less). In FREMS group, vascularisation of the wound bed was increased from the first application and repair process was reactivated at the end of treatment. The clinical improvement in wound healing corresponded to pain control that was achieved 48 hours after the first FREMS application. VAS was reduced from 7.1±2.9 to 2.9±2.0 (p < 0,0001) at the end of treatment.

Discussion / Conclusion
FREMS is safe and effective for the treatment of wounds of arterial origin in technically inoperable patients and with problems with the administration of prostaglandins.

OR042
Venous Ulcers Considered to be Difficult and Their Impact on the Quality of Life of Patients: Results of the Trajectoire Survey.

J-C KERIHUEL (VERTICAL, PARIS, FRANCE), A. DOMPMARTIN (CLEMENCEAU HOSPITAL, CAEN), A. ZAGNOLI (CLERMONT-TONNERRE HOSPITAL, BREST, FRANCE)

Objectives
The TRAJECTOIRE survey sought to describe the typology of ulcers deemed to be "difficult" and to assess their repercussions on quality of life.

Methods
Observational survey. The investigators reported, at most, the first 8 in-patients or out-patients in whom they deemed the ulcer to be difficult. An assessment of the wound was made at baseline and a EuroQol-5D (EQ5D) quality-of-life questionnaire was completed by the patient. If the patient was seen again within 30-120 days, the evolution of the wound was documented and a new EQ5D was completed.

Results
168 investigators included 1005 patients (64% women; 91% outpatients; 62% already seen; age: 73 ± 12 years). 48% of the patients had undergone vascular exploration and compression therapy was used in 76% of cases. 31% and 25%, respectively, had a history of venous surgery or phlebitis. The ulcer was recurrent in 55% of cases and more than one wound was present in 34% of patients. 22% of the ulcers had been present for more than 6 months. Diabetes or heart failure was observed in 20% and 11% of cases, respectively. An increase in surface area, the development of erythema and abundant exudation were the most commonly reported signs. On the EQ5D, the pain/discomfort and anxiety/depression dimensions were significantly the most reported. 652 patients were seen again by the investigating physicians. The EQ5D was significantly improved in the event of a favourable course of the ulcer.

Discussion / Conclusion
Ulcers deemed to be "difficult" in routine practice are associated with important impact on the EQ5D which is very sensitive when an improvement in wound condition occurred.

OR043
The Post-thrombotic Syndrome: Clinical and Genetic Risk Factors

Edwards J (The University of Western Australia, School of Surgery & Pathology, Fremantle Hospital), Wallace HJ (The University of Western Australia, School of Surgery & Pathology, Fremantle Hospital), Volikova A (Fremantle Hospital), Hoskin S (Fremantle Hospital), Stacey MC (The University of Western Australia, School of Surgery & Pathology, Fremantle Hospital)

Goals and Objectives
Post-thrombotic syndrome (PTS) is a chronic condition consisting of leg pain, oedema, lipodermatosclerosis and ulceration. PTS occurs in 20-50% of patients after deep vein thrombosis (DVT) and usually becomes established within 1-2 years. Severe post-thrombotic changes of lipodermatosclerosis and leg ulceration occur in 5-10% of patients. Identification of clinical and genetic risk factors associated with the development of severe PTS may enable the development of strategies to reduce the incidence of venous leg ulceration.

Purpose
To evaluate risk factors associated with the development of severe PTS.

Methods
Patients with a confirmed history of DVT of the lower leg more than 5 years ago were recruited using disease classification codes and radiology records. 393 patients were identified and 127 attended a study visit. Patients who were deceased, not contactable or suffered from serious illness such as cancer, were excluded. Objective clinical assessments were recorded using photoplethysmography, transcutaneous oxygen measurement, ultrasonography (skin thickness) and physical clinical assessment. Blood or saliva was collected for DNA. Genotyping for single nucleotide polymorphisms was performed.

Results
7.9% of patients with DVT displayed no visible or palpable signs of venous disease (CEAP classification C0); 7.9% displayed telangiectasies (C1); 4.7% varicose veins (C2); 23.6% oedema (C3); 31.5% pigmentation or eczema (C4a); 11.0% lipodermatosclerosis (C4b); 13.4% had a healed or active ulcer (C5-6). Therefore, in this sample of patients, 24.4% showed severe PTS changes of lipodermatosclerosis or leg ulceration. Using regression analysis there was a significant relationship between severity (CEAP category) and skin thickness (p<0.05).

Discussion / Conclusion
A high rate of skin changes was present in this sample of post- DVT patients. Increased skin thickness measured by ultrasound is associated with the severity of post-thrombotic skin changes and may be a useful tool to direct the application of preventative strategies.

OR044
ADAM12: A Potential Target for Treatment of Chronic Wounds

Stojadinovic, Olivera (Tissue Repair Program, Hospital for Special Surgery of the Weill Cornell Medical College), Harsha, Asheesh (Tissue Repair Program, Hospital for Special Surgery of the Weill Cornell Medical College), Brem, Harold (Wound Healing Program, Columbia University College of Physicians and Surgeons), Blobel, Carl P. (Arthritis and Tissue Degeneration Program;, Hospital for Special Surgery at Weill Medical), Tomic-Canic, Marjana (Tissue Repair Program, Hospital for Special Surgery of the Weill Cornell Medical College)

Background
Wound healing in its complexity of multiple participating cells and processes are coordinated by variety of signaling molecules. This signaling is not effective in the chronic wounds ADAM12 (a-disintegrin-and-metalloprotease-12) is a membrane anchored metalloprotease, implicated in ECM remodeling and activation/inactivation of growth factors, including HB-EGF and IGF, which play an important role in wound healing.

Purpose
To test if ADAM12 plays a role in pathogenesis of venous ulcers.

Methods
To evaluate the role of ADAM12 in wound healing and its pathogenesis we used biopsies from non-healing edge of patients with venous ulcers and performed microarray analyses. We also evaluated healing properties of ADAM12-/- mouse using skin explant wound model.

Results
Analyses of the non-healing edge of chronic ulcers revealed a five-fold increase in ADAM12 expression in patients' biopsies when compared to normal skin. This was confirmed by pronounced increase in membranous and cytoplasmic signal for ADAM12 in the epidermis of chronic wounds compared to controls. These findings prompted us to evaluate keratinocyte migration of Adam12-/- mice or WT controls and their response to EGF. Skin explants from knockout or WT mice taken at birth were placed in tissue culture, and used to quantify keratinocyte migration over a period of seven days. We found a statistically significant increase in keratinocyte migration of Adam12-/- keratinocytes compared to WT controls in both untreated (P=.0001) and EGF treated (P=.028) samples.

Conclusions
The upregulation of ADAM12 in chronic wounds, and the increased migration of keratinocytes in the absence of ADAM12 suggests that ADAM12 is an important mediator of wound healing. We propose that increased expression ADAM12 in chronic wounds impairs healing through the inhibition of keratinocyte migration, and that topical ADAM12 inhibitors might be useful to promote the healing of chronic wounds.

OR045
A Randomized, Cross-over, Clinical Trial of a Two-layer and Four-layer Compression Bandage System in the Treatment of Venous Leg Ulcers

Christine Moffatt (Thames Valley University, London), Lynfa Edwards (Ealing Primary Care Trust, London), Keith Harding (Wound Healing Research Unit, Cardiff), Mark Collier (Grantham & District Hospital, Grantham), Terry Treadwell (Institute for Advanced Wound Care at Baptist Hospital), Michael Miller (Wound Healing Center), Laura Shafer (Gwinnett Hospital System Wound Treatment Center), Gary Sibbald (University of Toronto), Alain Brassard (University of Alberta), Andrea McIntosh (Silver Cross Hospital), Alex Reyzelman (California School of Podiatric Medicine), Patricia Price (Wound Healing Research Unit, Cardiff), Stacia Merkel (Integra, CTS), Shelley-Ann Walters (3M Company)

Goals and Objectives
To evaluate bandage slippage, Health Related Quality of Life (HRQoL) and patient preference in venous leg ulcer patients treated with a two-layer* and a four-layer# compression bandage system.

Purpose
To demonstrate efficacy of a new, two-layer compression system.

Methods
This was an eight-week, ten-center, randomized, crossover, open-label, clinical trial. Participants (n=81) were randomized to one of the two compression systems. Treatment crossover occurred at week 4. All ulcers were covered with the same primary dressing,** and compression bandages were applied over the dressing. All other ulcer treatments were per standard procedure at each location. The primary endpoint was bandage slippage measured at each dressing change. Bandages were expected to be changed every week. Secondary endpoints included wound healing/wound area reduction, HRQoL as measured using the Cardiff Wound Impact Schedule (3 domains: Well-being, Physical Symptoms and Daily Living, and Social Life), and patient preference.

Results
Mean slippage estimated from a mixed ANOVA model (701 measurements) was 2.48 cm for the two-layer system and 4.17 cm for the four-layer system (p<0.0001). There were no significant differences in percent of wounds that healed (p=0.47) or in wound area reduction (p=0.87). During Period 1, the HRQoL Physical Symptoms and Daily Living Scores improved significantly more with the two-layer system than with the fourlayer system (p=0.046). Patients had a strong preference for the two-layer system (72%) vs. the four-layer system (22%), with 6% having no preference.

Discussion / Conclusion
This study demonstrated the efficacy of a new two-layer bandage system, with the additional benefit of improved activities of daily living and significantly less slippage. Patients now have an effective and comfortable compression option to manage their venous leg ulcers.

*Coban™ 2-Layer Compression System

#Profore™ multi-layer compression bandage system

**Tegaderm™ Foam Dressing

OR046
Identifying Optimal Compression Systems to Promote Healing and Quality of Life for Clients with Venous Leg Ulcers: A Prospective Cohort Study.

Prof. Helen Edwards (Institute of Health and Biomedical Innovation, Queensland University of Technology), Prof. Mary Courtney (Institute of Health and Biomedical Innovation, Queensland University of Technology), A/Prof. Harry Gibbs (Dept. of Vascular Medicine, Princess Alexandra Hospital, Brisbane), Kathleen Finlayson (Institute of Health and Biomedical Innovation, Queensland University of Technology), Michelle Gibb (Institute of Health and Biomedical Innovation, Queensland University of Technology)

Background
/Objectives Chronic leg ulcers occur in 1% of those aged over 60 and the majority are of venous origin. Although compression therapy is known to be effective for healing venous ulcers, debate exists on the optimal systems to use considering variation in cost, expertise required for application and acceptability to clients.

Purpose
To compare the effectiveness of three types of compression systems on wound healing and quality of life for clients with venous leg ulcers.

Methods
All patients diagnosed with a venous leg ulcer attending leg ulcer clinics in a metropolitan hospital or community nursing setting in Queensland, Australia, were invited to participate. Data on ulcer characteristics, wound care and compression were collected 4 weekly from enrolment for 24 weeks. Data on demographics, medical and venous history were collected from medical records and quality of life measures via questionnaires at baseline and 24 weeks.

Results
In a sample of 81 participants, lower healing rates were significantly associated with longer ulcer duration (p=0.002), larger ulcer area (p=0.004), lower Body Mass Index (p=0.033) and poor mobility (p=0.034). These variables were controlled for in analysis of healing at 24 weeks following intention to treat principles. No significant differences were found in either the proportion of participants fully healed, or in mean percent reduction in ulcer area for participants wearing either a short stretch system (mean % reduction 92.8, SD 12.9), a 4 layer system (mean 87.5, SD 24.6), or Class 3 (30-40mmHg) compression hosiery (mean 91.9, SD 19.2). There were no significant differences in quality of life scores between participants in the three groups, however, greater numbers of participants dropped out of the 4-layer group because of discomfort or allergies.

Discussion / Conclusion
These findings will assist consumers and health professionals select an effective compression system appropriate to their needs.

OR047
Management of Venous Leg Ulcers with Two Active Wound Dressings. Results of a Randomized Clinical Trial.

S. MEAUME (CHARLES FOIX HOSPITAL, IVRY/SEINE, FRANCE), J-L. SCHMUTZ (FOURNIER HOSPITAL, UNIVERSITY OF NANCY, FRANCE), A. DOMPMARTIN (CLEMENCEAU HOSPITAL, CAEN, FRANCE), S. FAYS ( FOURNIER HOSPITAL. UNIVERSITY OF NANCY, NANCY, FRANCE), Z. OURABAH (CHARLES FOIX HOSPITAL, IVRY/SEINE, FRANCE), V. THIRION (LEOPOLD BELLAN HOSPITAL, PARIS, FRANCE ), S.BOHBOT (LABORATOIRES URGO. R & D DEPARTMENT, CHENOVE, FRANCE)

Goals and Objectives
The Nano-Oligosaccharide Factor (NOSF) is a new compound aiming to promote wound closure mainly through inhibition of MMPs activity.

Purpose
The objective of this study was to document the performance of the NOSF* relative to a matrix containing collagen and oxidized regenerated cellulose (ORC**) effect, in the local management of venous leg ulcers (VLU).

Methods
This was an open, 2-arm multicentre randomized study. Patients were selected if the area of their VLU (ABPI>0.80) was ranged from 5 to 25 cm2 with a duration > 3 months. In addition to receiving compression bandage therapy, patients were randomly allocated to either NOSF-matrix* or ORC** treatment for 12 weeks. The VLUs were assessed on a weekly basis and wound tracings were recorded. Percentage wound relative reduction (RR) was the primary efficacy criterion. Secondary objectives were wound absolute reduction (AR), healing rate (HR) and % of wounds with >40% reduction compared to baseline.

Results
117 patients were included. Fifty six percent of the VLU were present for >6 months, 61% were recurrent, 68% were stagnating despite appropriate cares. Mean wound area at baseline was 11.2 ± 7.4 cm2. At the last evaluation, a superiority of NOSF-matrix* effect compared to ORC** was concluded (p=0.0059). The median of the wound area reduction was 61.1% and 7.7% in the NOSF-matrix* and control groups respectively (PP analysis) or 54.4% vs. 12.9% in ITT analysis. In the oldest and largest VLUs, a strong promotion of healing effect was particularly observed in the NOSF-matrix* group when compared to the control group.

Discussion / Conclusion
NOSF-matrix* is a very promising option for the local management of chronic wounds, especially for venous leg ulcers with poor healing prognosis.

* CelloSTART/UrgoCell START trademark by the Laboratoires URGO (France)

** PromogranÒ trademark by Johnson & Jonhson

OR048
Positive Experience of UK Patients and Clinicians with a Novel Two Layer Compression System, a Multi-site Case Series

Martin Arrowsmith PhD (3M Health Care), Claire Stephens RGN (3M Health Care), On behalf of the case series clinicians (14 UK study sites)

Goals and Objectives
Treatment of venous ulcers with multi-layer compression therapy has been validated by randomised controlled trials¹. However its limitations include issues with patient comfort, mobility, concordance, altered body image and bandage slippage².

Purpose
The purpose of this extensive case series was to test the value of a new 2 layer compression system in a range of patients, collecting input from both clinicians and clients.

Methods
Patients with ABPI>0.8 were admitted following Doppler assessment. Over six weeks, clinicians documented wear time, wound condition/dimensions and strike through. Bandage slippage was also recorded during weekly clinic visits.

Results
Data from 85 patients and 431 bandage applications were collated from 14 UK sites. 70% of systems lasted the full 7 days between clinic visits. Bandage slippage was low, with 74% slipping less than 2cm at the return visit. During the six week study period 18 ulcers closed.

98% of patients were concordant with therapy, 78% able to wear own shoes and 73% able to walk comfortably in the new system. Patients had a strong preference for treatment with the new two layer system.

Discussion / Conclusion
The findings show that the 3M Coban 2 layer compression system is a valuable alternative to bandage systems used to treat venous leg ulcers. The healing rate of 21% in six weeks is similar to that found with multi-layer bandaging. Together with evidence that 87% of patients preferred this new system to their previous therapy, results strongly indicate it aids concordance while maintaining therapeutic compression.

References

1. Cullum N, Nelson EA, Fletcher AW et al. Compression for venous leg ulcers (Review) The Cochrane Database of Systematic Reviews 2001; 1-34.
2. Anand SC, Dean C, Nettleton R et al. Health-related quality of life tools for venous-ulcerated patients. British Journal of Nursing 2002; 12(1): 48-61

Case series facilitated by 3M

OR049
A Year in Review: 2-Layered Compression System : Effectiveness, Economics and Patient Satisfaction

Valerie Larson-Lohr, MS, APRN (Warm Springs Rehabilitation Hospital), Patrick N. Kimbrell, MD (Warm Springs Rehabilitation Hospital), Edna Patricia Rios, MS, RN (Warm Springs Rehabilitation Hospital)

Goals and Objectives
One year ago, our center transitioned from primarily using a 4- layered compression wrap** to control lower extremity edema to a 2-layered compression wrap.* Our initial trial demonstrated high patient satisfaction for this product related to temperature, mobility and compliance. Staff time for application was markedly decreased, application was easier, and fewer products were used compared to the four-layer wrap. Effectiveness was demonstrated by maintaining healing outcomes of 90% at 5.1 weeks.

Purpose
To report the one-year experience of using a 2-layered compression system* in our wound care center. We evaluated 12 months of data to determine if our outcomes were maintained or improved.

Methods
A retrospective chart review was completed. A total of 3228 wrap applications were included in the 12-month analysis. We defined cost as product price, staff time, and length of time to heal. Length of time to heal included both effectiveness of the compression wrap and patient compliance with wearing the wrap. Staff satisfaction and perception of the 2-layered wrap were also assessed.

Results
Our center saved 81 hours of nursing time using 3228 twolayered products. Patient compliance was improved and was related to an increase in comfort, cooler temperature and less obtrusive appearance. Our overall healing rate was 92.5% with an average time to heal of 5.1 weeks.

Discussion / Conclusion
While the purchase price was modestly higher than the 4-layered wrap, cost effectiveness was demonstrated by staff time savings, allowing an increase in patients seen per day. Efficiency of department flow and an improvement in patient compliance was seen with the use of the 2-layered product. The 2-layered product has allowed us to accomplish our goals of cost effectiveness while still providing quality care and effective clinical outcomes as well as maintaining high patient and staff satisfaction.

OR050
The Angior Initiative: Results of a Randomised Controlled Trial Comparing the Effectiveness of Two Antimicrobials.

Suzanne Kapp (Royal District Nursing Service Helen Macpherson Smith Institute of Community Health, Melbo), Keryln Carville (Chain Nursing Association and Curtin University of Technology), Steve Saflekas (Royal District Nursing Service Helen Macpherson Smith Institute of Community Health.), Nelly Newall (Silver Chain Nursing Association), Gill Lewin (Chain Nursing Association, Curtin University of Technology, Edith Cowan University), Charne Flowers (Royal District Nursing Service Helen Macpherson Smith Institute of Community Health), Terry Gliddon (Royal District Nursing Service Helen Macpherson Smith Institute of Community Health), Leila Karimi (Royal District Nursing Service Helen Macpherson Smith Institute of Community Health.), Nick Santamaria (Curtin University of Technology)

Goals and Objectives
The aim of this research was to evaluate and compare the clinical effectiveness of cadexomer iodine and nanocrystalline silver in the control of bacterial colonisation and infection in wounds, and to demonstrate the subsequent effect on wound healing.

Purpose
The management of chronic leg ulcers is a significant care component for home nursing services. Covert and overt infection is a frequent complication in chronic leg ulcers and the increasing variety of topical antimicrobial dressings complicates care decisions for many clinicians.

Methods
A multi-site randomised controlled trial (RCT) funded by The Angior Family Foundation was conducted in Australia and compared the effectiveness of two commonly used antimicrobial dressings in the management of infected or critically colonised leg ulcers. A best practice wound management education program and a qualitative enquiry into the barriers and enablers to the use of compression bandaging preceded the RCT. There were 281 participants recruited to the RCT, with one or more signs of wound infection or colonisation. Participants were monitored for a 12 week period. Bacterial burden was quantified by wound swab analysis and a wound healing rate was determined with digital wound imaging and computerised planimetry.

Results
Significant differences in healing rate (p<.01) were identified between the two antimicrobial dressings early in the observed healing trajectory. The results of this RCT present new evidence for selection of antimicrobials for infected and colonised lower leg ulcers.

Conclusion
This RCT has the potential to inform best practice in the management of chronic leg ulcers within Australia and beyond.

OR051
Effects of Immediate Use of Water on Acid Burn Victims in Bangladesh

Dr.Mohammad Imtiaz Bahar Choudhury, MBBS, MPH (Acid Survivors Foundation, Bangladesh)

Goals and Objectives
Acid throwing is a vicious and damaging form of violence in Bangladesh and one of the worst criminal offenses against the Humanity. Acid is mainly thrown to the face, which causes deep burns, facial disfiguration and even blindness. Acid usually causes full thickness burns. It immediately starts destroying skin and other tissues and even bone. It causes permanent damage to vital organs leading to disfigurement and deformities along with deep ever-lasting psychological and social trauma. Women carry the scars for life they only have to observe the terror in other people's eyes to know that they are different. There are people who don't look at them as persons and that horror can't be removed.

Purpose
To evaluate the advantages of early water usage for chemical burns.

Methods
The study was conducted among 100 patients admitted in Acid Survivors Foundation Hospital. The sampling techniques were purposive. A semi- structured questionnaire was used to find the effectiveness of using water just after the contact of acid.

Results
Among 100 sample patients it reveals that 3 patients used water within 7 minutes of the contact with acid. The burn was superficial in their case. 28 patients used water within half an hour of contact with acid. Their burn was deep but the healing was within 18 days and caused relatively less disfigurement and disability. Other 69 patients used water after half an hour resulted a deep burn and needed more than 4 weeks for healing. Caused serious deformity and disability.

Discussion / Conclusion
Early use of water after acid burn saves life and limits injury and disability and the affected areas got early healing with little or no deformity and return to normal or near normal life.

OR052
Avoiding Heart Rupture During TNP Therapy in Poststernotomy Mediastinitis

Richard Ingemansson (Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden), Malin Malmsjo (Department of Clinical science, Lund University Hospital, Lund, Sweden)

Purpose
Topical negative pressure (TNP) is a promising therapy for poststernotomy mediastinitis. The surgical technique, results and long term outcome are well described in the literature. There are now several reports of right ventricular rupture in patients treated with TNP therapy. We believe that the problem arises when both the right and left hemisternum are attached to the heart by adherences. During the TNP therapy, the patient may move or cough, and the strain is transmitted to the heart when the right and left hemisternum are moving apart. The heart will rupture where weakest, namely in the right ventricle. We describe a surgical technique of how to minimize the risk of heart rupture during TNP therapy.

Methods
Upon application of TNP, the right sternal edge should always be dissected free, out to the right pleura, at the time of the first wound revision. By doing this, the right sternal edge is freed and will not be attached to the heart (direct or indirect via the right pleura or adherences), and the heart will only be attached to the left hemisternum. During the application of negative pressure, the right sternal edge will be mobile and flip in, towards the left side, and no strain will be transmitted to the heart if the right and left sternal edges were to move. Thereby, the stress on the right ventricular wall will be minimized.

Results
Between January 1999 and November 2005 we have consecutively operated 88 patients with poststernotomy mediastinitis. No right ventricular rupture, re-infection in mediastinitis or 90 days mortality has been observed during this period.

Discussion / Conclusion
We describe a technique, in which the right sternal edge is freed during the application of TNP in poststernotomy mediastinitis. We believe that this may minimize the risk of right ventricular rupture.

OR053
Development of an Assessment and Treatment Enabler for the Care of Children with Partial Thickness Burns Including Those with Blisters

Douglas Baron, BSc PT (Calgary Health Region)

Goals and Objectives
To develop an assessment and treatment enabler for the rehabilitation staff in a children's hospital to aid their clinical decision-making skills when treating partial thickness burns that often include blisters.

Purpose
The literature reveals a controversy on whether or not a clinician should leave blisters intact or debride them. The enabler includes critically reviewed clinical practice guidelines (CPG's) that have been recently been published in this area of interest.

Methods
CPG's were reviewed by a cross section of local burn and wound care professionals. The review was performed using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument that assesses scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence. Based on the AGREE Scores and the comments made by the appraisers, the enabler was developed. Rehabilitation staff were educated on the development process. After a period of one month, a questionnaire was sent out to all users to provide feedback to the author. From the comments received, changes were made to the enabler to become the final product.

Results
Based on the responses provided by the appraisers, the majority of the published CPG's were included in the enabler. When developing the enabler, it was felt to be important to have the information in an easy to read and follow one page tri-fold document. The enabler includes an adapted form of an already published wound bed preparation paradigm, the selected CPG's and dressing choices available within the facility.

Discussion / Conclusion
The process of enabler development has proven that there is still a controversy surrounding the management of blisters in the partial thickness burn. The staff that use the enabler find it helpful when assessing and treating their pediatric clients. It has also spurred interest for the author to consider further research in this area.

OR054
Nanocrystalline Silver Anti-inflammatory Activity in Porcine Chemical Burns

Patricia Nadworny (University of Alberta), Dr. JianFei Wang (University of Alberta), Dr. Edward Tredget (University of Alberta), Dr. Robert Burrell (University of Alberta)

Goals and Objectives
Nanocrystalline silver, a broad spectrum antimicrobial agent, may also have anti-inflammatory activity which promotes healing during burn treatment. Soluble Ag0 clusters, rather than Ag+, may be responsible for this activity.

Purpose
To determine if nanocrystalline silver has enhanced antiinflammatory/ pro-healing efficacy relative to Ag+ in a porcine chemical burn model.

Methods
Chemical burns were induced on the backs of swine using dinitrochlorobenzene (DNCB) over two weeks. For 72h, three negative controls and three positive controls were treated with saline-soaked dressings, three pigs were treated with 0.5% AgNO3, and three pigs were treated with nanocrystalline silver dressings. Clinical changes in these animals were assessed. Biopsies were used for histological analysis, gelatinase activity assessment, and immunohistochemical staining for changes in apoptosis and cytokines (tumor necrosis factor-α, interleukin-8, and transforming growth factor-β).

Results
Nanocrystalline silver-treated tissues showed visual improvements over 72h, with significantly decreased erythema and edema scores (p<0.001), and decreased total and active gelatinases (p<0.05), relative to AgNO3 and saline-treated animals. At 24h, AgNO3 induced significant non-specific apoptosis in the epidermis (p<0.001), while nanocrystalline silver induced significant inflammatory cell-specific apoptosis in the dermis (p<0.05). At 72h, decreased inflammatory cells and decreased expression of pro-inflammatory cytokines were observed with nanocrystalline silver treatment compared to AgNO3 or saline treatment.

Discussion / Conclusion
In comparison to AgNO3, nanocrystalline silver significantly decreased DNCB-induced inflammation as indicated by decreased pro-inflammatory cytokine expression, gelatinase activity, and clinical signs of inflammation. Elimination of inflammatory cells via apoptosis induced by nanocrystalline silver treatment may partially account for these observations. In contrast, AgNO3 non-discriminately induced apoptosis, impairing wound healing. Thus, the form of silver selected to treat inflamed burned tissue has a significant impact on the clinical outcome, with nanocrystalline silver proving more efficacious than AgNO3 (Ag+) in this study.

OR055
Treatment Methods of Donor Sites and Partial and Full Thickness Burns: Results of a Global Survey

Michel H.E. Hermans, M.D (Hermans Consulting Inc.)

Introduction and methods. In 1998, we published results of a survey on different treatment modalities used in burn care. Since then, numerous new dressings and techniques have become available. An internet survey was sent to 200 heads of burn centers to learn which, if any, new materials and techniques are used.

