EWMA Journal Vol 8 No 2

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Vo|ume 8
Number 2
May 2008
Pub|lsbed by
European
Wound Management
Assoclatlon
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Jos Verd Soriano
EWMA Council Tbe EWMA Journa|
ISSN number: 1609-2759
Volume 8, No 2, May, 2008
E|ectronlc Supp|ement May 2008:
www.ewma.org
Tbe Journa| of tbe European
Wound Management Assoclatlon
Published three times a year
Edltorla| oard
Carol Dealey, EJ|to
Deborah Hofman, EJ|to
E|octoo|c Sopp|omoot
Sue Bale
Michelle Briggs
Finn Gottrup
E. Andrea Nelson
Marco Romanelli
Zbigniew Rybak
Peter Vowden
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reect the opinions of the Editors
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Management Association.
Copyright of all published material
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Christina Lindholm
Patricia Price E. Andrea Nelson
Christine Moffatt
Position Document Editor
Peter Franks
Immediate Past President
Marco Romanelli
President
Deborah Hofman
Carol Dealey
EWMA Journal Editor
Marcus Grgen Judit Darczy Sue Bale
Luc Gryson
Treasurer
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Recorder
Zena Moore
Secretary

Zbigniew Rybak Rita Videira Salla Seppnen Peter Vowden
CO-OPERATING ORGANISATIONS' OARD
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For contact information, see www.ewma.org
Edltorla| oard Members
Carol Dealey, UK (Editor)
Sue Bale, UK
Michelle Briggs, UK
Finn Gottrup, Denmark
Deborah Hofman, UK
E. Andrea Nelson, UK
Marco Romanelli, Italy
Zbigniew Rybak, Poland
Peter Vowden, UK
Paulo Jorge Pereira Alves, Portugal
Caroline Amery, UK
Mark Collier, UK
Bulent Erdogan, Turkey
Madeleine Flanagan, UK
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Peter Franks, UK
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Salla Seppnen, Finland
Jos Verd Soriano, Spain
Rita Gaspar Videira, Portugal
Carolyn Wyndham-White, Switzerland
Gerald Zch, Austria
EWMA Journa| Sclentl6c Revlew Pane|
EWMA Journal 2008 vol 8 no 2 2
Conferences
Organlsatlons
EWMA
EWM
Sclence, Practlce and Educatlon
Dear Reader
W
elcome to the second issue of the EWMA Journal for 2008. This is
also our conference issue, timed to coincide with the 18th Confer-
ence of the European Management Society in Lisbon and given to
all conference delegates. It also means that the electronic supplement for this
issue comprises the abstracts for all the papers and posters being presented at
the conference. I believe that this provides readers with a great opportunity
to see the wide range of developments in wound management research that
will be presented at the conference.
Of course our readership does not just comprise conference delegates as we
have a circulation of 13,000 as the Journal is sent to all our members and also
to all our 40 cooperating organisations. It is important not to forget those
who access the journal via the internet as this is increasing in number. In
November 2007 there were 960 hits for Issue 3 rising to 1881 hits in Febru-
ary 2008 for the same issue as well as a further 1205 hits for the rst issue of
2008. It would appear that once internet users nd the journal website they
nd it sufciently useful to revisit it.
The purpose of the Journal is to provide a mix of scientic and clinical papers
alongside news of developments in wound care in Europe. I believe that this
issue more than fulls this remit. Three of the papers provide details of studies
looking at different methods of wound management, all from different angles
and stages in development. For example, Marcus Grgen reports a small study
investigating the use of autologous platelet-rich plasma for chronic wounds
which is at the early stages of investigating this product. Thomas Eberlein and
Kurt Khn have investigated methods of wound cleansing, an area worthy of
more investigation. I must particularly mention the paper by Georgina Gethin
as she was the recipient of a EWMA award to support her PhD studies. It
is always encouraging to see the outcome of awards as it helps to reinforce
their value, particularly as so few are available for studies in wound healing
and management. The fourth research paper is on another important topic:
wound-related pain and it is encouraging to see an international study looking
at it from the patients perspective.
As well as news from some of our co-operating societies, there is information
about the World Union of Wound Healing Societies (WUWHS) conference
in Toronto in June. As EWMA is one of the co-operating societies for the
WUWHS meeting and a member of the WUWHS, it is good to have this
opportunity to share further details about the conference, which we hope will
be a great success. It would seem that this summer is a great opportunity for
learning more about the latest developments in wound healing and manage-
ment. For those of you not fortunate enough to be able to attend the EWMA
conference and/or the WUWHS conference we hope to bring you reports
from both conferences in the next issue of the Journal and some of the best
conference papers in the next few issues.
So may I wish you an interesting and productive time over the next few
months, remembering that we are always interested in receiving papers on
all aspects of wounds, their prevention and management. Full details of the
instructions for authors can be found on our website: www.ewma.org.
Carol Dealey, EWMA Journal Editor
3 Edltorla|
Cao| Doa|o,
5 Treatment of cbronlc wounds wltb auto|o-
gous p|ate|et-rlcb p|asma
Nacos Coqoo
13 Po|ybexanlde (PHM) and etalne ln
wound care management
lot laooo, Toomas Ebo|o|o
19 Patlents' experlence of wound-re|ated paln:
An lnternatlona| perspectlve
E||zaboto I NoJqo
31 Ef6cacy of boney as a des|ougblng agent:
overvlew of current evldence
Cooq|oa Coto|o
36 Abstracts of recent Cocbrane Revlews
Sa||, 8o||-S,o
40 Wor|d Unlon of Wound Hea|lng Socletles
Congress 2008
Dooq|as NcQoooo
42 EWMA Journa| Prevlous Issues
42 Internatlona| Journa|s
44 EWMA Corporate Sponsors Contact Data
45 Hard-to-bea| Wounds - a bo|lstlc approacb,
tbe EWMA Posltlon Document 2008
Co|st|oo No//att
46 Conference Ca|endar
47 SEINKO, Hungarlan Assoclatlon for tbe
Improvement of Care of Cbronlc Wounds
and Incontlnentla
48 SWHS, Serblan Wound Hea|lng Soclety
50 Cooperatlng Organlsatlons
51 Assoclated Organlsatlons
/TM The following are trade marks of E.R. Squibb & Sons, L.L.C.: Versiva, Versiva XC and Hydrofiber. ConvaTec is an authorised user.
2008 E.R. Squibb & Sons, L.L.C. 2008. EU-08-780
References: 1. Vanscheidt W, Mnter K-C, Klvekorn W, Vin F, Gauthier J-P, Ukat A. A prospective study on the use of a non-adhesive gelling foam dressing on
exuding leg ulcers. J Wound Care 2007; 16: 261-265. 2. Bishop S. Versiva
XC
Gelling Foam Dressing cushioning and protection claims R&D justification.

WHRI2749 MS002 June 2005. Data on file, ConvaTec.
www.convatec.com
Versiva
XC
Gelling Foam Dressing-

The only dressing
with the gelling foam
advantage, redefining
patient care
Offers more for wound management than just a
moist wound environment
Designed to protect periwound skin and reduce
the risk of maceration
Comforts patients over time whilst the dressing
is in situ and upon removal
1
Gel cushions in a way that only a Gelling Foam dressing can
2
See what Gelling Foam
can do for your patients
Marcus Grgen,
MD, Senior Consultant
Surgeon
Dept.of Surgery
Srlandet sykehus HF
4400 Flekkefjord
Norway
marcus.gurgen@sshf.no
Abstract
Background: One of the emerging new treat-
ments for chronic wounds is the use of autolo-
gous platelet-rich plasma. However, there is little
experience with this kind of treatment as well as
limited proof of its effectiveness.
Aim: The aim of this study was to gain further
information about the benets of platelet-rich-
plasma in chronic wounds.
Materials and methods: Thirteen patients with
14 chronic wounds were enrolled in an open label
prospective study. The wounds included had not
shown signs of epithelialization over a period of
four weeks despite treatment of underlying causes
and standard local wound care.
Results: After treatment with platelet-rich plasma,
50% of the wounds had healed, 35.7% had re-
duced in size and 14.2% were unchanged in terms
of area and condition. Recurrencies were not ob-
served during the follow-up period of an average
of 34.5 weeks (range 6,5 weeks-52 weeks).
Conclusion: The use of autologous platelet-rich
plasma should be reserved for treatment of recal-
citrant wounds where there is lack of improve-
ment despite treatment of underlying causes and
good local wound care. Further research in form
of controlled trials is required.
INTRODUCTION
Wound healing is a complex process mediated by
interacting molecular signals involving mediators
and cellular events. Platelets play two important
roles in wound healing: hemostasis and initiation
of wound healing. After platelet activation and
clot formation, growth factors are released from
-granules located in the thrombocyte cell mem-
brane. Growth factors work as biologic mediators
to promote cellular activity by binding to specic
cell surface receptors
1,2
.
Autologous growth factors from concentrat-
ed platelet suspensions have been used to treat
chronic wounds for more than twenty years
3
,
however, there is still a lack of research to prove
their effectiveness. However, a few studies with
small sample sizes showed promising results with
complete wound healing rates between 37.5% and
66%
4,5,6
.
Eppley, et al. determined platelet numbers
and growth factor concentration in platelet-rich
plasma produced by one commercially avalaible
system (GPS
II, Biomet Biologics, Warsaw, In-

diana). They found an 8-fold increase in platelets
compared to whole blood. The concentration of
growth factors varied from patient to patient,
but increased with increasing platelet numbers
(Table 1)
7
.
The aim of this study was to gain further infor-
mation about the benets of platelet-rich-plasma
in chronic wounds.
Treatment of chronic
wounds with autoIogous
pIateIet-rich pIasma
Tab|o 1. locoaso o/ qowto /acto coocootat|oo |o p|ato|ot |co p|asma7
Growtb factor Concentratlon ln wbo|e b|ood Concentratlon l PRP
PDGF- 3.3 +/-0.9 ng/ml 17 +/- 8 ng/ml
TGF-1 35 +/- 8 ng/ml 120 +/- 42 ng/ml
VEGF 155 +/- 110 pg/ml 955 +/- 1030 pg/ml
EGF 129 +/- 61 pg/ml 470 +/- 320 pg/ml
IGF No increase
MATERIALS AND METHODS
Materials
The wound healing unit at Srlandet sykehus Flek-
kefjord in Norway treats about 250 patients with
chronic wounds of various origins each year. The
use of autologous platelet-rich plasma was intro-
duced to our unit in February 2007. Since there
was limited experience with this kind of technol-
ogy, we decided to do a prospective open-label
study on all patients treated during 2007.
From February 2007 until December 2007,
13 patients with 14 recalcitrant leg and foot ulcers
of various aetiologies were included in the study.
The sample consisted of 3 females and 10 males with an
average age of 52.1 years (range 35-76). The largest groups
of wound diagnoses were venous leg ulcers (n=6) and dia-
betic foot ulcers (n=3). The average duration of the ulcers
was 6.8 years (range 2 months -21 years).
Since treatment with platelets is regarded as an estab-
lished method, acceptance from the local ethical commit-
tee was not needed. All patients had given their written
informed consent before entry to the study.
Methods
This was a prospective open label study to look at the effects
of treatment with autologous platelet-rich plasma.
Inclusion criteria were chronic wounds with a dura-
tion more than 8 weeks that had not shown any progress
(decrease in size, formation of granulation tissue, epitheli-
alization) over a four-week period despite treatment of the
underlying causes and appropriate local wound treatment.
Wounds had to be free for necrosis. The ankle-brachial
pressure index (ABPI) had to be more than 0.6.
Ulcers that showed evident clinical signs of infection
or were exudating heavily, were excluded.
Determination of ankle-brachial pressure index was
done on all patients.
Venous leg ulcers were assessed by clinical features and
by measuring the ankle-brachial pressure index .
All diabetic ulcers were assessed with both ankle-bra-
chial pressure and toe pressure. An ABPI < 0,8 and toe
pressures less than 30-50 mmHg indicated arterial disease.
Neuropathy was examined by testing sensibility in diabetic
feet with a 10-g-Semmes-Weinstein-monolament and a
128 MHz-tuning fork.
Wounds were also assessed in terms of formation of
granulation tissue, moisture balance, and infection. These
assessments were used to describe the wounds as improved,
unchanged or deteriorated.
Preparation of platelet-rich plasma
Platelet-rich plasma gel to treat wounds was prepared
by using a desktop centrifugation system (Gravitational
platelet separation system, GPS
II, Biomet Biologics

Inc., Warsaw, Indiana) and a reaction chamber to pro-
duce autologous thrombin (Thrombin Processing Device,
TPD, Thermogenesis Corp., Rancho Cordova, Cali-
fornia). Making platelet-rich plasma starts by drawing a
volume of 55 ml blood from the patient and mixing it with
5 ml citrate. The blood is then transferred to the GPS
-
disposable which is placed in a centrifuge. It is spun at
3200 rpm for 15 minutes. During centrifugation, blood
is separated into three different fractions: platelet-poor
plasma, platelets and white blood cells, and red blood cells
(Figure 1). The platelet-poor plasma and the concentrated
platelets and white blood cells are drawn from the tube
using separate ports. Thrombin is produced by mixing
platelet-poor plasma with an ethanol/CaCl2-reagent in
the TPD reaction chamber. Platelet concentrate and
thrombin are then drawn into seperate syringes, the plate-
let-thrombin ratio at 10:1. The syringes are connected
using a Y-connector. When mixed, thrombin activates the
platelets. The result is a platelet gel that sticks to the sur-
face of the wound when applied. Growth factors are also
released upon platelet activation. Three different methods
can be used to apply platelet gel onto wounds. Using the
Y-connector, thrombin and platelet concentrate can be
sprayed as a steady stream into the wounds. This method
ts best to ll cavity wounds. It is also possible to attach a
special tip to the Y-connector, which applies the mixture
as a ne spray onto more shallow or large wounds. A third
possibility is to create a clot in a sterile container, and then
transfer the clot as a whole or cut into pieces into the
wound (Figure 2, 3). As more experience with this type
of treatment was aquired, the latter was preferred due to
less leakage, more stable clotting and better utilization of
the amount of platelet gel.
F|qoo 1. Too CPS-ll-tobo
a/to sp|oo|oq.
F|qoo 2. P|ato|ot coocootato aoJ toomb|o /om
a c|ot wooo m|xoJ |o a sto||o coota|oo.
F|qoo 3. Too c|ot cao bo cot accoJ|oq to
woooJ s|zo bo/oo bo|oq taos/ooJ to too woooJ.

