May 24, 2012 - EWMA

MY FOOT
Volume 12
Number 2
May 2012
Published by
European
Wound Management
Association

The EWMA Journal
ISSN number: 1609-2759
Volume 12, No 2, May, 2012
Electronic Supplement May 2012
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The Journal of the European
Wound Management Association
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Jan Apelqvist, Sweden
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Carolyn Wyndham-White, Switzerland
Gerald Zöch, Austria

5 Editorial
Science, Practice and Education
7 A structured approach to surgical treatment in deep
infection in diabetic foot
Cedomir S Vucetic, Javorka B Delic, Zoran S Vukasinovic,
Goran Dz Tulic, Ivan K Dimitrijevic, Cedo Dj Vuckovic,
Vesna K Kalezic
15 Endothelial progenitor cells, a unipotent stem cell, involved
in neovascularization of wound healing in diabetic foot ulcer
Jacqueline Chor Wing Tama, Chun Hay Ko, Ping Chung Leung,
Kwok Pui Fung, Clara Bik San Lau
23 Bacteriophages for the treatment of severe infections:
– a ‘new’ option for the future?
Daniel De Vos, Gilbert Verbeken, Thomas Rose, Serge Jennes, Jean-
Paul Pirnay
31 Developing evidence-based ways of working:
– Employing interdisciplinary team working to improve patient
outcomes in diabetic foot ulceration – our experience
Kristien Van Acker
36 Exploring the characteristics of a venous leg ulcer that contribute
to the emotional distress experienced by patients
Jessica Walburn, John Weinman, Suzanne Scott, Kavita Vedhara
39 Development of a wound healing index for chronic wounds
Juan Carlos Restrepo-Medrano, José Verdú Soriano
Cochrane Reviews
49 Abstracts of Recent Cochrane Reviews
Sally Bell-Syer
EWMA
56 EWMA Journal Previous Issues and other Journals
58 EWMA Teacher network
Zena Moore
58 Austrian Diabetic Foot Symposium, EWMA 2012
60 EWMA Update, The Patient Outcome Group
Patricia Price
62 We want to make a difference! – EWMA future projects
Jan Apelqvist
64 EU ‘Week For Life’
Jan Apelqvist
66 EWMA focus on multidisciplinarity in wound management
Jan Apelqvist
68 EWMA participation in EU Conference on Antimicrobials
Resistance – it’s time to take joint action!
Rytis Rimdeika
70 Eucomed, Woundcare reflections on the EU 2020 strategy
Hans Lundgren
Organisations
72 EWMA Corporate Sponsors
73 Conference Calendar
74 10th DFCon Global Diabetic Foot Conference.
EWMA President Jan Apelqvist receives Diabetic Foot Award.
Diabetic Foot Experts Attend Global Meeting to Share Ideas
on Amputation Prevention
75 AAWC, The Association for the Advancement of
Wound Care
Terry Treadwell
76 AWMA, The Australian Wound Management Association
national conference
Bill McGuiness
78 DEBRA International
John Dart
80 EPUAP, News from the European Pressure Ulcer Advisory
Panel – Latin American Activities on Prevention of Pressure
Ulcers
Michael Clark
82 EWMA Cooperating Organisations
ELECTRONIC SUPPLEMENT
May 2012
The May 2012 edition of the EWMA Journal
Electronic Supplement consist
of all the accepted abstracts for the EWMA
2012 Conference in Vienna.
It is divided into Oral presentations
and Poster presentations and it
is possible to download individual
abstracts as well as the entire supplement
(including all the abstracts) at
www.ewma.org/english/ewma-journal/
electronic-supplement.html
WWW.EWMA.ORG
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It is a great pleasure for me to introduce the
theme of this issue of the EWMA Journal:
The diabetic foot. This is not only because
it is my area of expertise but also because it
gives EWMA an opportunity to highlight
some of the many important activities that
have been initiated by the diabetic foot
organisations in Europe and internationally,
as well as the activities that EWMA is
currently supporting.
The diabetic foot will also be covered
thoroughly during the EWMA 2012 Conference
in Vienna. In addition to a key
session on the diabetic foot, an Austrian
Diabetic Foot Symposium will be held on
Thursday 24 May. The symposium is
arranged in collaboration with AWA 1 ,
DFSG 1 and IWGDF 1 and will focus on
implementation of the IWGDF guidelines
on management of the diabetic foot and
offer international examples of the organisation
of treatment.
The diabetic foot counts for a substantial
number of hard to heal ulcers treated in primary
and secondary care settings throughout
the world. Due to the high risk of amputations,
long healing rates and risk of adverse
Editorial
1 Austrian Wound Association (AWA), Diabetic Foot Study Group (DFSG) and The International Working Group
on the Diabetic Foot (IWGDF)
2 Apelqvist, J, Larsson, J: What is the most effective way to reduce incidence of amputation in the diabetic foot?,
Diabetes/metabolism research and reviews, Diabetes Metab Res Rev 2000; 16 (Suppl 1); pp. 75-S83
3 Driver Vickie R, Fabbi M, Lavery L A, Gibbons G: The cost of diabetic foot: The economic case for the limb
salvage team, Journal of vascular surgery, September Supplement 2010
events, treatment of the diabetic foot is a
costly process which calls for involvement of
many different disciplines and care settings
2,3 . Without a well defined organisation
of treatment, patients are often lost in the
system. These challenges are similar with
regards to all patients suffering from hard to
heal ulcers.
Thus the diabetic foot case illustrates the
general need for interdisciplinary care as well
as the need for a fundamental change in the
health care system with regards to health
economics and reimbursement strategies.
In this issue of the EWMA Journal you will
find two scientific articles on treatment of
the diabetic foot as well as a background article
on the effect of interdisciplinary teams on
patient outcomes in diabetic foot ulceration.
Throughout the journal you will also find
information about different initiatives
aiming to support improved prevention and
treatment of the diabetic foot.
We hope you will enjoy reading this issue.
Jan Apelqvist, EWMA President
EWMA Journal 2012 vol 12 no 2 5

ETHICAL
COLLABORATION
IN HEALTHCARE
CERTIFIED
Licensed by Eucomed

A structured approach to
surgical treatment in deep
infection in diabetic foot
ABSTRACT
Background: It is generally acknowledged that
chronic wounds can take months or years to heal.
Patients often need to undergo many therapeutic
procedures to support and promote the best environment
for healing, including the prevention
and early treatment of bacterial load and infection.
This is especially pertinent to the management
of patients with diabetic foot ulceration,
who are prone to osteomyelitis as the most common
complication.
Aim: The aim of this study is to test a surgical protocol
applied in the treatment of bone infection
and chronic wounds related to bone infection.
Methods: In management of ulcers III­V level,
Wagner classification, surgical treatment was applied.
Surgical debridement and soft­tissue reconstruction
were carried out.
Results: Surgical treatment included 23 patients
with ulcers. Ulcers were classified according the
Wagner classification as level III 8 (34.5%),
level IV 8 (34.5%) and level V 7 (30.4%). Surgical
treatment included: surgical debridement
23 patients (100%), bone resection 11 patients
(47.8%), disarticulation 2 patients (8.7%), perfusion
2 patients (8.7%), antibiotic instillation 3
patients (13%), suture or approximation of the
wound border lines 14 patients (60.9%). Duration
of the treatment after operation until the
wound healing and the end of the secernation
were reached was overall 7.5 weeks (2­16 weeks).
Conclusion: Surgical treatment includes the exploration
of the changed bone and minimal resection
which spares the bone. It is advisable to
undertake surgical treatment without delay and
additional diagnostic procedures. Surgical treatment,
followed by local and systemic application
of antibiotics, achieves shorter healing time and
more successful patient outcomes.
Key words: chronic wounds, osteomyelitis, diabetic
foot ulcers, local antibiotics
INTRODUCTION
It is generally acknowledged that chronic wounds
can take months or years to heal. Patients often
need to undergo many therapeutic procedures
to support and promote the best environment
for healing, including the prevention and early
treatment of bacterial load and infection. This is
especially pertinent to the management of patients
with diabetic foot ulceration, who are prone to
osteomyelitis as the most common complication.
Chronic wounds have been defined as having
multiple physiological impairments to healing,
including: inadequate angiogenesis, impaired
innervation, direct pressure, microcirculatory
ischemia and impaired cellular migration, all of
which may contribute to extensive morbidity 1 .
The therapeutic possibilities are huge, often with
big limitations and also including the amputation
surgery. Chronic bone and joint infection is
followed by appearance of fistulas, skin defects,
metaplasia, and sometimes by malignant alteration,
permanent or periodical secretion. Bone and
joint infection appearance on the skin cannot be
treated separately from general treatment of bone
and joint infection (fig.1, 2, 3). Current treatment
options for diabetic foot ulcers (DFU) include offloading
to reduce pressure on the wound, wound
care to prevent infections, and wound debridement
to remove necrotic debris and re­stimulate
the wound healing process 2 .
Approximately 2­2.5% of patients with diabetes
mellitus have complication on their feet 3,2 .
If there are infected ulcers on feet, the level of
osteomyelitis is high, 66% 4 . Among outpatients
with diabetic foot the level of osteomyelitis appearance
is 10­20% 5,6 .
Diabetic foot ulcrs have osteomyelitis as the
most common complication. It is also possible
that osteomyelitis appears as a complication in soft
tissue infection without the initial ulcers. Reduced
circulation, tissue trophic and neuropathy result
�
Science, Practice and Education
1,2 Cedomir S Vucetic,
MD PhD
3Javorka B Delic, MD,
2,4Zoran S Vukasinovic,
MD PhD,
1,2 Goran Dz Tulic,
MD PhD,
2,5 Ivan K Dimitrijevic,
MD PhD,
1Cedo Dj Vuckovic,
MD PhD
2,6 Vesna K Kalezic,
MD PhD
1 Institute for Orthopaedic
Surgery and Traumatology,
Clinical Center of Serbia,
Belgrade
2 School of Medicine,
University of Belgrade,
Belgrade, Serbia
3 Institute for Dermato-
Venereal Diseases,
Belgrade
4 Institute of Orthopaedic
Surgery Banjica, Belgrade
5 Clinic for Psychiatry,
Clinical Center of Serbia,
Belgrade
6 Clinic for endocrinology,
diabetes and metabolic
diseases, Clinical Center of
Serbia, Belgrade
Correspondence:
cedomir.vucetic@
gmail.com
Conflict of interest: none
Acknowledgement
This work is supported by
grant number III 41004,
Ministry of Education and
Science Republic of Serbia.
EWMA Journal 2012 vol 12 no 2 7