Results
Fifty-five (27.5%) responses were received. In partial thickness burns, silver sulphadiazine cream 1% (ssd) is the most widely used material (18.4-23.9%, depending on the type of burn). Silver dressings are used in 9.5-14.2%, again depending on the type of injury. Other therapies and materials that scored more than 5% are antimicrobial creams (other than SSD), impregnated gauze, xenografts (only in deep partial thickness (DP) < 20% TBSA), hydrocolloid dressings (only in superficial burns (SP), < 20% TBSA) and early excision and grafting in DP, > 20% TBSA. For donor sites, medicated gauze dressings (13%), silver dressings (12.3%) and alginates (10.3%) reached the highest percentages.

For full thickness burns (FT), early excision and same session grafting is the preferred method (44.1% for burns < 20% TBSA, 34.3% for burns > 20% TBSA). In large burns coverage of large surfaces (as opposed to functional areas) is preferred by 66.5% of all respondents and 49% use cultured cells. In 74.1%, these are autologous cells, mostly from commercial sources (53.3%). The use of complex coverage techniques (i.e. sandwich technique, intermingled technique) and Integra depends on the geographical location of the burn center and the economic environment. Generally, modern (often more expensive) techniques and materials are more often used in wealthier countries.

Discussion
and Conclusion Of all new treatment options, only silver dressings and cultured cells have made an impact on daily burn management. In spite of its well described disadvantages, SSD is still the most commonly used material in burn care.

OR056
Coexistence and Expression of Three Types of Opioid Receptors, mu, delta and kappa in Human Hypertrophic Scars

Biao Cheng (Department of Plastic Surgery, Guangzhou Liuhuaqiao Hospital, Guangzhou, 510010, China), Hong-wei Liu (Department of Plastic Surgery, the First Affiliated Hospital of Jinan University, Guangzho), Xiao-Bing Fu (Wound Healing and Cell Biology Laboratory, Institute for Basic Research), Zhi-Yong Sheng (Wound Healing and Cell Biology Laboratory, Institute for Basic Research,), Jian-Fu Li (Department of Plastic Surgery, Southwest Hospital, the Third Military Medical University)

Goals and Objectives
Pruritus or nociceptive pain is a significant clinical problem of hypertrophic scar. Recently, emerging evidence has indicated the possible involvement of opioid receptors (ORs) in abnormal cutaneous sensation; however, little is explored about the pathophysiological role of OR in local cacesthesia in hypertrophic scars.

Purpose
To study the expression profile of ORs in normal human skin and hypertrophic scar with cacesthesia.

Methods
Skin biopsy was performed in 10 patients newly diagnosed as hypertrophic scar with cacesthesia or 10 healthy individuals, respectively. Parts of these skin tissues were subjected to primary culture of keratinocytes and fibroblasts. Localization of ORs was examined by immunofluorescence staining and quantitation of ORs was determined by real-time polymerase chain reaction (PCR).

Results
Immunofluorescence staining revealed that MOR, DOR and KOR were co-expressed and mainly located in the keratinocytes and fibroblast-like cells. Real-time PCR indicated that the expression of MOR, DOR and KOR in hypertrophic scars was enhanced compared with the normal skin. In consistant with the

Results
from skin biopsy, we observed similar expression pattern of MOR, DOR and KOR in the cultured keratinocytes and fibroblasts, derived from normal skin and hypertrophic scars.

Discussion / Conclusion
Our results demonstrated that expression of three types of ORs including MOR, DOR and KOR was marked upregulated in human hypertrophic scars, suggesting the possible link between upregulated ORs and local cacesthesia in hypertrophic scars.

OR057
OASIS, an Alternative to Split Skin Grafting?

Barendse-Hofmann, Minke (Rijnland Hospital), Steenvoorde, Pascal (Rijnland Hospital), Hedeman-Joosten, Paul (Rijnland Hospital), Oskam, Jacques (Rijnland Hospital), Doorn, Louk van (Rijnland Hospital)

Goals and Objectives
Oasis (Health Point) is an extracellular matrix used in the final phase of wound healing, in order to close wounds.

Purpose
Oasis is a product that can be used easily in the home care setting. Split skin grafting is a procedure that usually needs admission and operation, with subsequent morbidity and even mortality.

Methods
15 patients suited for split skin grafting were treated with Oasis. If the Oasis would fail, they would be treated with a split skin graft.

Results
/Discussion. 14/15 wounds healed without the need for split skin grafting. This seems a promising treatment strategy in patients in whom split sking grafting could lead to morbidity and even mortality.

OR058
Exposed Tendon: Cost Effective Application of Extracellular Matrix (ECM) Derived from Porcine Small Intestine Submucosa (SIS) to Stimulate Wound Closure - Two Case Studies Presented

Rosemary Hill BSN CWOCN, Enterostomal Therapist (Vancouver Coastal Health - Coastal (Lions Gate Hospital))

Goals and Objectives
Exposed tendons on the anterior aspect of the lower limb are a healing challenge for health care professionals. Traditionally these surgeries have required plastic surery, extended length of hospital stay, and subsequent increased community nurse visits. It has becomes imperative to consider alternatives to hasten wound closure in a cost effective manner. A biomaterial obtained from porcine small intestine submucosa (SIS) is an extra-cellular matrix that not only provides a scaffold for tisssue growth but components that enhance wound healing..

Purpose
To evaluate the effectiveness of the application of extracellular matrix (OASIS Wound Matrix) on two patients with wounds that had exposed tendon. The frist case study is a 48 year old male with a fractured ankle and associated wound. The second case is a 64 year old male with an injury to his achilles tendon. Despite standard approaches to their wound care, wound size and progress had "stalled" in both instances and exposed tendon remained.

Methods
Wound measurements and consecutive photos were conducted for each case study detailing wound progress following the biweekly and weekly application of OASIS over a period of 4-12 weeks.

Results
In both cases, complex plastic surgery was avoided as wound closure occurred at 6 weeks in the first case and 12 weeks in the second case. The application of the SIS was considerably cost effective as the total cost was approximately $100.00 for the first case and less that $250.00 in the second case.

Discussion / Conclusion
Application of Oasis wound matrix was a cost effective alternative offering wound closure in two difficult to heal wounds with exposed tendon.

OR059
Migration of Bone Marrow-derived Mesenchymal Stem Cells Induced by TNFalpha and its Possible Role in Wound Healing

Sa Cai (1. Wound Healing and Cell Biology Laboratory, The First Affiliated Hospital, General Hospi), Xiaobing Fu (1. Wound Healing and Cell Biology Laboratory, The First Affiliated Hospital, General Hospi), Bing Han (Wound Healing and Cell Biology Laboratory, The First Affiliated Hospital, General Hospital), Tongzhu Sun (Research Institute of Basic Medical Science, Trauma Center of Postgraduate Medical College), Zhiyong Sheng (Research Institute of Basic Medical Science, Trauma Center of Postgraduate Medical College)

Goals and Objectives
We aimed to investigate the effect of tumor necrosis factor-α (TNF-α) on the expression of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) and on the migration ability of mesenchymal stem cells (MSCs) in the context of wound healing. We sought to explore the role of p38 MAPK and ERK signaling pathways in the migration of MSCs.

Methods
MSCs were isolated from bone marrow and cultured. Immunocytochemistry, western blotting and RT-PCR were used to observe the effect of TNF-α on the expression of ICAM-1 and VCAM-1 in MSCs. The chemotaxis effect of TNF-α on MSCs was investigated by the trans-well system and the inhibition of the TNF-α effect by use of its antibody. Western blotting analysis was used to observe the activation of JAK-STAT and MAPK signaling pathways, and ERK was inhibited with PD98059 and p38 with SB203580 to observe the effect of TNF-α on MSC migration and ICAM-1 expression.

Results
The expression of ICAM-1 could be upregulated by 50μg/l TNF- α (P<0.05), whereas that of VCAM-1 remained unchanged (P>0.05). As well, TNF-α enhanced the migration ability of MSCs (P<0.05). Antibody treatment inhibited the effect of TNF-α. Treatment with 50 μg/l TNF-α increased the expression of phospho-ERK and phospho-p38. SB203580 but not PD98059 could suppress the chemotaxis effect and up-regulation of ICAM-1 induced by TNF-α in MSCs (P<0.05).

Discussion / Conclusion
TNF-α up-regulates the expression of ICAM-1 in MSCs and enhances the cells' migration ability. The enhanced migration ability might be associated with up-regulated ICAM-1 in MSCs, and the p38 signaling pathway might be involved in the migration ability induced by TNF-α. The migration of MSCs may play some roles in wound repair and regeneration.

OR060
A Prospective Trial of Near-infrared Spectroscopy (NIRS) as a Continuous Noninvasive Method of Flap Monitoring Following Breast Reconstruction

S.A. Cairns (Welsh Centre for Burns and Plastic Surgery, Swansea, Wales, UK), I.S. Whitaker (Welsh Centre for Burns and Plastic Surgery, Swansea, Wales, UK), M.D. Barrett (Welsh Centre for Burns and Plastic Surgery, Swansea, Wales, UK), L.Y. Hiew (Welsh Centre for Burns and Plastic Surgery, Swansea, Wales, UK), D.E. Boyce (Welsh Centre for Burns and Plastic Surgery, Swansea, Wales, UK), M.A.C.S. Cooper (Welsh Centre for Burns and Plastic Surgery, Swansea, Wales, UK), D.J. Leaper (Department of Wound Healing, Cardiff University, Wales, UK)

Goals and Objectives
Flap failure following breast reconstruction incurs significant physical and psychological morbidity. Efficacious postoperative monitoring is mandatory to allow early re-exploration and improved salvage rates. Near Infra-red spectroscopy is a novel technique currently under investigation. There is a paucity of published literature assessing its efficacy.

Purpose
This prospective pilot study investigates the utility of NIRS as an adjunct to clinical monitoring by assessing the specificity and sensitivity of detecting early signs of flap compromise.

Methods
Fifteen patients requiring breast reconstruction following mastectomy were recruited. Using the Inspectratm St02 monitor (Hutchinson®), measurements of tissue oxygen saturation (St02) and total Haemoglobin Index (THI) were undertaken pre, intra and post-operatively for 72 hours. Patients were nursed in HDU, recording hourly clinical observations of both the flap and patient.

Results
Of the 15 patients, 12 exhibited no significant changes in either their St02 or THI. One patient's St02 showed a significant downwards trend in the presence of normal clinical examination. In one patient the NIRS probe gave an 'early warning' to impending flap compromise - six hours postoperatively there was an upward trend in the THI, preceding clinical signs of incipient failure by 2 hours. The patient was returned to theatre and the flap was removed after several attempts to revise the venous anastomosis. One other patient's St02 declined immediately post-operatively and the flap was pale. The patient was returned to theatre, and the arterial anastomosis was successfully revised. There was partial flap necrosis long term, treated conservatively.

Discussion / Conclusion
Near infrared spectroscopy has great potential in the field of reconstructive surgery, it is a powerful non-invasive flap monitoring tool. This pilot study using the Inspectratm St02 monitor was welcomed by clinical staff with high patient satisfaction.

OR061
Surgical Site Infection (SSI) Rate

AHMED KHAN SANGRASI (Liaquat University of Medical & Health Sciences Jamshoro, Pakistan), ABDUL AZIZ LEGHARI (Liaquat University of Medical & Health Sciences Jamshoro, Pakistan), AISHA MEMON (Liaquat University of Medical & Health Sciences Jamshoro, Pakistan), ALTAF.K.TALPUR (Liaquat University of Medical & Health Sciences Jamshoro, Pakistan), GHULAM ALI QURESHI (Liaquat University of Medical & Health Sciences Jamshoro, Pakistan), JAN MOHAMMAD MEMON (Liaquat University of Medical & Health Sciences Jamshoro, Pakistan)

Goals and Objectives
Surgical Site Infection (SSI) cause considerable morbidity and economic burden .In most of the developing countries surgical site infection (SSI) rates are not observed routinely.

Purpose
This prospective study aimed to determine the Surgical Site Infection rate and associated risk factors was carried in a general surgical ward at Liaquat University Hospital Jamshoro.

Methods
460 patients requiring elective general surgery from July 2005 to June 2006 were included in this study. All four surgical wound categories were included. Primary closure was employed in all cases. Patients were followed up to 30th day postoperatively. All cases were evaluated for postoperative fever, redness, swelling of wound margins and collection of pus. Attending surgical residents were blinded for operating surgeon. Cultures were taken from all the cases with any of the above finding.

Results
Mean ± SD age of the patients was 38.8 ± 17.4 years with male to female ratio of 1.5:1. The overall rate of Surgical Site Infection was 13.0%. The rate of wound infection was 5.3% in clean operations, 12.4% in clean-contaminated, 36.3% in contaminated and 40% in dirty cases. Age, use of surgical drain, duration of operation and wound class were significant risk factors for increased surgical site infection (P< 0.05). Postoperative hospital stay was double in cases who had surgical site infection. Sex, haemoglobin level and diabetes were not statistically significant risk factors(P > 0.05).

Discussion / Conclusion
In conclusion Surgical Site Infection rate of 13% found in this study is slightly higher as compared with results from developed countries, similar to other less developed countries and better to African countries. As SSI cause considerable morbidity and economic burden, the routine reporting of SSI rates stratified by potential risk factors associated with increased risk of infection is highly recommended.

OR062
Traumatic Injuries in a Methane Gas Environment Increase Clostridial Gas Gangrene Risk

Mrs. Hiske Smart (Wound Healing and Hyperbaric Oxygen therapy unit: Welkom Medi-Clinic), Dr. Frans J. Cronje (Dept. of Interdisciplinary Health Sciences, University of Stellenbosh)

Goals and Objectives
Acute gas gangrene is a rare, but life-threatening condition caused by the anaerobic organism Clostridium perfringens. It requires emergency surgery, antibiotics and hyperbaric oxygen therapy (HBO). As the mortality rate is very high and early HBO critical to survival, a high index of suspicion is required. Methane gas is the end-result of anaerobic breakdown of organic components (mostly carbon and water). Clostridial organisms are known to be acid forming precursors in the methane gas production process.

Purpose
This study proposes that traumatic injuries, sustained within an environment characterized by methane gas production, have a high probability for Clostridial contamination and gas gangrene.

Methods

1. Confirmed Clostridial gas gangrene patients admitted to our hospital and/ or referred to the HBO unit from 2002-2007 were enrolled in this retrospective study (N=5).
2. Microbiological samples were obtained from sites in and around the areas the injuries were sustained.
3. A biogas digester was built using organic material to produce methane gas (CH4) as energy source. The slurry was analyzed for micro-organisms present in the methane gas production process.

Results
Four patients (N=5) had mining occupations. Two sustained traumatic injuries, one had a diabetic foot ulcer and one received intravenous re-hydration directly from underground. All four were from mines with a historical and current methane gas explosion risk. Microbiological data of the site and bio-digester slurry revealed a high yield of Clostridial organisms.

Discussion
s/Conclusion Although the evidence is circumstantial, our study supports the hypothesis that acute traumatic injuries, sustained in an environment where methane gas is produced, are at risk for developing Clostridial gas gangrene and should be managed accordingly.

OR063
Chemical War Burns: A Review of Skin Lesions from Sulfur Mustard Exposure

Yahya Dowlati (University of Tehran), Yekta Dowlati (University of Tehran), Alireza Firouz (University of Tehran), Masoud Davoodi (University of Tehran), Afsaneh Alavi (University of Toronto)

Goals and Objectives
Exposure to the chemical warfare agent, Sulfur Mustard, has still some victims in the world. Sulfur Mustard (SM), a potent alkylating agent, was first used as a chemical war weapon in April 22, 1915 (World War I) in Ypres, Belgium. Although the protocol of Geneva in 1925 has prohibited the use of such agents, unfortunately, it was used again as a chemical warfare agent in 1980s, about 70 years later. It would naturally be preferable if this protocol was followed all over the world, but this did not happen in the real world.

Our aim is to discuss about mechanism of action, clinical manifestation, and therapy, which is still needed in reality.

Methods
In Iran-Iraq conflict in 1980's, SM was used in several locations against Iranian soldiers and civilians by Iraqi army. Majority of these patients were treated in the Iranian hospitals inside the country. Several patients were evacuated during 1984-1986 to European hospitals in Belgium, Germany, Spain and etc. Sulfur Mustard is an oily liquid that vaporizes slowly at temperate climates and may be aerosolized with spraying or by explosive blast. Although SM may be lethal, but is more likely to cause incapacitating injuries to the eyes, respiratory tracts, and skin of advancing forces. In severe cases it can affect bone marrow as well. We will mostly discuss skin lesions in this review article.

Discussion / Conclusion
We will share our information and experience in the diagnosis, management, of these patients and will try to introduce a guideline, which will include advances in wound care. Some skin manifestations still exist many years after exposure to this agent. Hopefully this review will provide better care and give relief to these patients, who are victims of this inhumanity incident.

OR064
Early Initiation of Negative Pressure Wound Therapy using Open Cell Foam in Acute Care Patients with Traumatic Wounds has a Positive Impact on Economic Outcomes.

Mark Kaplan (Albert Einstein Medical Center), Stephen Stemkowski (Premier, Inc )

Goals and Objectives
To examine whether early initiation of negative pressure wound therapy using open cell foam (NPWT/OCF) as delivered by the V.A.C.® Therapy* System could influence the overall length of stay in acute care and also the total direct treatment costs in the acute care setting.

Purpose
Evaluate the impact of early (NPWT/OCF) initiation on acute care treatment outcome measures: hospital length of stay (LOS), ICU LOS, ICU admission rate, OR time and total direct treatment costs.

Methods
We conducted a retrospective analysis using patient discharge administrative data from the Premier Perspective™ database, of 202 hospitals between January and December 2005. Patients had a diagnosis of traumatic wound and were classified as "early" (NPWT/OCF initiated within two days of hospital admission) or "late" (NPWT/OCF initiated on day three or later).

Results
There were 1,518 patients fulfilling study criteria (n = 518 early and n=1000 late). Early patients had fewer patient days (10.4 vs 20.6, p < 0.0001), shorter treatment time (5.1 vs 6.0, p =0.0498), shorter ICU stays (5.3 vs 12.4, p < 0.0001), but higher ICU admission rates (51.5% vs 44.5%, p = 0.0091) compared to late patients. In addition, the early group experienced shorter OR times (4,989 vs 10,830 minutes, p < 0.0001) and had lower mean total and variable costs per patient ($32,175 vs $43,956, p < 0.0001; $15,805 vs $22,891, p < 0.0001, respectively).

Discussion / Conclusion
In this study, early initiation compared to late initiation, was associated with a statistically significant reduction in patient days, length of treatment, ICU days, OR time and mean total and variable treatment costs. Early use of NPWT/OCF may have a positive impact on overall treatment costs.

* V.A.C. ® Therapy, KCI USA, San Antonio, TX

OR065
Pattern of Burn Injuries in Ibadan, Nigeria

Oluwatosin OA (College of Medicine, University of Ibadan, Nigeria), Ademola SA (College of Medicine, University of Ibadan, Nigeria), Akinyemi O (College of Medicine, University of Ibadan, Nigeria), Oladeji S (College of Medicine, University of Ibadan, Nigeria), Oluwatosin OM (College of Medicine, University of Ibadan, Nigeria)

Goals and Objectives
Burn injury constitutes severe trauma. The outcome is worse when associated with Inhalational injury. While outcomes have improved in developed countries, improved outcomes is yet unproven in the developing world. This is therefore a study of the current status of burns in a developing economy with a view to developing strategies for improved outcomes.

Purpose
To study the pattern of burn injuries in Ibadan, Nigeria and use the data in burn prevention and treatment strategies.

Methods
A retrospective, cross sectional study involving key primary, secondary and tertiary hospitals in Ibadan was carried out by reviewing the records of patient who sustained burns between January and December 2007. All patients who sustained burns were included. The data was analysed using the Statistical Package for Social Sciences (SPSS) version 11 computer software.

Results
Eighty seven (87) patients were included in the study. Males constituted 67% while females were 33% . The mean age was 24 +/_ 18 years and the mean total body surface area burnt (TBSA) was 41 +/- 31%. The cause of burns was flame in 58%, scald 35%, electricity 4 % and contact 3%. Over 90% of flame burns were from explosion of adulterated petroleum products and pipeline fires. Inhalational injuries occurred in 30% and the overall mortality was 58%. Patients who sustained more than 55% burns also sustained Inhalational injury and 85% of patients with Inhalational injury died.

Discussion / Conclusion
This study shows that burn injuries in Ibadan, are often a result of flame from explosion of petroleum product/pipeline, they are often associated with Inhalational injury and the mortality is high. There is need for prevention of these fires, preparedness for victims of mass burns and expertise in management of severe burns in order to improve outcomes.

OR066
The Relationship Between Anxiety, Anticipatory Pain, and Pain During Dressing Change in the Older Population.

KY Woo (Women's College Hospital), RG Sibbald (Women'sCollege Hospital)

Goals and Objectives
Pain is a significant concern in patients with chronic wounds. Evidence suggests that anxiety may lower the threshold and tolerance to pain in patients with burns. Litlle is known about the relationship between pain and anxiety in the chronic wound population.

Purpose
The purpose of this study is to evaluate the relationship between pre-dressing change anxiety, anticipatory pain and pain during the dressing change procedure in the older population.

Methods
Ninety-six patients with chronic wounds were asked to rate their anxiety level (Spielberger State-Trait Anxiety Inventory short form) and anticipatory pain (0-10 numeric rating scale or NRS) before dressing change. Pain levels were remeasured at dressing removal, cleansing of the wound, and application of dressing with NRS. The quality of pain was captured by the McGill Pain Questionnaire (MPQ) at the end of the study.

Results
Patients reported both nociceptive and neuropathic pain according to the MPQ. Pain was most intense at dressing change and cleansing. Anxiety levels before dressing change were significantly related to anticipatory pain (r=.661), pain at dressing removal (r=.527), and pain at cleansing (r=.436) (all p values <0.01).

Discussion / Conclusion
Findings of this study suggest that chronic wound pain is complex involving both nociceptive and neuropathic components. The assessment of patients' anxiety should be part of chronic wound pain evaluation and management. Interventions to relieve pain should focus on decreasing trauma during dressing removal and cleansing.

OR067
Bacterial Biofilm and Microcolony Formation in Chronic Wound Colonization.

Anders Andersen (Statens Serum Institut, DK), Michael Keig Sonnested (Statens Serum Institut, DK), Klaus Kirketerp-Moeller (Copenhagen Wound Healing Center, DK), Bo Joergensen (Copenhagen Wound Healing Center, DK), Tonny Karlsmark (Copenhagen Wound Healing Center, DK), Carsten Struve (Statens Serum Institut, DK), Karen Angeliki Krogfelt (Statens Serum Institut, DK)

Goals and Objectives
Wounds are susceptible to infection due to the development of microbial communities within and around the wound environment. Recent studies have suggested that bacteria exist within chronic wounds as aggregates in microcolonies or as biofilms. The biofilm mode of growth confers higher antibiotic tolerance to the bacteria and makes them less susceptible to eradication by the host immune system. Furthermore interspecies synergy may exist within biofilms, increasing the overall virulence and persistence of bacteria within the wounds.

Purpose
To investigate the spatial distribution and interspecies arrangement of Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA) within a standardized patient group with colonized non-clinically infected chronic venous leg ulcers.

Methods
Material from 10 patients with persisting colonized chronic venous leg ulcers examined in a pervious study by culture analysis was retrospectively included in this study. Paraffin imbedded 4mm punch biopsies from the central wound bed were sectioned and in series HE and Gram stained for histological orientation and DAPI and Alcian-Blue stained in order to visualize bacterial extracellular polymer matrix (EPS). Adjacent slides were subjected to rRNA fluorescence in situ hybridization (FISH) analysis with PA, SA and Eubacterial specific probes.

Results
PA and SA did not appear to co-colonize the same area of the tissue sections. SA was dispersed as single cells whereas PA appeared both as single cells and in microcolony like aggregates. The EPS staining with DAPI was unsuccessful, however Alcian- Blue staining did in two samples correspond to areas colonized with PA

Discussion / Conclusion
The results indicate that no synergies occur between PA and SA in wound colonization and that microcolony formation by SA in wound colonization does not occur. Biofilm formation may however play a role in the colonization of PA in chronic wounds.

OR068
Acral Lentiginous Melanoma of the Foot. A Review of 26 Cases

Ivan Bristow (University of Southampton, UK), Katharine Acland (St Thomas' Hospital, London, UK)

Goals and Objectives
Acral lentiginous melanoma (ALM) is an uncommon but aggressive superficial tumour, particularly affecting the feet. Few studies have investigated this sub-type of melanoma which has been shown to have a poorer prognosis than melanoma elsewhere on the body owing to its late and varied presentation.

Purpose
The purpose of this study was to investigate and profile the clinical characteristics and presentation of ALM. Such information could be used to review practice and elucidate possible areas where practitioner awareness could be improved.

Methods
We performed a register-based review of all cases of ALM, arising on the foot, from a single, large tertiary care Hospital. We reviewed patient demographics, history and histological details. All relevant details were then reviewed, tabulated and analysed.

Results
Over a six year period, 26 cases of ALM were identified in 19 females and 7 male patients (38 to 96 years of age). The typical location of lesions was plantar area 65%, particularly under the first metatarsal head. The average time patients took from recognising a lesion to seeking medical consultation was 13.5 months. The mean thickness of lesions at diagnosis was 3.55mm. Patient reported symptoms included bleeding, ulceration and colour changes. Twenty three percent of ALM were previously misdiagnosed as lesions such as diabetic foot ulcerations, fungal infections, warts and other foot pathologies.

Discussion / Conclusion
This study has provided information on the clinical information on a case series of acral lentiginous melanoma. Furthermore, it demonstrated the ALM is a skin tumour of the foot which is frequently not recognised and subsequently diagnosed late as a thicker tumour. Further initiatives are required to raise both the patients and the clinicians awareness to this problem.

OR069
Symptoms Associated with Malignant Wounds

Dr. Vincent Maida (University of Toronto), Dr. Marguerite Ennis (University of Toronto), Dr. Craig Kuziemski (University of Ottawa), Linda Trozzolo, RN (William Osler Health Centre, Toronto)

Goals and Objectives
Assess the prevalence of malignant wounds in the setting of advanced cancer patients.

Define the commonest symptoms associated with malignant wounds as well as their prevalence.

Assess the anatomic sites of malignant wounds in relation to their symptom burden.

Methods
A prospective study based on a sequential case series of cancer patients referred to a palliative medicine consultative service. Patients with malignant wounds were asked to complete a questionnaire in which they listed up to three symptoms that were directly related to their malignant wounds.

Results
Malignant wounds were found in 14.2% of cancer patients. 67.7% of malignant wounds were associated with at least one of the following symptom types: pain, mass effect, aesthetic distress, exudation, odor, pruritus, bleeding, and crusting. 21.9% of wounds were associated with two symtoms, and 11.5% of wounds were associated with three symptoms. Their overall point prevalence at baseline is pain 30.2%, mass effect 17.7%, aesthetic distress 16.7%, exudation 14.6%, odor 10.4%, pruritus 5.2%, bleeding 4.2%, and crusting 2.0%. In addition, the sites of malignant wounds were documented; their prevalence rates were chest/breast 31.2%, head/neck 24%, abdomen 18.8%, thoracic/lumbar spine 13.5%, perineum/genitalia 8.3%, upper extremity 2.1%, and lower extremity 2.1%.