A degradable dressing (Topkin, Biomet Europe, Dor-
drecht, the Netherlands) and a secondary absorbent layer
(Mepilex, Mlnlycke Health Care, Gothenborg, Sweden)
were used to cover the wounds. Treatment of the underly-
ing wound causes such as compression therapy for venous
ulcers and off-loading for diabetic ulcers was continued.
Outcome measures
In order to assess wound healing accurately, we used dig-
ital planimetry (Visitrak, Smith & Nephew, Hull, UK) to
measure wound sizes. Digital measurements of the ulcers
size were routinely taken on day 7 and day 28. As wounds
were followed-up, wound tracings were performed about
every four weeks.
The primary endpoint was time to healing, and the
secondary endpoint was reduction in ulcer size if wounds
had not healed.
RESULTS
Wounds were measured at day 0 with digital planimetry
and showed an average wound size of 6.7 cm
2
(range
0.4 cm
2
- 22.3 cm
2
).
On day 7 after treatment, ulcer size had reduced by
an average of 31.4% (range 2.1%-77.7%) in 11 of 14
wounds. Two wounds were unchanged in size, and 1
wound had increased in size by 4.3%. 13 wounds were
clinically assessed as improved, and 1 as unchanged.
After 28 days, 1 wound had healed completely. Of the
remaining ulcers, 12 had decreased in size to an average
of 55.2% (range 6.2%-80%) of their original size. All of
those were clinically assessed as improved. One wound
remained unchanged in both size and condition.
The number of treatments with platelet-derived
growth-factors varied from 1-4 (average 2.1 treatments).
Follow-up continued for an average of 8.4 months
(range 1.5-12). Two ulcers showed signs of infection dur-
ing the course of treatment. In both cases, Pseudomonas
species were cultured and infections successfully treated
with systemic antibiotics. Other side-effects were not re-
corded.
Seven (50%) of the ulcers healed within an average
of 153 days (range 30-317). Of the non-healed wounds,
2 (13.3%) showed signs of improvement within the rst
4 weeks, but have since deteriorated. The remaining 5
(35.7%) of the wounds continued to show improvement
and are between 68.7% and 6.8% of their original size.
(Table 2) Recurrencies were not observed.
DISCUSSION
Wound healing is a complex process that is regulated by
interactions between a large number of cell types, extracel-
lular matrix proteins and mediators such as cytokines and
growth factors. Lack of balance between these interactions
may result in a chronic wound. One possible cause of
imbalance in the wound healing process is high bacterial
F|qoo 4. Pat|oot o. 2 (Tab|o 2}. A oooo|scoom|c J|abot|c
ooo| o|co p|o to toatmoot w|to p|ato|ot qo|.
F|qoo 5. Da, 27. too woooJ s|zo |s oJocoJ b, 40.
F|qoo . Da, 155. Too woooJ oas ooa|oJ a/to two
app||cat|oos o/ p|ato|ot qo|, o//-|oaJ|oq aoJ qooJ |oca|
woooJ cao.
counts leading to a prolonged inammatory response with
high levels of cytokines. This leads to increased production
of matrix metalloproteases. High matrix metalloprotease
activity results in uncontrolled breakdown of extracellular
matrix and growth factors
8
. If measures are not taken to
re-establish the balance between the factors involved, a
chronic wound fails to heal.
About 88% of all wounds treated at our wound heal-
ing unit heal when the underlying causes are treated and
good local wound care is established
9
. For the remaining
wounds, advanced wound-healing strategies can be consid-
ered in order to obtain wound closure. A common feature
of these advanced strategies is an attempt to inuence the
bioactive wound environment by, for example, lowering
pH-values, applying extracellular matrix, binding matrix
metalloproteases, or, in the case of platelet-rich plasma,
by increasing numbers of growth factors.
Despite the fact that concentrated platelets have been
used to treat chronic wounds for more than 20 years, there
is a lack of high-quality studies describing their use in the
literature. Literature ndings do not allow to draw a clear
conclusion on the use of platelet concentrates. Senet, et
al. used frozen autologous platelets that had no signicant
adjuvant effect on healing of chronic venous leg ulcers
10
.
Reutter, et al. found neoangiogenetic abilities to platelet
derived wound healing factors, but not any signicant clin-
ical advantage
11
. Human recombinant epidermal growth
factor failed to signicantly enhance re-epithelialization in
venous leg ulcers
12
. However, other publications showed
encouraging clinical results with the use of growth factors
Tab|o 2. Pat|oot coaacto|st|cs
Nr. Sex,
age
Wound dlagnosls Duratlon
of tbe
wound
Wound
slze (cm)
Number of
treatments
-cbange
ln area at
day 7
-cbange
ln area at
day28
Resu|t December
2007
1 F, 76 Venous leg ulcer 10 years 21.8 1 22.5 27.1 Deteriorated, no signs
of epithelialization
2 M, 53 Neuroischemic diabetic heel ulcer 27 weeks 22.3 2 23.3 49.7 Healed day 155
3 F, 64 Neuroischemic diabetic heel ulcer 30 weeks 0.9 1 77.7 100 Healed day 30
4 M, 56 Traumatic leg ulcer associated
with an open distal leg fracture
8 weeks 4.8 1 2.1 16.6 Healed day 62
5 M, 39 Pressure ulcer, leg, associated
with spinal cord injury
1 year 5.6 4 7.7 16.1 Reduced by 42.9%
6 M, 50 Venous leg ulcer 18 years 2.1 4 0.0 0.0 Healed day 233
7 F, 72 Venous leg ulcer 21 years 1.3 2 31.8 69.3 Healed day 238
8 M, 44 Venous leg ulcer 30 weeks 4.4 3 + 4.3 13.1 Reduced by 93.2%
9 M, 55 Mixed-etiology leg ulcer 4 years 16.3 1 14.2 38.7 Deteriorated after
10 weeks
10 M, 39 Venous leg ulcer 3 years 5.7 4 0.0 6.2 Reduced by 59.7%
11 M, 35 Heel ulcer after cutaneous ap
transfer
21 years 0.7 2 57.1 71.4 Reduced by more
than 80%
(impossible to meas-
ure due to small size)
12 M, 58 Neuropathic diabetic heel ulcer 36 weeks 0.4 1 50 50 Healed by day 317
13 M, 37 Venous leg ulcers 9 years 8.0 / 1.5 1 12.5 /
46.6
68.8 / 80 Reduced by 72% /
healed by day 35
in in both venous and diabetic ulcers
13,14,15,16
. Crovetti,
et al., McAleer, et al., and Steenvorde, et al. reported
wound closure rates in recalcitrant ulcers between 37.5%
and 66%
4,5,6
. The results of this small sample of patients
show that 50% of all wounds healed.
Treatment with platelet-rich plasma was reserved for
patients with wounds that had not healed despite the use of
other treatment strategies. Some of these prior treatments
lasted for many years as the average duration of ulcers
treated in this study (6.8 years) shows. In those cases, the
use of platelet-rich plasma not only lead to wound closures,
but also to improved the healing time. The average healing
time for the wounds that closed was less than 6 months.
42,8% of 7 venous ulcers in this study healed within 6
months after treatment with platelet-rich plasma and two-
layer compression bandage. Nelson, et al. showed 67%
healing rates of venous ulcers within 24 weeks when us-
ing four-layer compression therapy and 49% healing rates
when using single-layer compression therapy
17
. However,
it might be difcult to compare outcomes because of the
low number of patients included in the present study.
Two minor complications in form of infection with
Pseudomonas aeruginosa were observed. Both wounds
were cultured for Pseudomonas aeruginosa prior to plate-
let gel treatment. In both cases, platelet-rich plasma was
sprayed on the wounds. The clot that forms in the wound
after spraying does not seem to be as stable as the clot
produced in a sterile container. There is also some leakage
when spraying, which may contribute to an excessively

Targeling bacteria
ano prclecling the skin
The new Mepilex /q is reconnenoeo lor wounos with increasinq siqns
ol bacterial inlluence ano where healinq ooes not proqress nornally.
Mepilex /q is a superior conbination ol silver ano Saletac solt silicone
technoloqy. Mepilex /q inactivates bacteria in 8O ninutes ano lasts lor
up to 7 oays
1
. The Saletac technoloqy nininises trauna to the wouno,
surrounoinq skin ano pain to the patient.
Molnlycke Health Care /B lpubl.l, Box 18O8O, SE-/O2 o2 0oteborq, Sweoen. Phone -/o 81 722 8O OO, www.nolnlycke.con
The synbol ano the woro nark are both reqistereo traoenarks or traoenark penoinqs ol Molnlycke Health Care.
1. Taherine|ao et al. Sustaineo ano instant antinicrobial ellect ol a silver inpreqnateo loan oressinq on
connon wouno pathoqens. Poster presentation, 17th EWM/ conqress, 0lasqow, 2OO7.
moist wound environment, creating suitable conditions
for Pseudomonas aeruginosa growth. This is another rea-
son why the external clot is preferred over the spraying
technique.
One nal reason that the externally-created clot is
preferred is that less platelet concentrate is lost during
application. When spraying platelet concentrate onto a
smaller and/or more shallow wound, some often has to be
discarded because it seeps beyond the edges of the wound.
An externally-created clot can easily be cut or formed in
accordance to ulcer size and fashion. Thus a larger amount
of growth factors are retained in the wound bed to benet
the healing process.
No pattern in the speed of wound healing could not
be discerned. Some wounds showed rapid progression of
healing after application of concentrated platelet gel, but
later slowed down, and in some cases the wounds be-
gan deteriorating again. Other wounds did not seem to
demonstrate any early healing after treatment, but showed
signicant progress by the end. There is no plausible ex-
planation for this. To date, there has been no determina-
tion of a standard treatment frequency or duration. The
treatment program of Crovetti, et al. recommends weekly
application of platelet gel. Complete healing was achieved
in 9 wounds with an average of 10 applications
4
. In this
study, wound closure occured in 7 wounds with an aver-
age of 1.7 platelet gel applications. Crovetti, et al. used a
different system to prepare platelet gel, which may have
resulted in different concentrations of platelets and growth
factors that were applied to the wounds.
A possible treatment protocol based on the experiences
gained during this study is to repeat the application of
platelet gel at least 3 times over a 6- to 9-week period,
and to measure wound sizes regularly. If the wound does
not show progress 4-6 weeks after cessation of treatment,
a new course of three applications is recommended.
A single treatment cost about 900 Euro, which makes
it a costly method. The time needed for preparation and
application of platelet-rich plasma is about 90 minutes.
However, the use of autologous platelets seems to be cost-
effective since ulcers that did not show improvement prior
to treatment healed.
Implications for Clinical Practice
The preparation and application of platelet-rich plasma
can be considered in case of non-healing wounds who do
not respond to treatment of the underlying causes and
good local wound care. The procedure of preparing plate-
let gel is easy to learn and reliable. Platelet gel prepared as
an external clot seems to be easier to handle. It probably
also allows better utilization af the amount of growth fac-
tors prepared.
Further Research
Controlled studies with sufcient sample sizes have to be
initiated. Cost-effectiveness should assessed when doing
those studies. As there are several manufacturers provid-
ing equipment for in-hospital production of platelet-rich
plasma, the different systems must be examined for differ-
ences in increase in platelets, growth factor concentrations,
preparation time, and applicability.
CONCLUSION
The use of platelet-rich plasma can be an option when
treating recalcitrant wounds of differing aetiologies.
It should be reserved to wounds that do not show any
progress after 6 months with treatment of wound aetiology
and standard wound care.
Further research in the eld is required. Controlled
studies with sufcient sample sizes are needed to prove
the efcacy of platelet-rich plasma to treat wounds. Such
studies should focus on outcomes as well as for varia-
tions in platelet counts, growth factor concentrations, and
applicability and cost-effectiveness. The results of this study
encourage the author to try to start a Norwegian multi-
center trial.
References:
1. Ernesto C. Clinical review 35: Growth factors and their potential clinical value. J Clin
Endocrinol Metabol 1992; 75: 1-4.
2. Rothe M, Falanga V. Growth factors. Arch Dermatol 1989; 125: 1390-1398.
3. Knighton DR, Ciresi K, Fiegel VD, et al. Classication and treatment of chronic non-
healing wounds. Successful treatment with autologous platelet-derived wound healing
factors (PDWHF). Ann Surg 1986; 204: 322-0.
4. Crovetti G, Martinelli G, Issi M, et al. Platelet gel for healing cutaneous chronic
wounds. Transus Apher Sci 2004; 30: 145-1.
5. McAleer JP, Kaplan E, Persich G. Efcacy of concentrated autologous platelet-derived
growth factors in chronic lower-extremity wounds. J Am Podiatr Med Assoc 2006; 96
:482-8.
6. Steenvorde P, van Doorn LP, Naves C., et al. Use of autologous platelet-rich brin on
hard-to-heal wounds. J Wound Care 2008; 17: 60-3.
7. Eppley BL, Woodall JE, Higgins J. Platelet quantication and growth factor analysis
from platelet-rich plasma: implications for wound healing. Plast Reconstr Surg 2004;
114: 1502-8.
8. Mast BA, Schultz GS. Interactions of cytokines, growth factors, and proteases in acute
and chronic wounds. Wound Repair Regen 1996; 4: 411-420.
9. Grgen M. The TIME wound management system used on 100 patients at a wound
clinic. In: Dealey C, editor; Proceedings of the 17th Conference of the European
Wound Management Association; 2007, May 2-4; Glasgow, UK. European Wound
Healing Association; 2007. p.133.
Are you lnterested ln
submlttlng an artlc|e or paper
for EWMA Journa|?
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INTRODUCTION
The main problems related to non-healing wounds
are poor cleansing and insufcient attention to
bio-burden especially in outpatient wound care
where about 90% of chronic wounds are treated.
Wound coatings activate the innate immune sys-
tem, favour the growth of bacteria, and are the
origin of reactive oxygen species (ROS)
1
and
pro-inammatory mediators. These agents de-
stroy viable tissue and trigger massive granulocyte
accumulation in the microvasculature resulting
in obstruction of microcirculation at the wound
edges
2
. Thus, the aim of wound cleansing should
be complete removal of all non-vital materials.
Thorough and gentle wound cleansing is crucial
for proper wound bed preparation allowing the
wound to heal faster.
Wound cleansing by rinsing is routinely used
in wound bed preparation. Considering the hy-
drophobic and polymeric nature of the principal
components of wound coatings it is assumed that
the type of rinsing solution may be of particu-
lar importance to the effectiveness of cleansing.
Wound coatings contain denaturated proteins,
lipids from cell debris, and cross-linked brin all
in need of a surface tension reducing agent for
removal and solubilisation.
In home care the rst choice solution for
wound cleansing is often non-sterile tap water
usually contaminated with Pseudomonas aerugi-
nosa, followed by re- or overused asks of saline
or Ringers solution often contaminated by species
of the normal human ora or the natural environ-
ment
3
. Non-sterile wound rinsing may be cost-
effective at rst glance however it is denitely not
state-of-the-art of wound management.
To compare the cleansing efciencies of wound
rinsing solutions under controlled testing condi-
tions an in vitro model that mimics wound coat-
ings was developed. Removal of test coatings
were analysed using saline, Ringers solution and
a special wound rinsing solution containing Poly
(hexamethylenbiguanide)hydrochloride (PHMB)
and a Betaine surfactant. Subsequently the in vitro
results were veried by a retrospective analysis of
healing processes of chronic wounds of the type
Ulcus cruris venosum.
MATERIAL AND METHODS
Preparation of test wound coatings
Outdated frozen fresh plasma (FFP), anti-coagu-
lated and stabilised with CPS (citrate, phosphate,
dextrose) was thawed, applied to diagnostic slides
(adhesive design) and dried on them overnight.
For brin formation one volume part of 1.8 M
CaCl2 solution was added to nine volume parts
of CPD plasma. The brin formation started im-
mediately after mixing of the volume parts on
the slide.
Wound rinsing solutions
Physiological saline solution (0.9% NaCl), Ring-
ers infusion solution (0.860% NaCl, 0.030%
KCl, and 0.033% CaCl22H2O) and a solution
containing 0.1% Polyhexamethylene Biguanide
and 0.1% Undecylenamidopropyl Betaine (Pron-
tosan
) were obtained from B. Braun Melsungen

AG.
Protein measurement
Proteins were removed from the test coatings
either by dissolving or by inclusion in micellar
colloids of detergent. Dissolved proteins were de-
tected by means of a modied Biuret reaction rea-
gent (Roti
-Quant universal, Carl Roth GmbH

& Co. KG). Soluble proteins formed complexes
of a violet colour with copper ions of the reagent
(see gure 1). The extinction at 503 nm was di-
rectly proportional to the protein concentration.
Denaturated proteins enclosed in micelles were
not detected by the Biuret reaction.
In vitro test design
Test slides with dried-on blood plasma or brin
were placed in histological staining troughs lled
with test solutions. Each test preparation was
accompanied in parallel by a blind preparation
(rinsing solution without test slides). After 2.5,
PoIyhexanide (PHM) and etaine
in wound care management
30, and 60 minutes 1.5 ml aliquots were transferred to
reaction vessels and centrifuged immediately at 2,500 g
for 2 minutes. 0.1 ml supernatant was mixed with 0.1 ml
distilled water and 0.8 ml protein reagent. The extinction
was measured within 30 minutes at 503 nm (Beckman
DU-600 photometer). After subtraction of blind values
the extinction values of probes were plotted against in-
cubation time. For calibration plots 0.1 ml test solution,
0.1 ml of a bovine serum albumin (BSA) solution, and
0.8 ml protein reagent were mixed.
Clinical data
For retrospective analysis of wound healing processes,
medical records of 112 patients with Ulcus cruris veno-
sum were evaluated. Wounds of patients were routinely
cleansed using PHMB and Betaine containing rinsing
solution (n=59) or saline and Ringers solution (n=53)
respectively. The time to wound healing in both groups
was compared statistically.
Inclusion (+) / exclusion (-) criteria were:
+ wound at least three months old
+ conrmed diagnosis Ulcus cruris venosum
+ wound treatment according to the recommendations
of moist wound treatment
+ compression therapy in cases of venous ulcers by
short stretch bandaging
+ clear documentation of the type of rinsing solution
used during wound treatment
persistent, severe arterial circulation disorders (Fon-
taine stage II)
Statistical evaluation
The time to wound healing data were analysed using the
Kaplan-Meier method and the means of the two patient
groups were compared with the log rank test. In both
patient groups there were no drop-outs. The total obser-
vation period was predisposed to six months and started
with admission. About 90% of wounds healed within the
observation period in both patient groups.
Infection rates were compared and evaluated using Fischers
chi-square test.
RESULTS
Effect of rinsing solutions on test coatings
During the incubation period of standardised test slides
(coated with either FP or brin) the protein concentration
in all three wound rinsing solutions increased almost lin-
early, thus meaning that no saturation was reached under
the test conditions. Concentrations of dissolved protein
were lowest in Ringers solution and 3.5 times (FFP) and
5 times (brin) higher in saline. Most proteins were solved
in Prontosan
. Compared with saline, the concentrations

were 25% (FFP) and 75% (brin slides) higher (see g-
ures 2a and 2b).
In contrast to saline and Ringers solution the PHMB/
Betaine containing wound rinsing solution disintegrated
test coatings and solubilised denaturated proteins by en-
closing them in micelles (see gure 3). Micellar colloids
show strong refraction and hence turbidity in the PHMB/
Betaine containing solution increased during incubation
time.
F|q. 1. Fomat|oo o/ too
v|o|ot comp|ox botwooo
o|toqoo atoms o/ popt|Jo
booJs aoJ coppo |oos o/
too 8|oot oaqoot.
F|q. 2a. Poto|o
coocootat|oos |o
too sopooataots
o/ too tost so|os
w|to FFP s||Jos.
F|q. 3. D|s|otoqat|oo o/ tost coat|oqs b, so/actaot
(tost s||Jos |ocobatoJ |o Pot|-J|soos}