in the foot being vulnerable to infection. The early detection
of the clinical signs of infection in the diabetic foot
includes the evaluation of the foot for bone infection. The
possibility of bone infection is significantly greater if there
is a several weeks’ presence of soft tissue infection or fistula.
Plain film radiography of the foot can usually show the
bone exposure and signs of osteomyelitis. Primary phase
or acute state can show bone demineralisation, diffuse
lytic changes on the bone, localised circular changes or
confluent changes, with or without sclerotic parts of the
bone. Chronic osteomyelitis form comes with sequestra
and with more expressive sclerotic and osteolitic parts of
the bone. There are several clinical signs of osteomyelitis:
swelling and the ’sausage’ look of the finger; probe­to­bone
test; deep ulcer.
Laboratory indicators of infection are higher sedimentation
of erythrocytes (SE), higher number of leukocytes,
C­reactive protein (CRP), procalcitonin, bacteriological
smear examination, bone biopsy for bacteriological
and histological examination, repeated radiographic examination,
bone scintigraphy ( 99m Tc diphosphonate),
labelled autologous leucocyte scanning ( 111 In oxine or
99m Tc­HMPAO), antigranulocyte scintigraphy (AGS),
computed tomographic (CT), and magnetic resonance
imaging (MRI) 3,7,8 .
Therapeutic strategies:
Literature describes various approaches to osteomyelitis
healing in diabetic foot. Surgical exploration of infected
part of the bone and bone resection until reaching the
healthy part are marked as the traditional surgical approach.
The advantages of this surgical approach are radically
removing the bone changed by infection and faster
healing. The disadvantages are more bone removed than
necessary, possible disturbance of the foot biomechanics,
and greater surgical procedure.
Conservative surgery in osteomyelitis healing in diabetic
foot is an approach in which only the sequestra are
removed with very limited bone removal. The advantage
of this kind of healing is greater savings but the risk is
longer healing times.
Healing supported by the use of dressings and followed
by systemic antibiotic therapy, can achieve the wanted
result of healing even in 85% of osteomyelitis. Healing
by antibiotics alone prolongs healing time to/by 12­24
weeks 3 .
AIM:
The aim of this study is to evaluate the surgical protocol
applied in treatment of bone infection and chronic
wounds, which are related to bone infection in the treatment
of diabetic foot ulcers.
8
a b
c
e
g
Figure 1:
1a. Female, 44 years, osteomyelitis, phalange distal et proximal
big toe, fistula of the dorsum;
1b. Plantar ulcer, purulent secernation seven months
1c, d. Rtg. pre-operative joint subluxation interphalangeal
1e, f. Operative exploration, sequestrectomy, fistula excision,
sutural, continual lavage
1g, h, Condition 2 months post-operatively
Description of the surgical protocol:
Surgical protocol applied in this study included: 1. surgical
debridement, 2. reconstruction, with the aim of closing
the operative wound as much as possible, 3. application
of antibiotics locally, and 4. surgical procedures of wound
covering with the transplantates or with local flap applied
when needed,. Surgical debridement included: exploration
of the part affected by infection; debridement of devitalised
tissues, sequestra and infected joints and bones. Reconstruction
with the aim of closing the operative wound
was also part of the surgical plan, as much as it was possible.
Local application of antibiotics was enabled by setting
the catheter for continual instillation of antibiotics.
If it was possible, the drain was also set. The additional
procedure of skin defect covering was applied if there was
a need for it after the resolution of infection.
d
f
h
EWMA Journal 2012 vol 12 no 2

a
c
Figure 2:
2a. Male, 67 years. Condition after the amputation of
IV finger and resection of the V MT bone
2b. Rtg after the second operation resection of IV and
V MT bone
2c. condition one week after the operation, debridement
and approximation of wound’s lines with local instillation of
antibiotics
2d. condition 5 weeks after the operation
METHODS
Ulcers on diabetic foot level III­V, according to Wagner,
were surgically treated. The applied osteomyelitis treatment
at diabetic foot is the synthesis of surgical treatment
which intends to save as much as possible while carrying
out necessary debridement and providing the necessary
conditions for wound healing. Practically, that meant the
use of minimally invasive surgery, which included debri­
Table 1. Infection clasification in diabetic according the intensity and form criteria
Acute infection
Chronic infection
Low intensity it appears suddenly,
looks like basical ulcer with
after the minor injury,
smaller secernation, without typical
only some signs of inflammation clinical signs of infection, long lasting,
smaller secernation
can be treated non-operatively
High intensity febrility, sepsis, colour and without local swelling and colour,
swelling of entire foot,
with ulcer or fistula with great
abscess or present secernation,
often skin necrosis
purulent secernation.
b
d
Science, Practice and Education
dement and soft­tissue reconstruction. When there were
clinical signs of infection and ulcers which reached the
fasciae and tendons with secernation, these demanded use
of incision, necrectomy, detritus debridement and possible
exploration. If there was no rapid calming of clinical
signs of infection during the first week of the treatment,
or if there was clinically obvious infection of a chronic
nature, clinical exploration with sparing removing of infected
part of the bone and soft­tissue reconstruction was
done (fig.2). In cases of chronic forms of osteomyelitis
after the resection of part of the bone or after the debridement,
we applied perfusion drainage or local instillation
of antibiotics (fig.1e, 2c). The antibiotics were given locally
for not more than two weeks, followed by parenteral
systemic antibiotic therapy for 2­6 weeks. Osteomyelitis
with smaller ulcers can be healed in two weeks. When
there is also a skin defect, it is often necessary to carry out
the additional skin transplant. In diabetic foot, we can see
a difference between chronic and acute infection and also
a difference in intensity between the low­intensive infection
and high­intensive infection (tempestuous reaction).
Acute infection appears suddenly, after a minor injury
or without a noticeable injury. Locally, only some signs
of inflammation can be noticed, swelling, pain, colour,
induration, with or without recurrence. Acute infection
can be of low­intensity, when there is a clinical presence of
local changes, but without noticeable significant systemic
changes. Acute infection of high­intensity is followed by
tempestuous local changes and systemic response (febricity,
sepsis). Local changes are colour and swelling of entire
foot, secernation or present abscess, and often also skin
necrosis. It is possible that infection develops fast over several
hours or days. Chronic infection of low­intensity looks
like a typical ulcer with smaller secernation, but without
the usual clinical signs of infection; it is long­lasting and
can be treated non­operatively. Chronic infection of high
intensity can turn over to the acute form and vice versa,
just as the infection of low­intensity can have the characteristics
of high­intensity infection and vice versa, too
(table 1).
Selecting patients for the study:
The inclusion criteria were: diabetes mellitus type 1 and
2; patient’s age­over 18, foot ulcers level III, IV and V;
EWMA Journal 2012 vol 12 no 2 9
�

treatment which includes surgical procedures, positive
smear of the wound.
The exclusion criteria were: inflammatory changes with
necrosis or foot gangrene, which were the indication for
below­knee amputation. The diagnosis of bone infection
was based on clinical findings, radiographic changes on
bones and microbiological findings of bones and tissue
from the operating room. The indication for surgical
treatment was based on clinical findings, the duration of
ulceration and failure of previous treatment, operative or
non­operative.
RESULTS
In the study 23 patients were selected – 23 patients with
ulcers, which were surgically treated. Of the patients, 19
were male (82.6%) and four were female (17.4%). The
average age was 55 years and the age range included patients
aged 44­78. Ulcers were classified according to the
Wagner classification as level III eight patients (34.5%),
level IV eight patients (34.5%) and level V seven patients
(30.4%). The clinical classification of the wounds showed
there were 20 patients with chronic wounds (87%), 15
with low­intensity infection (65.2%) and five with highintensity
infection (21.7). There were three patients (13%)
with acute wounds, one with low­intensity (4.4%) and two
with high­intensity (8.7%). Surgical treatment included:
surgical debridement 23, bone resections 11 (47.8%), disarticulation
two (8.7%), perfusion two (8.7%), instillation
of antibiotics three (13%), and suture or aproximation of
wound’s border lines 14 (60.9%). Additional comorbidity,
which may cause changes on foot or which may have
influence on present changes on foot, was recorded in eight
patients (34.8%), two with terminal renal insufficiency
(8.7%), three with neuropathic changes Scharcot (13%)
and one with pes excavatus (4.4%). Healing duration after
the operation until the wound healing and the end of
wound secretion was on average 7.5 weeks, (2­16 weeks).
Wound healing and bone infection cleansing seem to have
an improved outcome.
DISCUSSION
Surgical technique in diabetic foot has some characteristics,
which should be considered. Generally, surgical interventions
on foot should be done in the operating room,
just as every other type of bone surgery. Incisions, smaller
debridements and necrectomies could be done as smaller
surgical procedures. During the surgical exploration, the
soft tissue should not be divided and, generally, every manipulation
should be very sparing, so the vascularisation
can be saved. During the debridement, the incision should
follow the demarcation line, avoiding bleeding as much as
possible. When the wound is closing, no kind of tension is
10
a b
c d
Figure 3:
3a. female, 54 years, osteomyelitis phalanges medialis
et proximalis, dig.II ulceratio four months
3b. Rtg, inter-phalangeal joint subluxation
3c. operation: resection of proximal inter-phalangeal joint,
debridemant, sutural, fixation with filli-K.
3d. condition 4 weeks after the operation
allowed. If there is no skin defect, the wound lines should
be approximated. The flaps, which are formed, must have
very wide basis. It is also important to consider whether
wound drainage is necessary.
Therapeutic approach in diabetic foot includes surgery,
if there is a presence of ulcers and radiographic changes
on bones (fig.1c, 2b, 3b). The chronic ulcers with changes
on bones and joints can be persistent because of the bone
infection or because of the pressure of the fragments, or
both. These three situations need surgery as active therapy.
Surgical treatment should include the resection of the part
of the bone, which is infected or which protrudes out and
presses the skin (fig.3). Surgical debridement and resection
of part of the bone very often can enable the primary
wound to close or make conditions better for surgical reconstruction
of soft­tissues (fig.2).
We based the diagnosis of bone infection on clinical
findings, radiographic changes on bones and microbiological
findings of bones and tissue from the operating room.
We based the indication for surgical treatment on clinical
findings, the duration of ulceration and failure of previous
treatment, operative or non­operative. This study showed
that the applied procedure shortens the healing, avoids
complications, often results in a smaller scar, prevents the
recurrence and often corrects the inadequate anatomical
relation. This procedure also means more radical treat­
EWMA Journal 2012 vol 12 no 2

ment, a larger procedure for the surgeon and also for the
patient. Sometimes it is also necessary to repeat the surgical
treatment. A large study reporting the surgical experience
is needed to appraise the structured approach suggested in
this study. Observations we have made in this series match
the findings of other authors; after surgical treatment for
osteomyelitis, low rate of recurrence was achieved 9 ; early
and aggressive soft tissue reconstruction is in the patient’s
best interest and is crucial for resolution of the chronic
non­healing wound 10 . Diabetic foot infections are a major
cause of morbidity. Infection is the common sequel
of diabetic foot ulceration that leads to delayed wound
healing 11 . We believe that bone biopsy remains the gold
standard for the detection of osteomyelitis 12­15 . Realising
that deep ulcers with detritus and secretion should
be surgically treated, our opinion is that exploration and
debridement should be done according to the clinical
findings, even without the former confirmation of osteomyelitis
diagnosis. It is best to take the bone tissue for
histopathological and microbiological examination during
the surgical treatment. This is important because there
are recommendations which say that surgical percutaneous
bone biopsy specimen after a 14­day antibiotic­free
period represents the gold standard of care for diabetic foot
osteomyelitis 14 . It is known that infection is the cause of
great complications ­ major amputations are thought to
be primarily due to arterial inflow and minor due to bone
infection 1 . Radiology data revealed that 55% of the amputated
limbs showed the presence of osteomyelitis compared
with 38% of the limbs of non­amputees (p=0.39) 1 .
Osteomyelitis may underlie a diabetic ulcer and is often
treated by resection of the infected bone and always by
antibiotics, the mode and length of treatment depending
on the adequacy of the debridement 16 . Considering that
the surgical treatment is a must when there is a serious
infection, necrosis, and long­termed secretion, it should
not be delayed. On the contrary, surgical treatment should
be used to enable 1 – the more complete exploration, 2
– debridement, 3 – taking the tissue samples for HP and
microbiological examination, 4 – local antibiotic application
and 5 – reconstruction of the soft tissue covering on
foot. The findings of other authors can be the confirmation
for this. Debridement is indicated when necrotic tissue
is present. Topical antibiotics should be considered if
there is no improvement in healing after 14 days. Systemic
antibiotics are used in patients with advancing cellulitis,
osteomyelitis, or systemic infection 17 . Ray resection technique
is recommended for localized necrosis, infection,
and osteomyelitis and is an accepted procedure allowing
removal of the diseased toe and metatarsal and limits softtissue
dissection. Defects from the toe amputation can
be primarily closed, covered with a split­thickness skin
graft, or closed in delayed primary fashion with the use of
a mini­external fixation device 18 . The observed group of
Science, Practice and Education
patients with ulcers and bone infection, which was surgically
treated, had shown a significantly shorter period of
healing. Diabetic motor neuropathy is expressed as the loss
of function and the contracting of the intrinsic muscles
of the foot, leading to the classic claw toe deformity. The
mean wound healing time was 25.6 +/­ 6.2 days resection
arthroplasty for toe deformities with chronic infected
ulcers in diabetic patients is a good alternative treatment
to toe amputation 19 . Prolonged time of healing has been
described in chronic wounds. That some parameters can
also show 50% reduction in the wound area at four weeks
after treatment is a reliable indicator of healing 1 .
The application of the simple clinical evaluation of the
presence of bone infection may also be of interest to other
authors, as may the active surgical approach with tissue
reconstruction after the sanation of the infection. Simple
clinical evaluation and laboratory findings without using
expensive imaging methods may be important indicators
of osteomyelitis ­ 1 ESR > or =65 mm/h together with
a wound size > or =2 cm and also a sensitivity of 83%,
specificity of 77%, and positive predictive value of 80% 20 .
Osteomyelitis affects up to 32% of full­thickness
pressure ulcers. Seven steps in this structured approach
of care include: 1. acknowledgment of osteomyelitis risk
in patients with Stage IV pressure ulcers, 2. clinical evaluation
for local or systemic signs of infection upon initial
presentation, 3. radiographic evaluation, 4. surgical debridement
to remove all nonviable tissue and/or scarred
and infected bone, 5. obtaining pathology reports from
sterile bone biopsy and deep microbial cultures, 6. targeted
systemic antimicrobial therapy, and 7. tissue reconstruction
following resolution of infection 21 . Experiences with
local application of antibiotics ­ surgical debridement, implantation
of gentamicin polymethylmethacrylate beads
and long­term intravenous antibiotics ­ show the certain
advantage of this kind of healing. In the instillation group
the rate of recurrence of infection was just 10%, whereas
it was 58.5% in the control group 22 .
CONCLUSION
The results of surgical treatment on diabetic foot, type
Wagner III­V with bone infection, show significantly
shorter duration. The applied surgical treatment includes:
1. choosing the patients by clinical findings, laboratory
parameters, inflammation and radiographies;
2. surgical debridement with sparing resection of modified
bone;
3. local application of antibiotics at chronic infection
and higher­intensity infection,
4. intention for carrying out the approximation of
wound border­lines and reconstruction of the softtissue
defect;
EWMA Journal 2012 vol 12 no 2 11
�

Science, Practice and Education
5. local application of antibiotics no longer than two
weeks and parentelal application no longer than six
weeks,
6. the use of general methods of healing the complications
of diabetic foot; relief and metabolic balance.
Surgical treatment includes exploration of the exposed
bone and sparing resection. It is better to do the surgical
treatment without delay and additional diagnostic procedures.
Surgical treatment, with local and systemic antibiotic
application achieves shorter and more successful
healing. Earlier treatment of diabetic foot ulcers which
have lasted for several months or even several years can
be ended in few weeks. m
Reference:
1. Glinka MS, Margolis DJ, Tal A, Hoff tad O, Boulton AJM, Brem H. Preliminary
development of a diabetic foot ulcer database from a wound electronic medical
record: A tool to decrease limb amputations. Wound Repair Regen. 2009 Sep–Oct;
17(5): 657–665. doi: 10.1111/j.1524-475X.2009.00527.x PMCID: PMC2835515
2. Nouvong A, Hoogwerf B, Mohler E, Davis B, Tajaddini A, Medenilla E. Evaluation of
Diabetic Foot Ulcer Healing With Hyperspectral Imaging of Oxyhaemoglobin and
Deoxyhaemoglobin Diabetes Care. 2009 November; 32(11): 2056–2061. doi:
10.2337/dc08-2246
3. Hartemann-Heurtier A. Senneville E. Diabetic foot osteomyelitis. Diabetes &
Metabolism 34 (2008) 87-95.
4. Grayon ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in
infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients.
JAMA 1995;273:721-3.
5. Shone A, Burnside J, Chipchase S, Game F, Jeffcoate W. Probing the validity of the
probe-to-bone test in the diagnosis of osteomyelitis of the foot in diabetes. Diabetes
care (letter) 2006;29:945.
6. Lavery LA, Armstrong DG, Peters EJ, Lipsky BA, Probe-to-bone test for diagnosing
diabetic foot osteomyelitis: reliable or relic? Diabetes care 2007;30:270-4.
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7. Jeff G. van Baal. Surgical treatment of the infected diabetic foot. CID 2004;39
S123-9
8. Robinson AHN, Paspula C. Brodsky JW. Surgical aspects of the diabetic foot. JBJS Br
2009;91-B 1-8.
9. Sánchez JA, Martínez JLL, Herrero CH, Vilorio NC, Marrero YQ, Morales EG,
Herrero MJH. Does osteomyelitis in the feet of patients with diabetes really recur
after surgical treatment? Natural history of a surgical series. Diabet Med. 2011 Dec
8. doi: 10.1111/j.1464-5491.2011.03528.x.
10. Capobianco CM, Stapleton JJ, Zgonis T. Soft tissue reconstruction pyramid in the
diabetic foot. Foot Ankle Spec. 2010 Oct;3(5):241-8. Epub 2010 Jul 7.
11. Nagoba BS, Gandhi RC, Wadher BJ, Rao A, Hartalkar AR, Selkar SP. A simple and
effective approach for the treatment of diabetic foot ulcers with different Wagner
grades. Int Wound J. 2010 Jun;7(3):153-8. Epub 2010 Apr 23.
12. Miller AO, Henry M. Update in diagnosis and treatment of diabetic foot infections.
Phys Med Rehabil Clin N Am. 2009 Nov;20(4):611-25.
13. Lipsky AB.Medical treatment of diabetic foot infections.CID 2004;39:S 104-14.
14. Lesens O, Desbiez F, Vidal M, Robin F, Descamps S, Beytout J, Laurichesse H,
Tauveron I. Culture of per-wound bone specimens: a simplified approach for the
medical management of diabetic foot osteomyelitis. Clin Microbiol Infect. 2011
Feb;17(2):285-91. doi: 10.1111/j.1469-0691.2010.03194.x.
15. Iori I, Pizzini AM, Arioli D, Favali D, Leone MC. Infected pressure ulcers: evaluation
and management. Infez Med. 2009 Sep;17 Suppl 4:88-94.
16. Vuorisalo S, Venermo M, Lepäntalo M.Treatment of diabetic foot ulcers. J Cardiovasc
Surg (Torino). 2009 Jun;50(3):275-91.
17. Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management.
Am Fam Physician. 2008 Nov 15;78(10):1186-94. Minimum-incision ray resection.
Oznur A, Roukis TS. Clin Podiatr Med Surg. 2008 Oct;25(4):609-22.
18. Oznur A, Roukis TS. Minimum-incision ray resection. Clin Podiatr Med Surg. 2008
Oct;25(4):609-22.
19. Kim JY, Kim TW, Park YE, Lee YJ. Modified resection arthroplasty for infected
non-healing ulcers with toe deformity in diabetic patients. Foot Ankle Int. 2008
May;29(5):493-7.
20. Ertugrul BM, Savk O, Ozturk B, Cobanoglu M, Oncu S, Sakarya S. The diagnosis of
diabetic foot osteomyelitis: examination findings and laboratory values. Med Sci
Monit. 2009 Jun;15(6):CR307-12.
21. Rennert R, Golinko M, Yan A, Flattau A, Tomic-Canic M, Brem H. Developing and
evaluating outcomes of an evidence-based protocol for the treatment of osteomyelitis
in Stage IV pressure ulcers: a literature and wound electronic medical record
database review. Ostomy Wound Manage. 2009 Mar;55(3):42-5.
22. Timmers MS, Graafland N, Bernards AT, Nelissen RG, van Dissel JT, Jukema GN.
Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide
antiseptic solution instillation in posttraumatic osteomyelitis. Wound Repair Regen.
2009 Mar-Apr;17(2):278-86.
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The patient experience of complex wounds
treated with NPWT
Ultrasound assessment of necrotic tissue in pressure ulcers with undermining
Chronic plantar ulcer secondary to congenital indifference to pain
Manuka honey as an effective treatment for chronic pilonidal sinus wounds
Silver and nanoparticles of silver in wound dressings
Efficacy of a PHMB-containing biocellulose dressing in the treatment of biofilms
C
Quantitative estimation of exudate volume
for full-thickness pressure ulcers
v o l u m e 2 0 . n u m b e r 9 . s e p t e m b e r 2 0 1 1
A proposed method of evaluating orbital exenteration wounds
Modelling the cost-effectiveness of bioelectric stimulation therapy in chronic VLUs
The effect of temperature and Evaluation humidity on the permeability of the of skin film dressings stripping of wound
Complex lower extremity wounds treated with skin grafts and NPWT dressing adhesives
The effect of simulated leg-length discrepancy on plantar pressure distribution
Wound healing through synergy of hyaluronan and an iodine complex
Innovation in tissue viability documentation for acute services
Necrosis in breast cancer patients with skin metastases receiving bevacizumab
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References
1. Serena T. et al. Protease activity levels associated with healing status of chronic wounds. Poster, Wounds UK 2011.
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3. International consensus. The role of proteases in wound diagnostics. An expert working group review. London: Wounds International, 2011.

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Presented at
EWMA 2011
Brussels · Belgium
Endothelial progenitor cells, a unipotent
stem cell, involved in neovascularization
of wound healing in diabetic foot ulcer
ABSTRACT
Foot ulceration associated with diabetic complications
is prevalent in patients with diabetes worldwide,
leading to limb amputation. Reduction of
peripheral blood flow and decrease in local neovascularization
are critical factors contributing to
slow healing or non­healing wounds among these
patients. Presumably, mature endothelial cells are
regarded as the sole candidate for participation in
angiogenesis in wound healing. In recent decades,
endothelial progenitor cells (EPCs) have been recognized
and are being investigated as the main
cellular effectors responsible for postnatal neovascularization
and playing a vital role in wound
healing. In this review, the role of EPCs involved
in the neovascularization in wound healing will be
evaluated. The process of EPCs from bone marrow
to blood circulation requires a complex and
sequential event including mobilization, homing,
adhesion, transendothelial migration, differentiation
and finally incorporation to newly formed
blood vessels. However, deficiency of circulating
EPCs and functional defects of EPCs have been
reported in diabetes, which adversely affect interfering
neovascularization of wound healing. Cellbased
therapy using EPCs would be a promising
therapeutic strategy for treating diabetic patients
with non­healing wound. Besides, the establishment
of traditional Chinese medicine (TCM) in
treating diabetic foot ulcer may develop new perspectives
of EPCs’ involvement in diabetic wound
healing.
INTRODUCTION
According to the data provided by World Health
Organization, about 346 million people worldwide
have diabetes mellitus. The prevalence of
diabetes has been increasing and represents a major
health burden for the 21 st century. Diabetes
mellitus is associated with various complications
including cardiovascular disease, neuropathy,
retinopathy, nephropathy and impaired wound
healing in lower extremities. Annually about 1%
to 4% of those with diabetes eventually develop a
foot ulcer and the annual incidence of amputation
is 0.21­1.37% [1] .
The pathophysiology of diabetic foot ulcer and
impaired wound healing has been well described.
The factors of delayed wound healing are contributed
to by progressive loss of sensory, motor
and autonomic nervous system in diabetic patients
leading to the loss of protective mechanisms
upon injury in lower extremities. Development of
peripheral vascular disease reduces the blood circulation
to the dermal area, thus minimizing the
supply of nutrients for normal wound repair [2] .
Wound healing is a well­orchestrated, integrated
and complex process that involves hemostasis,
inflammation, angiogenesis and tissue
granulation [3] . The coordination of multiple cells
including platelet, monocytes, macrophages, lymphocytes,
endothelial cells, fibroblasts and keratinocytes
is essential for normal wound healing.
However, the abnormal wound healing in diabetes
is characterized by diminished level of growth
factors, cytokines and chemokines; elevated inflammatory
response with enhanced proliferation
of inflammatory cells; inhibition in angiogenesis
with decreased proliferation, migration and tube
format
Restoring the blood flow to the wound site
is the prerequisite for successful wound healing.
It is generally believed that neovascularization is
solely aroused by the formation of new blood vessels
from pre­existing blood vessels (angiogenesis).
Over the past decades, the emergence of EPCs has
provided a new perspective in the involvement of
postnatal vasculogenesis in neovascularization. In
1997, Asahara et al. first isolated and identified
circulating EPCs from human peripheral blood
for postnatal neovascularization which is defined
as the de novo formation of blood vessels with the
recruitment and incorporation of EPCs. The findings
showed that EPCs differentiated into mature
endothelial cells in vitro and incorporated actively
�
Science, Practice and Education
Jacqueline
Chor Wing Tam 1,2
Chun Hay Ko 1,2
Ping Chung Leung 1,2
Kwok Pui Fung 1,2,3
Clara Bik San Lau 1,2,3
1 Institute of Chinese
Medicine,
The Chinese University of
Hong Kong, Shatin, New
Territories, Hong Kong
2 State Key Laboratory of
Phytochemistry and Plant
Resources in West China,
The Chinese University of
Hong Kong, Shatin,
New Territories,
Hong Kong
3 School of Biomedical
Sciences,
The Chinese University of
Hong Kong, Shatin,
New Territories,
Hong Kong
Correspondence:
claralau@cuhk.edu.hk
Winner of the
EWMA 2011 First Time
Presenters prize at
EWMA 2011
conference in Bruxelles.
Conflict of interest: none
EWMA Journal 2012 vol 12 no 2 15