Discussion / Conclusion
Malignant wounds occur with a signicant prevalence and have a wide anatomic distribution. Eight main symptoms are associated with maligant wounds. An accurate assessment of the relative symtom burden of maignant wounds will serve to stimulate research into the optimal methods for wound related pain and polysymptom management.

OR070
Randomized Controlled Trial of No Sting Barrier Film for the Prevention of Radiation Dermatitis in Patients With Nasopharyngeal Carcinoma

Lilu Chang (Koo Foundation Sun Yat-Sen Cancer Center), Jer-Min Jian (Koo Foundation Sun Yat-Sen Cancer Center), Hon-Giun Cheng (Koo Foundation Sun Yat-Sen Cancer Center), Yu-Chen Tsai (Koo Foundation Sun Yat-Sen Cancer Center), Pei-Ling Hsieh (Koo Foundation Sun Yat-Sen Cancer Center), Min-Chih Chen (Koo Foundation Sun Yat-Sen Cancer Center)

Background
Radiation dermatitis is a common acute side effect of radiotherapy. In the absence of clear and consistent data on the efficacy of preventive and therapeutic strategies, patterns of care for radiation skin reactions vary widely among treatment centers.

Purpose
This study is to investigate the effectiveness of Cavilon No Sting Barrier Film for the prevention or reduction of acute radiationinduced dermatitis of grade 2 or higher during radiation therapy for nasopharyngeal cancer patients, compared with no treatment.

Methods
Patients of both sexes, aged 18 or older, having biopsy-proven diagnosis of nasopharyngeal cancer at any stage, and given a fractionated radiation therapy, will be eligible for the study. Enrolled patients will be randomly assigned to apply Cavilon No Sting Barrier Film on the right side or left side of the treatment field. Intra-individual left/right self comparison

Method
(paired test) will be used. Skin dermatitis will be scored weekly utilizing the modified RTOG scale. A research nurse will perform scoring and interview patients one week before RT (baseline data), weekly during RT (on the date of doctor's appointment), and 4 weeks after RT.

Results
For 27 patients, in total 54 treatment areas, mean radiation dose was 70Gy. There was significant difference for maximum skin toxicity during radiotherapy between No-sting areas and the control areas. The occurrence of acute dermatitis of grade 2 or higher was significantly lower with the use No-Sting than without use of the product.

Discussion / Conclusion
The benefit of Cavilon No Sting Barrier Film is that it protects intact or damaged skin. The preliminary results of this study demonstrate advantage for the use of Cavilon No Sting Barrier Film in preventing skin breakdown during radiotherapy and consequently reducing the incidence of radiation dermatitis.

OR071
Wounds in Advanced Illness: A Prevalence and Incidence Study Based on a Prospective Case Series

Dr. Vincent Maida (University of Toronto), Mario Corbo (McMaster University), Michael Dolzhykov (York University), Dr. Marguerite Ennis (University of Toronto), Shiraz Irani, NP (Hope Health Care, Sydney, Australia), Linda Trozzolo, RN (William Osler Health Centre, Toronto)

Goals and Objectives
To ascertain an accurate inventory of the various wound classes and types.

To determine the point prevalence of the wound classes and types.

To determine the incidence rate of the wound classes and types.

To document the anatomic locations of the wound classes and types.

Results
43 individual wound types were identified and grouped into 9 distinct classes. 1,036 individual wounds (average 1.8 wounds per patient) were identified at baseline. 891 individual wounds (average 1.5 wounds per patient) were identified between baseline and their date of death. Pressure ulcers constituted the most commonly ocurring wound class affecting more than 50% of all patients. Malignant wounds were observed only in cancer patients. Baseline point prevalence for pressure ulcers, traumatic wounds, venous ulcers and arterial ulcers in non cancer patients exceeded that in cancer patients. At baseline, iatrogenic wounds were more prevalent in cancer patients than in non cancer patients. Incidence rates for pressure ulcers, traumatic wounds, diabetic ulcers, arterial ulcers and ostomies in non cancer patients exceeded those in cancer patients.

Discussion / Conclusion
The broad range of wounds along with high rates of prevalence and incidence, identified in this study, reflects that wounds represent a significant management issue for patients with advanced illness. Therefore, there exists a need for advancement in modalities and measures aimed at risk assessment, prevention and appropriate goal oriented management.

Methods
A prospective study based on a sequential case series of patients referred to a palliative medicine consultation service. 593 patients were studied between their baseline referral date and their death date. Data was stratified between patients suffering from malignant and non-malignant disorders.

OR072
The Role of Wound Care Education to Improve Hospital Nursing Knowledge (35 Tehran Hospitals)

Narmella Rabirad (University of Tehran), Dr. Afsaneh Alavi (University of Tehran), Dr. Mehdi Rahgozar (University of Tehran)

Goals and Objectives
The management of chronic wounds comprises a considerable proportion of a nurse's workload. The changes in practice are a rapidly changing dynamic process due to new advanced technologies and improved comprehension of the barriers to wound healing. In many settings, specially trained wound care nurses are the primary care providers in the treatment and prevention of chronic wounds.

Purpose
The aim of this study is to determine the impact of wound care educational programs on the knowledge and hospital practice of nurses in Tehran hospitals (35 institutions)

Methods
This study is a cross sectional quasi experimental study. We utilized a self- administered 37 question questionnaire divided into 3 sections; Demographic data, nursing knowledge and practice concerning pressure and diabetic foot ulcers. The questionnaire's content validity was tested by Chronbach's alpha (α=%95). We studied one hundred graduate nurses from 35 invited institutions with bachelors (BSN) or master degrees (MSN) that were also practicing wound care for more than 2 years. A questionnaire was completed by all attendees at the end of educational event, and one month post-event as part of their participation.

Results
The results of this study indicated that the nurses' theoretical knowledge was greater than the applied knowledge to practice. There was no significant difference in the mean knowledge scores for BSN participants that averaged 50 correct responses ( SD = 19) versus a slightly higher score for MSN participants of 54 ( SD = 16).

Discussion / Conclusion
Education improved nurse's knowledgelevels (6 sessions, each section 90 minutes) in two domains (diabetic foot ulcers, pressure ulcers). Ultimately, the findings of this study can be used to guide the planning efforts on continuous education of nurses in wound care area.

OR073
Nurse's Pressure Ulcer Knowledge; Are We Improving

Karen Zulkowki (Montana State University), Elizabeth Ayello (Clinical Editor, Advances in Skin and Wound Care & JWCET)

Goals and Objectives
Examine nurse's pressure ulcer knowledge overall, by amount of educational sessions attended, and certification. Additionally if years in nursing and nursing degree effect pressure ulcer knowledge

Purpose
Pressure ulcer prevention involves recognition of risk and appropriate care planning for that risk. Nurses are on the front line of this process. The appropriateness of nurse's treatment and prevention strategies is influenced by their level of accurate and current education in prevention and management. Education about wound prevention and treatment is included in curriculum for nursing students. Examination of nursing medical/surgical textbooks found information is either sparse or possibly outdated. Registered nurse across the US have been found to have a "C" level of pressure ulcer knowledge. The lack of knowledge compounds care planning and documentation issues and increasingly leads to litigation. The

Purpose
of this work is to examine if knowledge is improving and if years of practice, nursing degree or certification make a difference.

Methods
The Piper Pressure Ulcer Knowledge Test has been administered to nurses in multiple settings and locations for several years (N=2046). All testing was done prior to educational offerings. Scores were compared for 1st time respondents, by amount of educational sessions and certification.

Results
Overall nurse's knowledge scores have remained static (78%). Nurses that are attending educational programs score higher than those that are not. As more education sessions on pressure ulcer knowledge are taken, scores increase significantly. Nurses certified in wound care score significantly higher than those certified in other areas and those not certified in a specialty. Educational level and years in nursing did not relate to overall scores.

Discussion / Conclusion
Staff nurses are on the front lines of skin care and wound prevention. They have limited knowledge of pressure ulcer risk and preventative practices. Programs at facilities need to be developed to improve knowledge.

OR074
Predictive Validity of Waterlow Scale for Hospitalized Patients

Leticia Faria Serpa (German Oswaldo Cruz Hospital), Vera Lucia Conceição de Gouveia Santos (University of São Paulo), Gustavo Gomboski (University of São paulo), Sandra Marina da Silva Rosado (University of São Paulo)

Goals and Objectives
Pressure ulcers (PU) are considered to be a relevant public health problem since they result in hospitalization and loss of quality of life. Numerous PU risk assessment scales have been tested as Waterlow Scale.

Purpose
To evaluate the predictive validity of the Waterlow Scale in hospitalized patients.

Methods
A methodologic study took place in a private general hospital with 220 beds, average occupation rate is 7.4 days. Firstly the project was approved by Hospital Ethics Committee. The 6- month-period study was conducted with adult patients with Braden score ≤ 18. After consent patients were submitted to data collecting through alternate daily body examination and Waterlow scale assessment. During the hospitalization period, each patient was examined at least tree times to be considered for analysis. The data were submitted to sensitivity and specificity analysis through ROC curve and positive (+LR) and negative likelihood ratios (-LR).

Results
Most of the 98 patients who composed the sample of the study were man (50,0%), aged > 71 years old (63.3%). The cut-off scores in the 1st, 2nd and 3rd assessments were 17, 20 and 20 respectively. Sensitivity percentages were 71.4%, 85.7% and 85.7% and for specificity they were 67.0%, 40.7% and 32.9% respectively. Areas under ROC revealed good accuracy for the cut-off score at three assessments (64/ CI 95% 35 - 93; 59/ CI 95% 34 – 83; and 54/ CI 95% 35 – 7486 respectively). The results also showed probabilities of 14%, 10% and 9% for the development of pressure ulcers when the tests were positive (+LR) and 3% for negative tests (-LR) for the first, second and third assessments.

Discussion / Conclusion
The Waterlow scale showed a good performance for pressure ulcer prediction for hospitalized patients.

OR075
Pressure Ulcer Prevention in Users of Wheeelchairs. Is Possible a New Risk Assessment Tool.

Gago-Fornells, Manuel (Pinillo Chico Health Center. SAS.Spain.), Gracía-González, Fernando (Puerto Real Universitary Hospital.SAS.Spain.)

Aims
To evaluate the use of risk assessment tools (RATs) for developing pressure ulcers (PUs) in wheelchair users.

Methods
Population: Persons using a wheelchair at least two consecutive hours per day (from the handicapped persons census).

Objectives
To perform an analysis of potential risk factors for PU development in wheelchair users and to correlate them to the Waterlow and Braden Scales, as well as to Barthel's Index.

Results
The study comprised a sample of 136 wheelchair users with an average age of 46 years; 76 (55.88%) women and 60 (44.11%) men. The mean time using the wheelchair was 14 years (range 1 to 53). A total of 27.94% were unable to perform any movement in the sitting area without external help; 58.66% were able to move and change posture; and only 13.97% were able to move by tilting forward and displacing the buttocks laterally without raising them. This raising of the buttocks required external help in 41.91% of the cases. In the present series, 30.88% reported having suffered PUs, and 8.82% of the patients had this problem at the time of the interview.

In order to optimize the results, within the assumed sources of bias, and in order to ensure improved understanding of the findings, we divided the sample into two comparative groups: Group A (wheelchair users who never suffered PUs) and Group B (users who either have or have had PUs in the past). As to assessment of the two groups (A and B), based on the indices of the Colley scale, to determine the degree of buttock and position self-mobility in the wheelchair, in the context of the existing physical handicap, we found some significant discrepancies.

For a second assessment, on contrasting the two groups with respect to the corresponding level on the three-point scale, optimum mobility, risk presumed to be low, for a score of 0, we did not encode significant differences in terms of the comparative analysis made (Group A= 41.8% and B=58.2%). However, significant differences were observed on comparing optimum self-mobility in Group A (Colley score 0) versus Group B (Colley score 2), with very limited and dependent self-mobility (Levene test t=2.543, for p=0.05).

For the study of risk assessment tools (RATs) for developing pressure ulcers (PUs)(RATPUs) applied to patients with these characteristics, though exported on the basis of the levels of risk for suffering PUs in bed-ridden patients to patients in wheelchairs, the parallelisms between them implied negative correlations for the Braden versus the Waterlow scale (Spearman test δ= -0.321, p= 0.01). This explains the non-adaptation of these scales for use in patients in wheelchairs.

In turn, we found a positive correlation on comparing the Braden scale with the Barthel index - independence for daily life activities - taken from the supervising care giver (Spearman δ= 0.326; p= 0.01). This situation was repeated for the Waterlow scale and this same index (Spearman δ=0.467, p=0.01). Likewise, we also found significant differences between the degree of mobility in the chair as refers to buttock raising and autonomous mobility, versus the degree of disability as determined by the Barthel index (Spearman δ=0.621; p= 0.01).

On the other hand, no significant differences were seen on comparing the values of the Braden and Waterlow instruments with the higher values of the Colley scale (2 points) in both groups - thus indicating a lack of adequacy between the scales for preventing PU risk with the risk evaluations designed by Colley for wheelchairs. A correlation was noted between wheelchair mobility and the Barthel index (Spearman δ=0.799; p= 0.01), which a priori appeared unquestionable.

However, there were no differences in favor of humidity sensation and permanent or intermittent bladder catheterization, since we consider that the present study was unable to evaluate such a relationship.Significance was recorded on comparing humidity sensation and self-capacity to move the buttocks (Spearman δ=0. 231; p= 0.01), possibly as a result of observation and subjective adherence sensation to the sitting zone as personally perceived by the patient.

Conclusions
RATPUs cannot be exported to people in wheelchairs. Postural self-mobility in the wheelchair can influence the presence of PUs. Urinary incontinence in these patients, as in those bed-ridden, converge with the same risk factor. The Colley scale may be a good indicator to be validated. Specific RATPUs must be developed for people in wheelchairs, as tools for the prevention of PUs.

OR076
Predictive Validity of Braden Scale for Patients in Intensive Care Unit

Leticia Faria Serpa (German Oswaldo Cruz Hospital), Vera Lucia Conceição de Gouveia Santos (University of São Paulo), Ticiane CGF Campanili (University of São Paulo), Moelisa Queiroz (University of São Paulo)

Goals and Objectives
Patients in the Intensive Care Unit (ICU) show specific risk factors to the development of pressure ulcer (PU).

Purpose
To evaluate the predictive validity of the Braden Scale in critical patients.

Methods
A prospective cohort study took place in four ICUs at a private general hospital. Firstly the project was approved by Hospital Ethics Committee. The 6-month-period study was conducted with adult patients with Braden score ≤18. All of them by themselves or by a family member accepted to participate in the study. After consent patients were submitted to data collecting through alternate daily body examination and Braden scale assessment. During the hospitalization period in ICU, each patient was examined at least tree times to be considered for analysis. The data were submitted to sensitivity and specificity analysis through ROC curve and positive (+LR) and negative likelihood ratios (-LR).

Results
Most of the 72 patients who composed the sample of the study were man (66.7%) with an average age of 58.1 years. The cut-off scores in the 1st, 2nd and 3rd assessments were 12, 13 and 13 respectively. Sensitivity percentages were 85.7%, 71.4% and 71.4% and for specificity they were 64.6%, 81.5% and 83.1% respectively. Areas under ROC revealed very good accuracy for the cut-off score at three assessments (78.8/ CI 95% 29 - 100; 78.9/ CI 95% 27 – 100; and 80/ CI 95% 28 – 100 respectively). The

Results
also showed probabilities of 21%, 29% and 31% for the development of pressure ulcers when the tests were positive (+LR) and 2%, 4% and 4% for negative tests (-LR) respectively for the first, second and third assessments.

Discussion / Conclusion
The Braden scale showed a very good performance for pressure ulcer prediction in ICU patients with cut-off score 13 at the three assessments.

OR077
Intertriginous Dermatitis: Fungal or Not?

Kristy D. Edwards (University of Nebraska Medical Center, Department of Family Medicine), Janet Cuddigan (University of Nebraska Medical Center, College of Nursing), Joyce Black (University of Nebraska Medical Center, College of Nursing), Theresa Hackmann (University of Nebraska Medical Center, College of Nursing), Laura McMullen (University of Nebraska Medical Center, College of Nursing)

Goals and Objectives
Clinicians faced with intertriginous dermatitis (intertrigo) reflexively presume Candidal infection and treat with antifungal creams and powders. Our goal is to identify patients with intertrigo, culture their affected skin folds and correlate the

Results
with clinical assessments of erythema, odor, maceration, and presence of satellite lesions.

Purpose
To identify common microorganisms involved in intertrigo and determine inter-rater reliability for clinical assessments of intertrigo.

Methods
Hospitalized subjects not being treated with topical or systemic antifungals or Interdry Ag were initially identified by nurses on routine assessments. Anaerobic, aerobic and fungal cutaneous swab cultures were taken from a maximum of 2 sites of intertrigo per patient. Each site was independently evaluated by 2 investigators for erythema, odor, maceration and presence of satellite lesions.

Results
Eighteen cultures were taken from eleven subjects. One to six organisms were identified from each culture. Candida was identified in only 6 of 18 fungal cultures (33%). Over 50% of the organisms cultured were pathogenic. All but 2 subjects cultured positive for at least one pathogenic organism, most commonly Proteus and Enterococcus species. Four cultures yielded antibiotic resistant strains of bacteria (Vancomycin resistant Enterococcus faecium or ESBL Proteus mirabilis). Intraclass correlation (ICC) analysis was used to determine the inter-rater reliability for clinical assessments. ICC ranged from .828 (95% CI = .539 -.936) for assessments of maceration to 1.00 for degree of erythema.

Discussion / Conclusion
Pathogenic bacteria were more likely to be cultured from sites of intertrigo than Candida. Classical treatments for intertrigo are predominately topical antifungal creams and powders. Clinicians should rethink this reflexive response and consider approaches that control moisture, friction and bacterial burden. This is particularly important in cases not responding to topical antifungal therapy.

Funding Source
This work was funded by an unrestricted research grant provided by Coloplast Corporation.

OR078
IM Fraction: A Colostrum-derived Extract for Wound Management

C.J. Doillon (Oncology and Molecular endocrinology Research Center, CHUL's Research Center, CHUQ, Quebec), R.Paradis (Oncology and Molecular endocrinology Research Center, CHUL's Research Center, CHUQ, Quebec), R.Drouin (Advitech inc.), O. Moroni (Advitech.inc.), C.Juneau (Advitech.inc)

Goals and Objectives
Colostrum is the first milk produced after birth and is particularly rich in immunoglobulins, antimicrobial peptides, and other bioactive molecules, including growth factors. IMfraction is a colostrum-derived extract particularly rich in IGF-I, EGF and antimicrobial peptides (proline rich peptides, defensin & cathelicidin).

Purpose
The aim of the present study was to investigate the wound repair activity of IM-fraction.

Methods
Fibroblast mitochondrial activity (XTT assay), collagen contraction and synthesis by fibroblast were evaluated in presence or not of IM-fraction at different concentrations.

Results
Mitochondrial activity of fibroblast increased significantly (P<0.05) with IM-fraction at 1500 ug·ml-1 (230 311 ± 30 937 cells) compared to control value (FBS 0.5%; 10877 ± 7517 cells). Fibroblasts (5x105 cells·ml-1) were mixed in type I collagen solution (1.5mg/ml). After 5 days of incubation with IMfraction, collagen surface area was measured (mm2). In the presence of IM-fraction (0-2000 ug·ml-1) collagen gel contraction was prevented (0.68 ± 0.11 mm2 at 2000 ug·ml-1) in a dosedependent manner compared to control value (0.21 ± 0.02 mm2, P<0.05). Collagen synthesis and deposition was increased in low doses of IM-fraction, while soluble collagen release in culture medium was decreased in a dose-dependent manner compared to control value (P<0.05).

Discussion / Conclusion
In summary, IM-fraction increased fibroblast metabolic activity and collagen production while preventing its contraction. These data suggested that IM-fraction might be beneficial for wound closure while preventing excessive collagen contraction which might lead to disordered scars.

OR079
Biological Characterization of Epidermis of Chronic Wounds

Irena Pastar (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Olivera Stojadinovic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Stephan Barrientos (Tissue Repair Program, HSS at Weill Cornell Medical College; University of Rochester SOM & D), Agata Krzyzanowska (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Vukelic Sasa (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Michael S. Golinko (Wound Healing Program, Columbia University College of Physicians and Surgeons), Harold Brem (Wound Healing Program, Columbia University College of Physicians and Surgeons), Marjana Tomic-Canic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College)

Background
Biopsies of non-healing edges obtained from patients with chronic wounds show thick and hyper-proliferative epidermis with mitosis in suprabasal layers. We have shown that keratinocytes at a chronic wound edge are unable to migrate due to overexpression of c-myc. In addition, we found that epidermis of a non-healing edge is hyperkeratotic and parakeratotic as evident by presence of nuclei in a thick cornified layer. These findings suggest altered keratinocyte activation and proliferation.

Purpose
To identify molecular changes that lead to pathogenic alterations in keratinocytes activation and differentiation pathways.

Methods
We used Affymetrix HU133 chips and performed hybridizations of mRNA isolated from biopsies obtained from non-healing edges of venous ulcers and compare the transcriptional profiles to those obtained from normal, unwounded skin. We further confirmed these findings using immunohistochemistry and biopsies from new set of patients with venous ulcers.

Results
We identified 1,560 differentially regulated genes in a statistically significant manner. As indicated by histology findings, we found deregulation of differentiation and activation markers. Early differentiation markers, keratins K1 and K10 and a subset of small praline rich proteins (SPRRs) along with late differentiation markers filaggrin were suppressed, whereas late differentiation markers involucrin, transgultaminase 1 and another subset of SPRRs were induced. Desomosomes, cellular junctions of the differentiating keratinocytes were also found to be deregulated. Keratinocyte activation markers keratin K6, K16 and K17 were induced at the levels below what is expected in acute wounds. We also found differential regulation of signaling molecules that regulate these two processes, such as Notch, KLF, PLD1, PLD2, and PI3K.

Conclusion
We conclude that keratinocytes are not senescent at the nonhealing edge but rather incapable of executing either of the two pathways: activation and differentiation, resulting in thick callus formation at the edge of a chronic wound.

OR080
Microbial Diversity in Biofilms, Wounds and Medical Devices

S.A.Cairns (Department of Wound Healing, Cardiff University, Wales), D.W.Williams (Cardiff University, Wales), J. Thomas (West Virginia University, Morgantown, USA), S. Hooper (Cardiff University, Wales), M.Wise (University Hospital Wales, Cardiff, Wales), P.Frost (University Hospital Wales, Cardiff, Wales), S. Malic (Cardiff University, Wales), M. Lewis (Cardiff University, Wales), K. G. Harding (Department of Wound Healing, Cardiff University, Wales), D. J. Leaper (Department of Wound Healing, Cardiff University, Wales)

Goals and Objectives
It has been recognised that wound swabs and fluid culture are deficient as diagnostic tools, particularly in the field of wound management. These "snapshots" of a patient's bacterial burden bear little resemblance to the chronic, recurrent or intractable nature of many infective conditions. Diagnosing the presence of biofilm forming bacterial colonies within patients, their implants and wounds would aid treating these conditions.

Purpose
Biofilms have been shown to exist within medical implants as diverse as breast implants and intravascular cannulas, the

Objective
of this study is to characterise the microbial diversity in endotracheal tubes, tracheostomies, and chronic wounds and the dressings used in their management.

Methods
25 endotracheal tubes were obtained from a General ICU and in this ongoing work tracheostomy tubes are being obtained from a Burns ICU. Tissue biopsies are also being taken from chronic wounds (of venous, diabetic and pressure aetiology) with sequential used dressings from patients with chronic wounds. Sampling involves the physical removal of biofilms within the airway lumens and from the dressings. Denaturing Gel Gradient Electrophoresis (DGGE) was used to assess bacterial diversity and verified using quantifiable cell culture techniques.

Results
DGGE profiling of 16S rDNA amplicons revealed a variety of DNA bands in all samples ranging from three to thirty bands, indicating polymicrobial colonisation. Several different marker organisms were compared showing the presence of multiple species including Staphylococcus aureus, Pseudomonas aeruginosa, as well as Streptococcus mutans. Correlation with traditional culture techniques revealed a disparity between DGGE defined population diversity and that of cultivatable bacterial colonies.

Discussion / Conclusion
Both endotracheal and tracheostomy tubes have been shown to harbour polymicrobial biofilms. The presence of multispecies isolates from chronic wound dressings may not confirm the presence of biofilms but ongoing physical evaluation of the samples should elucidate further understanding in this area.

OR081
Molecular Markers of Pathogenesis of Chronic Wounds

Stephan Barrientos (Tissue Repair Program, HSS at Weill Cornell Medical College; University of Rochester SOM & D), Olivera Stojadinovic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Michael S. Golinko (Wound Healing Program, Columbia University College of Physicians and Surgeons), Eashwar B. Chandrasekaran (Wound Healing Program, Columbia University College of Physicians and Surgeons), Harold Brem (Wound Healing Program, Columbia University College of Physicians and Surgeons), Marjana Tomic-Canic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College)

Background
Keratinocytes are major contributing cells to the wound healing process. In the chronic wounds they proliferate, but do not migrate, thus contributing to the pathogenesis.

Purpose
Since wound healing requires activation of keratinocytes that are capable of migration and proliferation, we sought to identify changes that lead to abnormal keratinocytes in chronic wounds.

Methods
To identify molecular changes that lead to pathogenic alterations in keratinocytes we used biopsy specimens (n=20) obtained from venous, diabetic foot and pressure ulcers and characterize them by histology, immunohistochemistry and real-time PCR.

Results
Biopsies of non-healing edges obtained from patients with chronic wounds show thick and hyper-proliferative epidermis with mitosis present in the suprabasal layer, and no epithelial migration. In addition, it is also hyperkeratotic and parakeratotic as evident by presence of nuclei in a thick cornified layer findings consistent with over-expression of c-myc. Indeed, we found marked increase of c-myc throughout the epidermis of chronic wounds. Activation of c-myc in chronic wound raises the question of role of its activator, β-catenin. We found activation and nuclear presence of β-catenin in non-healing edges of all three type of ulcers: venous, diabetic and pressure. Interestingly, when we tested biopsy specimens obtained from the wound edge immediately post-debridement, we found marked reduction of c-myc expression and absence of nuclear β- catenin.

Conclusions
Our finding sheds new light on molecular mechanisms underlying development of chronic wounds and identify molecules that can be utilized as pathogenic markers. The challenge now is to identify the pathway that leads to activation of β-catenin and c-myc and delineate approach to decrease their abundance in chronic wounds that would allow proper keratinocytes functioning and progression to healing.

OR082
A Retrospective Analysis in the Assessment of the Quality of Life of Venous Ulcers Patients Using the Charing Cross Venous Leg Ulcer Questionnaire, before and after compression treatment.

Despatis MA (Cape Breton Health Care Complex)

Goals and Objectives
We use the Charing Cross Venous Ulcer Questionnaire (CCVUQ) which is a validated and reliable quality of life questionnaire specific to patients with venous ulcers.

Purpose
We hypothesized that the quality of life of our patient improved when treated with compression.