Effect of rinsing solutions on wound healing
All wounds were cleansed by thorough and gentle rinsing
using either a special wound rinsing solution or saline/
Ringers solution. The effect of a simple cleansing proce-
dure is shown in gures 4 a-c.
There were signicant differences between the two
patient groups concerning wound healing. In the group
treated with PHMB/Betaine containing wound rinsing
solution the wound healing rate was faster. After three
months already 60% (n=35) of wounds were healed com-
pared to 28% (n=15) in the group treated with saline or
Ringers solution (see table 1). At the end of the observation
period of six months the healing rates in both groups were
proved satisfactory (97% and 89%). Mean time to healing
in the PHMB/Betaine group was superior to the saline/
Ringers solution group (see gure 4). In the latter there
was a healing delay of more than one month: 4.42 1.41
compared to 3.31 1.32 months (p < 0.001).
Tab|o 1. WoooJ ooa||oq atos |o pat|oots toatoJ w|to J|//ooot t,pos
o/ woooJ |os|oq so|ot|oos (lap|ao-No|o-motooJ}
number of patients 53 59
rinsing solution saline or Ringers PHMB / Betaine
time scale wound healing rate (%)
end of 1
st
month 2 7
end of 2
nd
month 9 29
end of 3
rd
month 28 59
end of 4
th
month 51 81
end of 5
th
month 68 93
end of 6
th
month 89 97
During the period of wound treatment infection rates were
3% (n=2) in the PHMB/Betaine group compared to 13%
(n=7) in the saline/Ringers solution group (p = 0.056).
DISCUSSION
When proteins are dissolved in water each protein mol-
ecule is included in a structured hydration sheath of water
molecules which prevents aggregate formation and precipi-
tation. Saline and Ringers solution, both regularly used
in wound care practices, contain monovalent and biva-
lent salt ions (Na
+
, Ca
++
or Cl
-
) which bind many water
molecules (about 185 for monovalent ions) and therefore
compete with proteins for the water molecules. Increasing
F|q. 2b. Poto|o
coocootat|oos |o
too sopooataot o/
too tost so|os w|to
hb|o s||Jos.
c} tooo Ja,s |ato a/to omov|oq o/ woooJ Joss|oqs
F|q.4. C|oaos|oq o/ J|abot|c /oot o|co
a} a/to omov|oq coovoot|ooa| woooJ Joss|oqs
b} 20 m|ootos |ato a/to c|oaos|oq os|oq PHN8 aoJ 8ota|oo
coota|o|oq woooJ |os|oq so|ot|oo
salt concentrations (exact ionic strength*) destabilize the
hydration sheaths of proteins resulting in aggregate forma-
tion and precipitation (salting-out effect). In particular
salts with polyvalent ions like Ca
++
in Ringers solution
reduce the solubility of proteins
4
.
In an in vitro model for wound coatings (FFP/brin on
adhesive glass slides) differences between wound rinsing
solutions with regard to protein solubilisation could be
demonstrated. Ringers solution, which contains 2.2 mM
divalent calcium ions was less effective than saline solu-
tion in dissolving denaturated proteins. Compared with
saline, only 20-30% of the amount of protein dissolved in
Ringers solution. A PHMB and Betaine containing special
wound rinsing solution which does not contain any salt
additive was most suitable for dissolving proteins from
test coatings. The Betaine surfactant improved protein
removal by disintegration of coatings and formation of
micellar colloids.
Results obtained by using the in vitro wound coating mod-
el were veried by retrospective analysis of chronic wounds
(venous leg ulcers). Improved cleansing efciency should
also improve wound healing by reducing oxidative stress
and levels of pro-inammatory mediators in the wounds.
Actually this hypothesis was supported by retrospective
clinical data. Wounds treated with PHMB/Betaine con-
taining wound rinsing solution revealed superior wound
healing. Mean time to healing was about three instead of
four months. Obviously the local wound milieu favoured
the occurrence of reparative processes when rinsed with
PHMB/Betaine solution. These ndings are consistent
with recent reports on effects of PHMB/Betaine solu-
tion
5,6,7
.
Another effect for better wound healing was the reduced
infection rate in the PHMB/Betaine treated patient group
(3% versus 13%, p = 0.056). Due to low overall infection
rates in the wound care unit the difference did not reach
the signicance level of 5% (p < 0.05). Infections were
treated by infusion of antibiotics. In both groups local an-
tiseptics were not applied during the period of observation.
Low infection rates during wound management reduce
complications in wound care, improve wound healing rates
and bring down costs. Considering that infection rates
below 2% are difcult to realise 3% in the PHMB/Betaine
group are near the optimum.
Wound healing is a highly complicated multifactorial proc-
ess and requires a sophisticated local wound management.
The most important point is to follow the recommenda-
tions of moist wound treatment as dened by Falanga
8
and Sibbald
9
. Typically, neutral physiological solutions
are used for that purpose. However, PHMB/Betaine con-
taining wound rinsing solutions may be superior to salt
solutions.
Betaine forms micelles and improves solubilisation of hy-
drophobic material from wounds. Poly(hexamethylenbigu
anide)hydrochloride (PHMB) is an antimicrobial agent
widely used as a preservative in commercial and in-
dustrial settings. The most common use is as an algicide,
fungicide, and sanitizer in swimming pool systems. In
medicine PHMB was introduced by Willenegger in 1994
10
as an antiseptic in abdominal surgery. Over the past years
end-use (ready-to-use) wound care products containing
PHMB have been successfully launched including wound
rinsing solutions, wound gels and dressings.
Special features qualify PHMB for growing and ef-
fective application in wound care management. To begin
with PHMB is very active against bacteria and Candida in
F|q. 5. T|mo cooso o/ woooJ ooa||oq
|o pat|oots toatoJ w|to J|//ooot t,pos
o/ |os|oq so|ot|oos. PHN8 aoJ
8ota|oo coota|o|oq woooJ |os|oq
so|ot|oo (b|oo} aoJ sa||oo o k|oqo's
so|ot|oo (oaoqo}.
* The ionic strength I of a salt is half the sum of the terms obtained by
multiplying concentration ci and charge z1 of the dissolved ions.
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2008 Pall Corporation.
, Pall and Pall-Aquasafe are trademarks of Pall
Corporation. indicates registered in the USA, and
indicates a common law trademark.
Qu/ck ConnecI/on. lmmed/aIe ProIecI/on.
low concentrations (0.01 to 0.1% (w/v)). In addition, the
acute toxicity of PHMB is low for both oral and dermal
use. The no observable effect levels (NOEL) in dogs are
90 mg/kg bw/day for systemic toxicity and 45 mg/kg bw/
day for chronic toxicity (oral route both). For individual
cases slight or moderate dermal irritations and/or allergic
type reactions were reported. However, compared with
other antimicrobial agents the safety margin of PMHB is
extremely high
11
.
CONCLUSIONS
In wound treatment cleanliness (no coatings, reduction
of detritus, removal of necrotic tissues, low microbial bio-
burden) is generally considered an important factor for
improving secondary wound healing without major prob-
lems. This fact applies to both acute and chronic wounds.
National and international professional associations and
societies recommend accepted standard procedures for
optimal wound cleansing and wound bed preparation to
obtain favourable conditions for healing. Particular atten-
tion is given to the risk of infection and to break the vicious
circle of colonisation, infection and non-healing.
In this context and in order to achieve the necrosis- and
detritus-free state of the wound great care must be taken
to ensure that there is no damage or harm to vital and
especially to naturally functional important structures.
Keeping this objective in mind, the application of PHMB/
Betaine containing wound rinsing solutions seems to be a
highly appropriate concept in supporting these effects and
to promote wound healing.
References
1. James TJ, Hughes MA, Cherry GW, Taylor RP. Evidence of oxidative stress in
chronic venous ulcers. Wound Rep Reg 2003; 11: 172-176
2. Kaehn K. Entzndungsreaktionen des Endothels und chronische Wunden.
Zeitschrift fr Wundheilung 2004; 4: 161-165
3. Gouveia JCF. Is it safe to use saline solution to clean wounds?
EWMA Journal 2007; 2: 7-12
4. Lehninger AL (ed). Biochemistry, 6
th
printing; Part1, Chapter 7:
Proteins behaviour in solution. Worth Publishers N.Y. 1972
5. Eberlein T, Fendler H, Andriessen A. Prontosan
-Lsung oder Standard-Behand-

lung? Die Schwester Der Peger 2006; 9: 2-4
6. Horrocks A: Prontosan wound irrigation and gel: management of chronic wounds.
Br J Nurs. 2006; 15: 1224-1228
7. Kramer A, Roth B, Mller G. Rudolph P, Klcker N. Inuence of the antiseptic
agents Polyhexanide and Octenidine on FL cells and on healing of experimental
supercial aseptic wounds in piglets. Skin Pharmacol Physiol 2004; 17: 141-146
8. Falanga V. Classication for Wound Bed Preparation and Stimulation of
Chronic Wounds. Wound Repair and Regeneration 2000; 8: 347352
9. Sibbald RG, Williamson D, Orstedt HL, Campbell K, Keast D, Krasner D, Sibbald D.
Preparing the Wound Bed Debridement, Bacterial Balance, and Moisture Balance.
Ostomy Wound Management 2000; 46: 1435
10. Willenegger H. Klinische Erfahrungen mit einem neuen Antiinfektivum.
Hygiene Medizin 1994; 4: 227-233
11. Kramer A. Stellenwert der Infektionsprophylaxe und therapie mit lokalen
Antiinfektiva: 15-25. In: Kramer A, Wendt M, Werner H-P (eds.). Mglichkeiten
und Perspektiven der klinischen Antiseptik. mhp-Verlag GmbH Wiesbaden 1995
Abstract
Background: Chronic wound healing is generally
a long and uncomfortable process. Consequently,
an understanding of wound-related pain from the
patients point of view and evaluation of the effect
of pain on a persons daily life is fundamental to
their holistic management.
Aim: The aim of the study was to involve patients
in discussion about their wound-related pain ex-
periences in order to inform the development of
a questionnaire, based on the views of patients
from different cultural backgrounds. This study
represented one of the preliminary phases of an
international survey which aimed to collect data
on patients wound-related pain experiences; from
15 countries world-wide.
Method: An international qualitative study was
conducted in patients presenting with chronic
wounds to identify those aspects of wound-related
pain which created most concern. French, Brit-
ish and Canadian patients with chronic wounds
participated in a series of focus group studies.
Results / Findings: Although a number of similar
patient issues were apparent in all three countries,
specic cultural differences were also observed: the
French group expressed particular concern with
body image, the British group were uncomfort-
able with medication use and the Canadian group
were anxious about nancial loss and apprehen-
sive of the healthcare system.
Conclusion: Wound-related pain can have a huge
impact on a persons everyday life and as such
each patients needs should be recognised and
considered.
INTRODUCTION
Chronic wound pain is associated with negative
mood, decreased activities of daily living, sleep
disturbance, reduced mobility and social with-
drawal
1,2,3,4,5
. Qualitative research in this area
has identied numerous aspects of pain and dis-
comfort which have a negative impact on qual-
Patients' experience of
wound-reIated pain:
an international perspective
E|lzabetb J Mudge,
MSc, BSc, MChS, SRCh,
D.Pod.M
1
Sy|vle Meaume, MD
2
Kevln Woo, RN, MSc
3
R Gary Slbba|d, MD,
FRCPC, MEd
3
Patrlcla E Prlce, PhD, BA
(Hons), AFBPsS CHPsychol
1
1.
Wound Healing Research
Unit, School of Medicine,
Cardiff University, Wales,
United Kingdom
2.
Service de Grontologie,
Hpital Charles Foix,
Ivry sur Seine, France
3.
Wound Healing Clinic,
Womens College Hospital,
University of Toronto,
Canada
Correspondence to:
Elizabeth Mudge
Cardiff University
Department of Wound
Healing
Upper Ground Floor
Heath Park
Cardiff
CF14 4XN
mudgee@whru.co.uk
ity of life among patients with chronic wounds
6
.
Activities that are important to the maintenance
of daily functioning such as working, walking,
standing and climbing stairs can often exacerbate
pain in wounds
5,7
and thus lead to restricted life-
style and a sense of connement
3
. These feelings
are often amplied by sleep disturbance and can
eventually result in social withdrawal in some in-
stances
8
. There is a strong connection between
pain and an individuals sense of well-being. Nega-
tive emotions such as anger, sadness, hopelessness
and despair are common in cases where a painful
wound is seen to control a persons existence
3,9
. It
is therefore not surprising to nd that a substantial
proportion (37.5%) of patients with venous leg
ulcers described pain as the worst aspect of hav-
ing an ulcer
10
. Various studies of patients with
venous leg ulcers
11,12,13
and diabetic foot ulcers
14
indicate that pain is signicantly associated with
diminished quality of life and forms a persons
foremost concern in their care
15
.
RESEARCH DESIGN AND METHODS
Four focus groups, each involving five or six
patients (total number of participants = 23:
10 male, 13 female) with chronic leg ulceration or
diabetic foot ulceration were conducted in France,
the United Kingdom and Canada. Focus groups
were chosen as this method can elicit a wealth of
opinions and emotional processes within a group
context. Purposive, non-probabilistic sampling
was used to identify specic people who had ex-
perience of discomfort and/or pain related to their
chronic wound. Only adult patients (18+ years
of age) with an active ulcer of over 6 weeks were
invited to participate. There were no exclusion
related to a predetermined level of intensity of
pain experienced at the time of the focus groups,
but only those who had some previous or cur-
rent experience of discomfort/pain related to their
wound were invited to participate. The inclusion
criteria were deliberately broad in order to capture
the full range of experiences related to discomfort/pain
and using a purposeful sample was deemed appropriate in
order to fully explore the participants pain experiences.
Following ethical approval and identication through
appropriate healthcare staff, patients were sent an infor-
mation sheet about the study followed by a telephone call
one week later. Those patients interested in participating
and who had provided written consent were asked attend
a specied non-clinical location for a two-hour focus group
meeting.
Each focus group was run by one or two facilitators
with experience in psychological aspects of wound heal-
ing, who explained the aim of the group, conrmed con-
dentiality and emphasized that the focus would be on
talking to each other rather than to the researchers. The
same schedule (see appendix 1) was followed in all three
countries in order to ensure consistency between groups.
The rst part of the discussion concentrated on general
wound-related pain experiences whereas in the second
phase the facilitators focused the discussion around the
topic of discomfort and/or pain during the dressing change
procedure. Pre-determined open questions/prompts were
used to facilitate conversation.
The discussions were tape recorded. The content of
the tapes were transcribed by one researcher, conrmed
by a second researcher and veried by the participants at
each location. The discussion transcriptions were evaluated
by means of content analysis
16
which enabled systematic
identication of a number of emergent themes represent-
ing the participants responses. Separate analyses were
conducted for each group and reliability of themes was
veried by a second researcher. The overall results were
then further evaluated between the three countries.
Appendlx 1. FOCUS GROUP Scbedu|e/ Prompts
Pa|o at Joss|oq coaoqo pocoJoo |o pat|oots w|to cooo|c woooJs
PART 1 - 1 Hour
Tlme Pbase Prompts
5-10 mlnutes Introductlon Introductions
Outline aims of project
30-40 mlnutes Open pbase
(Open discussion around
experiences of living with
a wound including pain
experiences)
Experience of living with a wound
Experience of pain
Intensity and description of pain
Timing of discomfort / pain
Impact of pain/ discomfort on everyday living
(including employment and impact on other family members)
10 mlnutes reak & Refresbments
PART 2 - 1 Hour
30-40 mlnutes Dlrected conversatlon Parts of the dressing change process
are they different in terms of discomfort / pain experience?
Anticipation of dressing change
Dressing removal
Cleansing
Application of new dressing
Location of the dressing change procedure
(e.g.: home, outpatient clinic or inpatient clinic)
Involvement of the patient in the process
Residual pain following change
Other aspects of wound related pain e.g.:
Infection
Surrounding skin
Other aspects of treatment related to pain e.g.:
Use of particular dressings
Antibiotics
What makes the experience worse?
What improves the experience?
What strategies help?
Is the patient able to self help?
Where does patient go to nd information on strategies to manage
pain/ discomfort?
5 mlnutes Wrap-Up and C|ose Open question to ensure that all the issues important to the patients
and relevant to the topic have been covered.