1st International Course on
The Neuropathic
Osteoarthropathic Foot
(Charcot)
Advanced Postgraduate Course,
Rheine, Germany
15-17 November, 2012
The international course will be based on the
expertise gathered from 10 consecutive years of
providing national courses on the Diabetic Foot.
The main focus are practical sessions in small
groups to train the diagnostic and treatment skills
necessary for the interdisciplinary treatment of
Charcot patients.
The course will be held at the Mathias-Spital in
Rheine.
The courses are open to anyone involved in
the treatment or management of Neuropathic
Osteoarthropathic Foot patients.
Number of participants: 25-50
Language: English
www.charcotfootcourses.org
into sites of angiogenesis in ischemic animal models [5] .
After that, a growing body has proposed that bone marrow
(BM)­derived EPCs can functionally participate in
neovascularization in wound healing and limb ischemia [6,
7] . It has been estimated that EPCs contribute up to 25%
of endothelial cells of newly formed vessels in animal models
[8] . Substantial evidence has demonstrated the role of
BM­derived EPCs in neovascularization [9,10,11] . In general,
it is now well accepted that recruitment of EPCs in BM
and the mature endothelial cells in pre­existing blood vessels
are essential in tissue vascularization in wound healing.
ORIGIN OF EPCS
EPCs are adult hemangioblast­derived cells in BM. Immature
stem cells originally exist in a quiescent state associated
with BM stromal cells. Under specific stimulation
and activation, stem cells will differentiate into EPCs
preceding the mobilization of EPCs in peripheral blood
for neovascularization. During their development, EPCs
gradually lose stem cell characteristics and progressively
gain mature endothelial cells characteristics.
EPCS ISOLATION AND CHARACTERIZATION
Numerous methods have been adopted for the isolation
of EPCs [12,13,14] . EPCs are often characterized by the
combination of different cell surface markers, including
CD34, CD133, CD146, platelet endothelial cell adhesion
molecule­1 (PECAM­1), vascular endothelial cadherin
(VE­cadherin), vascular endothelial growth factor receptor
2 (VEGFR2) and von Willebrand factor (vWF) [15,16] .
However, there is no defined set of markers which can
identify EPCs population uniquely. The reasons may be
attributed to the various origins of EPCs precursors during
extraction and isolation. The multiple precursors include
haematopoietic stem cells, myeloid cells, multipotent BM
progenitors or tissue resident stem cells. Moreover, EPCs
may exist in different differentiation stage in the lineage
References
1. Bartus C.L., Margolis D.J. Reducing the incidence of foot ulceration and amputation
in diabetes. Curr Diabetes Rep 2004: 4: 413-418.
2. Bowering C.K. Diabetic foot ulcers: pathophysiology, assessment, and therapy. Can
Fam Physician 2001: 47: 1007-1016.
3. Diegelmann R.F., Evans M.C. Wound healing: an overview of acute, fibrotic and
delayed wound healing. Front Biosci 2004: 9: 283-289.
4. Brem H., Tomic-Canic M. Cellular and molecular basis of wound healing in
diabetes. J Clin Invest 2007: 117: 1219-1222.
5. Asahara T., Murohara T., Sullivan A., Silver M., Van Der Zee R., Li T., Witzenbichler
B., Schatteman G., Isner J.M. Isolation of putative progenitor endothelial cells for
angiogenesis. Science 1997: 275: 964-967.
6. Asahara T., Masuda H., Takahashi T., Kalka C., Pastore C., Silver M, Kearne M.,
Magner M., Isner J.M. Bone marrow origin of endothelial progenitor cells responsible
for postnatal vasculogenesis in physiological and pathological neovascularization.
Circ Res 1999: 85: 221-228.
EWMA Journal 2012 vol 12 no 2

of EPCs development. It is likely that various markers
are present at EPCs at different points during their differentiation
cascade from immature progenitors to mature
endothelial cells. In line with this point of view, it
has been suggested that EPCs can be divided into two
distinct cell populations, which appear in cell culture sequentially.
They are named early EPCs and late outgrowth
EPCs (LOG EPCs). The technique to separate these two
cell populations is according to their adherence ability
in culture. Many studies demonstrated that only cells
that adhere early in culture (within 48 hours) are early
EPCs while cells adhering in the culture plate later than
48 hours are believed to be LOG EPCs [17] . The two cell
populations are shown to have morphological difference
in cell culture. Early EPCs have rounded or spindle­like
morphology with random dispersion on the culture plate
whereas LOG EPCs appear as cobblestone­like clusters
with elongated cells at the periphery and form colonies
in culture [18] . Apart from their difference in morphology,
it is interesting to note that the two cell populations
have been shown to have different roles in neovascularization
and vascular repair. Early EPCs mainly produce
angiogenic growth factors, which support the proliferation
and promote the functioning of LOG EPCs and mature
tissue­resident endothelial cells for neovascularization.
LOG EPCs demonstrate high proliferative activity and
are directly incorporated into the endothelium of newly
formed blood vessels [19] . Thus, LOG EPCs are considered
to be the true endothelial progenitor candidates in
vascular developmental biology while early EPCs are proangiogenic
cell population, which support the local neovascularization
indirectly.
THE INVOLVEMENT OF EPCS IN
NEOVASCULARIZATION OF WOUND HEALING
The recruitment and incorporation of EPCs in the formation
of new micro­vessels in wounds requires coordinated
and multi­disciplined steps. It involves sensing the
7. Takahashi T., Kalka C., Masuda H., Chen D., Silver M., Kearney M., Magner M.,
Isner J.M., Asahara T. Ischemia- and cytokine-induced mobilization of bone
marrow-derived endothelial progenitor cells for neovascularization. Nat Med 1999:
5: 434-438.
8. Tepper O.M., Galiano R.D., Capla J.M., Kalka C., Gagne P.J., Jacobowitz G.R.,
Levine J.P., Gurtner G.C. Human endothelial progenitor cells from type II diabetics
exhibit impaired proliferation, adhesion, and incorporation into vascular structures.
Circulation 2002: 106: 2781-2786.
9. Kalka C., Masuda H., Takahashi T., Kalka-Moll W.M., Silver M., Kearney M., Li T.,
Isner J.M., Asahara T. Transplantation of ex vivo expanded endothelial progenitor
cells for therapeutic neovascularization. Proc Natl Acad Sci USA 2000: 97:
3422-3427.
10. Majka S.M., Jackson K.A., Kienstra K.A., Majesky M.W., Goodbell M.A., Hirschi
K.K. Distinct progenitor populations in skeletal muscle are bone marrow derived and
exhibit different cell fates during vascular regeneration. J Clin Invest 2003: 111:
71-79.
11. Kopp H.G., Ramos C.A., Rafii S. Contribution of endothelial progenitors and
proangiogenic hematopoietic cells to vascularization of tumor and ischemic tissue.
Curr Opin Hematol 2006: 13: 175-181.
Science, Practice and Education
ischemia signal from distanced tissues, migration of EPCs
from BM to circulation, homing in of circulating EPCs to
the target sites, the integration of EPCs into blood vessels
and the in situ differentiation of EPCs into mature and
functional endothelial cells [20] .
Bone marrow is a major reservoir of adult progenitor
cells which exist in a quiescent state. In the course
of tissue damage or tissue hypoxia, the quantity of circulating
EPCs is greatly increased by the mobilization
of EPCs. The EPCs mobilization can be switched on by
up­regulation of endogenous factors in blood including
vascular endothelial growth factor (VEGF) [21] and fibroblast
growth factor­2 [22] . These stimulating factors activate
matrix metalloproteinase­9, resulting in the translocation
of EPCs to a permissive zone ready for mobilization into
blood circulation [23] .
A quantity of evidence strongly supported the EPCs
recruitment and homing to target sites via the stromal
cell derived factor­1a (SDF­1a)/chemokine receptor type
4 (CXCR4) axis [24] . SDF­1a expression is up­regulated
under hypoxic conditions and it binds exclusively to
CXCR4. Accordingly, experimental studies demonstrated
that blockage of either SDF­1a or CXCR4 significantly
reduced the adhesion of EPCs to mature endothelial cells
monolayer in vitro [25] and the in vivo homing of circulating
EPCs to ischemic limb in hindlimb ischemic model [26] .
Integration of circulating EPCs to blood vessels involves
the participation of integrins. It has been proposed
that adhesion of EPCs is similar to the adhesion mechanisms
of leukocyte on endothelium [27] . One of the integrins,
leukocyte b2­integrins, has been demonstrated
to be involved in EPCs adhesion mechanisms. In vitro
adhesion assay revealed that b2­integrins mediated the
adhesion of peripheral blood derived EPCs to endothelial
cell monolayers [28] . Moreover, a growing body showed the
essential role of b2­integrins in EPCs homing to ischemic
tissues and for the neovascularization capacity in vivo [29] .
After that, subsequent step of transendothelial migration
12. Hill J.M., Zalos G., Halcox J.P., Schenke W.H., Waclawiw M.A., Quyyumi A.A.,
Finkel T. Circulating endothelial progenitor cells, vascular function and cardiovascular
risk. N Engl J Med 2003: 348: 593-600.
13. Thomas R.A., Pietrzak D.C., Scicchitano M.S., Thomas H.C., McFarland D.C.,
Frazier K.S. Detection and characterization of circulating endothelial progenitor cells
in normal rat blood. J Pharmacol Toxicol Methods 2009: 60(3): 263-274.
14. Sekiguchi H., Li M., Jujo K., Yokoyama A., Hagiwara N., Asahara T. Improved
culture-based isolation of differentiating endothelial progenitor cells from mouse
bone marrow mononuclear cells. Plos one 2011: 6(12): e28639.
15. Hristov M., Schmitz S., Schuhmann C., Leyendecker T., Von Hundelshausen P.,
Krotz F., Sohn H.Y., Nauwelaers F.A., Weber C. An optimized flow cytometry
protocol for analysis of angiogenic monocytes and endothelial progenitor cells in
peripheral blood. ISAC 2009: 75A: 848-853.
16. Mazzolai L., Bouzourene K., Hayoz D., Dignat-George F., Liu J.W., Bounameaux H.,
Dunoyer-Geindre S., Kruithof. E.K.O. Characterization of human late outgrowth
endothelial progenitor-derived cells under various flow conditions. J Vasc Res 2011:
48: 443-451.
EWMA Journal 2012 vol 12 no 2 17
�

10th Scientific Meeting of the
Diabetic Foot
Study Group
of the EASD
28-30 September 2012
Berlin­Potsdam, Germany
Conference theme
Advancement
of knowledge
on all aspects of
diabetic foot care
Main subjects during conference:
� Epidemiology
� Basic and clinical science
� Diagnostics
� Classification
� Foot clinics
� Biomechanics, Osteoarthropathy
� Orthopaedic surgery
� Infection
� Revascularisation
� Uraemia
� Wound healing/outcome
www.dfsg.org
is vital for migration of EPCs from blood vessels to active
site of neovascularization in wound area. However, less is
known about the transendothelial migration of EPCs. Several
in vitro studies provided the relation of high expression
of CD99 or PECAM in EPCs, which could facilitate the
migration of EPCs through endothelial monolayer [30,31] .
Although the role of EPCs in the involvement of neovascularization
in wound healing is extensively investigated,
the genetic cascades regulating the maturation to
functional endothelial cells in the adult system are largely
unknown. During embryonic development, vascular endothelial
growth factor (VEGF) and its receptor play a crucial
role in stimulating hemangioblast differentiation into
endothelial lineage [32] . VEGF can strongly up­regulate the
expression of endothelial cell markers on progenitor cells
and thus increase the number of cell population capable
of repairing the endothelial monolayer and improving
vascular function. Besides, VEGF also initiates ex vivo
endothelial differentiation of various adult progenitor
precursor population [33] .
EPCS ALTERATIONS IN DIABETES
Incomplete and prolonged wound healing is caused by
compromised neovascularization, reduced cell recruitment
and defects in collagen matrix formation. Wound healing
requires the combined effort of inflammatory and noninflammatory
cells. EPCs are involved in a large proportion
of the non­inflammatory cells that migrate to the skin
for normal repair. Within the spectrum of diabetes, substantial
in vitro studies demonstrated a significant EPCs
reduction and dysfunction in type 1 and type 2 diabetes.
Fadini et al. confirmed for the first time that type 2 diabetes
was associated with severe depletion of circulating
CD34 + /VEGFR2 + EPCs, with the lowest level of circulating
EPCs in ischemic foot lesions [34] . Tepper et al. found
that EPCs isolated from type 2 diabetic patients exhibited
decreased proliferation and adherence to endothelial cells.
They were less likely to participate in tubule formation,
17. Sieveking D.P., Buckle A., Celermajer D.S., Ng M.K.C. Strikingly different angiogenic
properties of endothelial progenitor cell subpopulations. J Am Coll Cardiol 2008: 51:
660-668.
18. Yoder M.C., Mead L.E., Prater D., Krier T.R., Mroueh K.N., Li F., Krasich R., Temm
C.J., Prchal J.T., Ingram D.A. Redefining endothelial progenitor cells via clonal
analysis and hematopoietic stem/progenitor cell principals. Blood 2007: 109:
1801-1809.
19. Shantsila E., Watson T., Tse H.F., Lip G.Y.H. New insights on endothelial progenitor
cell subpopulations and their angiogenic properties. J Am Coll Cardiol 2008: 51:
669-671.
20. Hristov M., Weber C. Progenitor cell trafficking in the vascular wall. J Thromb
Haemost 2009: 7(Suppl. 1): 31-34.
21. Kalka C., Masuda H., Takahashi T., Gordon R., Tepper O., Gravereaux E., Pieczek
A., Iwaguro H., Hayashi S.I., Isner J.M., Asahara T. Vascular endothelial growth
factor165 gene transfer augments circulating endothelial progenitor cells in human
subjects. Circ Res 2000: 86: 1198-1202.
EWMA Journal 2012 vol 12 no 2

suggesting that hyperglycemia destructed EPC biology [35] .
Loomans et al. obtained nearly identical results in type 1
diabetic patients [36] . Moreover, many phenotypes of EPCs
appeared to be altered in diabetes. Egan et al. revealed a
significant decreased expression of the surface antigen in
EPCs by flow cytometry including CD31, CD34, CD133,
VEGFR2, VE­cadherin, vWF and CXCR4 [37] . However,
these established observations have no detailed mechanistic
explanation of the EPCs defects in diabetes. Circulating
EPCs reduction in diabetes can theoretically account for
decreased survival; change in the mobilization mechanism
from BM; altered extravascular homing and deranged differentiation.
There is evidence that EPCs from diabetic patients
displayed a reduced survival followed by an increased
rate of apoptotic cell death. Abundant in vivo animal studies
provided the evidence that diabetes led to an inability
of EPCs to mobilize from BM to peripheral circulation
under ischemia conditions [38] . In support of the hypothesis
of EPCs deranged differentiation, one study observed that
peripheral blood mononuclear cells were more prone to
differentiate into pro­inflammatory phenotype than into
EPCs phenotype in high glucose level [39] . Taking all these
findings together, diabetes seems to alter EPC biology,
thus inhibiting EPCs recruitment and incorporation to
the active site of vasculogenesis in diabetic wound healing.
PROMISING CELL-BASED THERAPy IN
DIABETIC WOUND HEALING
Among the various type of stem or progenitor cells, EPCs
are one of the representatives that have been moved from
experimental models to clinical trials. EPCs have been
tested in patients with acute and chronic ischemic heart
disease, and the outcomes were very promising. Assmus
et al. allocated patients with acute myocardial infarction
(AMI) to receive intracoronary infusion of either
BM­derived or PB­derived progenitor cells. The results
demonstrated the patients with AMI had regeneration
enhancement in global left ventricular ejection fraction
22. Fontaine V., Filipe C., Werner N., Gourdy P., Billon A., Garmy-Susini B., Brouchet L.,
Bayard F., Prats H., Doetschman T., Nickenig G., Arnal J.F. Essential role of bone
marrow fibroblast growth factor-2 in the effect of estradiol on reendothelialization
and endothelial progenitor cell mobilization. Am J Pathol 2006: 169: 1855-1862.
23. Rafii S., Lyden D. Therapeutic stem and progenitor cell transplantation for organ
vascularization and regeneration. Nat Med 2003: 9: 702-712.
24. Ceradini D.J., Gurtner G.C. Homing to hypoxia: HIF-1 as a mediator of progenitor
cell recruitment to injured tissue. Trends Cardiovasc Med 2005: 15: 57-63.
25. Ceradini D.J., Kulkarni A.R., Callaghan M.J., Tepper O.M., Bastidas N., Kleinman
M.E., Capla J.M., Galiano R.D., Levine J.P., Gurtner G.C. Progenitor cell trafficking
is regulated by hypoxic gradients through HIF-1 induction of SDF-1. Nat Med 2004:
10: 858–864.
26. Walter D.H., Haendeler J., Reinhold J., Rochwalsky U., Seeger F., Honold J.,
Hoffmann J., Urbich C., Lehmann R., Arenzana-Seisdesdos F., Aicher A., Heeschen
C., Fichtlscherer S., Zeiher A.M., Dimmeler S. Impaired CXCR4 signaling contributes
to the reduced neovascularization capacity of endothelial progenitor cells from
patients with coronary artery disease. Circ Res 2005: 97: 1142–1151.
27. Urbich C., Chavakis E., Dimmeler S. Homing and differentiation of endothelial
progenitor cells. In D. Marme & N. Fusenig (Eds.). New York: Springer: Tumor
angiogenesis; 2008. p. 309-324.
Science, Practice and Education
from 51.6+9.6% to 60.1+8.6% (p=0.003) and regional
wall motion in the infarct zone from ­1.5+0.2 SD/chord
to ­0.5+0.7SD/chord (p

Science, Practice and Education
have been conducted using traditional Chinese medicine
(TCM) in improving diabetic wound healing in Prince of
Wales Hospital (Hong Kong) and the Chinese University
of Hong Kong respectively. In 2001, Wong et al. first demonstrated
TCM in combination with simple debridement
as an alternative treatment of diabetic foot ulcer. Two
herbal drinks were orally taken by the patients. The first
herbal preparation consisted of Radix Astragali, Rhizoma
atractylodis marcocephala, Radix stephaniae tetrandrae,
Radix polygoni multiflori, Radix rehmanniae and Radix
smilax china which was aimed at muscle strengthening and
swelling control. Another herbal preparation contained
Radix rehmanniae, Fructus corni, Rhizoma dioscoreae,
Cortex moutan, Rhizoma alismatis, Rhizoma smilacis glabrae,
Radix astragli and Fructus schisandrae which promoted
regeneration. The results showed that about 85%
of diabetic patients avoided limb amputation. The consumption
of herbal preparations in patients appeared to
offer improvement in the local circulation as exemplified
by improved warmth and color of the toes. In addition,
granulation tissue formation at the ulcer bed was observed
as a sign of improvement [42,43] . In our previous clinical
study, the herbal extracts exhibited significant wound
healing effect in diabetic patients. In order to simply and
modify the TCM formula, individual herbs were tested
for the fibroblast viability in CRL­7522 fibroblast cell line
and primary fibroblasts from a diabetic foot ulcer patient.
The results supported the previously reported clinical efficacies
of the two herbal preparations and indicated the
individual herb with compromised primary fibroblast viability
effect [44] . With the results of our expertise, Tam
et al. presented the first scientific evidence towards the
efficacy of a Chinese herbal formula (NF3) with Radix
33. Dimmeler S., Aicher A., Vasa M., Mildner-Rihm C., Adler K., Tiemann M., Rutten
H., Fichtlscherer S., Martin H., Zeiher A.M. HMG-CoA reductase inhibitors (statins)
increase endothelial progenitor cells via the PI 3-kinase/Akt pathway. J Clin Invest
2001: 108: 391–397.
34. Fadini G.P., Miorin M., Facco M., Bonamico S., Baesso I., Grego F., Menegolo M.,
Vigili de Kreutzenberg S., Tiengo A., Agostini C., Avogaro A. Circulating endothelial
progenitor cells are reduced in peripheral vascular complications of type 2 diabetes
mellitus. J Am Coll Cardiol 2005: 45: 1449-1457.
35. Tepper O.M., Galiano R.D., Capla J.M., Kalka C., Gagne P.J., Jacobowitz G.R.,
Levine J.P., Gurtner G.C. Human endothelial progenitor cells from type II diabetics
exhibit impaired proliferation, adhesion, and incorporation into vascular structures.
Circulation 2002: 106: 2781-2786.
36. Loomans C.J.M., De Koning E.J.P., Staal F.J.T., Rookmaaker M.B., Verseyden C.,
De Boer H.C., Verhaar M.C., Braam B., Rabelink T.J., Van Zonneveld A.J. Endothelial
progenitor cell dysfunction: a novel concept in the pathogenesis of vascular
complications of type 1 diabetes. Diabetes 2004: 53: 195-199.
37. Egan C.G., Lavery R., Caporali F., Fondelli C., Laghi-Pasini F., Dotta F., Sorrentino
V. Generalised reduction of putative endothelial progenitors and CXCR4-positive
peripheral blood cells in type 2 diabetes. Diabetologia 2008: 51: 1296-1305.
38. Fadini G.P., Sartore S., Schiavon M., Albiero M., Baesso I., Cabrelle A., Agostini C.,
Avogaro A. Diabetes impairs progenitor cell mobilization after hindlimb ischemiareperfusion
injury in rats. Diabetologia 2006: 49: 3075-3084.
20
astragali and Radix rehmanniae in the ratio of 2:1 in enhancing
wound healing in a chemically induced diabetic
foot ulcer rat model (p