Methods
From November 2004 and July 2005, 25 consecutive patients with venous ulcers were considered for this study. 3 refused to participate and 2 patients could not understand and answer the questionnaire. 22 patients (C6 of the CEAP) answered 21 questions relating to the different domains of Social functioning, Domestic Activities, Cosmetics and Emotional status and finally pain. The CCVUQ was completed at the end of the treatment or at 12 weeks in the process of healing. The CCVUQ was repeated with the patient thinking of how the situation was at the start of the treatment.

Results
Once we weighted all the answers as per CCVUQ, we collected the final score for each domain, for pain and for the added questions. The paired student-t test was used for analysis. The average healing rates was 21 weeks, with 35% healed at 12 weeks. After treatment, we found improved Social functioning (p = 0.004), Increased Domestic Activities (p = 0.0007), Improved Cosmetics (p= 0.00001), improved Emotional Status (p = 0.00001) and a decrease in pain (p= 0.00002). Domains differences were as significant in the group that had healed compared to the group that had not healed after 12 weeks (p<.05).

Discussion / Conclusion
Treatment of the venous leg ulcers in our clinic as resulted in the improvement of the quality of life of our patients over the course of their treatment.

OR083
Relationship Security, Anxiety, and Pain in Patients with Chronic Wounds

KY Woo (University of Toronto), J Sadavoy (Univeristy of Toronto), S. Sidani (University of Ryerson), R. Maunder (Mount Sinai Hospital), RG Sibbald (University of Toronto)

Goals and Objectives
Wound associated pain is a complex. Certain individuals are more prone to anxiety and pain. Beliefs about whether the self is worthy of love and whether others are worthy of trust may influence how individuals relate to each other and the experience of pain and anxiety.

Purpose
The purpose of this study is to determine the mediating effect of anxiety between relationship security and pain during dressing changes in patients with chronic wounds

Methods
Ninety-six patients with chronic wounds were asked to rate their relationships with their significant others using the Relationship Styles Questionnaire. Anxiety level was determined by Spielberger State-Trait Anxiety Inventory short form and pain was rated on a 0-10 numeric rating scale before, during, and after dressing change.

Results
Relationship security, anxiety, and pain were all related. (p<0.001) The lower the security, the higher anxiety and pain reported by subjects.To test for the mediating effect of anxiety between relationship security and pain, multiple regression analyses were used.

In the first regression, relationship security was a significant predictor of pain explaining 26% of variance (p<0.001). In the second equation, the regression coefficient was significant between relationship security and anxiety (p<0.001). In the final equation, pain was regressed on relationship security and anxiety simultaneously. The standardized coefficient for the relationship between pain and anxiety was significant (p<-0.001) while the coefficient between relationship security and pain became non-significant. The results substantiated the mediating role of anxiety in the relationship between pain and relationship security in chronic wound patients.

Discussion / Conclusion
Based on differences in relationship with other people, insecure individuals are more prone to anxiety and pain. It is important to recognize this relationship as part of a comprehensive assessment and management of wound associated pain.

OR084
Quality of Life, Treatment Burden and Quality of Medical Care of Patients with Venous Leg Ulcers in Germany

Debus S (Dept. of Surgery, Asklepios Klinik Hamburg-Harburg, Germany), Schaefer I (CVderm, University Clinics of Hamburg), Purwins S (CVderm, University Clinics of Hamburg), Reich C (CVderm, University Clinics of Hamburg), Augustin M (CVderm, University Clinics of Hamburg, Germany)

Background
Few studies have evaluated patient-reported outcomes and medical care of leg ulcer from the patients perspective.

Objectives
Evaluation of quality of life (QoL), treatment burden and quality of medical care among patients with venous leg ulcers (VLU) in Germany.

Methods
Data were derived from a nationwide study on the cost-of-illness and medical care in VLU in 31 wound centers. Disease-specific QoL was assessed with the Freiburg Life Quality Assessment (FLQA-w) including a specific tool for treatment burden. Patient-reported treatment benefits were measured using the patient benefit index (PBI-w). Patient satisfaction and patient assessment of quality of care were evaluated by standardized questions.

Results
Out of 218 total VLU patients investigated, 213 (97.7%) revealed QoL reductions due to their chronic wounds. Significant reductions of health were found in 27.1% regarding general health, 43.5% regarding wound condition and 38.5% regarding QoL. 46.4% showed significant burden of treatment, 46.6% considered therapy time-consuming, 48.8% were strongly depending on the help of others. Regarding treatment benefits, 85.4% of patients showed a PBI>1, indicating at least a minimum patient-defined benefit of the most recent treatment. In 60.4% of the patients, there was a PBI>2 which reflects relevant treatment benefit. Asked about their subjective appraisal of medical care, 67.5% of patients rated a good or very good care, 89.7% were satisfied with treatment.

Discussion
This is the first nationwide German study on the quality of care in VLU. The patients were recruited in specialized wound centers. This may explain why a great proportion of patients is satisfied with treatment. However, even under optimal treatment, most patients with VLU face reductions of QoL. Hence, a special focus in the management of VLU should be put on patient-relevant problems such as pain and treatment burden. This study was supported by a grant from Molnlycke Healthcare, Germany.

OR085
Negative Pressure Wound Therapy in Children: Expanded Indications

Dhruti Contractor, MPH, MA (George Washington University School of Medicine), Justin Larkin (George Washington University School of Medicine), Cinzia Brandoli, PhD (Children's National Medical Center), June K. Amling, MSN (Children's National Medical Center), Laura L. Tosi, MD (Children's National Medical Center, George Washington University School of Medicine)

Objective
To demonstrate the expanding range of indications for negative pressure wound therapy (NPWT) in the pediatric population.

Purpose
To document the versatility of NPWT in children of various ages, co-morbidities, diagnoses, and wound etiologies.

Methods
We conducted an IRB-approved, retrospective medical record review of NPWT provided to children at our facility between January 2001 and May 2007. Data evaluated included wound etilogy, wound location, significant co-morbidities, and days on NPWT.

Results
171 children, newborn to age 21, were identified: 6 newborns, 20 infants, 39 children ages 1-5, 51 ages 6-10, 43 ages 11-18, and 12 ages 19-21. Etiologies included 60 surgical wounds (avg 17.8 days of treatment), 33 traumatic wounds (avg 18.5 days), 32 burns (avg 8.7 days), 18 pressure ulcers (avg 29.5 days), 10 osteomyelitis (avg 18.6 days), 10 other infection/abscesses (avg 20 days), 5 pilonidal cysts (avg 4.4 days), 3 i.v. extravasation (avg 29.7 days). Important co-morbidities included cerebral palsy, spina bifida, cancer, sickle cell anemia, scoliosis, obesity, and diabetes. 71.7 % of surgical wounds and 33.3% of traumatic wounds were infected prior to NPWT treatment. Surgical wounds included 16 sternal and 16 abdominal wounds. 21 of 32 burn wounds were full-thickness. All pressure ulcers were stage 3 or 4. In addition to NPWT, 29 of 171 children also required split thickness skin grafts to achieve wound closure.

Discussion/Conclusion
If NPWT is to be used in children, it must be shown to be effective in patients with a wide range of co-morbidities, diagnoses, and wound etiologies. This six-year retrospective study documents the use of NPWT in 171 children who had a far broader range of indications than those examined by previous authors. The results of this study will be used to develop an improved wound care pathway at our institution.

OR086
Skin Tear Risk Factors in a Tertiary Hospital Setting

Pam Morey (Sir Charles Gairdner Hospital)

Goals and Objectives
Primary objectives of this study included identification of:

• skin tear prevalence
• anatomical location, classification and cause of skin tears
• key risk factors for skin tear development

Purpose
Skin tears are a common occurrence in the elderly and yet there has been little investigation into this problem in the tertiary hospital setting. The aim of this study was to gain a better understanding of skin tears within an acute care teaching hospital in Western Australia because of the implication of this injury to patients and the health care system.

Methods
A descriptive study design was used, with the survey conducted in conjunction with a hospital wide pressure ulcer survey. A convenience sample was used, with all patients invited to participate. Surveyors were trained on the use of the Payne- Martin Classification system.

Results
The prevalence of skin tears was found to be 8.5% (n=37) amongst a sample of 436 patients surveyed. The mean age of patients with skin tears was 76.6 years (range 56-92 years, SD 9.1).

Skin tears occurred predominantly on the upper limb (54.2%) and usually occurred secondary to a knock (59%) or a fall (24%). Most skin tears (71%) were assessed as Payne-Martin category 1. Key risk factors for skin tears included: age ≥65 years (c2 =16.6, df=1, p = 0.000), impaired mobility (c2 =5.4, df=1, p = 0.02), and altered behaviour (c2 =11.2, df=1, p = 0.000).

Discussion / Conclusion
Skin tears are an issue for patients in the tertiary setting. Results from this study provided a baseline for formulation and introduction of evidence-based clinical practice guidelines for the risk identification, prevention and management of skin tears.

OR087
Pressure Ulcer Prevention Across the Continuum: Bridging the Gap Between Acute Care and Long Term Care

Sharon Stahl Wexler,PhD, RN, BC (New York Hospital Queens), Michaelle Williams, MA, RN, CNAA (New York Hospital Queens), Marie Mitchell, RNC, BHA, CDONA (The Silvercrest Center for Nursing and Rehab), Setlidz Saint Louis, RN, CWOCN (New York Hospital Queens)

Goals and Objectives

• To improve communication between the acute and long term care settings related to pressure ulcer prevention.
• To decrease the number of hospital acquired pressure ulcers

Purpose
To measure the impact of a collaborative approach to pressure ulcer prevention between the acute and long-term settings related.

Methods
This study measured the impact of a pressure ulcer collaborative between a community academic medical center and a skilled nursing facility. Teams were formed with staff from both facilities, which compared assessment tools; pressure relieving support surfaces, pharmaceutical products and nutritional supplements. Weekly rounds of all long-term care residents were conducted. Changes were made in the assessment tools to utilize the Braden Scale and an anatomical figure for documentation. Facilities shared skin assessment documentation with each transfer. Long term care adopted nurse driven protocols for intervention. Joint education sessions were provided both in the classroom and at the bedside. Two inpatient units were chosen for this intensive effort, the Medical Intensive Care Unit (MICU) and the ventilator unit. Data was collected prospectively via pressure ulcer prevalence studies and retrospectively through medical record review.

Results
Preliminary results demonstrated a marked decrease in hospital acquired pressure ulcers on both the Medical Intensive Care Units (22% in 2006 vs. 0% in August 2007) and the Ventilator Unit (9% in 2006 vs. 5.4% in August 2007). Anecdotal data highlighted relationship building and a team approach to pressure ulcer prevention and management across the continuum.

Discussion / Conclusion
The increase in communication and enhanced team building across the continuum resulted in decreased pressure ulcer prevalence on two units. Plans are to expand the process to the emergency department with the development of emergency department nurse driven protocols as well as throughout the rest of the medical center.

OR088
Implementation of a Leg Ulcer Strategy in Slovenia- Case Identification

Helen K Peric (Slovenian Wound Management Association), Marta Gantar (Slovenian Wound Management Association), Peter J Franks (European Wound Management Association)

Introduction
Management of chronic leg ulceration represents a problematic challenge in Slovenia as well as in many other European countries. Patients don't have an equal access to services and medical devices. There is clearly a lack of data to assess adequately the effectiveness of wound management and to implement changes.

SWMA and EWMA decided to undertake project to produce evidence to improve leg ulcer management. The first part of the project, a prevalence study forms the basis of this presentation. Further steps include more detailed evaluation, development of more effective strategies and their implementation in practice.

Aim
The complete project aim is to develop a rational approach to the leg ulcer management. The aim of the first part of the study is to gather existing data

Methods
Southeast of Slovenia with a population of 138.872 was studied. Questionnaires were distributed in all health care institutions managing leg ulcers. Prior to the questionnaire distribution meetings were held in institutions to introduce the study.

Results
309 patients were identified in the study (1.87/1,000 population). 2/3 of patients were women. The mean age was 72,5 years. Almost half of the diagnosis are made on clinical assessment alone. A wide variety of staff treat patients with chronic ulceration. Pain is an important issue. The average number of visits is high (3,82/week).

Discussion
More detailed data analysis from this study is still in progress (e.g. cost-effectiveness). Initial data suggests higher incidence of leg ulcerations compared to some other countries. There is a reliance on clinical diagnosis without the use of appropriate investigations in many patients. A clear need exists to develop guidelines on treatment including an appropriate product formulary.

OR089
Costs-of-illness of Venous Leg Ulcers in Germany

Augustin M (CVderm, University Clinics of Hamburg), Herberger K (CVderm, University Clinics of Hamburg), Purwins S (CVderm, University Clinics of Hamburg), Schaefer I (CVderm, University Clinics of Hamburg), Debus S (Dept. of Surgery, Asklepios Klinik Harburg)

Background
Venous leg ulcers (VLU) are of great medical and social importance in western countries. In spite of their high prevalence, only few economic studies on VLU have been published. Particularly in Germany, no data on the costs-ofillness are available.

Goals and Objectives
To assess the costs of venous leg ulcers in Germany under stateof- the-art treatment conditions.

Methods
Nationwide cross-sectional study in 31 specialized wound centers, including office and clinic-based dermatologists, surgeons, GPs and internists. Patients with confirmed diagnosis of venous leg ulcer(s) were consecutively recruited, interviewed and asked to fill standardized questionnaires. Major outcomes parameters were the direct, indirect and intangible costs from the societal perspective. The patient case report form included questions on pre-treatments, quality of life (QoL, measured with the Freiburg Life Quality Assessment for Wounds, FLQA-w), patient-defined treatment benefits (PBI), quality of care and personal costs. The physician questionnaire focused on clinical data, wound status, resource consumption and costs.

Results
In total, n=218 patients (average age: 69.8+12.0 years, median 71) were investigated, including 62.1% women and 37.9% men. The median duration of wound was 7.0 years. Average total costs per patient and year ranged from € 9,900 to € 10,800, including 92% direct costs and 8% indirect costs. Direct costs to a large extent (88.9%) were costs for the statuatory health insurances, the other costs being out-of-pocket expenses (11.1%). Major cost-driving factor was inpatient treatment, followed by nursing fees (home care) and medical products. Disease-specific QoL was significantly impaired in almost all patients, indicating high intangible costs of disease.

Discussion / Conclusion
Venous leg ulcers in Germany are associated with relevant direct, indirect and intangible costs suggesting early and qualified disease management. The authors wish to thank all study centers for their participation. This study was supported by a grant from Molnlycke Healthcare, Germany.

OR090
Discriminatory Power of the Cardiff Wound Impact Schedule in Patients with Diabetic Foot Ulceration.

Riddell AD. (Department of Wound Healing, School of Medicine, Cardiff University, UK), Jeffcoate W (Foot ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University), Harding KG (Department of Wound Healing, School of Medicine, Cardiff University, UK), Price PE (Department of Wound Healing, School of Medicine, Cardiff University, UK)

Goals and Objectives
In order for health-related quality of life to become firmly established as an appropriate measure of outcome, assessment tools must demonstrate sound clinimetric properties.

Purpose
The Cardiff Wound Impact Schedule (CWIS) has shown promise in this area, but confirmatory studies are needed, particularly in patients with diabetes related ulceration.

Methods
As part of a large government funded dressing trial conducted in the UK with full ethical approval, 317 adult patients with a diabetes related foot ulcer [which had been present for at least 6 weeks with a cross-sectional area between 25 and 2500 mm2] were asked to complete the CWIS at baseline, 12 and 24 weeks (or at healing). All patients were treated using guideline–based standard clinical protocols with appropriate off-loading.

Results
Mean age of the sample was 59.6 (SD=12.6) years; 240 patients were male. Mean duration of diabetes was 15.7 years (SD=10.8). Eighty-eight patients were withdrawn from the study prior to week 24, 135 healed and 94 remained unhealed. The CWIS data were analysed (Intention to Treat, with last value carried forward) by healing status at the two follow-up assessments. There were statistical differences between the groups such that those with healed ulcers reported higher levels of health-related quality for the domains of Physical Functioning and Well-Being at both 12 (p<0.008 and p<0.003 respectively) and 24 weeks (p<0.02 and p<0.001 respectively), and a difference in social functioning at 24 weeks (p<0.001).

Discussion / Conclusion
CWIS, a condition-specific tool for assessment of health-related quality of life has demonstrated strong discriminatory power, suggesting it is suitable for use in clinical trials in this patient population.

OR091
Implementation of Best Practice to Patients with Lymphoedema

CJ Moffatt (CRICP, Thames Valley Univesity, London), DC Doherty (CRICP, Thames Valley University, London), PA Morgan (CRICP, Thames Valley University, London), PJ Franks (CRICP, Thames Valley University, London), PS Mortimer (St George's Medical School, London)

Goals and Objectives
Recent work undertaken by the Lymphoedema Framework (LF) project has developed a Best Practice Document (BPD) which has received international endorsement.

Purpose
To examine the clinical consequences of implementing the BPD to a population of patients suffering from Lymphoedema.

Methods
Following a case identification study a random sample of 107 patients (mean age 69.2 years, 82% women) identified with lymphoedema > 3 months undertook a series of evaluations at six monthly intervals during the implementation process.

Results
Of the sample 41.1% had arm swelling and 60.7% leg swelling. Overall 14% were considered to have complex condition with midline swelling and/or involvement of both upper and lower limbs.

Prior to the evidence based service the incidence of cellulitis was 10.3% in the first six months and 7.8% in the second six months. Following implementation this reduced to 2.9% in the first six months, and zero in the second six months. The number of patients who required hospitalization for their cellulitis reduced from 2.3% and 1.0% at baseline to zero in both six month periods following implementation. There was a corresponding increase in health related quality of life as assessed by the SF-36, particularly with respect to bodily pain and socialization. Further evidence of a benefit to patients was the health utility scores as given by the Euroqol EQ-5d with mean utilities 66.2 prior to the new service and 72.7 following implementation, with an overall mean health gain of 6.5.

Discussion / Conclusion
This improvement indicates that there is great potential for demonstrating cost efficiency of the new service over existing service provision.

OR092
Development of a Relational Databank for Chronic Wounds

Michael S. Golinko (Wound Healing Program, Columbia University College of Physicians and Surgeons), Eashwar Chandrasekaran (Wound Healing Program, Columbia University College of Physicians and Surgeons), Dave Kaplan (Hudson Valley Cardiology Group, Cortlandt Manor, NY), Harold Brem (Wound Healing Program, Columbia University College of Physicians and Surgeons)

Background
Care of the patient with chronic wounds may involve over 20 specialists. Multiple variables are required to make a clinical decision including laboratory values, cultures, radiology and wound area among others. Often this data is dispersed and hard to gather in one location.

Purpose
To document all the clinical variables and track healing progress of a wound, a relational Diabetic and Foot Ulcer Wound Databank was created with goal of decreasing amputations in the persons with diabetic foot ulcers and preventing progression to stage IV pressure ulcers.

Methods
We designed a HIPPA compliant Wound Electronic Medical Record (WEMR) was designed using Access (Microsoft Corporation, Redmond, WA) allowing the user to enter up to 152 individual variables and query the database to produce unique reports. A digital photograph of the wound at every visit along with the area measurements are entered into the WEMR at each visit

Results
Over a 4 year period, 15,291 digital wounds photographs have been entered of 3,947 wounds from 1,183 patients have been entered into the databank. The WEMR produces a single datasheet with a graph of wound area and a summary of all the 152 variables. Non-invasive flow studies, radiology, pathology, cultures and laboratory values are entered. Color codes denotes abnormal values. Outcomes such as a healed ulcer or amputation are entered.

Conclusion
Use of the WEMR has significantly decreased the time to process all clinical variables by the clinician. The use of the WEMR has significantly decreased amputations and decreased progression to stage IV ulcers. Development of a Wound Alert System will email the clinician when an abnormal laboratory value is entered of the wound stops decreasing in area.

OR093
The Relationship of Organizational Context to Nursing Management of Pressure Ulcers for Hospitalized Older Adults

Catherine O'Neill D'Amico (Hunter College Bellevue School of Nursing)

Goals and Objectives
Examine the influence of the organizational context on the nurses' perceived ability to prevent and treat pressure ulcers for older adults.

Purpose
To examine the relationship between the geriatric nursing practice environment and the nurses' perceived ability and knowledge to provide preventative care and treatment for pressure ulcers in hospitalized older adults.

Methods
This is a secondary analysis of data collected by the Nurses Improving Care for Health System Elders (NICHE) program as a benchmarking tool for hospitals to assess their strengths/weaknesses in geriatric care prior to NICHE implementation. Data from 10,078 nurses of 88 hospitals collected between 1997-2005 were analyzed using Wald's Chi Square and linear mixed effects modeling.

Results
Satisfaction with the geriatric nursing practice environment is significantly associated with the perceived ability to prevent (Wald Chi Sq. p=0.001) and treat pressure ulcers (linear mxd. effects, p=<0.001) and fewer disagreements (linear mxd. effects, p=<0.001) between disciplines regarding pressure ulcer care. How ever the geriatric nursing practice environment has a limited effect on nurses' knowledge of pressure ulcer prevention and treatment practices (Wald Chi Sq. p=<0.001).

Discussion / Conclusion
These findings support the overall aims of the NICHE program – to facilitate organizational-level improvements in the geriatric nursing practice environment, which, in turn, has positive outcomes for patient care. The nurses' lack of knowledge underscores the importance of system-wide educational efforts for clinical problems such a pressure ulcers that disproportionately effect older hospitalized adults.

OR094
Comparison of Knowledge Transfer Between Three Teaching Methods

Leah Shapera RN, MSN, GNC(C) (Providence Health Care), Shelley Masyoluk RN, BSN (University of Victoria)

Goals and Objectives
To determine and recommend the most effective method(s) of teaching nurses about wound care techniques, product use, and dressing application.

Purpose
With the changing pace of the acute care environment, coupled with the ever-increasing demands on nurses' time, the use of inperson teaching is becoming increasingly infeasible. The

Purpose
of this study was to compare the degree of knowledge transfer achieved using 3 different teaching strategies.

Methods
A group of 124 nurses completed a written pre-test on a selected wound dressing. The group was randomly divided into 3 subgroups, each of which received education about the selected dressing using 1 of 3 teaching methods, including a) an inperson inservice b) a written policy/procedure to read, and c) a short video clip showing a real-time demonstration by the agency's Clinical Nurse Specialist. All nurses completed a written post-test.

Results
The percentage improvement in knowledge between the pre-test and the post-test was highest (37%) in the group receiving the face-to-face inservicing. Next highest improvement (23%) was in the video clip group, and the lowest improvement (14%) was in the policy/procedure group.

Discussion / Conclusion
The low level of knowledge transfer in the policy/procedure group is particularly disturbing, as this is often the only accessible information source for in-house clinical procedures. While the face-to-face teaching method appears to be the most effective in achieving knowledge transfer, this

Method
is often infeasible given today's health care pace and environment. The use of short video clips appears to be the next best strategy for achieving knowledge transfer for this type of procedure-based information. Based on these findings, the test agency has produced 15 video clips which have been loaded onto the agency intranet, and hyper-linked to the corresponding on-line policies/procedures.

OR095
Iranian Nurses Knowledge and Expertise of Diabetic Foot Care

Mahvash Salsali (University of Tehran), Maryam Alaa (University of Tehran), Hayedeh Noktedan (University of Tehran)

Background
Diabetic foot ulcers develop in approximately 15% of diabetic patients. Nurses have significant role to positively effect on the clients' quality of life.

Purpose
The purpose of this study was to evaluate nurses' knowledge and expertise of diabetic foot care as well as the current diabetic foot nursing care principals in educational hospitals of Tehran.

Methods
An exploratory descriptive design was employed. Forty graduated nurses in educational hospitals in Tehran composed the study sample. A researchers-developed questionnaire was used to determine nurses' knowledge and expertise of diabetic foot care and professional skills as well as observational checklist which filled by researchers. Data were analyzed using parametric and non-parametric statistics.

Results
Since nurses' knowledge and expertise have always been a major part of university based nursing curriculum, they must be approached analytically, objectively, and comprehensively. Although most of the subjects had good information about foot education (75.99%), 61.24% of them were aware of diabetic foot assessment and diagnosis, and 78.75% of nurses knew about the nursing care of diabetic foot, but in evaluation the nurses' approach to nursing care of diabetic patients' foot and diabetic foot education, just 38% and 32% of them respectively did nursing care according to standard care.

Conclusions
Although the nurses' knowledge in diabetic patient assessment, nursing care, and patient education in all settings was not bad, but the results attained by diabetological nurses represent minimal skills and achievable goals for caring in diabetic patients in hospitals of Tehran. It is necessary to provide a range of practical data for developing guideline to support national diabetes care in which nurses understand what they should done step by step. The ultimate goal is the improvement of the quality of nursing care for these patients.

Funding Source: Endocrine and Metabolism Research Center, Tehran University of Medical Sciences.

OR096
Investigation of Choice of Dressings Used in the Treatment of Chronic Wounds: An International Patient Perspective.

Elizabeth Mudge (Cardiff University), Hilde Fagervik-Morton (Cardiff University), Keith Harding (Cardiff University), Patricia Price (Cardiff University)

Goals and Objectives
Growing evidence suggests that pain associated with chronic wounds is particularly distressing for patients.

Purpose
Qualitative research has established that the choice of dressing applied to a wound can be fundamental to patient's evaluation of their pain experience. The current plethora of diverse wound dressing materials can make individual dressing choices confusing.

Methods
This cross-sectional international survey collected information on choice of dressings used for 2,018 patients from 15 different countries (across Europe, North America and Australia), with a mean age of 68.6 years (S.D. 15.4) and a mean wound duration of 19.6 months (S.D. 51.8). A total of 3361 dressings were being used, 10 wound types were recorded and 10 specific wound dressing types were categorised.

Results
The most commonly used dressing type were antimicrobial dressings (n=650). These were the leading dressing type used in Australia, Belgium, Canada, Finland, Germany, Italy, Spain, UK and USA. Adhesive foam dressings were the leading dressing type used in Denmark, Norway, Sweden and Switzerland. Alginate dressings were the leading dressing type used in France and non-adhesive dressings were the leading dressing types used in Mexico. For some patients up to seven different dressings were used which is questionably not cost effective, could be considered uncomfortable for patients and would suggest a need for educational intervention. 30% of patients specified particular products that made the dressing change procedure less painful and 32% specified particular products that made the dressing change procedure more painful.

Discussion / Conclusion
These data confirm an international preference for use of specific products, highlight country specific trends, reimbursement issues and availability, and demonstrate the popularity of antimicrobial dressings in some countries.

OR097
Proteomics Analysis of Human Chronic Wound Fluid

Stephanie F. Bernatchez (3M), Katri Huikko (3M), Suzanne Grindle (Consultant), Joseph Stoffel (3M), William Lindroos (3M), George Peltier (Hennepin County Medical Center)

Goals and Objectives
We describe the development of a proteomics method to analyze the protein composition of wound fluid from chronic wound patients using Matrix-Assisted Laser Desorption / Ionization Time-of-Flight (MALDI-TOF) mass spectrometry.

Purpose
Our purpose is to create a library of proteins expressed in wound fluid and therefore identify biological markers of wound healing.

Methods
Wound fluid samples were obtained from 10 patients with various chronic wounds using the Levine swab technique and analyzed using MALDI-TOF. In parallel, additional swabs were collected for microbiological analysis. The organisms were identified and counted. The MALDI spectra were analyzed using the Mascot software, and the NCBInr database was explored using 'Homosapiens' taxonomy and trypsin enzyme cleavage values for protein identification. At the protein level, a large variability between patients was observed. The Ingenuity Pathways software was then used to group the proteins in the relevant metabolic pathways.