RESULTS
The participants in all three countries agreed that pain
was a constant feature of their wounds but that it varied
in intensity throughout the day. Constant pain was per-
ceived by one of the French participants to change ones
appearance; It shows in the face, whereas in the Canadian
and UK groups, adjectives such as burning, throbbing
and shooting were used to describe their everyday pain.
A more intense and sudden pain was also vividly described
which caught the participants off guard at any time dur-
ing the day or night. This pain was considered far more
distressing than their ordinary pain and was described
as follows:
Participant (France) Its as if I have a bar behind
my thigh and someone is pressing it against me and
tightening it up
Participant (UK) Its like an iron band with spikes
pressing hard
Participant (Canada) Tremendous pain, I crawl on
all fours
Participant (France) I have the sensation that some-
one is eating my esh, like a dog biting me. It hurts
terribly
Quality of Life
The impact of pain revealed a number of psychologi-
cal processes that were common regardless of gender or
culture. Many participants felt that wound-related pain
reduced their condence in carrying out everyday tasks
and in maintaining social and recreational activities. These
feelings manifested themselves by a sense of isolation and
a loss of identity which reinforced an awareness that their
lives had irreversibly changed:
Participant (France) Its only goodbye
Participant (UK) It feels like we are been taken over
to a different route in life than the one we expected
Participant (Canada) You think its never going to
end
It appeared difcult for the participants to distinguish be-
tween the impact of the ulcer and the repercussions of the
pain. Nevertheless, a number of points were emphasised.
All of the participants had encountered difculties with
walking and many were afraid of falling:
Participant (France) I havent been able to go walk-
ing outside for about six months. I cant get down
the stairs any more
Participant (UK) I always look down when I walk;
I am so afraid I am going to fall
Participant (Canada) Walking becomes worse as
neuropathy slowly progresses and youre unable to
weight-bare. I cry like a baby and I am unable to
deal with it
Driving a car had become difcult or impossible for most
of the participants thus increasing their sense of isola-
tion:
Participant (France) I recently started driving again.
But I cannot drive for long, as I can no longer feel
my foot on the pedal
Participant (UK) Because of the pain I cannot drive
anymore
Participant (Canada) You are at the mercy of some-
one else
This loss of mobility was perceived by the participants as
preventing them from independently performing various
tasks of daily living which greatly reduced their sense of
well-being and their overall quality of life.
Feeling isolated
The participants portrayed stigmatisation caused by hav-
ing a chronic ulcer. In addition to the negative appearance
of the wound and the dressings, pain also contributed to
feelings of marginalisation:
Participant (France) If I havent got my mor-
phine at those times, I just dont want to see
anybody
Participant (UK) I had to drop from things I really
enjoy
Participant (Canada) When in severe pain I do not
want to say anything or talk to my family
Social isolation was frequently linked to a sense of
shame:
Participant (France) I no longer go out because I
am ashamed of my stick and my slippers, and above
all I am afraid of falling over I dont go anywhere
unless someone comes with me. I stay at home

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Moreover the participants linked their mood state directly
to their wound which was described by one participant as
a depressing disease. Such emotions were possibly ampli-
ed by a common tendency for not wanting to burden
or bore friends or relatives with their feelings:
Participant (France) Its not difcult to talk about
it but I dont want to share this painful experience
with those close to me
Participant (UK) You cannot whinge too much to
friends otherwise you will not have any friends
you have to keep it to yourself
Participant (Canada) I am not a complainer
I dont want to be a burden
Participant (UK) A lot of people did not know
of my problem for 20 years; I kept it to myself
The participants even intimated that they would avoid
speaking to their caregivers or healthcare practitioners
about their pain, particularly if they had been seeing
them for many years as they felt that they had said it all
before.
Body image
Aesthetic considerations toward both the wound and the
dressing further impacted on the participants quality of
life and these were strongly linked with social isolation.
Negative body image was passionately discussed among
the French group:
Participant (France) A leg ulcer is very ugly
Participant (France) It (the dressing) certainly
isnt feminine. Thats why I always wear trousers
Participant (France) The bandage is lighter in
colour than my leg and is not at all attractive.
I avoid going out
Embarrassment concerning body image was augmented
by wound odour:
Participant (France) A woman sitting beside me in
a waiting-room said about another patient; That
woman doesnt wash, for sure. Its awful isnt it?
Sleep deprivation
Sleep deprivation was a common discussion point within
all the groups and had an overwhelming impact upon their
ability to cope with pain and their quality of life:
Participant (France) At night sometimes it is
so bad that I wake up
Participant (UK) Every night youd be rubbing
your leg, you dont know what to do, I get up in
the night and walk about, anything, then go back
to bed
Participant (Canada) I am constantly watching
the news or clock for distraction at night
Healthcare system
Frustration with the healthcare system was reported to
have a negative inuence on wound-related pain experi-
ence for some of the participants and was the focus of
considerable discussion in the Canadian group. Particular
issues concerning frequent turn around of nurses, incon-
sistency of care, misunderstanding of pain and lack of
information caused the participants to loose faith in their
healthcare system:
Participant (Canada) Healthcare providers are
geared toward acute injuries; they have no under-
standing of chronic ulcers
Furthermore, nancial concerns due to time taken off work
to attend healthcare appointments or misunderstanding of
their condition led to much anxiety and distress:
Participant (Canada) My work cut off my pension
(because they did not consider me to be disabled
enough)
Dressing change
Anticipation of the dressing change produced a mixture of
positive and negative emotions, but having a fresh dress-
ing put on the wound was generally perceived to be a very
painful and fearful time for the participants and represent-
ed a permanent reminder of the existence of their wound.
Favourable aspects arose from the fact that changing the
dressing relieved the compression, allowed them to bathe
their feet and legs or take a shower, observe any changes
in the wound and to see the nurse who, in some cases,
would be the only social contact of the day.
Dressing the wound was linked to pain and many pa-
tients took some form of analgesia before their appoint-
ment. Pain was particularly intense when the dressing had
adhered to the wound and also during cleansing of the
ulcer. In some instances fearful anticipation of these pro-
cedures was intensied by past memories:

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Participant (France) When she scrapes, thats the
worst moment
Participant (UK) Once you disturb it when you do
a dressing youve got to wait at least half an hour af-
terwards for it to settle down where you just
dont want to move from the spot
Participant (Canada) When the blade comes out,
thats when my pain level goes through the roof
Some participants stated that the dressing change proce-
dure was made worse if the ulcer was left exposed/uncov-
ered for long periods of time and this was linked to a fear
and a misunderstanding of infection. Such concerns were
amplied by a sense that there were inadequate numbers of
staff or resources and that the dressing change procedure
was out of their control. However, many participants re-
ported that they felt the dressing change procedure could
be improved by continuity of care, regular or familiar
healthcare professionals and having a good support net-
work.
Medication
Concern about long term use or reliance on pain-relieving
medication and fear of poly pharmacy was highlighted by
the UK participants and created prominent discussion
in this group. Those participants who took pain-killers
reported that the possibility of delay of the dressing change
would cause anxiety which was based on fear that their an-
algesia could wear off. Many of the participants admitted
to using alcohol to calm their nerves yet were concerned
about stigma associated with addiction to pain-relieving
medication or getting so used to taking tablets that they
would lose their effect:
Participant (UK) I dont like taking a lot of tablets,
not through choice, some tablets make me sick
I mean you take all these tablets over the years and
it says do not take alcohol and you think oh what
the hell, a glass of red wine will do wonders
Participant (UK) Ive just stopped now (taking
analgesics) and try to tolerate the pain you know
because you just dont know what these (tablets)
are doing to your insides over the years
Infection
Overwhelmingly the greatest perceived concern in all
three countries was that of infection and this was ampli-
ed by the knowledge that infection intensied pain. The
participants expressed constant fear of infection and this
was particularly prominent during the dressing change
procedure, as many believed that their wound was only at
risk of infection when it was uncovered:
Participant (France) Its excruciating, its awful
Participant (UK) It never sees the light of day so
how does it get infected?
Participant (Canada) You live in fear of getting an
infection, you do everything you can and then they
say you have an infection and you start the battle all
over again
DISCUSSION
It is impossible for patients to forget about their chronic
wounds when their everyday life tends to revolve around
their condition. The combined effect of persistent wound-
related pain and spontaneous intermittent bursts of in-
tense pain are debilitating and distressing for patients yet,
although the participants in this study found it difcult
to cope with the unpredictable nature of their pain, they
were reluctant to talk about it with friends and family. An
insidious progression toward marginalisation and isolation
appeared to be a direct result of pain and as a consequence
impacted on the participants ability to carry out everyday
activities. This was amplied by negative physical appear-
ance, odour, uncertainty of the healthcare system, and
misunderstanding and fear of infection.
The participants in this study, particularly those in
the French group, emphasised feelings of shame about
the appearance of their wound/dressings and accentuated
that pain led to negative facial expression, subdued body
appearance and a reluctance to socialise. Psychological re-
search in the area of body image reinforces the view that
attractiveness is valued highly within all societies and that
the less conventionally attractive receive less in the way of
support from others which can result in a decrease in self
esteem and negative self-image
17
. Furthermore a denite
relationship has been observed between depression and
negative body image
18
. Studies of health-related quality
of life suggest that patients with chronic conditions adapt
over time to their altered lifestyle
4
, however it would ap-
pear that the participants in this study were reluctant to
accept their new status in society.
Ineffective treatment of pain is a constant nding in
the research
19
and never being completely free of pain may
have a signicant inuence on a persons evaluation of their
healthcare in general. This is perhaps enhanced in patients
with chronic wounds due to a limited understanding of
their condition
9
, an over-reliance on other people and a
tendency to base current perceptions (particularly of the
dressing change process) on previous negative experiences.
Yet for some of the participants an unrealistic expecta-

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tion that pain should be tolerated was preferable to the
perceived stigma of becoming reliant on pain relieving
medication.
Fear of infection appeared to be a constant source
of anxiety among all the participants regardless of cul-
tural background and these feelings were reinforced by
inadequate explanation of the cause of infection. There
is little evidence of the impact of wound-related pain on
factors such as hope and optimism but it could be as-
sumed that constant episodes of unexplained infection
and persistent pain would have a negative inuence on a
persons emotional health or their ability to maintain an
optimistic outlook. Participants in this study were known
to have a history of pain, and consequently may not be
truly representative of all patients with chronic wounds.
However, research has indicated that substantial numbers
of patients report pain as one of the worst aspects of their
condition
20,21
.
CONCLUSION
The impact of pain on a persons life is a multifaceted and
individual experience and its overall effect should never be
underestimated. Patients day to day lives are permanently
dictated by their condition which presents a constant re-
minder that they have a wound. Pain is ever-present and
at times can be difcult to tolerate, leading to difculties
in carrying out daily tasks, a reduced feeling of well-being
and social isolation. A conict of interest can exist when
the trajectory of patient management is focused on healing
yet the patients aspirations are to feel pain-free so that they
can take up everyday activities once more.
Implications for clinical practice
The impact of pain plays a huge part of the patients
life.
Each individual patients needs should be recognised
and re-evaluated regularly.
Giving patients the opportunity to talk about their
pain experiences with others who understand can be
extremely comforting.
Further Research
A questionnaire has been developed based on the
results from this study and this has been used in an
international survey which aimed to collect data on
patients wound-related pain experiences; from 15
countries world-wide.
Potential Conict of Interest: This work is supported by
an unrestricted educational grant from Mlnlycke Health
Care.
Acknowledgements: The authors would like to thank the
participants, nurses and staff at
Hpital Charles Foix, Ivry-sur-Seine, France,
the Wound Healing Research Unit, Cardiff University,
Wales, UK and
Womens College Hospital, Toronto, Ontario, Canada.
References
1. Franks PJ, Moffatt CJ, Connolly M, Bosanquet N, Oldroyd M, Greenhalgh RM,
McCollum CN. (1994). Community Leg Ulcer Clinics: Effect on quality of life.
Po|obo|oq, 9: 83-86
2. Price P. An holistic approach to wound pain in patients with chronic leg ulceration.
WoooJs (2005) 17 (3): 55-57
3. Ebbeskog B, Ekman SL. Elderly persons experiences of living with venous leg ulcer:
living in a dialectal relationship between freedom and imprisonment. ScaoJ|oav|ao
Ioooa| o/ Ca|oq Sc|ooco (2001) 15(3): 235-43.
4. Price P and Harding KG. Measuring Health Related Quality of Life in Patients with
Chronic Leg Ulcers. WoooJs (1996) 8 (3): 91-94
5. Walshe C. Living with a venous leg ulcer: a descriptive study of patients experiences.
Ioooa| o/ AJvaocoJ Nos|oq (1995) 22 (6): 1092-100.
6. Krasner D. The chronic wound pain experience: a conceptual model. Ostom, aoJ
WoooJ Naoaqomoot (1995) 41(3): 20-35.
7. Pieper B and DiNardo E. Reasons for non-attendance for the treatment of Venous
Ulcers in an inner-city clinic. I WoooJ Ostom, aoJ Coot|oooco Nos|oq. (1998)
25(4): 180-6.
8. Noonan L, Burge SM. Venous leg ulcer: is pain a problem? Po|obo|oq, (1998) 13:
14-19.
9. Charles H. The impact of leg ulcers on patients quality of life Po/oss|ooa| Noso
(1995) 10 (9) : 571-574
10. Hamer, C. Cullum N.A. Roe B.H. Patients perceptions of chronic venous leg ulcers.
Ioooa| o/ WoooJ Cao (1994) 3 (2): 99-101.
11. Hareendran, A. Bradbury, A. Budd, J. Geroulakos, G. Hobbs, R. Kenkre, J. Simonds,
T. Measuring the impact of venous leg ulcers on quality of life. Ioooa| o/ WoooJ
Cao (2005) 14 (2): 53-57.
12. Douglas V. Living with a chronic leg ulcer: an insight into patients experiences
and feelings. Ioooa| o/ WoooJ Cao (2001) 10 (9): 355-360
13. Krasner D. Painful venous ulcers: themes and stories about living with the pain
and suffering. I WoooJ Ostom, Coot|oooco Nose (1998) 25(3): 158-68.
14. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T. Health-related quality of life
among patients with diabetes and foot ulcers: association with demographic
and clinical characteristics. Ioooa| o/ D|abotos aoJ |ts Comp||cat|oos. (2007)
21: 227-236.
15. Briggs M, Closs SJ. Patients perceptions of the impact of treatments and products
on their pain experience of leg ulcer pain. Ioooa| o/ WoooJ Cao (2006) 15 (8):
333-337.
16 Stemler S. An overview of content analysis. Pact|ca| Assossmoot kosoaco aoJ
Eva|oat|oo. 7 (17): 1-9.
17. Newell R. Body-image disturbances: cognitive behaviour formulation and interven-
tion. Ioooa| o/ AJvaocoJ Nos|oq (1991) 16: 1400-1405
18. Noles SW, Cash TF, Winstead BA. Body image, physical attractiveness and depres-
sion. Ioooa| o/ Cooso|t|oq aoJ C||o|ca| Ps,coo|oq, (1985) 53 (1): 88- 94.
19. Persoon, A. Heinen, M.M. van der Vleuten, C.J.M. de Rooij, M.J. van de Kerkhof,
P.C.M. van Achterberg, T. Leg ulcers: a review of their impact on daily life.
Ioooa| o/ C||o|ca| Nos|oq (2004) 13: 341-354.
20. Nemeth KA, Harrison MB, Graham ID, Burke S. Pain in pure and mixed aetiology
venous leg ulcers: a three phase point prevalence study. Ioooa| o/ WoooJ Cao
(2003) 12 (9): 336-340
21. Hofman D, Ryan T, Arnold F et al. Pain in venous leg ulcers. Ioooa| o/ WoooJ Cao
(1997) 6 (5): 222-224
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Georglna Getbln
PhD, HE Dip Wound healing,
RGN, Dip Anatomy,
Dip Physiology, Lecturer
Research Centre
Faculty of Nursing and
Midwifery
Royal College of Surgeons
in Ireland
123 St Stephens Green
Dublin 2, Ireland
ggethin@rcsi.ie
INTRODUCTION
Chronic wounds are characterised by duration,
prolonged inammation, increased risk of in-
fection and are associated with either a local or
systemic altered physiological state. Slough is an
impediment to healing in these wounds as it pro-
vides a stimulus for inammation, the optimal
culture medium for bacterial proliferation, im-
pedes epithelial edge advancement, and impairs
visualisation of the wound bed
1,2
. Additionally it
increases exudate production and malodour
3
.
Many case studies and randomised control-
led trials (RCTs) report the efcacy of honey in
rapidly removing slough from a variety of wound
aetiologies
4-10
. There is however, variability in the
type of honey used and the method of outcome
evaluation thus reducing the potential for com-
bined evaluation of efcacy, except in the case of
Manuka honey
10
. This limitation applies to other
RCTs which have evaluated the efcacy of topical
agents to deslough wounds
11-13
.
UNDERSTANDING SLOUGH
Slough is a form of necrotic tissue which is vis-
ible on the surface of the wounds as moist, loose,
stringy tissue, typically yellow and represents a
complex mixture of brin, deoxyribonucleo-pro-
tein, serous exudate, leucocytes and bacteria
14
.
This tissue tends to accumulate continually in
chronic wounds because such wounds generally
result from underlying and uncorrected patho-
genic abnormalities such as diabetes mellitus or
venous insufciency
1
. Slough is related to the in-
ammatory phase of wound healing when dead
cells accumulate in exudate but the body normally
keeps pace with the its build up through a natu-
ral process of autolysis. Autolytic debridement of
slough is achieved by the body as it generates an
endogenous system capable of natural removal of
unwanted material
15
. During the normal wound
healing process leukocytes enter the wounds with
removal of devitalised tissue and foreign mate-
rial
15
.
Ef6cacy of honey
as a desIoughing agent:
overview of current evidence
Persistent necrotic tissue in the wound provides a
nidus for infection which in turn is associated with
the release of bacterial exotoxins into the wound,
consequently, inducing a continuous state of early
inammation and preventing the progression onto
healing (Himel 1995). Some bacteria produce am-
monia which, in itself, is necrotizing and can im-
pair oxygenation of the tissues by raising the pH
16
.
Alkalinity supports the activity levels of many pro-
teases in wound uid, consequently promoting
degradation of the extracellular matrix (ECM) and
key functional molecules such as growth factors of
the wound
17,18
. An elevated alkaline environment,
as recorded in chronic wounds is invariability cor-
related with non-healing
19-21
.
Slough and necrotic tissue also cause hypoxia
in the wound area which inhibits development
of granulation tissue and slows re-epithelization
(Konig et al. 2005). Furthermore, migration of
lymphocytes and macrophages is hampered in the
presence of slough or necrotic tissue
12,22
.
A prolonged inflammatory response and the
lack of regulation of protease activity in chronic
wounds results in degradation of the components
of the extra cellular matrix by the same processes
that normally have protective and restorative func-
tions, leading to the eventual tissue breakdown,
seen in chronic wounds
23
. This continual break-
down of wound tissue is visible as slough in the
wound bed.
It therefore follows that wound healing is
delayed in its presence and while many topical
treatment options are available for its removal, to
date, systematic reviews have concluded that no
one agent has demonstrated superior efcacy over
another and there are no studies which compare
debriding with no debriding
24,25
. In one systemat-
ic review, however, of the management of diabetic
there is evidence to suggest that hydrogel increases
the healing of diabetic foot ulcers compared with
gauze or standard wound care but it is not clear if