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Much has happened in a year, and we can’t wait to share
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gentle transparent breathable film dressing for skin protection, is the world’s first film with
Safetac ® , and one of many new reasons for patients and clinicians to smile!
Presenting New Science
In Pressure Ulcer Prevention
Learn more about new science in pressure ulcer prevention when
attending the Mölnlycke Health Care Satellite Symposium at the
European Wound Management Association Conference, Vienna, 2012.
Thursday 24th May, 13:15 to 14:15 in Room E1
Despite the widespread use of prevention strategies, pressure ulceration remains
a significant clinical and economic challenge to health care providers, as well as
impacting negatively on the quality of life of patients, their families and carers.
Chaired by Professor Michael Clark (President of the European Pressure Ulcer Advisory
Panel), the goals of this symposium are to emphasise the importance of developing
new strategies that will reduce the clinical, economic and social burden of pressure
ulcers; and to present new scientific and clinical data relating to the use of five-layered
soft silicone dressings as an adjunct to standard preventative interventions.
Speakers – Professor Michael Clark, Paulo Alves, Professor Cees Oomens.
EWMA 2012 VIENNA

Is the
chemistry
right? EWMA
When it comes to NPWT, the foam makes all the difference.
A comparative study 1,2 by HARTMANN shows that for NPWT products, the type of foam used really does matter. Significant differences
in the body's inflammatory response show that different foams can accelerate efficient wound healing. Could this make NPWT even more
economical? Vivano. Safety. And Simplicity.
You can find more information at our trade fair booth or at www.vivanosystem.info
Source: 1 Croizat et al., Journal of Investigative Dermatology (2011) 131: S134. 2 Walch et al., Wound Repair and Regeneration (2011) 19: A91.
2012
Visit our symposium:
Hall E2 on Wednesday;
23/05/12 at 12:30–1:30 pm

Presented at
EWMA 2011
Brussels · Belgium
Bacteriophages for the treatment
of severe infections:
A ‘new’ option for the future?
INTRODUCTION
The worldwide emergence of “Superbugs” and
a dry antibiotic pipeline threaten a return to the
pre­antibiotic era, i.e. prior to the 1940s when
millions of people died of bacterial infection 1 .
In hospitals in both high­income and lowincome
countries, the majority of nosocomial
outbreaks are caused by a small group of pathogens
– Enterococcus faecium, Staphylococcus aureus,
Klebsiella pneumoniae, Acinetobacter baumanni,
Pseudomonas aeruginosa and Enterobacter species,
hereafter referred to as “the ESKAPE bugs.”
These ESKAPE bugs are increasingly prevalent
in our hospitals and increasingly resistant to many
of our antimicrobial agents threatening patients’
lives and confronting society with huge socioeconomic
costs 1 .
While extensively drug resistant Acinetobacter
baumannii, often associated with military operations
(Iraq, Afghanistan), NDM­1 containing Enterobacteriaceae,
pan­resistant Pseudomonas aeruginosa
clones and methicillin resistant Staphylococcus
aureus (MRSA) are mainly prevalent in our hospitals,
it seems that the community as a whole is
threatened by these worrisome pathogens. This
was demonstrated by the EAHEC 0104:H4 epidemic
in Germany in 2011 2­5 . Some infectious
agents are indeed not confined to human beings
but actually deeply settled in our environment.
Beside the overuse, and misuse of antibiotics in
human medicine it seems also more and more evident
that the animal food production sector serves
as a major antibiotic consumer and consequently a
reservoir for multi­drug resistant (MDR) bacteria.
Our ever growing and crowded cities also seem
to play a role in the emergence of these ESKAPE
bugs 6­8 . Taking all this into account it is evident
that the situation is alarming.
A reflection on the biological role of natural, as
well as (semi­)synthetic antibiotics, in nature as
secondary metabolites and their use as antimi­
crobial agents in human, veterinary and agro­bio
industry reveals that we still have much to learn
about these molecules. The lack of fundamental
knowledge on the actual role of antibiotics (secondary
metabolites often functioning as signalling
molecules) in nature and their effect on living systems
(bacteria) in relation with the whole ecological
setting means that we actually disequilibrate
our natural environment as a consequence of the
mis/over use of those molecules. This biological
phenomenon of antibiotic resistance is typically
an emergent characteristic of a dynamic, highly
complex and self­organizing system that evolves
at the edge of chaos 9­10 .
Antibiotics are typically studied and developed
through models in which the bacteria are in a
planktonic (free living and growing) life style, but
most of the infections seem to be due to bacterial
infectious foci, which mainly harbour bacteria
that exhibit a biofilm life style 11 . It was shown by
gene expression analysis that planktonic and biofilm
lifestyle modes have distinct differential gene
expression profiles. This affects, amongst other
features, the bacterial sensitivity to antibiotics 12­13 .
These bacterial biofilm­related findings imply
that the mechanical barrier function of the biofilm
is not the main reason why bacteria residing in a
biofilm lifestyle mode do not respond as expected
to antibiotics. Some antibiotics can diffuse into
the biofilm complex and reach the bacteria, but
as a consequence of the changed bacterial physiology
and biochemical pathways in the biofilm
modus some antibiotics cannot interfere with the
biofilm bacteria in the same way as they would
do with free living and proliferating planktonic
bacteria. In a biofilm the bacterial growth rate is
dramatically slowed down while the mechanical
barrier protects them essentially from the immune
system. Antibiotics were developed only taking
into account the bacterium’s planktonic lifestyle,
but we know today that biofilms play a major role
�
Science, Practice and Education
1 Daniel De Vos, PhD
1 Gilbert Verbeken, MSc
1,2 Thomas Rose, MD
2 Serge Jennes, MD
1 Jean-Paul Pirnay, PhD
1 Laboratory for Molecular
and Cellular Technology,
2 Burn Wound Centre,
Queen Astrid Military
Hospital, Brussels, Belgium
Correspondence:
daniel.devos2@mil.be
Conflict of interest: none
EWMA Journal 2012 vol 12 no 2 23