Results
The IL-4 signaling pathway and the antigen presentation pathway were the most significantly represented in this group of patients. In addition, a selected group of clinical bacterial isolates from 4 of the patients were analyzed (also using MALDI-TOF) to identify the bacterial peaks corresponding to these species. The spectra obtained were also compared to the wound fluid spectra from the same patients and some peaks previously unidentified when searching for human proteins were identified as peaks from bacterial proteins.

Discussion / Conclusion
This method can be useful to create a library of proteins expressed in wound fluid and therefore identify biological markers of wound healing. These markers are useful to evaluate the healing potential of patients with conditions that may impair healing, to diagnose impairment of wound healing, and to monitor the evolution of the condition as well as the response to treatments. In addition, bacterial proteins can potentially be identified in the same samples.

OR098
Dilemma of Management Diabetic Foot Ulcers with Restricted Facilities?

Dr.Hamza Aboud (Medical College, Al -Mustansyriah University,Yarmuok University Hospital,Baghdad-IRAQ. )

Goals and Objectives
Although foot amputation is a devastating consequence of diabetes & it is a life- threatening, but still we can consider diabetic foot ulceration is a preventable long term complication

Purpose
Aim of our study is to evaluate the traditional method of management diabetic foot complications with limited facilities in developing countries?

Methods
A total of 100 patients with diabetic foot complications were evaluated in a retrospective study, which was done in orthopedic department in Al-Kahdymia University Hospital, Baghdad, Iraq. Our available tools used in our program are clinical examination, neuropathy symptoms score, joint mobility, Doppler ultrasound.All patients were followed-up every 3 months for a mean period of 27 months. The clinical out come & difficulties of our program were analyzed.

Results
All 100 referred diabetic foot patients represented with different types, stages, degrees of diabetic foot complications such as ulcers, infections, gangrene, hemorrhagic bullies, loss of sensation, were managed as follow: 25 case treated by major amputation, 25 case treated by minor amputation & 50 case treated successfully by conservative method through repeated wound debridement, daily dressing, combined antibiotic regime with certain educational advice regarding foot wear & care ?

Discussion / Conclusion
Lack of recent diagnostic & therapeutic equipments in developing countries, in addition to absence of specialized diabetic foot care centers & educational preventive programs, it can lead to big lose with high percentage of foot amputations, recurrences, high morbidity, long hospitalization ....But still there is something to do ??

OR099
Wound Healing Activity of Mollugo Nudicaulis Lam: Field Grown-leaf Versus In Vitro-derived Calli Extracts on Rats

Nagesh K.S (Botany)

Background
Mollugo nudicaulis Lam.[Molluginaceae] is a traditionally important wild medicinal herb, has been used by traditional practitioners in developing country to cure whooping cough and jaundice, as well as to promote wound healing. Because this small herb only grows in limited areas during rainy seasons, collection of plant material for the extraction of phytochemicals is a complicated task. In vitro cultures (calli) could be used as an alternative source to field-grown plants. Callus was induced from leaf explant of the species on Murashige and skoog's medium fortified with cytokinins and auxins.

Objectives
To evaluate and compare wound healing potential of field grown leaves and in vitro derived leaf.

Method
ology Aqueous extracts of in vitro-derived calli and field-grown (in vivo) leaves were evaluated for wound-healing activity in rats using excision and incision wound models. The aqueous extract of in vitro-derived calli promoted wound healing significantly in both wound models studied.

Results
High rates of wound contraction (P < 0.001), decrease in the period of epithelialisation (12.2 ± 0.12 days), high skin breaking strength (442.0 ± 3.63g), significant increase in the weight of the granulation tissue (P < 0.001) and hydroxyproline content (P < 0.001) were observed in animals treated with the aqueous extract of in vitro-derived calli. Histological studies of the granulation tissue from animals treated with extracts from the in vitroderived calli revealed fewer inflammatory cells and increased collagen formation compared to the control animals and animals treated with extracts from leaves of field-grown plants.

Conclusion
The data of this study indicate that the leaf extract of in vitroderived calli possesses better wound-healing activity than the leaf extract of field-grown plants. Wound healing attributed to higher level of total phenolic contents in in vitro derived calli. Further phytochemical studies are needed to isolate the active compound(s) responsible for these pharmacological activities.

OR100
An Open, Randomised, Comparative, Parallel Group, Multi-centre Clinical Trial of Amelogenin Extracellular Matrix Therapy in the Treatment of Hard-to-heal Venous Leg Ulcers: Follow-up Data

Marco Romanelli (Department of Dermatology, University of Pisa, Pisa, Italy), Peter Vowden (Vascular Unit, Bradford Royal Infirmary, Bradford, United Kingdom), Patricia Price (Wound Healing Research Unit, Cardiff, United Kingdom)

Goals and Objectives
Amelogenin is an extracellular matrix protein which, when applied to the wound bed, provides a temporary matrix for cell attachment and promotes healing. A clinical evaluation was carried out to assess the effect of amelogenin on hard-to-heal venous leg ulcers (VLUs)

Purpose
A follow-up of patients who had participated in a randomised controlled trial in which their hard-to-heal VLUs had been treated with either compression in combination with amelogenin* or compression alone was undertaken.

Methods
Patients were randomised to amelogenin plus compression bandaging, or compression alone (control). All participants received compression one month prior to, during a 3-week runin period, and throughout the treatment period (12 weeks or less if ulcers healed). At the end of the treatment phase, amelogenin therapy ceased and, if ulcers had not healed, standard therapy (i.e. compression with appropriate dressings) was resumed. Patients were followed up and the wounds re-evaluated 12 weeks after the final visit.

Results
The initial results demonstrated significant benefits for patients treated with amelogenin in terms of ulcer healing, reduction in pain and reduction in wound exudate levels. The follow-up data showed that the healing response had been maintained. Compared to the control, amelogenin therapy was associated with greater percentage reduction in ulcer size, larger percentage reduction in ulcer size, and higher percentage of patients with wound size reductions. There were more healed wounds and pain continued to be significantly reduced in the amelogenintreated group, compared with the control group.

Discussion/Conclusion
Amelogenin therapy, in conjunction with compression, was beneficial in the treatment of hard-to-heal VLUs when compared to compression alone. Healing was seen to be initiated by application of amelogenin in terms of ulcer size reduction, more healed and improved ulcers, and pain control; these were maintained post-treatment.

*Xelma (Molnlycke Health Care)

OR101
Wound Hypothermia: Prevalence and Implications in Chronic Wound Care

George Perdrizet (Hartford Hospital), Lisa Corbett (Hartford Hospital), Hohn Montminy (Hartford Hsopital)

Goals and Objectives
Determine systematically the wound bed temperature for patients with Chronic wounds presenting to a Multidisiplinary wound care center.

Purpose
Better understand the potential barriers to wound healing in the Chronic Wound population.

Methods
Temperatures were recorded with a noncontact thermometer (DermaTemp, Exergen, Brampton, ON) under standardized conditions. Six sites were routinely monitored: 1. wound bed (WB), 2. Proximal site (PROX), 3cm distal to fibular head, 3. Distal site (DIS), dorsum of foot, 4. Contra-lateral site (CONL), mirro image of contra-lateral leg, 5. Ambient (AMB) and 6. BT_TM, body temerature by tympanic membrane. Demographic and wound data were recorded. Mean temperatures were compared between sites using a two-tailed Student's t test.

Results
Thirty -six patients (20 females, 16 males), mean age of 65.7 +/- 14 years were tested. Mean wound age was 32 +/- 18 weeks. Most wounds (34/36, 94%) had temperatures below the PROX/CONL sites. Temperatures (mean+/- SD, degree F) in the WB (83+/- 3.3) were lower than PROX (86+/- 2.0, p<0.006) and CONL sites (87.8 +/- 2.4, p< 0.0004) but not different form DIS (83.7 +/- 4.3, p=0.8).

Discussion / Conclusion
Chronic wounds are relatively hyopthermic compared to surrounding intact skin. Might wound hypothermia represent a physiologic barrier to healing?

OR102
Synergy of Diabetes and Aging Impairs Wound Healing

Michael S. Golinko (Wound Healing Program, Columbia University College of Physicians and Surgeons), Andrew M. Hanflik (Keck School of Medicine, University of Southern California), Marjana Tomic-Canic (Tissue Repair Program, Hospital for Special Surgery at Weill Cornell Medical College), Vincent M. Wang (Department of Orthopedic Surgery, Rush University Medical Center), Hyacinth Entero (Ross University School of Medicine, Roseau, Commonwealth of Dominica), Harvey Rosenberg (Alebert Einstein College of Medicine), John Fallon (Department of Pathology, Mount Sinai School of Medicine,), H.Paul Ehrlich (Department of Surgery, Milton S. Hershey Medical Center), Harold Brem (Wound Healing Program, Columbia University College of Physicians and Surgeons)

Background
Both diabetes and advanced age have been implicated in delaying wound repair.

Purpose
To determine the contribution of age, diabetes and the combination of the two to the impairment of wound healing process.

Methods
Incisional wounds were made in young db/db mice, aged db/db mice, and their age-matched controls. Biomechanical properties (breaking load and tensile stiffness), epithelialization, and collagen deposition were determined 14 days after wounding.

Results
The aged db/db/ mice had a significantly lower wound stiffness (0.7±0.3 N/mm) vs. all other groups of mice (p<0.05) There was 36% reduction in stiffness between aged db/db mice and young controls. The aged db/db/ mice had a significantly lower breaking load (1.9±0.7 N) as compared with young controls (p<0.05). No significant differences were detected when controlling for age and for diabetes. (p>0.05) Histological analysis revealed the distance between dermal edges of the healing wounds of aged db/db mice increased 8.1 fold compared with young controls and 3.7 times more than young db/db/ mice. (p<0.05) This impairment is sustained independent of long-term glycemic control (HgA1c%). (p>0.05)

Conclusion
The combination of age and diabetes act synergistically to impair healing, while neither alone had a significant effect. Elderly patients may be expected to heal and the findings emphasizes a necessity of early and aggressive intervention in elderly patients with diabetic foot ulcers. 1

Reference

1. Brem H et al. Exp Gerontol 2007;42(6):523-531.

OR103
Proteomic Screening of Wound Fluids Using Antibody Microarray Method to Uncover Molecular Abnormalities in Chronic Venous Leg Ulcers

Magnus S. Agren (Bispebjerg Hospital, Copenhagen, Denmark), Rasmus Lundquist (Bispebjerg Hospital, Copenhagen, Denmark ), Lars N. Jorgensen (Bispebjerg Hospital, Copenhagen, Denmark), Tonny Karlsmark (Bispebjerg Hospital, Copenhagen, Denmark), Brian Haab (Van Andel Research Institute, Grand Rapids, Michigan, USA)

Goals and Objectives
Increased levels of pro-inflammatory cytokines, chemokines and tissue destructive proteinases but deficiencies of angiogenic and other growth factors, antimicrobial peptides, proteinase inhibitors and extracellular matrix components have been proposed to explain delayed healing of chronic wounds. We still lack information on the relative levels of these various regulatory proteins.

Purpose
To determine unique protein alterations in chronic venous leg ulcers compared to acute wounds using high-throughput antibody-based microarray proteomics.

Methods
The study was approved by the local Ethics Committee. Wound fluids were collected for 24 hours under occlusion from 9 patients (4 females; 82 ± 7 years [mean ± SD]) with 10 chronic (139 ± 262 months) venous leg ulcers (30 ± 31 cm2) at 1-week intervals for one month and from 21 patients (4 females, 27 ± 8 years) with 7-day-old open granulating acute wounds (9.8 ± 5.4 cm2) after excision of pilonidal disease. Sera were collected from all patients. A validated antibody microarray method using twocolor rolling-circle amplification was used to profile the relative levels of 48 proteins representing the above-mentioned categories of wound-healing modulators.

Results
The chronic venous ulcers showed no healing tendency over the 1-month sampling period. Unexpectedly the relative levels of several of the examined proteins were significantly (p<0.05, ttest) elevated in chronic wound fluids. For example, fibronectin levels were increased in chronic wound fluid more than 4-fold (p<0.001) without concomitant increase in serum. Increased fibronectin was confirmed with Western blotting and sandwichbased assay. Von Willebrand factor and C-reactive protein were increased 2-fold (p<0.01) in sera from chronic compared with acute wound patients.

Discussion / Conclusion
Multiple proteins including fibronectin are elevated in chronic venous leg ulcers with no indications of growth factor deficiencies.

Funding from The Pharmacy Foundation of 1991 and Mölnlycke Health Care AB.

OR104
Multivariate Analysis of Outcome Correlates Among Diabetes Patients with Lower Limb Ulceration, Dar Es Salaam, Tanzania

ZULFIQARALI G. ABBAS (Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania), JANET K. LUTALE (Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania), LENNOX K. ARCHIBALD (University of Florida, Gainesville, Florida, USA)

Goals and Objectives
The pathogenesis of foot ulcers among patients with diabetes in sub-Saharan Africa involves a complex interplay of risk factors that have largely remained uncharacterized. Thus, we conducted this study to ascertain correlates of foot ulceration.

Purpose
Data from this study are expected to be useful additions to the body of evidence-based literature dealing with improving outcomes among patients with diabetic foot ulcers in Africa.

Methods
Between January 1998 and June 2007, adult diabetes patients who presented with foot ulceration to the Muhimbili National Hospital diabetes clinic in Dar es Salaam were evaluated following informed consent. Recorded clinical and epidemiologic data included ulcer site and area, tissue loss grade, infection grade, presence of septicemia, Wagner score, and degree of neuropathy and limb perfusion. Recorded outcomes included septicemia, healing, and mortality.

Results
Of 1451 patients enrolled in the study, 952 (66%) were male, 997 (69%) were Muslim, 1317 (91%) had neuropathy, 295 (20.3%) had decreased or absent perfusion in the affected limb. Overall mortality attributable to the ulcer was 4.6%. On logistic regression analysis, the single independent clinical correlate for septicaemia was grade of tissue loss in the ulcer (adjusted odds ratio [AOR]: 33.5; 95% confidence interval [CI]: 11.4-143). Ulcer width (p <0.001) and perfusion (AOR: 1.7; CI: 1.2-2.4) were independently predictive of healing. Independent correlates of mortality were septicaemia (AOR: 6.8; CI: 2.1-19.7), reduced or absent perfusion (AOR: 1.6; CI: 1.0-2.6); or increased ulcer area (p <0.05).

Conclusion
PEDIS parameters, such as tissue loss grading of ulcers, limb perfusion, and ulcer size were significant predictors of healing, septicaemia, and mortality among diabetes patients in Dar es Salaam. In contrast, Wagner score and ulcer site did not correlate with these outcomes.

OR105
The Impact of Chronic Wounds on People Without Wounds

Paul Philcox (Monash University), Gregory Duncan (Monash University), Peteris Darzins (Monash University), Elizabeth Dyson (Monash University), Melinda Brooks (Monash University), Robyn Wright (Monash University)

Goals and Objectives
The Victorian Community Wound Study was undertaken in 2007, funded by the State Government, with the primary aim of determining the prevalence of chronic wounds in the Victorian community-based population.

Purpose
To analyse the significant amount of unsolicited qualitative feedback from repsondents since the large majority were without wounds.

Methods
As part of this study, a questionnaire was sent to a randomly selected sample of 400 people over 65 years of age in each of seven electoral districts: four metropolitan, two regional and one rural. For ease of completion of the questionnaire, potential participants were asked only to indicate whether or not they had a wound that had been present for at least six weeks, and whether they were willing to participate in the study. Potential participants were screened by telephone and if a qualifying wound was confirmed and consent given, home interviews and wound assessments were undertaken.

Results
The response rate to this survey was remarkable, with more than 75% of recipients replying either by post or phone. One unexpected result from the study was the addition of comments from people who, while not experiencing a chronic wound themselves, wished nevertheless to share their thoughts on the subject. The major themes of this qualitative data covered quality of life, cost and pain as expected but also described fears about wound development or recurrence, difficulty in caring for people with wounds and lack of concern by health professionals as people got older.

Discussion / Conclusion
Chronic wounds impact not only those who experience them but many of the people around them and in ways that are not often considered by the clinician. The impact of chronic wounds is something that concerns many older people and further research is needed to consider possible explanations for this phenomenon.

OR106
Skin Lesions of IV Drug Abusers in Iran

Mina Moslemi

Goals and Objectives
Drug abuse has become a serious worldwide health problem. Studies show 5% of the global population use illegal drugs annually. Injection is one of the most harmful methods of administration, causing numerous skin complications and infections.

Purpose
Identifying lifestyle choices and wound characteristics of IV drug abusers and classifying the resulting complications can lead to their early recognition, prevention and management.

Methods
A descriptive cross sectional study was carried out. A questionnaire inquiring about drug abuse habits, wound features and related co-morbidities was distributed among 135 addicts who currently had wounds. Five drop in centers were used in this survey. Microbiological assessment was also performed on the wounds.

Results
Cases were 15-57 years old, mostly unemployed and married. Average age for starting drug abuse was 15-20. Opium was mentioned most frequently as the first drug used. At present 48.9% used crack and 30.4% a combination of crack and other drugs. The majority had at least 4 wounds, located mainly on the hand, foot or both areas. Most wounds had no exudate, no pain, had necrotic tissue and hardened edges. Average wound size was 1.8 cm2.

61.4% reported sharing needles. 51.5% had an accompanying blood borne disease. 8.1% of the total population had HIV, 11.1% HBV and 47.4% had HCV. Most wounds were older than six months. Thrombophlebitis was the most common complication (37%), followed by cellulitis and abscess (22.2%). 41% had hyperpigmentation, panniculities and other complications. 54.1% of the wounds had gram positive cocci.

Discussion / Conclusion
Results confirmed previous studies regarding the atypical signs of infection in IV drug abusers. Therefore to medically manage these complications a clear understanding of the coexisting conditions is necessary. This will benefit both the individual and save time and costs for the health care service.

OR107
Relative Impact of Wound Related Symptoms Associated with Leg Ulcers: An International Patient Perspective.

Price, PE (Department of Wound Healing, School of Medicine, Cardiff University, UK), Fagervik-Morton, H (Department of Wound Healing, School of Medicine, Cardiff University, UK), Mudge, E (Department of Wound Healing, School of Medicine, Cardiff University, UK), Harding, KG (Department of Wound Healing, School of Medicine, Cardiff University, UK)

Goals and Objectives
/ Purpose Research into the impact of living with a chronic wound has demonstrated that symptom management has the biggest impact on a patient's quality of life. We investigated the relative impact of 6 key symptoms highlighted by patients during an earlier qualitative study.

Methods
This was an international, cross-sectional survey that collected the views of 902 patients with leg ulcers (venous = 571, arterial = 198, mixed = 133).

Results
For 35% of venous, 42.4% arterial and 35.3% of mixed Ulcers, this was the patient's first experience of ulceration. Mean duration was 21.86 months (st.dev = 41.8) for venous, 14.4 months (st.dev = 25.1) for arterial and 28.8 months (st.dev = 46.4) for mixed Ulcers. 43.6% with venous, 40% with arterial and 38% of those with mixed Ulcers reported pain 'most' or 'all of the time'. About a third of each group reported pain at dressing change 'most' or 'all' of the time (venous = 35.7%, arterial = 37.9% and mixed = 39.9%); for 32% (venous), 36% (arterial) and 43% (mixed ulcers) of patients pain following dressing change took more than three hours to resolve. Patients were asked to rate the problems they experienced with six wound symptoms (odour, leakage, pain, impaired mobility, not being able to have a bath, dressing/bandage slipping). Between the groups there were statistical differences in the experience of odour and leakage, with venous leg ulcer patients experiencing the most odour problems (p=0.007) and those with mixed ulcers experiencing the most leakage (p<0.001) from their wounds. There were statistically significant differences within each of the groups (p<0.001), with each group rating 'pain' as the most problematic, followed by 'not able to have a bath'.

Discussion / Conclusion
These data confirm the universality of the problems patients have with symptom management, particularly wound pain.

OR108
Changing Aetiopathogenesis of Chronic Leg/Ankle Ulcers in Ibadan, Nigeria

Ademola SA (College of Medicine, University of Ibadan, Nigeria), Oluwatosin OA (College of Medicine, University of Ibadan, Nigeria), Akinyemi O (College of Medicine, University of Ibadan, Nigeria), Oladeji S (), Oluwatosin OM (College of Medicine, University of Ibadan, Nigeria)

Goals and Objectives
Lower limb ulcers are the most common chronic wounds in Ibadan.

While common causes of ulceration in Nigeria include post traumatic, post infective haematologic and malignant causes, diabetes had not been known to be the leading cause of chronic lower limb ulceration. This study evaluates the differential diagnosis and pattern of chronic lower limb ulceration in Ibadan

Purpose
To provide information about the changing aetiology of lower limb ulceration in Ibadan and data for health planning in South Western Nigeria.

Methods
A retrospective, cross sectional study involving key primary, secondary and tertiary hospitals in Ibadan was done. Records of patients with chronic lower limb ulceration treated in these institutions between January and December 2007 were obtained. All patients with chronic lower limb ulceration except pressure sores were included. The data was analysed using the Statistical Package for Social Sciences (SPSS) version 11 computer software.

Results
There were sixty three patients with age range 3-91 (Mean 45 +/- 22) years. Fifty nine percent (59%) were males while 41% were females. Ulcer duration range from 8 weeks to 35 years. Aetiology of the ulcers was diabetes 35%, trauma 21%, venous disease 10%, malignancy 10%, haematological disease 8% and infection 8%.

Honey was the dressing agent used in majority of cases. Age related aetiology revealed that while the other causes of ulceration occurs in all age groups, diabetic ulcers and malignant ulcers did not occur below the age of 40years and 37 years respectively. There was no significant sex differences noted in the aetiologies of ulceration.

Discussion / Conclusion
This study shows that there is a change in the aetiology of chronic lower limb ulceration in Ibadan, Nigeria and this call for a major health policy intervention for the control of lower limb ulcers in Ibadan

OR109
A Collaborative Statewide Initiative Across Care Settings Reduces Pressure Ulcers

Theresa Edelstein, MPH, LNHA (New Jersey Hospital Association), Aline M. Holmes, RN, APNC, MSN, APRN, BC, CNAA, BC (New Jersey Hospital Association), Elizabeth A. Ayello, PhD, RN, APRN, BC, FAAN (Excelsior College), Karen Zulkowski, DNS, RN, CWS (Montana State University)

Goals and Objectives
The goal of the Pressure Ulcer Collaborative was to reduce the incidence of pressure ulcers across care settings by 25 percent.

Objectives were that the participating organizations would:

• conduct comprehensive skin and risk assessments (using the Braden Scale) for patients within 8 hours of admission to any healthcare facility
• implement preventive strategies within 24 hours of identifying a patient as being at-risk
• improve communication and collaboration between professionals across multiple settings

Purpose
Despite efforts by clinicians across care settings, pressure ulcer prevalence in one state was not decreasing. In 2004, mandatory reporting of Stage III and IV pressure ulcers by hospitals began. To address these issues, a statewide collaborative aimed at reducing the incidence of pressure ulcers across care settings was initiated.

Methods
Expert faculty developed a "bundle" of best practices based on evidence in the literature and provided 6 learning sessions over two years. Monthly conference calls, a dedicated listserv and website enhanced education and provided an interactive forum. Participants submitted monthly progress and data reports. Pressure ulcer knowledge was measured using a validated tool.

Results
After 20 months of data reporting, the Pressure Ulcer Collaborative demonstrated a 70 percent reduction in pressure ulcer incidence and a 30 percent reduction in pressure ulcer prevalence across the reporting organizations (acute care hospitals, skilled nursing facilities, home health agencies, rehabilitation and long term acute care hospitals and hospice). The education programs and conference calls raised the knowledge level for nurses involved in the Collaborative.

Discussion / Conclusion
Consistent implementation of comprehensive skin and risk assessment and preventive interventions, as well as education, can lead to the successful prevention of pressure ulcers. Having professionals from across care settings work collaboratively can lead to improved transitions of care for patients. This model is appropriate for healthcare facilities of all types.

OR110
Perceptions of Self and Other Can Influence Pain in Patients with Chronic Leg and Foot Ulcers.

KY Woo (Women's College Hospital), RG Sibbald (Women's College Hospital)

Goals and Objectives
Unremitting and recalcitrant pain is disabling and devastating in patients with chronic wounds. Many patients living with chronic wounds identified pain to be their first and foremost concern. Little is known how pereptions about self and other may influence pain perception.

Purpose
The purpose of this study was to demonstrate the different pain perception based on the cognitive models of self and others.

Methods
Four focus groups were conducted to include 19 leg and foot ulcer patients. Patients were asked to reflect on their experience of pain including self image, characteristics of pain, relationship with others, strategies to cope with pain, and barriers to effective pain management.

Results
Several major themes emerged linking pain and quality of life: pain had multiple characteristics; pain occurred with dressing change but also between dressing changes, pain affected family and social life; pain affected the personal sense of well-being; pain was difficult to manage; and pain management was influenced by the health care system. Based on patients' description of pain, we also examined the model of the inner self (self-worth and anxiety regarding rejection) versus model of our perception of others (trust and avoidance of close relationship) according to the attachment framework. Results were summarized into two orthogonal dimensions: discomfort with personal closeness and anxiety over relationships with others.

Discussion / Conclusion
Health care providers need to recognize the importance of pain for patients with chronic wounds. The pain experience can be modified by inner conflict (self-worth vs. anxiety) and external relationships with others (trusting relationships vs. alienation).

OR111
Successful Prevention of Heel Ulcers and Plantar Flexion Contractures in the High Risk Ventilation Patient Population

Tina Meyers, BSN, RN, CWOCN, ACHRN (Conroe Regional Medical Center), Rejeana Pezel, ICU/CCU unit secretary (Conroe Regional Medical Center), Jill Bennett, RN, MSN (Conroe Regional Medical Center), Vanessa Carroll, RN (Conroe Regional Medical Center), Ann Russell, RN, BSN (Conroe Regional Medical Center), Sharon Lagway, RN (Conroe Regional Medical Center), Salvacion Ramos, RN (Conroe Regional Medical Center), Eloisa Asilo, RN (Conroe Regional Medical Center)

Goals and Objectives
To assess the impact of a clinical intervention on heel pressure ulcer (hPU) rates and the prevention of plantar flexion contractures through the use of a heel protector in high risk, sedated, intensive care unit (ICU) population.

Purpose
Establish hPU and foot drop prevention protocols in high risk patient population, with earlier recognition of heel skin issues;

Purpose
was prevention of hPUs and plantar flexion contractures.

Methods
Study inclusion criteria: Patients sedated in ICU >5 days; may or may not be intubated; Braden score <16. Control group received pillow elevation of heels.

Intervention procedures:

• Skin assessment and Braden scale administered to all patients upon admission to ICU
• All ICU patients meeting criteria had initial ankle ROM measurement with a goniometer upon admission and before application of the heel protector.
• Braden scale, heel skin assessment, and Ramsey sedation scale also documented.
• All applicable patients had ankle ROM measured QOD
• Heel assessments, Braden scale, and Ramsey sedation scale done every shift, and recorded as part of study QOD
• Measurements continued until patient was either transferred, boots discontinued by physician, or had Braden scale of >16.
• Control patients received ankle measurements, heel skin assessment, Ramsey sedation scale, and Braden scale on admission and QOD

Results

• Effective prevention of hPU development [100%]
• Effective prevention of plantar flexion contracture development [100%]
• Enhanced protocol compliance
• 9.4% showed improvement in heel status from entry to discharge
• 11.3% of existing heel skin conditions stayed the same with no change or worsening in status

Discussion / Conclusion
A heel protector maintained heel suspension and foot/ankle alignment in study patients, preventing development of new PUs during this 7-month study. There was a 50% decrease in abnormal heel status, and no development of plantar flexion contractures.