this effect is due to debridement
26
. Moreover, while there
are no studies of debridement versus no debridement it is
not clear what percentage of the wound should be covered
in slough to signicantly affect wound healing.
The advantages to wound healing when wounds are deb-
rided are well documented
1,2
and can be summarised into
4 key areas as in Table 1.
Tab|o 1. AJvaotaqos o/ woooJ Job|Jomoot
Wound factors Potentla| outcome
Extent Allows visualisation of full depth and extent of the
wound
Consequence Reduces the possibility for infection, sepsis, or
amputation. Decreases exudate and malodour.
Investigation Allows tissue samples or culture swabs to be tak-
en from depth of wound. Facilitates visualisation
of all structures exposed in the wound
Outcome Removes impediments to wound healing such as
debris, slough, bacteria, and exudate.
HONEY AND WOUND HEALING
Honey has been used in wound management for over
4500 years
27
. Its use declined in the early 1900s with the
advent of antibiotics and a move towards modern wound
treatment options. A renewed interest in its use in wound
management in the last two decades is evidenced by in-
creasing numbers of in vitro and in vivo studies within the
literature
28
. However, honey is not a generic entity. The
variation in colour, taste, consistency, water content and
acidity is due to both the plant species and the foraging bee
together with the local climate and soil characteristics
29
. In
vitro studies have investigated the variability in antimicro-
bial properties, and have demonstrated clear differences in
the efcacy of honey as an antibacterial agent with Manuka
honey demonstrating efcacy against a wide range of or-
ganisms including; Methicillin resistant staphylococcus
aureus (MRSA) and vancomycin resistant enterococcus
(VRE)
30-32
. Currently, no clinical studies are published
in which direct comparison of different honeys used in
wounds have been made.
METHODS OF WOUND DERIDEMENT
There are many excellent texts which outline the options
for wound debridement and it would not be prudent to
revisit these here. The method used is dependent on the
aetiology of the wound, the skills, expertise, knowledge,
and resources of the clinician together with patient and
clinician treatment goals. The principle mode of action
of honey in wound debridement is through autolysis and
thus will be explored here.
Autolytic debridement is dependent on the local wound
environment, in particular the state of wound hydration;
but also the wound temperature, pH and enzymatic co-
factors availability
15
. Autolytic is the most selective form of
debridement, it requires minimal clinical training, is pain-
less and although slow, it leaves a clearly demarcated line
between the living and dead tissue
15,33
. It does however,
require at least some level of exudate to be effective
15
. A
limitation of this method is that older populations pro-
duce decreased amounts of endogenous proteases, such
as collagenase in their wound uid
1
. Baherastani
2
argues
that this resultant decreased production and activity of
endogenous collagenase may lead to insufcient debride-
ment of necrotic tissue, decreased deposition of granula-
tion tissue and matrix remodelling as well as decreased
proliferation and migration of keratinocytes. A further
limitation of this method is that it is not recommended
for clinically infected wounds or in those with a high po-
tential for anaerobic infection or if there is ischaemia of
the limb or digits
2,15,34
.
Autolytic debridement occurs to some extent in all
wounds, is a highly selective process whereby macrophages
phagocytise bacteria and endogenous proteolytic enzymes
such as collagenase, elastase, myeloperoxidase liquefy and
spontaneously separate necrotic tissue and pseudoeschar
from healthy tissue
2
. The wounds own uid contains
macrophages, and neutrophils that digest and solubilize
necrotic tissue
33
.
HOW HONEY CONTRIUTES TO
WOUND DERIDEMENT
Honey is a highly osmolar substance
35,36
. Colloidal honey
has a low osmotic pressure and when applied to wounds,
goes through a physiological change
37
. When in contact
with wound tissue, the hygroscopic quality of the honey
permits dilution by the tissue uids, so that the colloidal
sugar passes into molecular solution, the osmotic pressure
increases and plasmolysis becomes more active
37
. The high
osmolarity supports the outow of uid from deep wound
tissue to the surface tissue aiding cleansing, debridement
and reducing oedema and decreasing pain
35,36
. Moist
dressings (such as honey) allow endogenous enzymes in
the wound uid to liquefy necrotic tissue selectively
33
.
Chirife et al. (1983) investigated this outow of uid and
concluded that the application of sugar promotes move-
ment of water from an area of high concentration to an
area of low concentration thus, contributing to wound
cleansing. It is argued that this osmotic pressure could
possibly dehydrate delicate new cells in the wound and
thus delay healing
27
. Conversely, Chirife et al. [38] pro-
posed that in living organisms, a ux of water from the
inner regions replaces water as fast as it is transferred from
the surrounding cells to the wound surface; consequently
external tissue remains wet, and the healing process is not
adversely affected. Cooper (2001) supports this theory, as
movement of uid in response to this osmotic pull leads to
improvement in the microcirculation and increased levels
of dissolved oxygen and nutrients.
Of all the cells involved in the wound healing process,
monocytes are one of the most important as they contrib-
ute to the inammatory phase and play a role in wound
debridement. The effect of Manuka, pasture and arti-
cial honey on production of reactive oxygen intermediates
(ROIs), and Tissue Necrosis Factor alpha (TNF) release
in human monocytic cells demonstrated a spontaneous
release of TNF- from resting monocytic cells in vitro in
the presence of Manuka and pasture honey; but not with
articial honey
39
. The authors of the latter study suggested
that an unidentied component within these honeys may
be responsible and that honey modulated the activation
of monocytic cells in vitro without affecting viability and
this modulation gives inhibitory and stimulatory effects
39
.
This would suggest that Manuka honey is a stimulus for
wound debridement as it supports the cells necessary for
this action.
Autolytic debridement is pH sensitive and research has
shown that the application of Manuka honey can signi-
cantly reduce surface pH of chronic non-healing wounds
over a two week period (p < 0.001)
19
. Whether this effect
would contribute to preventing the build up of slough or
facilitate its removal is not clear but a reduction in 0.1 pH
unit was associated with an 8.1% reduction in wound size
(p < 0.029)
19
.
The literature records many case studies of honey effective-
ly removing slough from both acute and chronic wounds.
A pilot study using Honeysoft
(Mediprof, The Nether-

lands) reported on thirteen complex wounds of varying
aetiologies which were effectively debrided with reduced
exudate, malodour and improved epithelization over three
weeks
40
. This rapid debridement was also achieved when
a local honey (Nigerian) was used in the treatment of 43
cases of pyomyositis abscess in children
41
. Honey was ap-
plied daily and the authors reported shorter duration of
antibiotic use and hospital study when honey was used.
Other single case studies report rapid debridement of
between 2 days and three weeks in a variety of wound
aetiologies when honey dressings were used
7,9,42
. As case
studies do not prove a cause and effect relationship and
as the types of honey varied between cases, a more robust
approach to quantifying efcacy is required. One RCT
(described below) addressed this issue
10
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One hundred and eight patients with venous ulcers in

which 50% of the wound bed was covered in slough
were randomly assigned to either Manuka honey dress-
ing or Hydrogel therapy
10
. Wounds were dressed weekly
for four weeks and compression therapy continued in all
cases. The performance of both agents was highly clini-
cally signicant as the mean wound area covered in slough
decreased to 29% in honey group vs 43% in hydrogel
(p 0.065). While this was not an equivalence study it does
quantify the desloughing efcacy of both agents when
slough was the predominant tissue type. This study adds to
our body of knowledge as it investigated a specic sub-set
of venous ulcers i.e. having > 50% slough in wound bed
and quantied the expected healing rates after 12 weeks.
A further important nding in the latter study was that
wounds in which >50% slough was removed by week 4
had a greater probability of healing at week 12 (CI 1.92,
9.7, RR 3.3, p 0.029). This supports the expert opinion
that removal of slough promotes healing.
Direct comparison of desloughing efcacy of Manuka
honey with other studies is limited as slough was not the
predominant tissue type in other studies, the method of
outcome evaluation was very subjective and the duration
of the studies was very short
11-13
. Based on these studies,
honey can be said to be slower than larvae but faster than
some hydrogels, enzymatic agents, or hydrocolloids. Fu-
ture studies investigating desloughing efcacy of topical
agents should provide details of how outcomes were evalu-
ated, monitor patients up to 12 weeks and have slough
as the predominant tissue type. In so doing, efcacy and
impact on healing can be determined.
Foul odour is associated with necrotic tissue and is usually
caused by supercial bacterial colonisation. Malodour is
distressing for patients and indeed may affect compliance
with treatment regimes. Large case series and individual
case studies have reported honey as very effective in reduc-
ing malodour in chronic sloughy wounds
40,43
.
To maintain optimal effect of honey as a topical agent, it
is recommended that honey should stay in contact with
the wound. The ability of honey to maintain wound con-
tact and deslough is inuenced by the type of secondary
dressing, type of honey dressing used, level of exudate
and the frequency of dressing change
28
. NICE
44
guide-
lines recommend that choice of debriding agent should
be based on impact on comfort, odour control and other
aspects relevant to patient acceptability. Lewis
25
further
recommends that selection of debriding agents should be
guided by good evidence and cost. Honey and in par-
ticular Manuka honey meets many of these requirements
although cost benet analysis of its use as a debriding
agent is lacking.
CONCLUSION
Honey can be considered as an effective desloughing agent,
particularly in chronic wounds. The mode of action while
not completely understood, incorporates; natural cleansing
through the osmotic pressure it generates at the wound
surface; reduction in surface pH thus reducing potential
for protease activity; autolytic debridement through main-
taining a moist environment; antimicrobial properties
which reduces the potential for production of bacterial
endotoxins.
1 Himel H. Wound Healing: focus on the chronic
wound. Wounds. 1995;supp A(5):70A-7A.
2 Baharestani M. The clinical relevance of debride-
ment. Heidelberg: Springer-Verlag 1999.
3 Dealey C. The care of wounds: a guide for nurses.
3rd ed: Blackwell Publishing 2005.
4 Efem SEE. Clinical observations on the wound heal-
ing properties of honey. British Journal of Surgery.
1988;75:679-81.
5 Green AE. Wound healing properties of honey. British
Journal of Surgery. 1988;75(12):1278.
6 Hejase MJ, Simonin JE, Bihrle R, Coogan CL. Genital
Fourniers gangrene: experience with 38 patients.
Urology. 1996;47(5):734-9.
7 Dunford C, Cooper RA, Molan PC. Using honey as
a dressing for infected skin lesions. Nursing Times.
2000;96(NTPLUS 14):7-9.
8 Natarajan S, Williamson D, Grey J, Harding KG,
Cooper RA. Healing of an MRSA-colonised, hy-
droxyurea-induced leg ulcer with honey. J Dermatol
Treat. 2001;12:33-6.
9 Van der Weyden EA. The use of honey for the treat-
ment of two patients with pressure ulcers. British
Journal of Community Nursing. 2003;8(12):S14-20.
10 Gethin G, Cowman S. Manuka honey vs Hydrogel to
deslough venous leg ulcers: A Randomised Control-
led Trial. Paper presented at 17th EWMA Confer-
ence: 2-4 May 2007: Glasgow, UK. EWMA Journal
- Supplement, 2007, vol 7, May, p 28.
11 Colin D, Kurring PA, Quinlan D. Managing
sloughy pressure sores. Journal of Wound Care.
1996;5(10):444-6.
12 Thomas S, Fear M. Comparing two dressings for
wound debridement. Journal of Wound Care.
1993;2(5):272-4.
13 Wayman J, Nirojogi V, Walker A, Sowinski A, Walker
M. The cost effectiveness of larval therapy in venous
ulcers. Journal of Tissue Viability. 2000;10(3):91-4.
14 Thomas AM, Harding KG, Moore K. The structure
and composition of chronic wound eschar. Journal of
Wound Care. 1999;8(6):285-7.
15 Ayello E, Cuddigan J. Debridment: controlling the
necrotic/cellular burden. Advances in skin and wound
care. 2004;17(2):66-75.
16 Leveen H, Falk G, Borek B, Diaz C, Lyneld Y,
Wynkoop B, et al. Chemical acidication of wounds
An adjuvant to healing and the unfavourable action
of alkalinity and ammonia. Annals Surgery. 1973
December;178(6):745-50.
17 Greener B, Hughes A, Bannister N, Douglass J. Pro-
teases and pH in chronic wounds. Journal of Wound
Care. 2005;14(2):59-61.
18 Trengove N, Stacy M, Maculey S, Bennett N, Gibson
J, Burslem F, et al. Analysis of the acute and chronic
wound environments: the role of proteases and their
inhibitors. Wound Repair and Regeneration. 1999
November-December;7:442-52.
19 Gethin G, Cowman S. Change in pH of chronic
wounds when a honey dressing is used. International
Wound Journal. 2007;in press.
20 Tsukada K, Tokunaga K, Iwama T, Mishima Y. The
pH changes of pressure ulcers related to the healing
process of wounds. Wounds: a compendium of clini-
cal research and practice. 1992;4(1):16-20.
21 Romanelli M, Schipani E, Piaggesi A, Barachini P.
Evaluation of surface pH on venous leg ulcers under
Allevyn dressings. London: The Royal Society of
Medicine Press 1997.
22 Morrison M, Moffatt C. A Colour Guide to the As-
sessment and Management of Leg Ulcers. 2nd ed.
London: Mosby 1994.
23 Schultz G, Mozingo D, Romanelli M, Claxton K.
Wound healing and TIME: new concepts and scien-
tic applications. Wound Repair and Regeneration.
2005;13(4):S1-S11.
24 Bradley M, Cullum N, Sheldon T. The debridement
of chronic wounds: A systematic review. Health
Technology Assessment. 1999 September 1999;3(17
Pt 1).
25 Lewis R, Whiting P, ter Riet G, OMeara S, Glanville
J. A rapid and systematic review of the clinical effec-
tiveness and cost-effectiveness of debriding agents in
treating surgical wounds healing by secondary inten-
tion. Health Technology Assessment. 2001;5(14).
26 Smith J. Debridement of diabetic foot ulcers. The
Cochrane database of systematic reviews 2002:Art.
No. CD003556. DOI: 10.1002/14651858.
27 Forrest R. Early history of wound treatment1. Journal
of Royal Society of medicine. 1982 March;75:198-
205.
MICROSPHERES FOR MEDICINE & BIOTECHNOLOGY
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range of chronic wounds
which were incurable by
conventional treatments.
Our wound-care products
are easily applied by the
caregiver or patient and
signicantly reduce the
hospitalization period and
treatment costs.
Drinaghan, Knocknarea, Sligo, Ireland
To: President, European Wound Management Association
Re: Research Grant
Date: 22/04/2007
Dear Prof Vowden,
In 2003 I was the proud recipient of a research grant from EWMA at the
conference in Pisa, Italy. This grant of 10,000 was made towards my
research on the use of Manuka honey in venous ulceration.
As a consequence of this grant I was able to continue with my studies
which up to that point has been completed without funding. Following
this, I applied to the Health Research Board of Ireland for a clinical
research fellowship in nursing and midwifery and was granted this in
2004. The international review process for this application recognised the
grant aid that was already received. The research board recommended
that my studies continue to PhD which they would fund accordingly.
After almost 5 years of study the RCT which compared Manuka honey to
a standard agent to deslough venous ulcers will be presented for the rst
time at the EWMA conference in Glasgow. Throughout the course of my
studies I have completed other research on wound measuring, wound pH
and wound assessment, and again I have presented these through EWMA
conference and journal.
In each publication and in each presentation I have been proud to
acknowledge the grant aid from EWMA and wish to thank you for the
contribution this organisation has made to my studies and career. On my
return to Ireland from Glasgow I look forward to nalising and submitting
my PhD thesis.
Thanking you again Cooq|oa Coto|o
28 Molan P. The evidence supporting the use of honey
as a wound dressing. Lower Extremity Wounds.
2006;5(1):40-54.
29 White JW, Doner LW. Honey composition and prop-
erties. Beekeeping in the United States agricultural
handbook number 335. 1980 October.
30 Cooper R, Molan P, Harding KG. Antibacterial activ-
ity of honey against strains of Staphylococcus aureus
from infected wounds. Journal of Royal Society of
Medicine. 1999;92:283-5.
31 Cooper R, Molan P, Harding KG. The sensitivity of
honey to Gram-positive cocci of clinical signicance
isolated from wounds. Journal of Applied Microbiol-
ogy. 2002;93(5):857-63.
32 French V, Cooper R, Molan P. The antibacterial
activity of honey against coagulase-negative sta-
phylococci. Journal of Antimicrobial Chemotherapy.
2005;56:228-31.
33 Sieggreen M, Malkebust J. Debridement: choices and
challenges. Advances in wound care. 1997;10(2):32-
7.
34 Davies P. Current thinking on the management of
necrotic and sloughy wounds. Professional Nurse.
2004;19(10):34-6.
35 Thomas S. Functions of a wound dressing in: Wound
Management and Dressings. London: The Pharma-
ceutical Press. 1990.
36 Cooper RA. How does honey heal wounds? In: Munn
P, Jones R, eds. Honey and Healing. United King-
dom: International Bee Research Association. 2001.
37 Seymore F, West F. Honey - its role in medicine.
Medical Times. 1951;79(2):104-7.
38 Chirife J, Herszage L, Joseph A, Kohn E. In vitro study
of bacterial growth inhibition in concentrated sugar
solutions; Microbiological basis for the use of sugar
in treating infected wounds. Antimicrobial Agents
and Chemotherpy. 1983;23(5):766-73.
39 Tonks A, Cooper RA, Price AJ, Molan PC, Jones KP.
Stimulation of TNF-alpha release in monocytes by
honey. Cytokine. 2001;14(4):240-2.
40 Ahmed A, Hoekstra M, Hage J, Karim R. Honey-
medicated dressing: transformation of an ancient
remedy into modern therapy. Annals of Plastic
Surgery. 2003;50(2):143-8.
41 Okeniyi J, Olubanjo O, Ogunlesi T, Oyelami O. Com-
parison of healing in incised abscess wounds with
honey and EUSOL dressing. The Journal of Alterna-
tive and Complementary medicine. 2005;11(3):511-
3.
42 Gray D. Mesitran Ointment Case Studies. Wounds
Uk Honey Supplement. 2005;1(3):32-5.
43 Dunford CE, Hanano R. Acceptability to patients of
a honey dressing for non-healing venous leg ulcers.
Journal of Wound Care. 2004;13(5):193-7.
44 NICE. Guidance on the use of debriding agents and
specialist wound care clinics for difcult to heal surgi-
cal wounds. National Institute for Clinical Excellence,
Technology Appraisal Guidance -No 24. 2001(24).
Sa||y e||-Syer, MSc
Review Group Co-ordinator
Cochrane Wounds Group
Department of
Health Sciences
Area 2
Seebohm Rowntree Building
University of York
York,
United Kingdom
sembs1@york.ac.uk
ABSTRACTS OF RECENT
COCHRANE REVIEWS
EWM
Publication in The Cochrane Library Issue 2, 2008:
Vltamln C for preventlng and treatlng
tetanus [Review]
Heml|a H, Kolvu|a TT
Too Cocoaoo Databaso o/ S,stomat|c kov|ows
To be published in Issue 2, 2008 Copyright 2005
The Cochrane Collaboration. Published by John Wiley
& Sons, Ltd.:
ASTRACT
ackground: Tetanus is a severe infection that can be
prevented by vaccination. In developing countries
vaccination coverage is not always high and in devel-
oped countries cases may still occur, particularly in
elderly people owing to their reduced immunoprotec-
tion. It has been estimated that there are about one
million cases of tetanus per year globally. In animal
studies, vitamin C protected against various infections.
In a study with rats, vitamin C protected against
tetanus toxin.
Ob[ectlves: To assess the prophylactic and therapeutic
effect of vitamin C in tetanus.
Searcb strategy: We searched the Cochrane Central
Register of Controlled Trials (CENTRAL) (The
Cochrane Library, 2007, issue 4), MEDLINE (1950 to
January 2008), EMBASE (1980 to 2008 Week 03), the
Cochrane Wounds Group Specialised Register (January
2008), the Cochrane Infectious Diseases Group
Specialised Register (June 2007), and the reference
lists of relevant reviews and monographs.
Se|ectlon crlterla: We included controlled trials of
vitamin C as a prevention or treatment for tetanus,
whether or not placebo controlled, in any language,
published or unpublished. Two authors independently
made inclusion decisions.
Data co||ectlon and ana|ysls: Both review authors
independently extracted data from trial reports.
Maln resu|ts: One single trial was eligible for inclusion.
This non randomised, controlled, unblinded treatment
trial involved 117 tetanus patients and was undertaken
in Bangladesh. Vitamin C at a dosage of 1 g/day was
administered intravenously alongside conventional
treatment. At recruitment, the participants were strati-
ed into two age groups and the results were reported
by age. In the children aged 1 to 12 years (n = 62),
vitamin C treatment was associated with a 100%
reduction in tetanus mortality (95% condence interval
from -100% to -94%). In people aged 13 to 30 years
(n = 55), vitamin C treatment was associated with a
45% reduction in tetanus mortality (95% condence
interval from -69% to -5%).
Autbors' conc|uslons: A single, non randomised,
poorly reported trial of vitamin C as a treatment for
tetanus suggests a considerable reduction in mortality.
However, concerns about trial quality mean that this
result must be interpreted with caution and vitamin C
cannot be recommended as a treatment for tetanus on
the basis of this evidence. New trials should be carried
out to examine the effect of vitamin C on tetanus treat-
ment.
P|aln |anguage summary: Tetanus is a disease caused
by tetanus toxin, which is produced by the bacterium
Clostridium tetani. This bacterium typically infects
penetrating wounds contaminated by foreign material
such as soil. In developing countries, poor hygiene
after childbirth may cause tetanus in newborn babies.
Even though vaccination has dramatically decreased
the burden of tetanus, there are still about one million
cases per year globally. We found one controlled trial
that examined whether 1 gram per day of intravenous
vitamin C would help in the treatment of tetanus
patients. Vitamin C was used alongside standard treat-
ments for tetanus. Intravenous vitamin C reduced
mortality of children aged between 1 and 12 with
tetanus by 100% and mortality of 13 to 30 year old
patients by 45%. The trial was not properly conducted
and therefore great caution is required in the interpre-
tation of the ndings. Vitamin C cannot be recom-
mended as a treatment for tetanus on the basis of this
single study. Further investigation of the role of vitamin
C in tetanus treatment is warranted.
Intermlttent pneumatlc compresslon for
treatlng venous |eg u|cers [Updated Review]
Ne|son EA, Manl R, Vowden K
To be published in Issue 2, 2008 Copyright 2005
The Cochrane Collaboration. Published by John Wiley
& Sons, Ltd.:
ASTRACT
ackground: Intermittent pneumatic compression
(IPC) is a mechanical method of delivering compres-
sion to swollen limbs that can be used to treat venous
leg ulcers and limb swelling due to lymphoedema.
This review analyses the evidence for the effectiveness
of IPC as a treatment for venous leg ulcers.

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Ob[ectlves: To determine whether IPC increases the healing of
venous leg ulcers. To determine the effects of IPC on health
related quality of life of venous leg ulcer patients.
Searcb strategy: We searched the Cochrane Wounds Group
Specialised Register (December 2007); the Cochrane Central
Register of Controlled Trials (CENTRAL) - The Cochrane Library
Issue 4, 2007; Ovid MEDLINE - 2006 to November Week 2
2007; Ovid EMBASE - 2006 to 2007 Week 49 and Ovid
CINAHL - 2006 to December Week 1 2007.
Se|ectlon crlterla: Randomised controlled studies either
comparing IPC with control (sham IPC or no IPC) or compari-
sons between IPC treatment regimens, in venous ulcer manage-
ment were included.
Data co||ectlon and ana|ysls: Data extraction and assessment
of study quality were undertaken by one author and checked by
a second.
Maln resu|ts: Seven randomised controlled trials (including 367
people in total) were identied. Only one trial reported both
allocation concealment and blinded outcome assessment.
In one trial (80 people) more ulcers healed with IPC than with
dressings (62% vs 28%; p=0.002). Four trials compared IPC
with compression against compression alone. The rst of these
trials (45 people) found increased ulcer healing with IPC plus
compression than with compression alone (relative risk for
healing 11.4, 95% Condence Interval 1.6 to 82). The
remaining three trials (122 people) found no evidence of a
benet for IPC plus compression compared with compression
alone. One small trial (16 people) found no difference between
IPC (without additional compression) and compression band-
ages alone. One trial compared different ways of delivering IPC
(104 people) and found that rapid IPC healed more ulcers than
slow IPC (86% vs 61%; log rank p=0.003).
Autbors' conc|uslons: IPC may increase healing compared with
no compression, but it is not clear whether it increases healing
when added to treatment with bandages, or if it can be used
instead of compression bandages. Rapid IPC was better than
slow IPC in one trial. Further trials are required to determine
whether IPC increases the healing of venous leg ulcers when
used in modern practice where compression therapy is widely
used.
P|aln |anguage summary: Venous leg ulcers (open sores) can be
caused by a blockage or breakdown in the veins of the leg.
Compression, using bandages or hosiery (stockings), can help
heal ulcers. However, they do not always work, and some people
are not willing or able to wear them. Intermittent pneumatic
compression (IPC) uses an air pump to inate and deate an
airtight bag wrapped around the leg. This technique is also used
to stop blood clots developing during surgery. However, the
review of trials found conicting evidence about whether or not
IPC is better than compression bandages and hosiery. Intermit-
tent pneumatic compression (IPC) is better for healing leg ulcers
than no compression but it is uncertain if it improves healing
when bandages or hosiery are already used.
Toplca| negatlve pressure for treatlng cbronlc
wounds [Updated Review]
Ubblnk DT, Westerbos SJ, Evans D, Land L, Vermeu|en H:
To be published in Issue 2, 2008 Copyright 2005 The Cochrane
Collaboration. Published by John Wiley & Sons, Ltd.:
Abstract: ackground: Chronic wounds mainly affect the elderly
and those with multiple health problems. Despite the use of
modern dressings, some of these wounds take a long time to heal,
fail to heal, or recur, causing signicant pain and discomfort to the
person and cost to health services. Topical negative pressure
(TNP) is used to promote healing of surgical wounds by using
suction to drain excess uid from wounds.
Ob[ectlves: To assess the effects of TNP on chronic wound
healing.
Searcb strategy: For this second update of this review we searched
the Cochrane Wounds Group Specialised Register (December
2007), The Cochrane Central Register of Controlled Trials
(CENTRAL) - The Cochrane Library Issue 4, 2007, Ovid MEDLINE
- 1950 to November Week 2 2007, Ovid EMBASE - 1982 to 2007
Week 50 and Ovid CINAHL - 1980 to December Week 1 2007.
In addition, we contacted authors, companies, manufacturers,
and distributors to identify relevant trials and information.
Se|ectlon crlterla: All randomised controlled trials which evaluated
the effects of TNP on people with chronic wounds.
Data co||ectlon and ana|ysls: Selection of the trials, quality assess-
ment, data abstraction, and data synthesis were done by two
authors independently. Disagreements were solved by discussion.
Maln resu|ts: Two trials were included in the original review.
A further ve trials were included in this second update resulting
in a total of seven trials involving 205 participants.
The seven trials compared TNP with ve different comparator
treatments. Four trials compared TNP with gauze soaked in either
0.9% saline or Ringers solution. The other three trials compared
TNP with hydrocolloid gel plus gauze, a treatment package
comprising papain-urea topical treatment, and cadexomer iodine
or hydrocolloid, hydrogels, alginate and foam. These data do not
show that TNP signicantly increases the healing rate of chronic
wounds compared with comparators.
Data on secondary outcomes such as infection rate, quality of life,
oedema, hospitalisation and bacterial load were not reported.
Autbors' conc|uslons: Trials comparing TNP with alternative treat-
ments for chronic wounds have methodological aws and data do
demonstrate a benecial effect of TNP on wound healing however
more, better quality research is needed.
P|aln |anguage summary: Topical negative pressure (TNP)
therapy is the application of negative pressure across a wound to
aid wound healing. The pressure is thought to aid the drainage of
excess uid, reduce infection rates and increase localised blood
ow. TNP is also known as vacuum assisted closure (VAC) and
sealed surface wound suction. Seven trials compared TNP with
either moistened gauze dressings or other topical agents and
found no difference in effects. One very small, poor quality trial
(7 wounds) showed a reduction in wound volume and depth in
favour of TNP. There is no valid or reliable evidence that topical
negative pressure increases chronic wound healing.
EWM
0ooo seal ooesn`t hurt
Wound Dressings
1. While R. Evidence Ior alraumalic soIl silicone wound dressing use. Wounds UK 2005, 1 l3. 10-10.
2. While R., Wounds UK, 2008, vol , no 1
The Molnlycke Heallh Care name and logo and Mepilex
are regislered lrademarks oI Molnlycke Heallh Care AB.

Molnlycke Heallh Care AB lpubl., Box 13080, SE-02 52 0oleborg, Sweden. Phone + 31 722 30 00. www.molnlycke.com
Mepilex
dressings benel Irom SaIelac
, a palenled soIl silicone adhesive lechnology

lhal conIorms lo every crevice oI lhe skin. This lechnology seals lhe wound margins,
prevenling exudale Irom spreading onlo lhe surrounding skin, causing maceralion
1
.
Somelimes lhe genllesl louch is lhe mosl assured.
SaIelac lechnology is also lhe reason why palienls using Mepilex dressings Ieel signi-
canlly less pain on dressing removal
2
. This combined wilh excellenl Iluid managemenl
make lhe Mepilex range an eIIeclive wound care managemenl choice.
Il`s nice lo be genlle. Il`s even nicer lo be sure.
EWMA
Dr. Gary Sibbald, president-elect of the World Union
of Wound Healing Societies (WUWHS) and chair of
the third meeting, discusses the innovative structure of
the meeting with the International Wound Journal.
Q: What is unique and innovative about
the third congress of the WUWHS?
GS: The organising principle of the Toronto 2008
meeting is the evaluation of the evidence base in wound
care, which will be considered in the context of ef-
cacy, efciency and effectiveness to form a framework
for best clinical practice. The synthesis of these three
major pillars of evidence-informed practice will pro-
vide clinicians with a new and comprehensive way of
reviewing their practice and ensuring their care is pa-
tient focused
Q: How does the scientic program support
this innovative design?
GS: The scientic program is divided into streams
that provide an in-depth review of a range of clinical
Wor|d Unlon of Wound Hea|lng Socl
Doug|as McQueen
T
he third meeting of the World
Union of Wound Healing So-
cieties is truly a partnership be-
tween wound care associations (includ-
ing EWMA), wound care publishers and
also industry.
As individuals we all participate, in one way
or another, in the creation and dissemination of
knowledge in the eld of wound care. All share
the common problem of treating wounds and
together provide a unied voice to ensure the de-
velopment of wound care as a clinical specialty.
That is One Problem One Voice.
Congress 2008 provides a forum for the dis-
semination of evidence informed practice on a
global basis. The primary goal of Congress 2008
is to present the wound care evidence base and
transfer the knowledge, skills, and attitudes for
improved patient outcomes.
Treating acute and chronic wounds is an
ongoing challenge for health care profes-
sionals in all corners of the world. Social,
economic, and technological differences,
however, can create a vast divide in global
approaches to wound care.
Congress 2008 embraces the multicultural,
multidisciplinary nature of its audience and pro-
vides an opportunity not only to network but also
to work together for the benet of all wound heal-
ers on a global basis. This will be accomplished
through a preconference day, three plenary ses-
sions, and 10 concurrent streams each with 100
educational sessions.
A web-based initiative, established prior to
this Congress, facilitating a review and appraisal
of the wound care evidence, resulted in concise
evidence statements and this evidence has been
problems. The keynote addresses will echo the impor-
tance of evidence and patient care. An expert panel
will discuss the clinical signicance of evidence-based
medicine; Stephen Lewis will examine healthcare sys-
tems, advocacy and AIDS in Africa; and Marla Sha-
piro, MD, will focus on life/work balance and her own
experiences. The closing plenary session will present
highlights from each stream, and provide participants
with a congress overview.
Toronto 2008 also takes a pioneering approach to
evidence, choosing to evaluate evidence quality accord-
ing to the type of information, from guidelines to pre-
clinical data. This methodology allows a broader range
of knowledge to be considered in developing a clinical
strategy, and it is being used in the development of a
comprehensive set of evidence-based summaries on all
major topics in wound care. These summaries provide
clinicians with rapid access to up-to-date practical in-
formation in a quick and easy Web-based format.
AN INTERVIEW WITH THE CHAIR OF THE WORLD UNION CONGRESS 2008
etles Congress 2008
ELECTkONlC
$UPPLEMENT
MAY 2008
Tbe May 2008 edltlon of tbe
EWMA Journa| E|ectronlc
Supp|ement conslsts of a||
tbe accepted abstracts for
tbe EWMA 2008 Conference
ln Llsbon.