OR112
Diabetic Foot Ulcer Pain: The Hidden Burden

Sarah Bradbury (Department of Wound Healing, Cardiff University)

Background
Diabetic Foot Ulcers (DFU) are often considered painless due to sensory peripheral neuropathy, with pain only occurring with infection or other complications. However, recent research suggests DFU pain is more prevalent than expected and severely impacts on quality of life.

Purpose
To explore the presence and characteristics of DFU pain and evaluate the relationship between ulcer pain, aetiology and DFU-related complications.

Methods
Consecutive patients with diabetes and one foot ulcers below the malleolus attending a specialist DFU clinic over an eight week period were audited cross-sectionally. Data were collected on clinical history, diagnosis and wound status. DFU pain was assessed using a modified Short-Form McGill Pain Questionnaire.

Results
28 patients were recruited aged 43 to 92 years (mean 67.5, sd 13.56). 18 patients had one or more DFU-related complications (Infection, Osteomyelitis and Charcot Arthropathy). 16 patients were taking regular oral analgesia, although not always for DFU pain alone.

86% of patients (n=24) reported some degree of DFU pain. The mean visual analogue scale (VAS) score was 26.36 (sd 24.29). Patients with neuro-ischaemic ulceration reported a higher mean VAS score than neuropathic ulceration (32.15 v 21.57). Mean VAS scores for patients with DFU complications was 26.01 (sd 24.4) versus 26.9 (sd 25.4) without complications.

Aching was the most common sensory pain (n=14) followed by hot-burning (n=11), tender (n=11) and sharp (n=10). Tiring/exhausting was the most common affective descriptor (n=10).

Discussion / Conclusion
Specific DFU pain occurs more frequently than anticipated in patients with neuropathic and neuro-ischaemic aetiology. Concomitant analgesic use may also lead to underestimation of DFU pain. The presence of DFU pain is not limited to patients experiencing infection or other complications. Further research is required to explore this phenomenon in clinical practice to improve patient management.

OR113
The STAR Skin Tear Classification System

Keryln Carville (Silver Chain Nursing Association and Curtin University of Technology), Gill Lewin (Silver Chain Nursing Association and Curtin University of Technology), Nelly Newall (Silver Chain Nursing Association), Nick Santamaria (Curtin University of Technology), Rene Michael (Curtin University of Technology), Pamela Roberts (Curtin University of Technology)

Goals and Objectives
To gain agreement from Australian nurse experts in wound management on a classification system for skin tears and to test the reliability of the resulting classification system.

Purpose
Skin tears are common wounds amongst older or disabled individuals and associated health costs are significant. Although the Payne and Martin Skin Tear Classification System was developed in the early 1990s it remains poorly utilised in Australia.

Methods
A library of skin tear photographs was established and a nominal group technique was used for consensus development on skin tear definition and classification. A State Development Group of 9 expert wound care nurses in Western Australia achieved a consensus for definition and a classification system. The classification was then referred to a National Expert Panel of 14 expert nurses from each state and territory, for review. Following some refinement both groups agreed on a classification that was developed into a tool. However, reliability testing of this tool amongst 26 nurses from various healthcare settings failed to demonstrate a sufficiently high level of agreement when using Cohen's Kappa statistic. The development and refinement cycle was therefore repeated and the tool tested again.

Results
The reliability of the STAR Classification was tested amongst 36 nurses employed across all healthcare settings. The results were again analysed using Cohen's Kappa Statistic and a significant level of agreement was achieved.

Discussion / Conclusion
The Skin Tear Audit Research (STAR) study is a collaborative Australian project that resulted in the development and testing of the STAR Skin Tear Classification System.

OR114
Experience at Dressing Change: An International Patient Perspective

Hilde Fagervik-Morton (Cardiff University), Elizabeth Mudge (Cardiff University), Keith Harding (Cardiff University), Patricia Price (Cardiff University)

Goals and Objectives
Pain is one of the symptoms that patients find particularly distressing when living with chronic wounds.

Purpose
Little is known about patient's perspective on reducing pain at dressing change.

Methods
This cross-sectional international survey collected the selfreported views of patients using a specifically designed questionnaire developed from issues relevant to patients captured through focus groups.

Results

Results
were obtained for 2018 patients from 15 different countries (across Europe, North America and Australia) with a mean age of 68.6 years (S.D. 15.4), and mean wound duration of 19.6 months (S.D. 51.8). 73.6% (n=1985) agreed that they wanted 'to be actively involved in the process of changing their dressings'(p = 0.0001, S.D. 1.17). When asked 'is there anything that you / those caring for you can do to relieve or reduce the pain you experience at dressing change?' and 'if there was one thing that you would like health professionals to do for you to help with your pain at / during dressing-related procedures, what would it be?' patients (n = 1519 and n = 1344) responded consistently across the two questions. 42.7% and 35.4% of patients felt that nothing could be done, 10.7% and 11.1% did not know what could be done, and 3.0% and 4.4% were satisfied with the care provided. However, 17.4% and 14.9% patients respectively wanted analgesics / anaesthetics administered before dressing change, 5.2% and 3.4% felt that moistening / soaking the dressing before removal was beneficial, 5.4% and 3.9% felt it important being consulted, listened to and communicated with, 1.6% and 1.6% did not the wound touched / scrubbed, whereas 2.7% and 4.6% highlighted the importance of quality, consistency and reduced speed of dressing change.

Discussion / Conclusion
These data highlight the importance of patient empowerment through involvement in dressing change procedures.

OR115
A Drop-in Leg Ulcer Clinic in a Needle Exchange Service

Bernadette McNally (The Nepean Hospital, Sydney), Julie Page (Needle Exchange Service, Sydney West Area Health Service)

Goals and Objectives
To reduce the number of presentations to the emergency department for clients with a history of intravenous drug use who have chronic leg ulcers;

To reduce the number of hospital admissions due to chronic leg ulcers;

To improve collaboration between hospital and community services in the care of this group of clients;

To improve client satisfaction in relation to the management of their leg ulcers.

Purpose
To provide a safe and supportive environment and appropriate management of clients with leg ulcers who have a history of intravenous drug use, in a safe and supportive environment.

Methods
A drop in leg ulcer clinic was established in a needle exchange service to improve management of clients with a history of intravenous drug use who have chronic leg ulcers. Collaboration between this multidisciplinary service and the hospital-based wound management advanced practice nurse (APN) allows for complex management of clients presenting to the clinic, within a primary health care framework. The link between the community and hospital allows timely and appropriate care when the client's condition deteriorates, requiring hospital admission. Discharges back to the needle exchange service for appropriate follow-up is a collaborative effort by the APN, needle exchange team and treating team.

Results
Presentations to the emergency department have decreased by 75%

Hospital admissions for management of leg ulcers have decreased by 30%

Length of stay has remained unchanged

Client satisfaction has improved

Discussion / Conclusion
The collaborative work undertaken between the hospital and community services is achieving optimal outcomes for this population. Management regimes based on simple treatments that the client is able to cope with, as opposed to standard, more complex treatment, has increase client satisfaction with the management of their wounds. Future directions include improved liaison with general practitioners, the use of Nurse Practitioners in the leg ulcer clinic, and implementing the service in other needle exchange services.

OR116
Smart Phones - Smart Wound Care

Keryln Carville (Silver Chain Nursing Association), Robin Howse (Silver Chain Nursing Association), Allan Turner (Silver Chain Nursing Associatin)

Goals and Objectives
Wound care consumes the greatest component of home nursing time. The largest home nursing agency in Western Australia developed and uses an enterprise wide community and residential patient management system called ComCare, which connects with 'smart phones' for wound monitoring purposes.

Purpose
ComCare Mobile was expanded to allow nurses to admit and monitor every wound on every patient.

Methods
ComCare Mobile is an application that front-ends ComCare in the field and is designed to run on the current generation of smart phones, Windows based laptops or tablets. Connectivity between ComCare Mobile and the ComCare database is achieved using industry standard encrypted channels through the internet. Information recorded on the smart phones includes client demographics, wound assessment and treatments. Wound locations are plotted on a human outline and assessments are plotted on a wound image on the smart phone screens and exception reporting pro-actively identifies areas that need attention. Additional functionality facilitates quick and easy wound image transfer from the point of care to a nurse consultant who can then provide real-time advice on treatment.

Results
ComCare Mobile has successfully been used for 4 years to monitor hospice patient care. During the past 2 years it has enabled the monitoring of wound practice and benchmarking of healing outcomes. This technology proved its effectiveness when used to conduct a prevalence survey across 85 public hospitals in Western Australia. Data was able to be uploaded during the survey and made immediately available for analysis across remote locations.

Conclusion
Clinical IT technology enables assessment and management of wounds and remote consultation and the role out of evidence based education and guidelines. Comprehensive wound data bases provide valuable data for benchmarking healing outcomes and other research projects.

OR117
Incorporating Wound Care in a Christian Village Health Worker Training Program

Linda Benskin, BSN, RN, SRN (Ghana), CWCN, CWS, DAPWCA (Church of Christ Mission Clinic, Yendi, Northern Region, GHANA, West Africa)

Problem
Villagers in underdeveloped areas frequently have infected nonhealing wounds because of inappropriate wound care. Traditional healers and modern hospitals often extract high fees from uneducated patients without take time to prepare the wound bed or apply moist wound healing. As a result, wound patients endure much suffering. Limbs and even lives are needlessly lost due to lack of adequate wound care.

Purpose
Although some modern wound techniques are costly, TIME can be used in any setting with minimal equipment. When sanitation, hygiene, and nutrition are taught and good wound healing principles are practiced, health workers have progressively fewer patients from which to extract fees. So, knowledge and hard work must be coupled with altruism in order to improve the health of impoverished villagers.

Methods
Students applying for our village health care worker course had to agree that their health work would not fully support their families, but they would continue farming or trading. The course was held adjacent to a Christian clinic with a wound care emphasis; the primary instructors were known for their wound care. The students received four weeks (120 hours) of intensive classroom health care training, plus practical training and direct observation. Approximately one third of the coursework was specifically skin and wound care, nutrition, sanitation and hygiene.

Results
The students were impressed by the prominence wound care had at the clinic. They saw many diverse wound cases. Some came to the clinic extra hours to observe and to practice bandaging techniques. All of them learned to make and use appropriate wound cleansing solutions and keep wounds moist.

Conclusion
The clinic sees comparatively few wound patients from villages with our trained health workers. When clinic staff visit these areas for "mobile clinics," villagers often comment specifically on how much wound care the health worker is doing.

OR118
Predivtive Validity of Braden Scale for Hospitalized Patients

Santos, Vera Lucia Conceição Gouveia (School of Nursing- University of São Paulo), Serpa, Leticia Faria (School of Nursing- University of São Paulo), Cardoso, Juliana Rosa da Silva (School of Nursing - University of São Paulo), Matuo, Carla Mye (School of Nursing - University of São Paulo)

Goals and Objectives
Pressure ulcers are an important health problem and the best strategy to avoid them is prevent through risk assesment scales, like Braden Scale. However, different cut-off score has been used to determine the risk of developing pressure ulcer.

Purpose
To evaluate the Braden scale's predictive validity in hospitalized patients by determining the best cut-off score that indicates the risk of developing pressure ulcer.

Methods
A prospective cohort study took place in a private general hospital with 220 beds divided among 13 hospitalization units of different specialties. Most of the patients attended by the hospital are of surgical nature and its average occupation rate is 7.4 days. Firstly the project was approved by Hospital Ethics Committee. The 6-month-period study was conducted with hospitalized adult patients with Braden score ≤18. All of them accepted to participate in the study. After consent patients were submitted to data collecting through alternate daily body examination and Braden scale assessment. During the hospitalization period, each patient was examined at least tree times to be considered for analysis. The data were submitted to sensitivity and specificity analysis through ROC curve and positive (+LR) and negative likelihood ratios (-LR).

Results
Most of the 98 patients who composed the sample of the study aged > 71 years old (63.3%). The cut-off scores in the 1st, 2nd and 3rd examinations were 11, 13 and 13 respectively. Sensitivity percentages were 42.6%, 85.7% and 85.7% and for specificity they were 79.1%, 57.1% and 65.9% respectively. Areas under ROC revealed very good accuracy for the cut-off score at first evaluation (64/ CI 95% 0.34- 0.94) and good accuracy for the scores ate second and third evaluations (69/ CI 95% 0.33 – 1.00; and 76/ CI 95% 0.31 – 1.00 respectively). The results also showed probabilities of 14%, 13% and 16% for the development of pressure ulcers when the tests were positive (+LR) and 5%, 2% and 2% for negative tests (-LR) respectively for the first, second and third evaluations.

Discussion / Conclusion
The Braden scale showed good performance for pressure ulcer prediction for hospitalized patients with cut-off scores of 11 and 13 at three first evaluations.

OR119
Implementation of a Means for the Collection of Wound Assessment Data into a Hand-held, Wound Measurement Device

Catherine E Hammond (Nurse Maude Association, Christchurch, New Zealand), Jeannie M Randles (Nurse Maude Association, Christchurch, New Zealand), Suzanne Kapp (Royal District Nursing Service, Melbourne, Australia), Janine Sunderland (Royal District Nursing Service, Melbourne, Australia), Terry Gliddon (Royal District Nursing Service, Melbourne, Australia), Mark A Nixon (ARANZ Medical Limited, Christchurch, New Zealand), Bruce LK Davey (ARANZ Medical Limited, Christchurch, New Zealand)

Background
Studies have shown that the ARANZ Medical SilhouetteMobileTM hand-held, PDA-based wound measurement device, can efficiently, accurately and reliably be used for quantitative assessment of wounds. However additional information is clinically important to more completely document wound healing.

Purpose
To specify a protocol and implement an efficient means for collecting wound assessment information directly into an electronic medical record; and to evaluate this tool for use in clinical research and practice.

Methods
Wound-care Specialists in two home care organizations in Australia and New Zealand identified protocols used to capture wound assessment data. Key users from these organizations reviewed the information gathered to develop a common assessment tool, to be implemented into the device. Wound area measurements were obtained by five clinicians from each country, in order to investigate the repeatability and reliability of the technology. Clinicians captured and traced images of multiple wounds "at the bedside" for intra-rater reliability measures. The SilhouetteCentralTM database then "swapped" all the images amongst all the users who, remotely using the images only, traced the wounds. The data from these measurements were analyzed in order to establish inter-rater reliability.

The nurses completed questionnaires regarding the usability/value of the resulting system.

Results
A software tool for collecting wound assessment data was added to the system.

Item analyzes undertaken on rater scores of area measurements revealed very strong reliability, with a correlation coefficient (Cronbach alpha) of 0.93. Intra-class correlation coefficient for the raters was 0.93. Inter-item coefficient reliability was 0.83. The questionnaire was completed, on a scale of 1 (poor) to 10 (excellent), and scores ranged from 7.5 to 10.

Conclusion
The results of the reliability analysis and clinician feedback provide strong evidence that the system is a highly reliable instrument, which is supported by it's ease of use as a portable wound imaging device.

OR120
WoundsWest: Identifying the Prevalence of Wounds Within Western Australia's Public Health System

Dr Jenny Prentice (WoundsWest, Western Australia), Veronica Strachan (Silver Chain Nursing Association, Curtin University, West Australian Department Health), A/Prof Keryln Carville (Silver Chain, Nursing Association, Curtin University, Western Australia), Prof Nick Santamaria (Curtin University Technology, Western Australia), Roslyn Elmes (Western Australian Health Department), Dr Phillip Della (Wesyern Australian Health Department)

Background
The prevalence of wounds within Australian public health systems is unknown. In addition, the efficacy, efficiencies and effectiveness of wound management strategies are inconsistent across health care sectors due to the absence of good clinical governance.

Purpose
WoundsWest, a West Australian ambulatory healthcare initiative sought to quantify, for the first time in Australia, the epidemiology of wounds within WA's public health system. Further, it sought to understand what health services did in terms of strategic planning, education, resources and patient management for patients with wounds.

Methods
In 2007, all neonates, paediatric and consenting adult in-patients within Western Australian public hospitals were examined for wounds, which were categorised into 6 groups: acute, pressure ulcers, skin tears, burns, malignant and other wounds. Surveyors were educated, tested and deemed competent to ensure consistency in audit methods and wound classification. Participating organisations responded to an online questionnaire providing contextual data on wound management resources and services within their facility.

Results
Approximately 2,800 patients were examined; the prevalence of wounds being 49% with acute wounds (31%) pressure ulcers (11%) and skin tears (8%) constituting the majority of wounds. Most patients had more than one wound. Compliance with evidence-based guidelines for wounds was low. Few organisations had governance structures in place for the prediction, prevention and management of wounds. Recommendations for lowering the prevalence of preventable wounds, increasing staff education, equity and access to resources to improve delivery of wound management services have been made.

Conclusion
Data collected from 85 organisations who have participated in the 2007 and 2008 wound prevalence surveys has and will continue to facilitate strategic direction within Western Australia's public health system in terms of educational requirements, clinical guidelines, cost of wounds and research initiatives such as investigating wounds in indigenous populations that have the potential to lower quality of life and life expectancy.

OR121
Electrical Stimulation Therapy Increases Healing of Pressure Ulcers in Community Dwelling People with Spinal Cord Injury Pamela E. Houghton, PT, PhD (University of Western Ontario, London, Ontario, Canada), Karen E Campbell, APN, MScN, PhD(c) (London Health Sciences Centre-University Hospital), Christine Fraser, HBSC, RD (St Joseph's Health Care London - Parkwood Hospital), Connie Harris, ET (Kitchener-Waterloo, Ontario), M Gail Woodbury, BSc, MSc, PhD (University of Western Ontario)

Goals and Objectives
Electrical stimulation therapy (EST) is an adjunctive therapy involving delivery of low levels of electrical current to the wound bed using specialized electrodes and equipment. It has been recommended for the treatment of non-healing pressure ulcers, however, the success of this therapy has not been tested in a community-based health care system.

Purpose
To investigate whether EST administered as part of a community-based, interdisciplinary, wound care program can improve healing of pressure ulcers of people with spinal cord injury(SCI).

Methods
Adults (51+14y) with SCI and stage II(n=4), III(n=16), IV(n=14) pressure ulcers living in the community received standarad wound care including a pressure management program. Half of the subjects (n=18) were randomly assigned to also receive EST (100mA, 80Hz, alternating polarity) for an average of 372 hours over 3 months using a portable, programmable HVPC device.

Results
The percentage decrease in wound surface area was significantly greater in subjects receiving EST (71+25%) compared to those who just received standard wound care (36+61%; p<0.05). Wound appearance, as measured by photographic wound assessment tool (PWAT), was also significantly improved after EST treatment but not standard care. Complete wound closure occured in sixty-nine percent of subjects receiving EST +standard wound care and 39% of those with standard wound care alone. Average EST treatment time to produce wound closure was 175+138days.

Discussion / Conclusion
These results demonstrate that EST can improve wound size, appearance, and rate of healing of pressure ulcers in persons with SCI. EST can be incorporated successfully into an interdisciplinary wound care program in the community. This project was funded by Ontario Neurotrauma Foundation.

OR122
Clinical Diagnosis of Local Wound Infection in Non-arterial Leg Ulcers Using a Validated Assessment Tool

Marjorie D. Fierheller (Cardiff University ), Michael Clark (Cardiff University ), R.G. Sibbald (University of Toronto)

Goals and Objectives
A reliable method was needed to confirm the presence of local wound infection for an investigation into the relationship between increased peri-wound skin temperature and infection in non-arterial leg ulcers (results reported elsewhere). Gardner et al's (2001) Clinical Signs and Symptoms Checklist (CSSC) is a validated tool capable of identifying both classic and secondary signs and symptoms of localized chronic wound infection frequently sited in related literature.

Purpose
Forty leg ulcers were evaluated for signs and symptoms of local infection using the CSSC.

Methods
Patients with non-arterial leg ulcers (n = 40) were recruited from within a chronic wound clinic. All these wounds were evaluated for signs and symptoms of infection using the CSSC and the descriptive data analyzed.

Results
Of the forty wounds assessed, 18 were not diagnosed as infected and 22 were. Signs and symptoms found to be most sensitive to infection included: wound breakdown and "pocketing" (1.0); serous exudate (1.0); foul odour (1.0); increased peri-wound skin temperature (.94); and discoloured granulation tissue (.93). Those most specific included erythema (.92) and delayed healing (.86).

Discussion / Conclusion
These results reflect a combination of both classic and secondary signs and symptoms of infection and despite differences in study format, similarities to those identified by Gardner et al (2001) were noted. Although sample characteristics and study

Method
ology may limit transferability of these findings, evidence to support of this tool for the assessment of infection in chronic leg ulcers is provided

OR123
Sensitivity and Specificity of NERDS and STONEES for the Diagnoses of Increased Bacterial Burden in Chronic Wounds

KY Woo (Women's College Hospital), RG Sibbald (Women's College Hospital)

Goals and Objectives
In view of the ubiquitous presence of microbes, the clinician must discern whether bacterial balance (contamination or colonization) or bacterial damage (critical colonization or infection) is present. The diagnosis of infection in a chronic wound is best confirmed and supported by documenting clinical signs and symptoms.

Purpose
Sibbald et al. created a mnemonic NERDSã and STONESã to categorize two levels of bacterial damage. The purpose of this study was to validate this theoretic framework in the assessment of increased bioburden in chronic wounds.

Methods
We evalauted a cohort of 92 patients with leg and foot ulcers. The diagnosis of wound infection was made based on the clinical presentation (NERDS and STONEES) and compared with semiquantitative culture results (3+ or 4+).

Results
The sensitivity and specificity were calculated for each individual sign (see table). By collating 3 clinical signs, the sensitivity for NERDS and STONES was 73.3% and 90% respectively while the specificity was 80.5% and 69.4%.

	Signs and symptoms	Sensitivity, %	Specificity, %
	Superficial
N	Non-healing	32	47
E	Exudate	70	64
R	Red friable tissue	45	86
D	Debris (discoulouration)	62	78
S	Smell	37	86
	Deep and surrounding
S	Size increasing	50	83
T	Temperature (> 4 F) (heat)	76	71
O	Os (Probe to bone)	40	81
N	New breakdown	37	89
E	Edema/erythema	87	44
E	Exudate	70	64
S	Smell	37	86

Discussion / Conclusion
By focusing on salient clinical signs to separate superficial and deep compartment involvement, clinicians can identify and differentiate wounds with increased bacterial burden that may respond to topical antimicrobials whereas deep infection usually requires the use of systemic antimicrobial agents.

OR124
Predicting Covert and Overt Infection in Leg Ulcers: A Randomised Controlled Trial

Keryln Carville (Silver Chain Nursing Association and Curtin University of Technology, Western Australia), Suzanne Kapp (Royal District Nursing Association, Victoria), Nelly Newall (Silver Chain Nursing Association), Steve Saflekas (Royal District Nursing Association), Gill Lewin (Silver Chain Nursing Association), Terry Gliddon (Royal District Nursing Association), Charne Flowers (Royal District Nursing Association), Leila Karimi (Royal District Nursing Association), Nick Santamaria (Curtin University of Technology)

Goals and Objectives
A randomised controlled trial (RCT) examined the clinical characteristics of wounds and associated wound swab results to determine the effectiveness of topical antimicrobial dressings for the treatment of wound infection.

Purpose
Chronic leg ulcers are colonised by micro-organisms, which under some conditions may reach critical levels and progress to covert or overt infection. Several authors list a number of clinical wound observations that indicate alterations in tissue appearance and delayed wound healing, but not associated with the classical signs and symptoms of infection.

Methods
A multi-site RCT which was funded by The Angior Family Foundation was conducted in Australia. The study examined the healing rate associated with the use of two commonly used antimicrobial dressings (cadexomer iodine and nanocrystalline silver) in the treatment of infected leg ulcers. The relationships between observed clinical wound characteristics and laboratory analysis of wound swabs as predictors of covert or overt wound infection were examined.

Results
Analysis of data reveals significant predictors of wound colonisation (p <.001). The study also revealed that macro observation of wound characteristics and documented wound healing rate are highly correlated with laboratory confirmed wound colonisation.

Conclusion
The implications of wound infection are significant. International consensus is lacking in regard to the concept of critical colonisation, covert or occult wound infection. This study confirmed that changes in wound characteristics can be used as clinical predictors for determining the presence of covert infection in chronic leg ulcers.

OR125
The Lived Experience - Patients' Stories

Ellie Lindsay (Independent Specialist Practitioner), Jen Hawkins (Independent Health Psychologist)

Goals and Objectives
Patient stories have never formed an integral part of nursing research, they have never been considered academic enough. On rare occasions they may be presented as case studies or accounts but never as evidence based research in their own right. The experience of diagnosis, care and treatment represent critical chapters in their unique patient story.

Purpose
The purpose of research in nursing is to ask questions, the resultant answers refine existing knowledge or add to our existing body of knowledge. Patient stories and narratives add a further and profound dimension to that knowledge.

Methods
Talking openly to another creates pathways to past memories, feelings, and thoughts which we do not always know we have, enabling us to discover, explore, clarify and make connections to our present.

Patient stories and narratives are about individuals, about how they think and feel, rather than about what they do or have done to them. They provide us with new and important information, encourages holism and a move to a more therapeutic approach to care.

Results
In telling their story a patient in mental and, or physical distress provides the health professional with a wealth of evidence which can be used to help the patient on the journey to recovery.

Discussion / Conclusion
Currently those patient stories which do form the basis for nurse research are not about facilitating an increased understanding of the patients experiences but rather about the ideas, theories, questions and suggestions which help nurses identify how best they can help the patients be treated and cared for. The focus being on enhancing the development of nursing practice rather than the empowerment of patients and true acknowledgement of their unique experiences.

OR126
Reforming Healthcare Through Patient Empowerment: The Role of the Wound Care Nurse Practitoner

Michelle Gibb (Queensland University of Technology), Prof Helen Edwards (Queensland University of Technology), Kathy Finlayson (Queensland University of Technology), Prof Mary Courtney (Queensland University of Technology)

Goals and Objectives
The increasing trend towards community-based leg ulcer treatment and the ageing population means that there is a growing demand for treatment in the community. It is widely recognised that wound care itself is not the only predictor of wound healing. The establishment of an innovative Wound Healing Community Outreach Service (WHCOS) based on a social model of health combines treatment processes with peer support, health promotion and prevention strategies. The nurse practitioner is in an ideal position to facilitate and enhance patient empowerment by responding to both the clinical and holistic psychosocial needs of patients.

Purpose
To determine if the establishment of an innovative WHCOS piloted by a nurse practitioner improves access to health care which meets the physical, psychosocial and long-term chronic disease management needs of patients with chronic wounds.

Methods
Exploratory prospective cohort study with a convenience sample of patients attending the WHCOS. Data collection methods include surveys, focus groups, in-depth semi-structured interviews, and medical chart audit specifically looking at wound healing rates, quality of life, self-care activities, patient satisfaction, waiting time, continuity of care and recurrence rates.