It ls dlvlded lnto 140 Ora|
presentatlons and 376 Poster
presentatlons and lt ls posslb|e
to down|oad lndlvldua|
abstracts as we|| as tbe entlre
supp|ement (lnc|udlng a|| tbe
abstracts) at www.ewma.org
WWW.EWMA.ORG/EWMA2008
EWMA2008 14-16MAY LISON PORTUGAL
Wound Management Wound Hea|lng
- Responslbl|lty and Actlons
18th Conference of the European Wound Management Association
Organised by
the European Wound Management Association in cooperation with
the Portuguese Wound Management Associations APTFeridas and GAIF
A
$
T
k
A
C
T
$
Vo|ume 8
Number 2
May 2008
Pub|lsbed by
European
Wound Management
Assoclatlon
WWW.EWMA.OkG
proliferated throughout the meeting in a logical, easy-to-
follow agenda.
This is not a one-time effort! Through a continued part-
nership with our Platinum Sponsors this will be an ongo-
ing initiative for the World Union. Under the stewardship
of Professor R. Gary Sibbald, during his tenure as Presi-
dent, the initiative will be a legacy of the WUWHS. This
is not the end, merely the beginning!
As a global community of wound care specialists, we
need to share our insights, data, and awareness of common
wound care concerns and solutions. When we do this, we
can build new initiatives to advance wound care practices
and to improve patient outcomes globally. The following
is the perspective of the Chair of the Congress.
Reglster now to partlclpate
ln tbls ground-breaklng congress
www.wuwbs2008.com
Q: To which healthcare professionals will
this congress be of interest?
GS: Toronto 2008 is being hosted by the University of
Toronto, with the active participation of the follow-
ing co hosting groups: the Canadian Association of
Wound Care, Canadian Association of Enterostomal
Therapists, Registered Nurses Association of Ontario,
National Pressure Ulcer Advisory Panel, and American
Professional Wound Care Association. The scientic
program will be relevant to all clinicians irrespective
of professional background , researchers, and teachers
working in the eld of wound healing and tissue repair
caring for patients with wounds of all aetiologies.
Q: Whats next for the WUWHS?
GS: Toronto 2008 is a key step in building the WU-
WHS as an international association. After the con-
gress, we will focus on disseminating the educational
toolkits developed at the meeting and sharing expertise
between associations.
EWMA Journal 2008 vol 8 no 2
EWMA Journal
Previous Issues
Too EWNA Ioooa|s cao bo Jowo|oaJoJ /oo o/ coaqo /om www.owma.oq
International Journals
The section on International Journals is part of
EWMAs attempt to exchange information on
wound healing in a broad perspective.
Vo|ume 7, no 3, October 2007
Vacuum asslsted c|osure for cbronlc wounds:
a revlew of tbe evldence
E. AoJoa No|soo
Genera| practltloner support to care bomes: co||aboratlon wltb a
tlssue vlabl|lty nurse specla|lst and prescrlblng support pbarmaclst
L,ooo Watot, kacoo| 8oco
Integrated system of cbronlc wound care bea|lng
- creatlng, managlng and cost reductlon
Ho|oz I. Iao8oo, ko|aoJ 8oc|o
Gulde|lnes for tbe management of partla|-tblckness burns ln
genera| bosplta|-recommendatlon of a European worklng party
8aoo A|sbo, Aooo|oa 8ootzoo
Dlabetlc Foot U|cer - From Flctlon to Management.
Tbe deve|opment of g|oba| gulde|lnes
Iao Apo|qv|st, lao| 8a||o, Co|o/ D Va||
Wound Hea|lng ln Medleva| Eng|and
Cao| Doa|o,
Deve|opment of C|lnlca| Practlce Gulde|lne on Pressure U|cers
lat|oo VaoJowoo
Advances ln Skln & Wound Care, vo|. 21, Aprl| 2008
www.aswcoooa|.com
Codlng and Payment Cbanges for Pbyslclans
lato|ooo D. Scoaom
Tbe Status of Wound Care ln razl|
Voa Lc|a Cooco|o Jo Coovo|a Saotos,
8oat|z Fa|as A|vos YamaJa,
Na|a Ho|ooa Saotaoa NaoJo|baom
Assesslng tbe Tota| Patlent
Cato, Toomas Hoss
Eoq||so Eoq||so
Vo|ume 7, no 1, January 2007
Se|f-care actlvltles of venous |eg u|cer patlents ln Fln|and
Sa||a Soppaooo
Smoklng ls not contra-lndlcated ln maggot debrldement
tberapy ln tbe cbronlc wound
Pasca| StooovooJo
Effectlveness of non-a|cobo| 6|m formlng skln protector
on tbe sklns ls|es lnslde tbe u|cers and tbe bea|lng rate of ve-
nous |eg u|cers
Taoa P|ao|oso| koc|qa
Wound measurement: tbe contrlbutlon to practlce
Cooq|oa T. Coto|o
Improvlng educatlon ln wound care: crosslng
tbe boundarles of lnterprofesslona| |earnlng
Cao||oo Nclotoso
Water[et debrldement of deep and lndetermlnate deptb
tberma| ln[urles
Na,o Toooooaos
Acta Vu|no|oglca vo|. 6, no 1, Marcb 2008
Effect of -|lpolc acld ln tbe treatment of
cbronlc wounds wltb byperbarlc oxygen tberapy:
modu|atlon of genes lnvo|ved ln anglogenesls
and tlssue remode||lng
A||ova k., Tomasott| N., Sat|o| D., Emaooo||| N.,
8oqo| 8., D| Dooato F., Naso|o E.
Tlssue englneerlng ln p|astlc surgery. A c|lnlca|
revlew after 10 years of metbodo|ogy app|lcatlon
P|oaoqo|| N., Asto|h N., Naazz| N. Pooz|o l.,
8otao|A., Sca||so A.
P|ate|et ge|: eva|uatlon of lts ro|e ln wound bed
preparatlon and c|lnlca|-qua|ltatlve ana|lsls
Pooz|o l., P|oaoqo|| N., Nacoos|o| A., Caboo| A.,
Ta|ov| D., Cassott| L., Potocc| E., 8otao| A., Sca||so A
Tbe lmportance of measurlng tbe subbandage
pressure and tbe presentatlon of a new measurlng
devlce
Nost| C., kossa| S.
Tbe experlence of a c|lnlca| and management
trla| ln a dlstrlct ln F|orence area
8ot|o| N., Coo|||o| F., Do| Cooto C., F|||pp|o| F., Not| N.,
PaaJ|so E., Tozz| C., Faqq|oo| S.
Eoq||so Eoq||so
He|cos 2008, vo| 19, no 1
Eva|uatlon ln vltro of tbe propertles of slx dresslngs for tbe
bea|lng wet envlronments of exudatlve wounds
k|os Taoo||a I, Lopoz 8oto k
In vlvo eva|uatlon uslng confoca| mlcroscopy of protectlve
effect of no-stlng barrler 6|m 3 M Cavl|on on perlwound
skln
Soqov|a T, Noo IA, Cooza|oz S
Reduclng tbe effect of a domestlc burn
Cac|a Cooza|oz F, Caqo Fooo||s N, koJ|qooz Pa|ma N,
Cazto|o Va|Js V, Cac|a Co||aotos NA,
koJ|qooz 8ocaooqa IC
Spao|so Spao|so
Vo|ume 7, no 2, May 2007
Is lt safe to use sa|lne so|utlon to c|ean wounds?
Ioo C. F. Coovo|a, C|st|oa l. N. N|qoos,
C||a L. S. Noqoo|a, Nata l. P. A|vos
Tbe cost of pressure u|ceratlon
Poto I Fao|s
Epldemlo|ogy of wounds treated ln Communlty Servlces
ln Portuga|
E|a|oo P|oa
Improvlng wound assessment tbrougb tbe provlslon of
dlglta| cameras across a Prlmary Care Trust
A||soo Hop||os
Tbe use of te|emedlclne ln wound care
ko|/ Io|oos
Lord Josepb Llster: tbe rlse of antlseptlc surgery and
tbe modern p|ace of antlseptlcs ln wound care
Dav|J Loapo
Ferldas, vo|. 2, no 2, 2008
Intervlew wltb Armlnda Costelra (Nurse and Founder
of APTF)
Tecbnlca| Artlc|e - "Pressure U|cers: Cost to tbe Natlon
and Cost to tbe Indlvldua|"
Poto Fao|s
Tecbnlca| Artlc|e - "Tberapeutlca| Posltlonlng:
Preventlg Pressure U|cers"
Dom|oqos Na|ta
Invltatlon to tbe EWMA 2008
Naco komaoo|||, F|oo Cottop, Ao|ba| Iost|o|aoo
Potoqooso Potoqooso
Vo|ume 8, no 1, January 2008
Prob|em drug ln[ectlng: Wound care,
barm reductlon and socla| lmpact
Aoqo|a D Co||J
Larva| tberapy ln tbe treatment of dlabetlc foot wounds
- A revlew of tbe |lterature
Fao| L 8ow||oq
Oplnlon plece: Wound bea|lng ln bot c|lmates
Toooco I k,ao
Deve|oplng researcb capaclty and capabl|lty ln skln breakdown
I|m D|c|
Tbe Internatlona| Journa| of Lower Extremlty Wounds vo|. 7, no 1, 2008
ottp.//||ow.saqopob.com
Ma[or Deve|opments ln Wound Care: A Crltlca| Appralsa|
Uwo Wo|||oa
Measurements ln Wound Hea|lng
V|ocoot Fa|aoqa
Semlnar Revlew: Wounds and Dresslngs
kos|oo vao Joo 8o|c|
Current Treatment of Acute Lower Extremlty Deep Venous Tbrombosls
N|coao| P. Iao|q|ao, 8at E. Noos
Eva|uatlon of Wound-Hea|lng Potentla| of Plsonla grandls R.r:
A Prec|lnlca| Study ln Wlstar Rats
D. Pabo, N. Napp|ooa|, l. PooooJoa|, l. Paboo
MRSA Infectlon ln Lower Extremlty Wounds
8oo EJ|s, Iamos F. kooJ, lll
Tbe Lack of Re|labl|lty of C|lnlca| Examlnatlon ln tbe Dlagnosls of
Wound Infectlon: Pre|lmlnary Communlcatlon
Toomas E. Soooa, Iasoo k. Hao/t, kobot So,Jo
Mu|tldrug-Reslstant Enterococcus raf6nosus from a Decubltus U|cer:
A Case Report
V|ocoozo Sav|o|, Assoota Naooa, C|ovaoo| D| 8ooavootoa,
Co|aa Catav|to||o, Naz|a Ta||a, AoJoa 8a|b|oot, Fab|o Fobbo,
Domoo|co D'Aotoo|o
Fusarlum so|anl ln tbe Post-transp|ant Patlent: An Unusua| Fungus
Acot ko|oa, Aoopma I. l|oJo, Aooama|a| kav|
Eoq||so Eoq||so
Journa| of Wound Care, Aprl| lssue, vo|. 17, no 4, 2008
www.oooa|o/woooJcao.com, wc@omap.com
A study of blo6|m-based wound management ln sub[ects
wltb crltlca| |lmb lscbaemla
k.D. Wo|cott, D.D. kooaJs
Impact of adbeslve surglca| tape and wound dresslngs on
tbe skln, wltb reference to skln strlpplng
l.F. Cott|oq
ene6ts of lmp|ementlng a |lnk nurse group across botb
an acute and a prlmary care trust
D. Evo|tt
A bo|lstlc approacb to tbe management of a neuropatblc
p|antar u|cer
S. NcC|os|o,, C. CooJa,
An ln vltro examlnatlon of tbe antloxldant and
antl-lnammatory propertles of buckwbeat boney
A.I.I. vao Joo 8oq, E. vao Joo Wom, H.C. Qoa|os vao U//oJ,
S.8.A. Ha||os, N.I. Hoo|sta, C.I. 8oo|o|mao
Pbase 2 study of a new Hydro6ber dresslng for super6cla|
cbronlc or acute wounds
N. Faocoo, S. Eo|o, F. V|o, T. Doq
Eoq||so Eoq||so
EWMA
Internatlona| Wound Journa|, Marcb 2008, vo|. 5, Issue 1
www.b|ac|wo||pob||so|oq.com
Tbe revlslt of 2004 tsunaml ln Tbal|and: cbaracterlstlcs of
wounds
Toavat Pasat|toa, kacoata Tooqs||pat, Pa|o Waaco|t
Tbe use of marrow-derlved stem ce||s to acce|erate bea|lng ln
cbronlc wounds
Loo C koqos, N|coo|as I 8ov||acqoa, Dav|J C Amstooq
Wben wl|| I see you agaln? Tbe fate of researcb 6ndlngs from
lnternatlona| wound care conferences
Io C Domv|||o, Em||, S Potoo|c|, N|c|, Co||om
Leg u|ceratlon ln Portuga|: qua|lty of |lfe
lat|a FotaJo, E|a|oo P|oa, Co|st|oo I No//att, Poto I Fao|s
Radlotberapy and wound bea|lng
Haoso L Dova||a, Loc, Naosho|J
Tbe ro|e of tbe vacuum-asslsted c|osure tberapy ln tbe sa|vage
of venous congestlon of tbe free ap: case report
Fat|o U,qo, Ha|o| Domao, Es|o U||o, 8aoatt|o o||oz
Eoq||so Eoq||so
Haava, no 1, 2008
www.soomoooaavaooo|to,oJ|st,s.h
Wounds of Rbeumatrtboldltls Patlents
Aooa Hoppo
Recognltlon and Management of Ma|lgnant Wounds
T||oa Iaa|o|a
Cba||englng Wound Management
Ho|v| H|otaooo
Cbronlc Wounds and Prob|ems of Clrcu|atlon
Po||a lotoso|om|
Wound Management Practlses ln Maternlty and
Gyneco|oglca| Wards
Pao|||oa V|t||a|ooo, Too| Va|saooo
Imp|ementatlon of crlterlans for documentatlon of wound care
U||a-Na| l|oooooo, la|a Saaota, Aooo|| Eos|o
Peer Support of Llmb Amputatlon Patlents, Part 3
E||a Tootto
Can tbe Wounds be Cared by Pbone?
Taa Saa|ooo
F|oo|so F|oo|so
Wund Management, vo|. 2, no 2, 2008
Eoq||so abstacts ao ava||ab|o /om www.mop-vo|aq.Jo
Wound bea|lng ln tbe course of tlme
l. Co. Nooto
Tbe use of medlca| boney ln wound bea|lng
l. loqo
Water 6|tered lnfrared (WIRA) for tbe lmprovement of wound
bea|lng of acute and cbronlc wounds
C. Ho//maoo
Comao Comao
Journa| of Tlssue Vlabl|lty, vo|. 17, no 2, 2008
Ava||ab|o oo||oo at www.sc|oocoJ|oct.com
Ma|lgnant 6brous blstlocytoma of tbe mandlb|e ln tbe context
of a traumatlc Mar[o|ln's u|cer
A|| Hosso|o NosqazaJoo, kam|o Nostoh ZaJoo Faaoao|,
Natoao|o| To|sto
Essence of Care and tbe pressure u|cer bencbmark -
An eva|uatlon
F|ooa 8ot|o
Mlnlma||y lnvaslve tecbnlque for tbe surglca| treatment of
cbronlc osteomye|ltls
l. S|oqo, N. Fass|aJ|s, l. Iooos
Eoq||so Eoq||so
Rane, vo|. 1, no. 2, November 2007
Ava||ab|o oo||oo at www.|ocoooaoa.com
Examlnatlon of tbe corre|atlon between rlsk factors and
cbaracterlstlcs of tbe venous u|cer and lmp|lcatlons on tbe
granu|atlon occurrence and bea|lng tlme
I. Do||c
Surglca| treatment of tbe dlabetlc foot
C. Vocot|c, 8. Do||c, l. D|m|t|ov|c, N. la|oz|c, N. 8ombas|ov|c,
N. Naz|c, I. Ioom|c
Tlssue adbeslve as tbe antlblotlc carrler ln tbe treatment of
surglca| slte lnfectlons
S. 8oov|c, D. ZJav|ov|c, 8. a||a, 8. Po||c
Nurse actlvltles ln preventlon and treatment of pressure u|cers
ln tbe gerlatrlc department
S.A. N||ot|oov|c
Importance of tbe anemla treatment ln patlents wltb wounds
8. a||a
Surglca| treatment of patlents wltb cbronlc venous
lnsuf6clency and |over extremlty venous u|cers
D.I. N|||c
Sob|ao Sob|ao
Wounds (SR) vo|.16, no 1, 2008
Surgery for Slnus pl|onlda|ls - bow can lt be lmproved?
Nacos Coqoo
Treatment of venous |eg u|cers wltb Atrauman ag
Aooo Na|o Lasoo, E|so L|oooboq, F|oo Cottop
Exce| cbanges nutrltlon practlce
Ioos Foooosboco
Indlcators must be used ln tbe measurement of tbe qua|lty
of pressure u|cer treatment and preventlon
Ioos Foooosboco
ScaoJ|oav|ao ScaoJ|oav|ao
Sr
Utvarderlng av F|exl-Sea|
FMS: ett system for banterlng

av faeceslnkontlnens
Ovosatto|oq oco sammao/atto|oq Aooo H|oJooJo
Svra vl||kor for srpatlenter l Tanzanla
Co|st|oa L|oJoo|m
Jod-gamma| metod l nytt |[us
Ovosatto|oq oco boaboto|oq av Aooo H|oJooJo
Vlvostat
PRF (P|ate|et Rlcb Flbrln) for beband|lng av kronlska sr

8o Iqoosoo, Naqoos LooJao|, Coo|||a Lassoo, Haos Nooboq
Pu|serat monokromatlskt |[us - kan det pskynda |aknlngen av
fotsr bos patlenter med dlabetes
Ovo Doo||o, So|vo E|msto|
SwoJ|so SwoJ|so
Corporate A
Co|op|ast
Holtedam 1-3
DK-3050 Humlebk
Denmark
Tel: +45 49 11 15 88
Fax: +45 49 11 15 80
www.coloplast.com
ConvaTec Europe
Harrington House
Milton Road
Ickenham, Uxbridge
UB10 8PU
United Kingdom
Tel: +44 (0) 1895 62 8300
Fax: +44 (0) 1895 62 8362
www.convatec.com
Covldlen
154, Fareham Road
PO13 0AS Gosport
United Kingdom
Tel: +44 1329 224479
Fax: +44 1329 224107
www.covidien.com
Jobnson & Jobnson Wound Management
Gargrave
North Yorkshire
BD23 3RX
United Kingdom
Tel: +44 1756 747200
Fax: +44 1756 747590
www.jnjgateway.com