Results
Potential outcomes include:

• Improved wound healing and quality of life for patients with chronic wounds
• Decreased fragmentation in wound care services
• Increased patient satisfaction

Discussion / Conclusion
Caring for people with chronic wounds represents a challenge to health professionals and the health care system. It is recognised that direct wound care itself is not the only predictor of an adequately healed wound. Many environmental and psychosocial factors can impact on healing and these must be incorporated into future wound care practice. The establishment of a Wound Healing Community Outreach Service meets this demand by addressing the psychosocial and quality of life issues associated with chronic wounds by promoting patient empowerment.

OR127
What is Bedrest Really Like? The Lived Experience

Laurie M. Rappl, PT, CWS (Span-America)

Purpose
Eliminating pressure is the cornerstone of most treatment programs for pressure ulcers. A common prescription for treatment of ischial or coccyx pressure ulcers in sitting dependent patients is bedrest 24/7. Most patients find it difficult to carry out this directive, and are labeled noncompliant by caregivers.

Objective
To communicate to prescribers the rigors of bedrest through interviews with patients attempting to follow that directive.

Method
Extensive interviews were done with 5 patients who were prescribed bedrest for pressure ulcers on the ischials or coccyx and who are insensate in the wound area. Interviews were done during 24/7 bedrest, or within 3 weeks of ending bedrest and weaning onto a normal sitting schedule. Interviews were done by the same interviewer from a prepared list of questions. The general nature – but not the individual questions - of the interview was communicated to the participants ahead of the interview.

Results
This qualitative study paints a picture of the lived experience of "bedrest". Common themes include feelings of isolation, despair, lethargy, and resignation. Self-blame was found in statements such as - why did I let this go so long? Lack of sensation in the area of the wound made bedrest even more difficult to accept, for example - If I could feel it, it would be easier. Appreciation for friends, family, and caregivers was often repeated. Frustration at the slowness of wound healing, (it will never end) were also common.

Conclusion
The small sample size hinders firm conclusions, but the consistency of the responses gives the viewer a picture of what most patients on bedrest are probably experiencing. The viewer will have a greater appreciation for the seriousness of the bedrest prescription, and be less cavalier with the noncompliant label.

OR128
Evaluation of Patient-defined Benefits in Wound Therapy - A Novel Approach.

Augustin M (CVderm, University Clinics of Hamburg), Schaefer I (CVderm, University Clinics of Hamburg), Reich C (CVderm, University Clinics of Hamburg), Koenig S (CVderm, University Clinics of Hamburg), Rustenbach J (CVderm, University Clinics of Hamburg, Germany)

Background
Benefit assessment of drugs and medicinal products has become a law-based part of medicine. The patient-defined therapeutic benefits are crucial for reimbursement of drugs and medicinal products.

Objective
Development, validation and clinical testing of a method of recording patient-defined benefits in wound therapy.

Methods
A collection of 83 items on benefits from the patients point of view was acquired by means of an open survey of n=50 patients with chronic wounds. The item pool was compiled to a 22-item questionnaire by an interdisciplinary team of experts with the assistance of patients. The questionnaire is used prior to therapy to record patient-defined preferences with respect to benefits (Patient Needs Questionnaire, PNQ) and after therapy to record the benefit attained (Patient Benefit Questionnaire, PBQ). A weighted Patient Benefit Index (PBI) is created over all items from the individually-selected therapy goals and the benefits assessed subsequently. The procedure was examined for validity and practical feasibility in a prospective study.

In this study, n=172 patients with acute and chronic wounds were questioned after use of topical negative pressure treatment (TNP) about clinical parameters, quality of life (QoL), therapeutic benefit and tolerance.

Results
The questionnaire was well-accepted by the patients and rated relevant with respect to the disease. The patients selected a broad spectrum of possible therapeutic benefits at the start of the study. After therapy, the Patient Benefit Index (PBI) score revealed a high percentage (95.4%) of patients with demonstrable benefit. Cronbachs Alpha was 0.88 (PNQ). There was good construct validity in comparison with both QoL and patient satisfaction.

Conclusions
The PBI for wounds is a valid and reliable instrument which can be easily used in practice to record patient-defined benefits in the therapy of acute and chronic wounds.

OR129
Clinical Use of Semi-quantitative Wound Culture Swabs: A Review of Results From Infected and Not Infected Non-arterial Leg Ulcers.

Marjorie D. Fierheller (Cardiff University), Michael Clark (Cardiff University ), R.G.Sibbald (University of Toronto)

Goals and Objectives
To help identify the presence of infection for an investigation into the relationship between increased peri-wound skin temperature and infection in non-arterial leg ulcers (results reported elsewhere), semi-quantitative wound culture swabs were obtained and evaluated. Although quantitative biopsy is considered to be the "gold standard" for bacterial culture, it is not often routinely used in clinical practice. A "reasonable" correlation of biopsy with quantitative, and semi-quantitative wound culture swabs has been documented in related literature.

Purpose
The usefulness of semi-quantitative culture swabs for identification of local wound infection in leg ulcers was evaluated.

Methods
Participants with non-arterial leg ulcers (n = 40) were recruited from within a chronic wound clinic. Twenty-two of these wounds were subsequently diagnosed as infected based on signs and symptoms and clinical judgment. Semi-quantitative wound surface swabs were obtained from all wounds using the Levine

Method
and sent to a central outpatient laboratory. Results were analyzed using descriptive statistics.

Results
Fifty percent of the non-infected wounds and 77% of the infected, demonstrated positive swab results of heavy bacterial growth and/or more than one bacteria cultured (sensitivity .77, specificity .50, PPV 65%, NPV 64%). In both groups, the bacteria most frequently cultured included Staphylococcus aureus followed by mixed or other gram negative bacteria, including Psuedomonas aeruginosa.

Discussion / Conclusion
Despite the limitation of a clinical vs. research setting, study

Results were similar to those identified in related literature. Diagnosis of infection based on routine semi-quantitative swab results cannot be supported. Instead, the need to base diagnosis on clinical signs and symptoms, supplemented with bacteriology for direction of appropriate antimicrobial treatment is reinforced.

OR130
Use of Ibuprophen-releasing Foam in Patients Affected by Progressive Systemic Sclerosis.

Failla G. (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.), Campo S. (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.), Ardita G (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.), Finocchiaro P (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.), Mugno F., (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.), Attanasio L (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.), Di Salvo M. (Vittorio Emanuele, Ferrarotto, S. Bambino University Hospital.)

Goals and Objectives
Progressive systemic sclerosis is often worsened by the appearance of cutaneous ulcers. The main characteristic of these scleroderma lulcers is pain and this has a significant effect on the quality of life for these patients. For this reason, besides vasoactive drug treatment to prevent skin ulcers with trometamolo, more recently with bosentan, these patients also require some form of treatment for systemic or local pain. Advanced dressings have improved some aspects of the management of ulcers, e.g. decreasing the pain at dressing changes and the possibility of administering the antiinflammatory drugs locally at the point where the ulcers presents the least exudation.

Purpose
To evaluate the efficacy in pain reduction of a Ibuprophenreleasing foam in patients affected by progressive systemic sclerosis.

Methods
The present study enrolled eight patients with progressive systemic sclerosis (5 females, 3 males, age range: 38-75 years). All presented painful single or multiple cutaneous ulcers of the hands, feet and malleolus. The patients were treated with polyurethane foam that released 0,5 mg of Ibuprophen/cm2. The level of pain was verbally measured at the first, third and fifth application using a numerical scale.

Results
The average pain recorded at the first dressing was 8.75 and this dropped to 3 at the third application and reduced even further, to 1.75, at the fifth dressing. Use of the Ibuprophen-releasing foam proved effective both in reducing acute pain ― measured verbally with a numerical scale (NBS)― and in maintaining the antalgesic effect even after the medication was suspended.

Discussion / Conclusion
Although this study involved a very small sampling, these clinical findings suggest that the role of the Ibuprophen in systemic sclerosis ulcers goes well beyond a simple reduction in pain, intervening on the local inflammatory mechanisms in the chronic ulcers.

OR131
Contact Allergens in Persons with Leg Ulcers:A Canadian Wound Healing Clinic Study

Victoria Smart (University College Cork, Ireland), Afsaneh Alavi (University of Toronto), Pat Coutts (Mississauga Wound Clinic), Sunita Coelho (Women College Hospital), Marjorie Fierheller (Mississauga Wound Clinic), R Gary Sibbald (University of Toronto)

Goals and Objectives
Individuals with chronic leg ulcers commonly develop contact allergic reactions to topical preparations applied both on their wounds and the surrounding skin.

Purpose
The objective of this study was to determine the frequency of positive patch test responses to common allergens in patients with leg ulcers or venous disease followed in a dermatologist supervised leg ulcer clinic.

Methods
We enrolled 100 consecutive, consenting patients with chronic venous disease and other causes of leg ulcers that were available for patch testing into a case series. The patients were tested with 39 common allergens including those most relevant to persons with leg ulcers

Results
Forty six percent of the patients had at least one positive patch test response. Multiple reactions were common. The most frequent groups of sensitizers were fragrances, lanolin derivatives, antibacterial agents and rubber related allergens.

Discussion / Conclusion
Though the prevalence of positive patch test reactions is high in this population, it is lower than other leg ulcer patch test series. This may be the result of avoiding the use of common sensitizers in this group of patients.

OR132
Testing Threshold Values for Sub-epidermal Moisture: Identifying and Predicting Stage I Pressure Ulcers

Barbara M. Bates-Jensen PhD, RN (UCLA School of Nursing, David Geffen School of Medicine, Division of Geriatrics), Heather E. McCreath PhD (UCLA David Geffen School of Medicine, Division of Geriatrics), Voranan Pongquan MPH (UCLA School of Nursing)

Significance
Previously, we showed sub-epidermal moisture (SEM) measured with surface electrical capacitance predicted erythema and stage I pressure ulcers (PUs) one week before visually detected at the sacrum and buttocks in nursing home (NH) residents. SEM would be useful if threshold values could be identified to target prevention.

Objective
To examine the relationship, sensitivity, and specificity of 3 SEM threshold values as non-visual predictors of stage I PUs in NH residents.

Methods
We pooled data from two phases of a descriptive, cohort NH study with 66 residents in 4 U.S. NHs to test 3 SEM thresholds. Concurrent visual assessments and SEM were obtained at right and left buttocks, ischium, and sacrum weekly using a handheld dermal phase meter, where higher values indicate greater SEM (range: 0-999 dermal phase units [dpu]). Visual assessment was rated as normal, erythema, stage I PU, or stage II+ PU. SEM thresholds of 50dpu, 150dpu, and 300dpu were tested as predictors of erythema and PUs one week later (controlling for clustering); with risk status, and anatomic site as covariates.

Results
Participants had a mean age of 84.4 years, were 83% female 77% non-Hispanic white, with some functional and cognitive impairment. Unadjusted sensitivity values were strongest when using 50dpu as threshold, while specificity was strongest with 300dpu as the threshold criteria. Persons with SEM > 150dpu were 4 times more likely to exhibit stage I PU damage the following week compared to persons with SEM <150dpu. Similarly, persons with SEM >300dpu were 7 times more likely to exhibit stage II+ PU the following week compared to persons with SEM < 300dpu.

Conclusions
SEM threshold values show promise as an objective non-visual biophysical measure of PUs. Persons classified with these SEM thresholds are more likely to develop PUs in the subsequent week and would benefit from aggressive prevention interventions.

OR134
Pain in Chronic Lower Limb Wounds: An Exploration of Impact on Quality of Life

Nicoletta Frescos (La Trobe University, Melbourne, Australia), Jana Gazarek (Yarraville Podiatry, Melbourne, Australia)

Goals and Objectives
Chronic lower limb wounds can be painful and have a considerable impact on patients' Quality of Life (QoL) and may seriously affect wound healing. Over 70% of patients experience moderate to severe pain from their wounds, however wound pain is often ignored or inadequately controlled.

Purpose
This study aimed to identify differences which may exist in pain and QoL, between 7 different wound types (Arterial, Venous, Mixed, Infectious, Metabolic, Miscellaneous and Vasculitic) and patients' perception of wound pain.

Methods
82 patients with chronic lower limb wounds were recruited. Two validated questionnaires; the McGill Pain Questionnaire and the Brief Pain Inventory were utilised in collection of pain and QoL data. Patient demographics, and details of pain management and wound type were collected. A focus group was also conducted to obtain information on patient's experience and perception of their wound pain and what impact it has on their QoL

Results
61% of patients reported pain in their wound, with vasculitic wounds exhibiting the highest prevalence of pain. General activities, mobility and sleep were the most affected aspects of QoL. No statistical significance was found between wound types, pain intensity and QoL scores. 64% of patients reporting pain were taking self chosen pain medication. Patients felt there was a stigma attached to taking pain medication and that phycisians did not fully understand their pain.

Discussion / Conclusion
Wound pain is under-assessed and under-treated resulting in patients' perception that wound pain as something they just have to suffer. Wound practitioners need to address this problem and integrate pain assessment and management to improve the patients QoL and wound healing.

OR135
Pain Experience During Dressing Change Comparing Two Foam Dressings

Woo Kevin (Sunnybrook & Womens College Health Science Centre, Toronto, Canada), Dr Aldons Pat (The Prince Charles Hospital, Brisbane, Australia), Dr Anseeuw Marleen (Sint-Truiden, Belgium), Professor Dr Beele Hilde (University Hospital Gent, Belgium ), Professor Boccalon Henri (Hospital Rangeuil, Toulouse, France), Professor Harding Keith (Department of Wound Healing, Cardiff University, UK), Dr Del Marmol Veronique (University Hospital Erasme, Brussels, Belgium), Prof Dr Med Mrowietz Ulrich (Department of Dermatology, University of Kiel, Germany), Professor Price Patricia (Department of Wound Healing, Cardiff University, UK), Dr R Sibbald Gary (Sunnybrook & Womens College Health Science Centre, Toronto, Canada), Dr Toussaint Pascal (HIA Robert Picque, Bordeaux, France)

Background
Wound-related pain is complex, integrating the experience of chronic persistent pain as well as acute pain often associated with recurrent wound related procedures. Previous studies indicated that a large proportion of patients with wounds experienced pain during dressing change especially at dressing removal. It was previously demonstrated that repeated application and removal of adhesives (tapes and dressings) can strip the surface layers of the stratum corneum leading to skin damage and pain.

Objective
The aim was to assess the pain experience during dressing change comparing two foam dressings (Mepilex Border with soft silicone, Mölnlycke Health Care, versus Allevyn Adhesive with acrylic adhesive, Smith & Nephew).

Methods
73 patients with chronic ulcers completed this open, randomised, cross-over, multicentre investigation. Patients were randomized to a dressing with soft silicone or acrylic adhesive for two weeks, followed by cross-over to the alternate dressing for another two weeks. At each study visit, patients indicated the intensity of pain using Visual Analogue Scale (VAS) and the quality of pain using the Short-Form McGill Pain Questionnaire©(SF-MPQ). The dressings were evaluated by the patients and investigators. Data were analysed using Fisher's exact non parametric test.

Results
The VAS pain intensity scores at dressing removal were lower in patients treated with soft silicone (p<0.05). Results also indicated that patients consistently rated high levels of pain on the affective and sensory subscales of the SF-MPQ with acrylic adhesive (p<0.05).

Evaluation by patients and investigators suggested that the soft silicone dressing was superior for its conformability (p<0.001). Investigators were also more satisfied with its fluid handling (p<0.0001) and overall performance (p<0.0001).

Conclusion
Dressing removal was less painful with the use of soft silicone dressings in this cohort of patients. The advantages of the soft silicone dressing may be related to its conformability and fluid handling capacity.

OR136
Treatment Benefits and Quality of Life in Topical Negative Pressure Therapy

Augustin M (CVderm, University Clinics of Hamburg, Germany), Zschocke I (SCIderm Ltd., Hamburg, Germany), Radtke M ( CVderm, University Clinics of Hamburg, Germany), Herberger K ( CVderm, University Clinics of Hamburg, Germany)

Background
Topical negative pressure therapy (TNP) is a standard treatment for acute and chronic wounds. Only few studies, however, have addressed the question of patient-defined benefits in TNP.

Objectives
Recording the patient-defined benefits and the QoL of patients undergoing TNP treatment in clinics and in home care.

Methods
Multi-centre, open, uncontrolled observational study all over Germany. Consecutively, data were collected on n=264 patients with any kind of acute or chronic wound before and after TNP with the V.A.C. system. Major outcomes parameters were wound status, disease-specific quality of life (evaluated by the Freiburg Life Quality Assessment, FLQA-w) and patient-defined benefits, the latter assessed with the patient benefit index (PBI), a questionnaire specifically developed for the evaluation of therapeutic patient benefits.

Results
The mean disease-specific QoL improved significantly from 3.3 ± 0.7 to 2.6 ± 0.7 (higher values represent greater disease burden; p <0.001). Significant improvements were also noted in individual aspects of QoL: physical complaints, psychological well-being, daily life/working life, social life and therapy (p<0.001 for each aspect). Satisfaction with treatment was high, only 5.7% of patients feed-backed major problems with the therapy, e.g. noise and mobility. The most important patient-defined benefits initially mentioned included the recovery of function in activities of daily living, reduction in treatment burden (doctor/clinic visits), and gaining trust in the therapy, along with healing of the wound and lack of pain. These aims were achieved in a majority of the patients after VAC therapy. About 87% of the patients showed a PBI >1, indicating a substantial therapeutic benefit.

Conclusion
Patients with chronic wounds express a wide range of objectives for therapy, which must be considered when evaluating the therapeutic benefits. The data underline that TNP therapy leads to significant improvement of QoL and patient benefits in acute and chronic wounds.

OR137
Towards a Unified Outcome Criteria for Wound Assessment

Anand Deva (University of New South Wales), Raj Mani (University of Southampton)

Goals/purpose
The treatment of acute and chronic wounds has been one of the primary driving surgical goals since the birth of our profession. Clinicians have utilised their observational skill to assess progress of wound management. Visible changes to a wound including reduction in size, improvement in colour and quality of the granulation response are subjectively assessed over the course of either surgical or non-surgical treatment to evaluate success in management. Subjective evaluation however, is difficult to standardise for the purpose of clinical trials.

Purpose
To define trends in outcome research for wound healing. To list a "minimal data set" as a starting point for wound assessment.

Methods
Three 12 month periods were selected for analysis from medline. All publications with wound healing as the subject heading were extracted. Analysis of outcome assessment was performed.

Results
There were a total of 930 publications analysed. Over the last 20 years, there has been a significant increase in the number of articles investigating wound healing. The majority of the increase relates to basic science investigations. Clinical studies continue to be predominantly case series and case reports. Comparative studies and correlative clinico-pathological studies have not increased and form a minority of published reports.

Conclusion
It is important that a validated outcome score be generated. As a starting point, we have listed a "minimal data set" for wound outcome assessment. We hope that this provides the impetus for both clinicians and scientists to work toward establishing clear criteria for standard wound outcome assessment. Statistical techniques for pooling raw wound outcome data will also be discussed as a method of validating outcome assessment. Once established, standardisation in wound outcome assessment will form the basis of significant progress in both the clinical management and scientific understanding of wound healing.

OR138
Recommendations for Local Wound Care Based on Level-one Evidence from Cochrane Systematic Reviews.

Vermeulen H (Amsterdam Center of Evidence Based Practice at the Academic Medical Center of Amsterdam), Ubbink D (Amsterdam Center of Evidence Based Practice at the Academic Medical Center of Amsterdam)

Background
Patients with open wounds require specific local wound care. The variety in local wound care is huge, mainly due to the lack of strong evidence on the most appropriate local wound care. This study was initiated to gather level-one evidence from systematic reviews (SRs) to formulate recommendations for local wound care.

Methods
We searched the Cochrane Database of Systematic Reviews up to Issue 1, 2007 for SRs and protocols on local wound care. We extracted the recommendations for local wound care practice and assessed their scientific strength.

Results
The search identified 152 possibly suitable titles, of which 24 were relevant and comprised acute wounds (surgical & traumatic), ulcers (venous, arterial, diabetic and pressure) and miscellaneous wounds. These SRs comprise 1 to 42 RCT's. Strong evidence was found in a few SRs: Two SRs showed that tissue adhesives are an acceptable alternative to standard wound closure in traumatic and surgical wounds, high compression bandages aid the healing of venous leg ulcers, EMLA is an effective analgesic in the debridement of venous ulcers, bilayer artificial skin under compression improves healing of venous leg ulcers compared with simple dressings and compression, and hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care. Furthermore there is no evidence that any wound dressing is better than a gauze dressing for leg ulcer healing, nor is there evidence for the effectiveness of electromagnetic therapy in venous ulcers or pressure sores. Also, evidence is lacking for laser therapy in venous ulcers.

Conclusion
Even though SRs are available and some clinical recommendations can be drawn, more RCTs of high methodological quality (which are the basis for SRs) are needed. The results of such trials will help to guide physicians and nurses in their decision-making in wound care.

OR139
Wound Areas via Computerized Planimetry of Digital Images: Accuracy and Reliability

Harvey N. Mayrovitz (Nova Southeastern University, College of Medical Sciences), Lisa Soontupe (Nova Southeastern University, Allied Health and Nursing)

Goals and Objectives
Tracking wound size is an important part of treatment. Because initial wound size affects apparent healing rates, the surface area (S) to perimeter (P) ratio (S/P) is useful to document healing. Changes in S/P provide a quantitative index of movement of a healing wounds margin toward the center. To measure via computerized-planimetry, a wounds margin can be outlined on a computer screen and its perimeter and enclosed area automatically determined by readily affordable software*. Because wounds are evaluated by different caregivers and measurement-time is a consideration, it is important to have an estimate of accuracy, reliability and measurement-time with which S and S/P can be routinely determined.

Purpose
To determine accuracy, reliability and measurement-time of S and S/P when images recorded by digital photography were measured by 4th year student nurses.

Methods
Six images of various complexities having areas known to within ±0.1cm2 were measured by 20 students during two sessions one week apart. Images included; an ellipse (84cm2), two traced venous-ulcers (87cm2), a pressure-ulcer (82cm2), plantar-ulcer (6.5cm2) and venous-ulcer (41cm2). Area error was determined as the percentage difference between known and planimetry measured areas. Reliability was assessed from coefficient of variations (CV%) calculated from standard deviations (sd) of differences between the two measurement sessions.

Results
Area error (mean±sd) ranged from -3.8±7.0% to +2.4±2.2%. CV% was 0.85 to 8.45% for areas and 0.89 to 6.04% for S/P. The smallest wound (plantar) had the largest variance mainly due to variability in defining its margin. Average wound measurementtime was 81.0±10.5 seconds.

Discussion / Conclusion
Results suggest that simple computer-based planimetry of digital images can provide rapid, accurate and reliable estimates of wound area and S/P ratios.

*www.bimeco.org

OR140
A Cellulose and Polihexanide-based Dressing in Patients with Wound Infection

Giovanni Mosti (Clinica Barbantini Lucca Italy), Vincenzo Mattaliano (Clinica Barbantini Lucca Italy)

Goals and Objectives
Bacteria and their endotoxins block the healing process of chronic wounds. The control of the bacterial overload is mandatory in infected or critically colonized wounds to re-strat the healing process.

Purpose
To study if a new hydrobalanced cellulose-based dressing (sterile cellulose, water, polihexanide PHMB) is able to promote ulcer bed preaparation and wound closure in vascular leg ulcers.

Methods
We applied Cellulose+PHMB on 8 hospitalized (HP) and 11 outpatients (OP) with critically colonized or infected wounds (4 with arterial, 2 with mixed (W.I. > 60), 2 with vasculitic wounds; 11 outpatients with venous leg ulcers; ulcer surface 15 to 180 cm2, duration 6 months to 4 years). The dressings were changed every day or other day (5 dressings, range 3-7) in the HP; every 5 to 7 days in the OP. In these patients the dressing was changed to Cellulose when infection was resolved. Compression treatment was adapted to the ulcer pathophysiology: light compression in arterial and vasculitic ulcers; strong compression in venous ulcers.

Results
The wound bed preparation was achieved in 6.2 +/- 1.3 days in HP and after 4 dressing changes (range 3-6) in the OP. Bioburden was significantly reduced from 572.000+/-401.986 to 74.500+/-174.060 CFU in the HP and from 765.000+/-345.000 to 50.000+/-15.000 CFU in OP. Pain (VAS) decreased from 7.8+/- 1.5 to 5.5+/- 1.2 in the HP and from 7.3+/-1.9 to 2.8+/-0.8 in the OP. Outcomes: the HP were thereafter submitted to skin graft that took in all the cases. OP: 1 patient suddenly died (stroke); 10 healed within 16 weeks.

Discussion / Conclusion
This dressing was effective in debridement, infection and pain control; it was well tolerated and no damages of peri-wound skin was reported.

OR141
WoundsWest: Changing the Face of Wound Management in Western Australia

Veronica Strachan (Silver Chain Nursing Association, Curtin University, Western Australian Health Department), Jenny Prentice (University of Western Australia), Keryln Carville (Silver Chain Nursing Association, Curtin University), Nick Santamaria (Curtin University), Roslyn Elmes (Western Australian Health Department), Phillip Della (Western Australian Health Department)

Background
Research showed that implementing evidence-based wound management, education and an electronic imaging and remote referral system improved patient outcomes and reduced the burden on health care services.

Objectives
This paper outlines the planning, progress and outcomes to date of WoundsWest, which aims to improve wound management through an integrated state-wide health system of audit, education, electronic wound imaging and remote expert referral. The presentation will focus on logistical and communication challenges and successes involved implementing the program across Western Australia (WA). WA occupies one-third of Australia's landmass and covers 2.5 million km2, equivalent in size to continental Europe with health service complexity ranging from 900 bed tertiary metropolitan hospitals to 2 bed remote rural sites.

Methods
Extensive planning and communication using collaborative project management processes to engage health care providers is required to achieve the improvements in clinical practice and health outcomes of the magnitude envisioned. WoundsWest uses the project management principles of concept, development, implementation and finalisation. Critical success factors include: precisely defined scope and comprehensive project plan; strong executive support; clear roles and responsibilities for all project groups and members; understanding of known project risks and assumptions; and a logical change implementation process.

Results
WoundsWest has successfully completed the first 6 of 10 stages. Since November 2006 steering, advisory and working groups have been convened and meet regularly; 2 state-wide wound prevalence surveys have been completed (6,000 patients in 85 metropolitan and remote health services); website and online wound education program have been established; and a wound imaging and remote expert referral system has been developed and piloted.

Discussion / Conclusion
Investing in a comprehensive project planning process, which identifies common values, engenders commitment to change, articulates and promulgates agreed outcomes through consistent communication is essential to achieving project outcomes and implementing a sustainable state-wide evidence-based wound management program.

OR142
Independent Predictors of Diabetic Foot Ulcer Healing, Dar Es Salaam, Tanzania

ZULFIQARALI G. ABBAS (MUCHS, AMC, Dar es Salaam, Tanzania), JANET K. LUTALE (MUCHS, Dar es Salaam, Tanzania), LENNOX K. ARCHIBALD (University of Florida, Gainesville, Florida, USA)

Goals and Objectives
Previous studies have identified neuropathy and poor glycaemic control as factors associated with delayed healing of foot ulcers in patients with diabetes. However, in our diabetes clinic, we continue to document poor ulcer healing among patients with little or no evidence of neuropathy, who had maintained satisfactory glycaemic control. Thus, we conducted this study to identify other factors that might be affecting positive healing outcomes in this population.

Purpose
Data from this study are expected to be useful additions to the body of evidence-based literature on diabetic foot ulcer management in Africa.

Methods
During January 1998 – June 2007, all adult diabetes patients who presented with foot ulceration to Muhimbili National Hospital were evaluated. Detailed clinical and epidemiologic data were recorded following informed consent, including occupation, ulcer size, tissue loss and infection grade, degree of neuropathy, and vascular perfusion. We followed patients in the clinic for continuation of care and documentation of healing.

Results
Of 1284 patients who met the case definition, 825 (64%) were male, 939 (73%) were African ethnicity, 1156 (90%) had neuropathy, 244 (19%) had decreased or absent perfusion in the affected limb. The median age was 55 (range: 12-98) years. On logistic regression analysis, independent predictors of healing were female sex (adjusted odds ratio [AOR]: 1.6; 95% confidence interval [CI]: 1.2-2.03), normal vascular perfusion (AOR: 1.8; CI: 1.4-2.5); or smaller ulcer size at presentation (p=0.03).

Conclusion
Vascular disease is adversely affecting the healing of foot ulcers among patients in Dar es Salaam. The negative effect of ulcer size on healing suggests that patients continue to delay seeking medical attention. Despite provision of foot care services at our centre, women continued to achieve better healing outcomes.

OR143
Developing a Transcultural Nursing Leadership Institute: USA to China

Kathleen Leask Capitulo DNSc, RN, FAAN (North Shore University Hospital, Manhasset, NY, USA), Liping Jiang MPH, RN (Wenzhou Medical College School of Nursing, Wenzhou, PR China)

Goals and Objectives
This project's goal was to build cultural bridges between nursing leaders in the United States and China.

Objectives
Identify strategies for successful global nursing partnerships

Lead workshops for nursing leaders in China

Establish a local Steering Committee

Connect nurse leaders from China and the U.S.

Facilitate joint nursing research and publications

Purpose
The purpose of this project was to develop professional, collaborative relationships between nursing leaders in the United States and Wenzhou, China, an industrial city serving over 43 million people, by developing a Transcultural Nursing Leadership Institute (TCNLI).

Methods
This project used Problem Solving for Better Health®., a model of the Dreyfus Health Foundation, teaching a method enabling local nurses to identify and solve problems by leading change projects with evidenced-based interventions and measurable outcomes. A steering committee of the Dean of the College of Nursing and the Chief Nurse Executives of affiliated hospitals worked with the project Director from New York. Two large conferences and workshops were held in Wenzhou, China over a period of 18 months.

Results
Over 200 nursing leaders attended the two conferences in Wenzhou.

Fifty seven nurse leaders participated in PSBH® workshops

Forty four Chinese nurses completed projects

A Steering Committee and Nursing leaders were prepared to be facilitators for sustainability

Examples of the projects include:
Preventing pressure ulcers in hospitalized patients
Developing a patient education program for colon surgery
Improving hand washing in hospitals

More than 10 publications in American, Chinese and international journals

Joint research on wound care and nursing leadership

Discussion / Conclusion
Nurses working on common health care issues make a difference and change the world!

OR144
The Comparison of Risk Factors for Amputation in Diabetic Foot Ulcers, Between Ischemic and Neuropatic Types

Abolfazl Shojaiefard (Tehran University of Medical Sciences), Sina Abdollahzade (Tehran University of Medical Sciences), Maryam Aalaa (Tehran University of Medical Sciences)

Goals and Objectives
The development of foot ulcer has been considered to result from a combination of peripheral vascular disease, peripheral neuropathy and infection. These lesions can result in gangren and amputation.

Purpose
To recognise and compare risk factors and amputation rate in diabetic foot ulcers assigned to subgroups including ischemic and neuropathic.

Methods
We admited 172 patients with diabetic foot lesion according to our inclusion criteria between 2004-2006 in Shariati hospital affiliated to Tehran University of medical Sciences, Tehran, Iran; and perform our managment protocol for assessing and management of these patients.

Results
One-hundred seventy two patients were enrolled with a mean (±SD) age and duration of disease of 58.8 (±11) and 10.8(±9), respectively. 34.9% of patients had ischemic ulcers, 59.3% neuropathic and 5.8% neuroischemic. Patients with ischemia suffered from a statistically significant prolonged course of disease (mean duration=14.63 years) compared to neuropathic group (mean duration=8.19 years). Creatinine level is also increased in ischemic group comparing to patients with neuropathic group (mean ± SD in former group is 1.75±1.97 versus 0.84 ± 0.78). Overall, eight major amputations (below knee) were performed in the series and 35 toe amputations. We performed 13 arterial bypasses for ischemic feet, seven were femuro-popliteal and six were infrapopliteal bypasses. Major amputations were more commonly carried out in ischemic group (P<0.05).

Discussion / Conclusion
In patients with established foot ulcers, ischemia and peripheral vascular disease confers a more severe course of disease and aggressive management strategies is warranted in this group of patients to save both limb and life. We could save neuropathic lesion with aggressive medical and surgical management and prventive cares and ischemic feet with aggressive management protocol consisting intravenous antibiotic therapy, surgical debridment and revascularization and if necessary toe amputation.

OR145
We Can Save Extensively and Deeply Infected Diabetic Foot Lesions Including Infected Large Heel Ulcers

Abolfazl Shojaiefard (Tehran University of Medical Sciences), Bagher Larijani (Tehran University of Medical Sciences), Soheila Shahbal (Tehran University of Medical Sciences)

Goals and Objectives
Management of extensively infected foot including infected large heel ulcers is a challenge in diabetic patients. Infected diabetic foot tends to progress to disastrous outcomes and if not treated appropriately it can become incurable that lead to amputation.

Purpose
With a multidisciplinary and systematic approach and protocol, we can save these types of diabetic foot lesions; thus, the patients can walk on their feet.

Methods
We designed a protocol consisting medical and surgical management including revascularization for extensively and deeply infected diabetic foot lesion including infected large heel ulcers (2004- 2006), from Shariati hospital affiliated to Tehran university of medical sciences (Tehran-Iran).

After two years, we analyzed data of 31 extensively and deeply infected diabetic feet and 23 feet with large heel lesions of 152 patients with diabetic foot lesion that required hospitalization. If the foot is not ischemic, we can elevate heel pad, like a flap with a pedicle, and after control of infection, we can reconstruct and suture the heel flap to its base.

Results
With a multidisciplinary and systematic approach, only four septic feet (12.9%) out of 31 required major amputation (Below Knee). We performed six femuropopliteal and four infrapopliteal bypass. Twenty-three feet with heel ulcers larger than three cm2 saved. Twenty-one patients (91.3%) had neuropathic diabetic foot; four feet (17.4%) were ischemic. We performed three infrapopliteal bypass and one distal bypass for ischemic heel ulcers. Totally, 20 large heel ulcers (87%) out of 23 saved. Only for three feet (13%) with large heel ulcer below knee amputation performed.

Discussion / Conclusion
Diabetic patients with extensively and deeply infected foot lesion including infected large heel ulcers can manage without amputation if aggressive medical treatment and surgical management including revascularization are performed.

OR146
Wound Care Challenges in the Developing World: The Case of Tanzania

Dr. Daudi Rajabu Mavura (R.D.T.C. at KCMC Moshi Tanzania)

Goals and Objectives
, Quality Wound care is a costly and highly specilized field of dermatology.Most health care facilities,even at tertiary level, lack the requisite facilities to provide effective wound care.

Purpose
To highlight the current wound care situation in Tanzania using the case of the Regional Dermatology Training center (RDTC) Wound Care Department.

Methods
RDTC is one of four Regional referral hospitals in Tanzania opened in 1992 by the International Foundation of Dermatology (IFD) and the Government of Tanzania. It offers advanced courses in Dermato-venerology to trainees from different African countries. The wound care department also cares for an ever increasing caseload of patients with a myriad of wounds including: trauma, surgery, diabetes, skin cancer-related wounds of albinos, leprosy patients with neuropathic feet, lymphedema secondary to filariasis, ulcerated Kaposi Sarcoma and Buruli ulcers.

Results
RDTC is at the forefront of spearheading new inroads into wound care through increased research, training opportunities and strategic partnerships with internationally recognized institutions like the International Wound healing Foundation. Key areas of research include honey and other locally produced cost effective remedies for wound care. A "fly laboratory" for larval debridement has been established and is an invaluable addition to this endeavor.

Discussion / Conclusion
There are challenges. Insufficient funding, lack of specialized and adequately trained staff, medical supplies and drugs, and improper facilities to undertake wound care procedures and training undermine the quality of wound care provided to patients in the centre. There is a critical need to strengthen local capacity by addressing these challenges. Wound care research with a focus on circumstances in developing countries should take centre stage. RDTC is uniquely placed at country and regional level to spreahead this initiative.

OR147
Efficacy of Injected Activated Macrophage Suspension in Decubital Ulcers; A Randomized Blinded Controlled Trial

Zuloff-Shani Adi (Research and Development Unit, Blood Services, Magen David Adom), Even-Zahav Aviva (Geriatric Rehabilitation Center, Sheba Medical Center), Adonsky Abraham (Geriatric Rehabilitation Center, Sheba Medical Center), Arie Orenstein (Department of Plastic Surgery, Sheba Medical Center), Jeremy Tamir (Department of Plastic Surgery, Sheba Medical Center), Shinar Eilat (Blood Services, Magen David Adom), Danon David (Research and Development Unit, Blood Services, Magen David Adom)

Goals and Objectives
To compare the efficacy of topical injections of activated macrophage suspension (AMS) with currently used conventional treatments of decubital ulcers

Purpose
Decubital ulcers are associated with increased co-morbidity and mortality in elderly patients. As activated macrophages play a crucial role in the process of wound healing, a randomized, blinded trail was performed to compare AMS local treatment vs. conventional treatments

Methods
Between August 2004 and July 2005, all patients admitted to the geriatric rehabilitation center located in one of the largest medical centers in Israel were screened for enrollment in the study. Patients were eligible if they had pressure ulcers at stage III or IV regardless of their co-morbidities. Data such as demographics characteristics, functional and cognitive status and nutritional status was collected, during 12 month follow-up. Ulcers size and stage were recorded and photographed at baseline and every two weeks during the follow-up period. These patients received only conventional treatments, serving as the control group. In the following 12 month, the exact protocol was used, only this time all ulcers were treated by local injection of AMS

Results
In the AMS group (75 patients, mean age 77.4 years old) 65.6%(109 out of 166 ulcers) were completely healed as compared to only 13.7% (17 out of 124 ulcers) in the control group (60 patients, mean age 77.1 years old) (p<0.001). Median healing times were 81.1 days for the AMS group and 125.6 days in the control group (p<0.01)

Discussion / Conclusion
We present cell therapy approach for disturbed wound healing process using AMS prepared from a whole blood unit in a cost effective, sterile closed system. This treatment modality proved to be significantly more effective than conventional methods for the treatment of stage III-IV decubital ulcers in elderly patients

OR148
Benchmarking Pressure Ulcer Prevalence and Incidence Data - US and International

Kathy T. Whittington, MS, RN, CWCN (KCI), Robin Briones, BBA (KCI)

Goals and Objectives

• Patients hospitalized in the acute care setting receive treatment for approximately 2.5 million pressure ulcers annually.
• Reducing pressure ulcer incidence is a quality indicator in facilities.
• In December 2006, IHI launched the 5 Million Lives Campaign. Identifying the Prevention of Pressure Ulcers as one of 12 interventions that improve quality of care for patients.
• Since 1992, KCI has provided facilities with a methodology and the tools for conducting Pressure Ulcer Prevalence and Incidence Studies.

Purpose
Provide a benchmark for facilities to measure pressure ulcer prevalence and incidence.

Methods

• In 1999 KCI standardized the data collection form and reports.
• KCI provided standardized data collection and education tools to participating facilities.
• Patients were assessed for pressure ulcers, demographic, wound, risk factors and other data.
• The completed data collection forms were submitted to KCI for processing and report generation.
• Prevalence was measured during a pre-determined 24-hour period.
• Incidence was measured using the average length of stay at each facility ("Length of Stay" Incidence).

Results

• Over 70,000 patients were assessed on Prevalence and over 9,000 patients on Incidence in the U.S. (2006)
• Over 2500 patients were assessed on Prevalence and over 700 patients on Incidence in International. (2006) The KCI International P & I database is comprised of the following countries: Australia, Canada, New Zealand, and the United Kingdom.
• Reports are sent to facilities to assist with quality improvement initatives.
• All facility results are compiled, creating KCI's National and/or International database for comparison.

Discussion / Conclusion
A standardized methodology for Prevalence and Incidence study data collection and reporting has been developed and utilized in successive studies and years. The data in KCI's U.S.and International databases provides benchmarks for facilities to measure pressure ulcer prevalence and incidence.

OR149
Grade 1 Pressure Ulcers - How Reliable Are Clinical Assessment?

Sterner, Eila (Karolinska University Hospital, Department of Orthopaedic, Stockholm, Sweden), Lindholm, Christina (Kristianstad University, Kristianstad, Sweden), Stark, Andre (Karolinska University Hospital, Department of Orthopaedic, Stockholm, Sweden), Fossum, Bjoorn (Sophiahemmet University College, Stockholm, Sweden)

Goals and Objectives
Pressure ulcers are a common complication to hip fracture surgery. The sacral area is most commonly affected. Early detection of grade 1 pressure ulcers is essential for the prevention of more severe pressure ulcers. Today observation and light skin pressure is state of the art to separate blanching erythema from non-blanching (grade 1 pressure damage).

Purpose
The purpose of the present study was to investigate degree of agreement/ disagreement between two independent observers who assessed skin condition in the sacral area of patients undergoing hip fracture surgery.

Methods
Seventy-five patients with hip fractures were followed daily, from the first day post surgery and to a maximum of five days. The sacral area was assessed independently by two nurses and graded as a)normal skin, b)blanching or c)non-blanching erythema (grade 1 pressure ulcers). After ocular skin assessment, blanching/ non blanching test with the thumb was performed. The correlation between the results of the two observers was analyzed using kappa statistics for categorical variables.

Results
Seventy-five patients were followed and investigated day one and two, 74 day three, 64 day four and 52 patient day five. Agreement between the two ocular assessments varied between the different days (kappa 0.7878 – 0.5944) and observers. When erythema was present by ocular inspection and compared to the blanching/ non-blanching erythema test, the kappa value varies from 0.5957 – 0.3755.

Discussion / Conclusion
This study demonstrated a high degree of disagreement between clinical observations of reactive hyperaemia and non-blanching erythema (grade 1 pressure ulcers). A more reliable test do identify the different stages of erythema seems necessary.

Practical Implication
Early detection of pressure ulcers grade 1 is a crucial factor for prevention strategies.Education might facilitate a more structured assessment, and other tools for this identification should be developed.

OR150
Biomarkers That Predict Response to Adjunctive Therapies in People with Spinal Cord Injury and Pressure Ulcers

Pamela E. Houghton, PT, PhD (University of Western Ontario, London, Ontario, Canada), Christine H. Fraser, HBSc, RD. (St Joseph's Health Care London - Parkwood Hospital, London, Ontario)

Goals and Objectives
Enter the goals and objectives here. Adunctive therapies are used to accelerate closure of hard to heal wounds. Identification of appropriate clients likely to benefit from these time consuming, expensive therapies is important in order to maximize treatment effectiveness and avoid patient disappointment.

Purpose
Enter the purpose here. To identify biomarkers that predict complete wound closure with adjunctive therapy treatment in people with pressure ulcers and spinal cord injury (SCI).

Methods
Enter the methods here. A retrospective analysis of data collected during a 3 year clinical trial was conducted. Individuals with SCI and pressure ulcers were followed for at least 1 year or to complete wound closure [Average=7+4months]. All subjects underwent an initial assessment to collect information about patient demographics, medical conditions, and wound history. A standard blood screen for anemia, iron profile, protein malnutrition, glucose regulation, hydration, and thyroid function was completed. Wound suface area (WSA) was recorded monthly during treatment with standard wound care (std-care) including pressure relief and electrical stimulation therapy (EST).

Results
Enter the results here. 39 subjects stage II(n=4), III(n=18), IV(n=14), X(n=3) pressure ulcer present for 18+24 months were included in this analysis. Eighteen of 39 subjects healed after 151+149 days of treatment. Fourteen of 18 people with two or less abnormal blood values at the time of screening had complete wound closure - 78% negative predictive value. Thirteen of 14 subjects with less than 50% decrease in WSA over 3 months of treatment did not heal -93% negative predictive value.

Discussion / Conclusion
Enter the discussion/conclusion here. Subjects who have fewer abnormal blood values have a greater chance of responding to an adjunctive therapy. If wound size has not decreased at least 50% after 3 months of using an adjunctive therapy, there is little chance that continued treatment will produce complete wound closure.

The project was funded by a grant from the Ontario Neurotrauma Foundation.

OR151
Reducing Incontinence Related Skin Injury in Acute Care Patients

Joan Junkin (BryanLGH Medical Center)

Goals and Objectives
The evidence base for incontinence associated dermatitis (IAD) proves this is a problem worthy of attention. The way to improve practice is to correctly differentiate IAD from pressure ulcers (PU) in order to better focus interventions. The author will use photos to make that difference real for participants.

Purpose
Tools to collect IAD prevalence and to stratify treatments will be shared. The audience will leave ready to collect data and implement treatment strategies.

Methods
Data was collected at US hospitals using an inpatient survey excluding obstetric and psychiatric units, but including geriatric psychiatry.

Results
In 2005 of inpatients with incontinence (198 of 976), 56% had some skin damage in the exposed areas. In 2006 the incontinent group (120 of 608) included 42.5% with injury.

Discussion / Conclusion
The Institutes for Health Improvement have recommended an all-in-one disposable cloth for incontinence clean-up but many facilities still use soap and water which can strip the skin of protective oils, increase the pH which decreases resistence to secondary infection, and also poses infection control hazards. The evidence base may not be utilized because staff is not educated about the issue. It was clear in these facilities that staff often did not know the difference between IAD and PU and were targeting ineffective interventions. The simple tool with photos teaches staff and families how to identify and treat IAD. Implications for quality of life are clear. It is not likely that someone with burned buttocks will cooperate in ambulation or even sitting up as they rehabilitate in acute care. The pain experienced with every clean-up makes it imperative that as a global health-care system we address this wide-spread problem. IAD increases the risk for pressure ulcers which not only cause pain and morbidity but are associated with mortality. Participants are urged to use these simple tools to clearly name and address this problem because what we don't know CAN hurt us and certainly our patients!

OR152
Multicenter Observational Study on Peristomal Skin Disorders: A Proposal of Classification - Italy

Giovanna Bosio (Azienda Ospedaliera "San Giovanni Battista di Torino" – Le Molinette Turin), Luigi Lucibello (Ospedale Piemonte - Messina), Francesco Pisani (Presidio Ospedaliero "San Luigi-Currò" – Catania), Antonello Fonti (Azienda Ospedaliera di Alta Specializzazione Ospedale "Garibaldi" – Catania), Assunta Scrocca (Policlinico Universitario "Campus Biomedico" – Rome), Christa Morandell (Ospedale Regionale - Bozen), Laura Anselmi (Ospedale Regionale - Bozen), Mario Antonini (Azienda U.S.L. 11 Ospedale "San Giuseppe" – Empoli), Gaetano Militello (Azienda U.S.L. 4 Ospedale "Misericordia e Dolce" – Prato), Stefano Gasperini (Scientific Department – ConvaTec - A Bristol-Myers Squibb Company), Diego Mastronicola (Scientific Department – ConvaTec - A Bristol-Myers Squibb Company)

Goals and Objectives
Backround: About 1/3 of colostomy patients and up to 2/3 of ileostomy patients show at least one skin disorder.

Purpose
Important studies show a connection between risk factors and peristomal skin complications. As these studies are based on a different etiopathogenesis, we decided to work out a new classification.

Methods
A prospective, observational study was conducted among eight ostomy centres across Italy between December 2003 and February 2006. Patients were divided into two groups according to the time elapsed since surgery (Group 1: <1 year; Group 2: >1 year), to differentiate between early and late skin lesions. Skin lesions were examined at set intervals and their changes noted over time. At the same time, blood chemistry and clinical data were recorded. Descriptive statistical analyses were conducted using the software SPSS 14.0.

Results
The study include 656 patients both colostomates (70) and ileostomates (30) aged 25-85, had been observed: 339 of those had peristomal skin disorders and were therefore included in the study.

After consensus conferences, a shared criterion for the classification of peristomal lesions was achieved. A pocket ruler guide for the classification was created to provide a summary and practical explanation on the classification system to be used by ET-Nurses in daily work. It provides both the 5 lesion definitions (L) and their topography (T).

Conclusion
This is the first large-sample study to identify a simplistic, rapid way to document peristomal lesion change over time and to provide Health Care Professionals with a tool to discuss lesion change. The parameters for classification (L and T) facilitate post-surgical assessment of lesions in an objective reproducible way. Further research to refine the tool and to correlate the additional data obtained from blood samples with the classification system is underway.

OR153
A Proactive Team Approach to Patient Hygiene Leads to Improved Outcomes

Ann Wolfman, RN, BN (St. Boniface General Hospital)

Goals and Objectives
To implement an interventional study to determine the effectiveness of standardized bathing and incontinence care clean up protocols in relation to patient outcomes and overall satisfaction.

Purpose

• Decrease incontinence-associated dermatitis (IAD) by ensuring single-step incontinence clean up ensuring consistent dimethicone barrier application after every incontinent episode
• Remove bath basins for cleansing due to concerns of multi-step bathing increasing likelihood of spreading microorganisms
• Enhance caregiver knowledge and collaboration
• Enhance staff productivity

Methods
An intervention was implemented on a 25-bed subacute medicine unit (peritoneal dialysis patient subpopulation) from 05/07/07 through 06/04/07 and was designed as follows: 1) pre-intervention baseline surveys were conducted on all incontinent patients to determine presence/absence of skin injury; 2) staff were in-serviced on all-in-one bathing and incontinence care products, as well as bathing and incontinence care protocols; 3) staff collaboration tools were utilized to enhance communication regarding patient skin conditions. Staff and patient satisfaction with products were determined by Likert scale surveys. Multiple data-points were measured regarding satisfaction and measured as: 1 strongly agree; 2 agree; 3 unsure; 4 disagree; 5 strongly disagree.

Results
The pre-intervention skin surveys demonstrated 58.3% (7 of 12) of incontinent patients had IAD. The post-intervention skin surveys revealed IAD decreased to 14.3% (2 or 14). Surveys on the bathing product (n = 25) revealed in 8 of 10 questions >90% agreed or strongly agreed with satisfaction (2 questions received 64% or higher satisfaction); surveys on the incontinence cleanup product (n = 25) revealed in 9 of 10 questions >96% agreed or strongly agreed with satisfaction (1 question received 80% or higher satisfaction).

Discussion / Conclusion
The initial intervention ended 06/04/07 but all products continued due to improved patient outcomes and enhanced patient/caregiver satisfaction. Staff education and team collaboration were key in affecting these favorable outcomes.

OR154
Animal Experimental Study Model for Pressure Ulcer by Persistence Stress in Local Skin

Jiang Liping (School of Nursing，Wenzhou Medical College，Wenzhou 325035, Zhejiang, P. R. China), Cai fuman (School of Nursing，Wenzhou Medical College，Wenzhou 325035, Zhejiang, P. R. China), Yang yeqin (School of Nursing，Wenzhou Medical College，Wenzhou 325035, Zhejiang, P. R. China), Wei jingyun (School of Nursing，Wenzhou Medical College，Wenzhou 325035, Zhejiang, P. R. China), Wu yongqin (School of Nursing，Wenzhou Medical College，Wenzhou 325035, Zhejiang, P. R. China)

Goals and Objectives
Pressure ulcer is a serious condition seen in medical practice. It is a wound caused by unrelieved pressure that damages underlying tissue. Many factors are at play in the development of pressure ulcers. The theory of pathology ischemia-reperfusion mechanism applied. The tissue ischemia and damage lead to the epidermis and dermis. Skin tissue injury from these will contribute to pressure ulcer development Based on those previous hypothesis we designed the animal model

Purpose
To explore a safety, reliable and effective methods for preventing pressure ulcer, based on the potential mechanism of pathology ischemia-reperfusion by persistence local stress on animal model in rats skin.

Methods
Animal pressure ulcer model was established as follows: The rats were randomly divided into three groups in terms of time and pressure, the control group, pressure for 2 hours group and reperfusion groups. The skin tissue's pathology and physiology changes were discovered after contacting pressure in rat's skin

Results
It was showed that the injury degree along with pressure time in local skin. In the skin tissue of subcutaneous and muscle there were happened in histopathologic alterations. The subcutaneous have a pathology changed and these fibroproliferative alterations may produce significant deformations and alter In pressure group and ischemia reperfusion group. The plasma of ET-1、MDA、LDH, SOD and NO were measured which SOD and the content of NO were significantly lower while ET- 1、MDA、LDH were significantly higher in reperfusion group compare to normal control group

Discussion / Conclusion
The pathological and physiological alterations which were by persistence pressure of shin may give rise to important mechanism in Ischemia-reperfusion. This result will help to understand the mechanism of pressure ulcer and revealed the value for the clinical applications. Health care providers need to be involved in preventing and treating these problematic wounds.

OR156
Genetic susceptibility to venous leg ulceration

Wallace HJ (University of Western Australia, School of Surgery & Pathology, Fremantle Hospital), Allcock RJN (University of Western Australia, School of Surgery & Pathology, QEII Hospital), Tan C (University of Western Australia, School of Surgery & Pathology, Royal Perth Hospital), Price P (University of Western Australia, School of Surgery & Pathology, Royal Perth Hospital), Stacey MC (University of Western Australia, School of Surgery & Pathology, Fremantle Hospital)

Goals and Objectives
Genetic differences may increase susceptibility to venous leg ulceration and require further investigation. Previously we found that the risk of venous leg ulceration was elevated in carriers of a single nucleotide polymorphism (SNP) in the tumor necrosis factor-alpha gene (TNFA-308A), located in the central MHC. In this region conserved blocks of genes are maintained, known as ancestral haplotypes (AHs). 70% of Caucasians carrying TNFA-308A also carry part or all of the 8.1 AH (HLAA1, B8, DR3, DQ2), associated with numerous immunopathological disorders.

Purpose
To define the region with the highest degree of association with venous leg ulceration.

Methods
Genotyping at HLA-B and -DR loci and fine mapping of the central MHC region (32 SNPs) was performed. Cases (n = 171) comprised patients with ulceration due to venous insufficiency. Controls (n = 172) were age- and gender- matched individuals with normal venous function. HLA alleles were genotyped using PCR and sequence-specific oligonucleotide probes. Fine mapping was performed using SNPplex, Amplifluor and TaqMan platforms.

Results
Risk of ulceration was confirmed to be elevated in carriers of TNFA-308A (OR 1.90, p=0.006) and another marker of the 8.1 AH, BAT1 intron10*2 (OR 2.31, p=0.001). Risk of ulceration was also significantly elevated in carriers of HLA-B8 (OR 2.28, p=0.002) or HLA-DR3 (OR 1.65, p=0.04). The highest risk was seen in HLA-B8/BAT-1 intron 10*2/TNFA-308A individuals (OR 2.58, p=0.0005). Fine mapping identified 3 SNPs (in TNFalpha, leukocyte specific transcript-1 and nuclear factor of kappa light

Poster Abstracts

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