3M Hea|tb Care
Morley Street, Loughborough
LE11 1EP Leicestershire
United Kingdom
Tel: +44 1509 260 869
Fax: +44 1 509 613326
www.mmm.com
Actlva Hea|tbcare Ltd
1 Lancaster Park
Newborough Road
Needwood
Burton on Trent
Staffordshire
DE13 9PD
Tel: +44 (0) 8450 606 707
Fax: +44 (0) 1283 576808
www.activahealthcare.co.uk
. raun Medlca|
204 avenue du Marchal Juin
92107 Boulogne Billancourt
France
Tel: +33 1 41 10 75 66
Fax: +33 1 41 10 75 69
www.bbraun.com
Ferrls Mfg. Corp.
16W300 83rd Street
Burr Ridge,
Illinois 60527-5848 U.S.A.
Tel: +1 (630) 887-9797
Toll-Free: +1 (630) 800 765-9636
Fax: +1 (630) 887-1008
www.polymem.com
KCI Europe Ho|dlng .V.
Parktoren, 6th oor
van Heuven Goedhartlaan 11
1181 LE Amstelveen
The Netherlands.
Tel: +31 (0) 20 426 0000
Fax: +31 (0)20 426 0097
www.kci-medical.com
Lobmann & Rauscber
P.O. BOX 23 43 Neuwied
D-56513
Germany
Tel: +49 (0) 2634 99-6205
Fax: +49 (0) 2634 99-1205
www.lohmann-rauscher.com
Mo|n|ycke Hea|tb Care Ab
Box 13080
402 52 Gteborg,
Sweden
Tel: +46 31 722 30 00
Fax: +46 31 722 34 08
www.molnlycke.com
Smltb & Nepbew
Po Box 81, Hessle Road
HU3 2BN Hull,
United Kingdom
Tel: +44 (0) 1482 225 181
Fax: +44 (0) 1482 328 326
www.smith-nephew.com
EWMA Corporate Sponsor Contact Data
Corporate B
Use tbe EWMA Journa| to pro6|e your company
DoaJ||oo /o aJvot|s|oq |o too Octobo 2008 |ssoo |s 1 Aoqost 2008
We|come to EWMA's two new
sponsors
Sanuwave and Synergy Hea|tbcare
EWMA
Pau| Hartmann AG
Paul-Hartmann-Strasse
D-89522 Heidenheim
Germany
Tel: +49 (0) 7321 / 36-0
Fax: +49 (0) 7321 / 36-3636
www.hartmann.info
Sanuwave AG
Kreuzlingerstrasse 5
CH-8574 Lengwil
Switzerland
Tel: +41 71 6868 900
Fax: +41 71 6868 901
www.sanuwave.com
Sorblon AG
Hobackestrae 91
D-45899 Gelsenkirchen
Tel: +49 (0)2 09-95 71 88-0
Fax: +49 (0)2 09-95 71 88-20
www.sorbion.com
Synergy Hea|tbcare (UK) Llmlted
Wound Care
1 Western Avenue
Matrix Park
Buckshaw Village, Chorley
Lancashire PR7 7NB
United Kingdom
Tel: +44 1772 299900
Fax: +44 1772 299901
www.synergyhealthcareplc.com
Laboratolres Urgo
42 rue de Longvic
B.P. 157
21300 Chenve
France
Tel: (+33) 3 80 44 70 00
Fax: (+33) 3 80 44 71 30
www.urgo.com
For further details contact
MEP Ltd, 53 Hargrave Road,
London N19 5SH.
www.mepltd.co.uk
or
EWMA Business Ofce,
Congress Consultants,
Martensens All 8,
1828 Frederiksberg,
Denmark
Tel: +45 7020 0305
Fax: +45 7020 0315
ewma@ewma.org
EWMA Posltlon Document 2008
Hard-to-bea| wounds
a holistic approach
Editor: Christine Moffatt
The seventh European Wound Management
Association position document will be launched
in May 2008 at the EWMA congress Wound
Management Wound Healing - Responsibility
and Actions, to be held in Lisbon, Portugal,
14-16 May 2008.
The document will be available in English,
French, German, Italian and Spanish, and can
be downloaded from www.ewma.org
It is possible to obtain permission to translate the
EWMA Position Documents into other languages.
Please contact EWMA Business Ofce.
Prevlous Posltlon Documents:
Conference Calendar
For web addresses p|ease vlslt www.ewma.org
Conferences
Conference Theme 2008
7th National Australian Wound Management
Association Conference
Dreams, Diversity, Disasters May 7-10 Darwin Australia
SAfW 5th Congress (National) May 8 Morges Switzerland
18th Conference of the European Wound
Management Association (EWMA 2008)
Wound Healing Wound Management
Responsibility and Actions
May 14-16 Lisbon Portugal
9th Congress of the European Society for Pediatric
Dermatology
May 15-17 Athens Greece
5th EADV Spring Symposium Dermatology Bridging the Continents May 22-25 Istanbul Turkey
WUWHS - 3rd Congress Wound Care Efcacy, Effectiveness &
Efciency
Jun 4-8 Toronto Canada
Deutsche Gesellschaft fr Wundheilung und
Wundbehandlung
Jun 13-14 Koblenz Germany
17th World Council of Enterostomal Therapists
meeting
Stoma care, Wound Management &
Incontinence
Jun 15-19 Ljubljana Slovenia
6th World Congress of the IACD Jun 18-20 Lisbon Portugal
Oxford European Wound Healing Summer School Different aspects of patient wound
management based on therapy innovation
and clinical research
Jun 18-21 Oxford UK
Wound Management Association of Kosova Training workshop with new Kosova assoca-
tion
Jun 23-25 Kosova
ETRS 18th Annual Meeting Joint Meeting with the Tissue Viability Unit
of Malta
Sep 10-12 Malta
7th Scientic Meeting of the Diabetic Foot Study
Group (DFSG) of the EASD
Sep 11-13 Lucca Italy
17th EADV Congress Sep 17-21 Paris France
VII Congresso Nazionale AIUC La terapia dellulcera cutanea: Un ponte tra
tradizione e innovazione
Sep 24-27 Rome Italy
11th Conference of SEBINKO The Development of Clinical Validy and Best
Practices Requirements
Oct 16-17 Tatabnya Hungary
2nd World Congress of TeleDermatology Healty Present and Healthier Future Oct 16-18 Chinnai India
Wounds UK Nov Harrogate UK
5 Congresso Nazionale AISLeC EBN e Wound Care: Nuove Frontiere Nov 13-15 Napoli Italy
WMAT 3rd National Congress Nov 27-29 Cesme, Izmir Turkey
2009
6th EADV Spring Symposium Apr 23-26 Bucharest Romania
19th Conference of the European Wound Manage-
ment Association
Healing, Education, Learning and Preventing
in Wound Care
May 20-22 Helsinki Finland
8th Scientic Meeting of the Diabetic Foot Study
Group (DFSG) of the EASD
Sep Bled Slovenia
18th EADV Congress Oct 7-11 Berlin Germany
EWMA Membership
Become a member of the European Wound Management Assoclatlon
and you will receive EWMA position documents annually and EWMA Journal
three times a year.In addition, you will have the benet of obtaining the membership
discount, which is normally 15%, when registering for the EWMA Conferences.
A membership only costs 25 EUR a year.
P|ease reglster as a EWMA member at
WWW.EWMA.OkG
The Hungarian SEINKO Association was
established in 1996 to improve the care of
incontinent patients and people with chronic or
non-healing wounds. It is a nationwide, volun-
tary organisation. In the beginning, its
members were mainly nurses, but today it has
doctors and whole institutions amongst its
members: 180 private and 16 whole staff insti-
tutions.
Our mission statement is as follows: The aim
of the SEBINKO Association is to develop a
wide scope nationwide cooperation and
consensus in the elds of chronic wound
prevention and treatment and the improve-
ment of the treatment of incontinence. This we
support by developing, teaching and training
scientic methods. We are striving to reach our
goals through continuous information ow, the
SEBINKO magazine, conferences, correspond-
ence, training programmes, and tenders,
together with wide-scale cooperation and
professional help. We support the development
of planned wound treatment and incontinence
treatment programmes developed by institutes
and responsible, reliable nursing care in the
elds of wound treatment and healing. We put
special emphasis on the topic of unied docu-
mentation and data processing and the
training of institutional coordinators for decu-
bitus and incontinence.
Our association is consciously supporting the
following values of professional help and care
in wound management: -reservation or rees-
tablishment of the self-care of patients, -secu-
rity -pain minimisation -infection-free treatment
-cost effectiveness in wound treatment.
We have developed strong working relation-
ships with the instigators and practitioners of
the nationwide consensus. Amongst them one
can nd professional politicians, members of
Parliament, members of medical and nursing
colleges, leaders of professional and civil
organisations, health industry professionals,
universities and practitioners and practicing
teams.
The focus of our consensus is the pressure
ulcer: the prevention and treatment of decu-
bitus.
At our 10th Anniversary Conference in 2006
we set out our aims for the following 3 years
for our members and association:
The development of clinical validity and best
practice requirements. To achieve this the
most important areas of focus will be the
development of everyday practices, continuous
evaluation, renewal of the nursing research
methods, development of training and
evidence research.
As a result of our cooperation in EWMA we
are hoping to develop methods and share
information to improve the healing of our
patients and the motivation of the members
of our association.
SEBINKO
Hungarian
Association for the
Improvement of Care
of Chronic Wounds
and Incontinentia
Contact: Dr. Maria Hok
hokmaria42@mail.datanet.hu
szaniko@chello.hu
www.sebinko.hu
1st announcement
ca|| for abstracts
11tb Conference of SEINKO
Tatabnya 2008.
16-17. oktber.
Tbe deve|opment of c|lnlca|
va|ldlty and best practlces
requlrements
EWMA2009
20-22 May
Helsinki
Finland
Organised by the European Wound Management Association
in cooperation with the Finnish Wound Care Society FWCS
Organlsatlons
The Serblan Wound Hea|lng Soclety was
established in December 2006 in Belgrade as
an effort for the organized and coordinated
approach to the area of wound management.
The Society promotes multidisciplinary involve-
ment and cooperation among medical care
providers dedicated to wound management.
We are proud to be a EWMA cooperating
organization since 2007.
SWHS is the rst institution in Serbia that
spreads modern attitudes in the area of wound
healing. Through the activities of the chronic
wound treatment school and workshops we
educate doctors and nurse how to treat
patients with wounds.
250 doctors and nurses attended our educa-
tion modules so far. But, our credo is quality
in front of quantity. We limit groups to 30 to 40
participants, so lectures are interactive and
workshops are real hands on.
In 2007, Society published rst issue, volume 1
and 2 of the journal Rane (Wounds). The
7th Scientic Meeting of the
Diabetic Foot
Study Group
of the EASD
11-13 September 2008
Lucca, Italy
www.dfsg.org
Advancement
of knowledge
on all aspects of
diabetic foot care
Main subjects during conference:
Epidemiology
Basic and clinical science
Diagnostics
Classication
Foot clinics
Biomechanics, Osteoarthropathy
Orthopaedic surgery
Infection
Revascularisation
Uraemia
Wound healing/outcome
Conference theme
intention is to create a place for experience
and knowledge exchange. Authors from
neighboring countries are welcomed to
submit papers.
We started with a new activity in 2008
TELEULCER. Teleulcer offers doctors and
nurses a possibility to present selected cases
of wounds and to get advices about the
initial treatment and treatment plan from
experts. Teleulcers is available on the Society
web site www.lecenjerana.com.
Our enthusiasm and high level of profession-
alism, initiated intensive presence of wound
care companies in Serbia. Some new
appeared and those already present
increased there activities.
In the future we plan to continue with the
intensive activities. We are looking forward to
establish cooperation with the regional
wound healing associations. Naturally,
reaching high EWMA standards of organized
and coordinated approach to the area of
Wound Management is our priority.
SWHS
Serbian Wound
Healing Society
www.lecenjerana.com
Organlsatlons
COPA FOAM DRESSINGS OUTPERFORM
THE LEADING COMPETITION IN FLUID
CAPACITY
9
8
7
6
5
4
3
2
1
0
COPA Alleryn Polymem
8
4.8
2.7
Absorptive capacity (cc/in
2
)
higher figure is more absorbent
COPA FOAM DRESSINGS PROVIDE
MAXIMUM PATIENT COMFORT
15
30
45
60
75
90
105
120
135
150
COPA Alleryn Polymem
7.8
20.7
120.5
Softness (N/cm) lower figure is softer
0
AFIScep.be
Wound Management
Association in Belgium
AISLeC
Italian Nurse Association for
the Study of Cutaneous Wounds
www.aislec.it
AIUC
Italian Association for Cutaneous Ulcers
www.aiuc.it
APTFeridas
Portuguese Wound
Management Association
www.aptferidas.com
AWA
Austrian Wound Association
www.a-w-a.at
BFW
Belgian Federation of Woundcare
www.befewo.org
CNC
Clinical Nursing Consulting Wondzorg
www.wondzorg.be
CSLR
Czech Wound Management Society
www.cslr.cz
CWA
Croatian Wound Management
Association
www.kbd.hr/index.php?id=799
DGfW
Deutsche Gesellschaft fr Wundheilung
www.dgfw.de
Danish Wound
Healing Society
DWHS
Danish Wound Healing Society
www.dsfs.org
FWCS
Finnish Wound Care Society
www.suomenhaavanhoitoyhdistys.
GAIF
Grupo Associativo de Investigaco
em Feridas
www.gaif.net
Cooperating Organisations
GNEAUPP
Grupo Nacional para el Estudio y
Asesoramiente en Ulceras por Presin y
Heridas Crnicas
www.gneaupp.org
GWMA
Greek Wound Management Association
ICW
Initiative Chronische Wunden
www.ic-wunden.de
LBAA
Latvian Wound Treating Organisation
LUF
The Leg Ulcer Forum
www.legulcerforum.org
LWMA
Lithuanian Wound
Management Association
MSKT
Hungarian Lymphoedema and
Wound Managing Society
www.euuzlet.hu/mskt/
NATVNS
National Association of Viability Nurse
Specialists (Scotland)
www.natvns.com
NIFS
Norwegian Wound Healing Association
www.nifs-saar.no
NOVW
Dutch Organisation of Wound Care
Nurses
www.novw.org
PWMA
Polish Wound Management Association
www.ptlr.pl
ROWMA
Romanian Wound Management
Association
www.artmp.ro
SAfW
Swiss Association for Wound Care
www.safw.ch
www.safw-romande.ch
SEBINKO
Hungarian Association for the Improve-
ment of Care of Chronic Wounds and
Incontinentia
www.sebinko.hu
SFFPC
La Socit Franaise et Francophone de
Plaies et Cicatrisations
www.sffpc.org
SSiS
Swedish Wound Care Nurses Association
www.sarsjukskoterskor.se
SSOOR
Slovak Wound Management Association
SUMS
Iceland Wound Healing Society
www.sums-is.org
SWHS
Serbian Wound Healing Society
www.lecenjerana.com
SWHS
Swedish Wound Healing Society
www.sarlakning.se
SAWMA
Serbian Advanced Wound Management
Association
TVNA
Tissue Viability Nurses Association
www.tvna.org
TVS
Tissue Viability Society
www.tvs.org.uk
WMAI
Wound Management Association of
Ireland
www.wmaoi.org
WMAK
Wound Management Association of
Kosova
WMAS
Slovenian Wound Management
Association
WMAT
Wound Management Association
Turkey
www.yaradernegi.org
Present your natlona| wound management organlsatlon
or wrlte a report about your organlsatlon's |atest meetlng.
ewma@ewma.org
DoaJ||oo /o sobm|tt|oq papos /o too Octobo 2008 |ssoo |s
1 Aoqost 2008
For more lnformatlon
about EWMA's Cooperatlng Organlsatlons p|ease vlslt
www.ewma.org
Associated Organisations
Leg Club
Lindsay Leg Club Foundation
www.legclub.org
LF
Lymphoedema Framework
www.lymphoedemaframework.org
LSN
The Lymphoedema
Support Network
www.lymphoedema.org/lsn
Organlsatlons
Conferences
Organlsatlons
EWMA
EWM
3 Edltorla|
Cao| Doa|o,
5 Treatment of cbronlc wounds wltb auto|o-
gous p|ate|et-rlcb p|asma
Nacos Coqoo
13 Po|ybexanlde (PHM) and etalne ln
wound care management
lot laooo, Toomas Ebo|o|o
19 Patlents' experlence of wound-re|ated paln:
An lnternatlona| perspectlve
E||zaboto I NoJqo
31 Ef6cacy of boney as a des|ougblng agent:
overvlew of current evldence
Cooq|oa Coto|o
36 Abstracts of recent Cocbrane Revlews
Sa||, 8o||-S,o
40 Wor|d Unlon of Wound Hea|lng Socletles
Congress 2008
Dooq|as NcQoooo
42 EWMA Journa| Prevlous Issues
42 Internatlona| Journa|s
44 EWMA Corporate Sponsors Contact Data
45 Hard-to-bea| Wounds - a bo|lstlc approacb,
tbe EWMA Posltlon Document 2008
Co|st|oo No//att
46 Conference Ca|endar
47 SEINKO, Hungarlan Assoclatlon for tbe
Improvement of Care of Cbronlc Wounds
and Incontlnentla
48 SWHS, Serblan Wound Hea|lng Soclety
50 Cooperatlng Organlsatlons
51 Assoclated Organlsatlons

EWMA Journal Vol 8 No 2

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FMS: ett system for banterlng

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