THE EWMA
UNIVERSITY
CONFERENCE
MODEL (UCM)
in Vienna
The EWMA UCM programme offers students of wound
management from institutes of higher education across Europe
the opportunity to take part of their academic studies whilst
participating in the EWMA Conference.
The opportunity of participating in the EWMA UCM is available
to all teaching institutions with wound management courses for
health professionals.
The UCM programme at the EWMA 2012 Conference
in Vienna will focus on increasing the networking opportunities
between the students from various UCM groups participating
in the programme this year.
In addition to the main conference programme, UCM Lectures
as well as assignments and workshops for mixed groups will
be arranged specifically for the UCM students.
EWMA strongly encourages teaching institutions and students
from all countries to benefit from the possibilities of international
networking and access to lectures by many of the most
experienced wound management experts in the world.
Yours sincerely
Zena Moore,
Chair of the Education Committee, Immediate Past President
Participating institutions:
Donau Universität Krems
Austria
Haute École de Santé
Geneva, Switzerland
KATHO university college Roeselare
Belgium
University of Hertfordshire
United Kingdom
ienna
EWMA 2012
23-25 May
Escola Superior de Enfermagem de Lisboa
Portugal
HUB Brussels
Belgium
Lithuanian University of Health Sciences
Lithuania
Universidade Católica Portuguesa
Porto, Portugal
For further information about the EWMA UCM, please visit
the Education section of the EWMA website www.ewma.org
or contact the EWMA Secretariat at ewma@ewma.org
in most infectious states 11 . New strategies, based on fundamental
biofilm research to cope with this problem are
under development. Recently, a review on bacterial biofilms
was published in this journal by Antonio Fonseca 14 .
Apart from the overuse and misuse of antibiotics there
are thus several additional reasons for the antibiotic crisis
which is partly a consequence of our current socio economic
society 15 . The pharmaceutical industry is not eager
to develop new antibiotics due to the long term resourceintensive
research and development costs while knowing
that eventually resistance will emerge and the return on
investment will decrease. As the industry antibiotic pipeline
is virtually dry and infectious diseases steadily on the
increase, experts struggle to find acceptable solutions 16­
18 . The use of bacteriophages, bacterio specific viruses, is
currently being (re)considered as a sensible option. Last
year several reports of clinical applications in animals and
humans were published 19­24 . With our actual knowledge
we can consider that bacteriophages are not harmful for
eukaryotic organisms, such as humans. Eukaryotic organisms
include fungi, plants and animals (including humans).
They typically have a specific membrane­bound
nucleus with its specific biochemical enzyme systems and
organelles in contrast to the prokaryotic bacteria. Thus
bacteriophages are bacterio­specific viruses that naturally
cannot infect and replicate in a eukaryotic cell. In order
to enter their host cell they need specific outer membrane
receptors beside the specific bacterial biochemical machinery
for replication. Bacteriophages (meaning bacteria eaters)
are in fact the bacteria’s natural predators. As such
they keep bacterial populations growth under control.
Wherever bacteria are present there are bacteriophages
(or phages in short) which are generally present in at least
a ten times higher order of magnitude than the bacteria
themselves and consequently constitute the most abundant
biological lifelike constituents of the biosphere of this
planet 25 . This observation shows us that actually we live
in an ocean of phages and have done since the dawn of
the human species and that natural phages are in principle
harmless to us. Ecologically they are key as bacterial controllers
and it is this ‘natural function’ of bacteriophages
that phage therapy is exploiting. In combination with or
as substitute for antibiotics they could be a therapeutic
option in the eradication or control of bacterial colonisations/infections.
Indeed applying a specific natural lytic
bacteriophage, targeted against a specific pathogenic bacterium,
on for example an infected wound, should result in
the lysis of the targeted bacterium after the amplification
of the phage in the bacterial cell. As a result the wound
would be cleared by the phage of its noxious bacteria. In
fact the bacteriophage could be considered as a self am­
EWMA Journal 2012 vol 12 no 2

plifying drug at the place of infection. Once the bacteria
are eradicated (through lysis) or brought to a low enough
density that the host’s immune system can take over the
situation, the bacteriophages will also be eliminated by
the host’s immune system.
However today there is a lack of standardized evidencebased
clinical research. This rediscovered antibacterial
therapeutic approach, first proposed by d’Herelle almost
a century ago, was only further developed, mostly empirically,
in the former Soviet Empire 17­18, 26­29 . Since the
early beginning of phage therapy this approach was continuously
used in medical practice and empirically adapted
so that today in countries like Georgia, phage therapy is
considered an established medical practice not requiring
any further questioning. To reintroduce it however in our
actual medical practice requires clinical studies in accordance
with current standards. But documenting a “lifelike”
entity is not the same as documenting a chemical static
substance, what an antibiotic in fact is. Also there is the
aspect related to Intellectual Property Rights (IP) that after
all looks to be the thorniest problem. Phage therapy could
provide a sustainable solution for the multi­drug resistance
crisis. Phage therapy is the use of natural exclusively lytic
bacterio­specific viruses as antibacterial agent. In fact by
setting up a screening system for the circulating noxious
bacteria and their respective phages it will always be possible
to obtain the right lytic phage against any emerging
pathogen. This way of working, taking into account the
co­evolution of the couplet bacterium/phage, makes it
just a fitting solution for a sustainable antibacterial phage
therapy industry. We think that phage therapy will surely
have its (exclusive) application setting(s) and in addition
could be used in combination (synergy) with antibiotics30
. Studies show that phages can enhance antibiotic’s
activity by interaction with the bacterial biofilm modus.
The search for a specific phage or phage cocktail against
a specific bacterium will not take the time nor require the
costs of searching and developing a new antibiotic. The
search for a potent natural phage and the preparation of
classic galenic preparation (physiological water, basic ointment…)
containing phages is practical and feasible in the
time frame of days to weeks, in contrast to new antibiotics
which require many years of research and development.
If an infection is caused by a pan­resistant bacterium it
is realistic to select a specific phage for clinical use, in
contrast to the search of a new antibiotic.
The clinical development of phage therapy however
faces major obstacles, typical of the current medico­phar­
maceutical environment, that hamper progress
18, 28­29, 31
n The lack of a specific adapted regulatory frame in the
medicinal product regulations (mainly based on the
classic static chemical drugs)
Science, Practice and Education
n It is difficult to obtain IP, and as a consequence
difficult to find investors
n The absence of well­defined, safe and targeted phage
preparations (technically feasible, but due to the
above mentioned reasons there are currently no
dedicated therapeutic phage centres)
n The societal false perception of viruses as ‘enemies
of life’.
AIM AND METHOD
It was our aim to evaluate the potential of phage therapy
and to bring it eventually to the patient.
A multidisciplinary team of biologists, medical doctors
and pharmacists was established and worked simultaneously,
from the start, on different aspects, ranging from the
regulatory to the in vitro and in vivo (clinical) experiments
of this antibacterial treatment.
n An exhaustive analysis of the current relevant drug or
medicinal products regulatory frameworks was performed
to analyse whether they could cater for phage
therapy.
n A small­scale production process for the preparation
of quality controlled and well­defined phage cocktails
for clinical use was set­up. The elaboration of
this project involved several research groups and a
clinical team. Parts of the quality control tests would
be outsourced. The final goal was to use this bacteriophage
cocktail as a topical treatment against MDR
P. aeruginosa and MRSA infected wounds in a pilot
trial in burn wound patients with the agreement of a
Belgian Medical Ethical Committee.
n To foster national and international interactions and
to promote phage therapy in Europe, an international
organization ‘Phages for Human Applications
Group – Europe’ (P.H.A.G.E.) was created.
RESULTS AND DISCUSSION
An analysis of the regulatory framework and multiple discussions
with several experts as well as the relevant competent
authorities revealed that clinical phage therapy applications
in the EU are possible, but that the regulatory
frame is not well­adapted 28­29 .
Although the development of phages as classical
medicinal products like an antibiotics, including Good
Manufacturing Practices (GMP) production, pre­clinical
and phase I, II and III clinical trial and marketing is possible,
it is, in our opinion, not the most appropriate route
Such a developmental path would cost millions of Euros
and take many years (± 10 years for biologicals). These
investments are not compatible with the apparent lack of
Intellectual Property (IP) protection (at least for natural
EWMA Journal 2012 vol 12 no 2 25
�

phages). Phages, as natural entities, belong to mankind
as a whole, and cannot be patented in the classical sense.
Also the idea of phage therapy itself first put forward by
Felix d’Herelle who coined the name of bacteriophages
meaning ‘bacterium eating entities’, cannot, in principle,
be patented since it belongs to the common knowledge
and has done for almost a century. This situation does not
stimulate the industry to invest, since the actual paradigm
is “no IP, no investment” 15 ­18 .
To overcome this embarrassing situation, new views
and consequent ways of (pharmaceutical) industrial models
have to be developed 29 .
Established pharmaceutical companies are not likely
to invest substantial amounts of money and time in the
development of potentially interesting products that will
need to be adapted (evolve) even more quickly than flu
vaccines, to be effective. This fast adaptation is needed to
exploit the main advantage of phages over classical ‘static’
drugs such as antibiotics, namely their ability to rapidly (in
a matter of days to weeks) evolve to target emerging pathogenic
strains. This is possible by continuously screening
bacteria and their phages, as is also done in Georgia. This
“Sur­mesure” or tailor­made pathway for the future implementation
of phage therapy is proposed and discussed
by Pirnay et al 29 . This view is also what was proposed to
the Innovation Task Force (ITF) at EMA. The discussion
is still ongoing.
Non profit institutions like hospitals that would like
to develop phage therapy are not necessarily disheartened
by the IP issues and the uncertainty of large profits, but
are generally unable to generate the necessary funding and
are furthermore most likely better served by a tailor­made
(e.g. to a patient or an outbreak) approach 29 . This means
that in a timeframe of days to weeks a specific phage can
always be found to target a specific emerging pathogen.
It is this specific power of phage therapy, namely its coevolutionary
aspect, which guarantees an efficient antibacterial
agent when needed.
As a result of this conundrum, until now, only local
and sporadic phage applications were performed in the
Western World, often under the umbrella of the Declaration
of Helsinki. In Poland, an EU member state, a specific
national adaptive regulation, based on the Declaration of
Helsinki, was issued to regulate phage therapy. A medical
doctor is allowed to apply phage therapy where proven
therapeutic methods do not exist or have been ineffective
(e.g. MDR infections) and provided that the patient or his
legal representative signs an informed consent.
In France, Dr. Alain Dublanchet, a veteran of phage
therapy, occasionally applies phages in desperate osteomyelitis
cases and with success 24, 29 In Australia, phage
therapy was recently applied under the umbrella of “compassionate
use” for the successful treatment of refractory
P. aeruginosa urinary tract infection in a cancer patient 24 .
26
Figure 1.
BFC-1 transmission electron micrographs (.
a) P. aeruginosa bacteriophage 14/1, a member of the
Myoviridae family. Bar: 100 nm.
b) PNM bacteriophages (Podoviridae) freed from a burst
P. aeruginosa bacterium. Bar: 500 nm.
c) Bacteriophage 14/1 attaching to the P. aeruginosa cell wall.
Bar: 200 nm.
d) ISP bacteriophages (Myoviridae) attaching to S. aureus.
Bar: 500 nm.
Ref. 26 Merabishvili et al 2009.
In Belgium a basic clinical safety trial was performed with
the approval of a leading Medical Ethical Committee.
Clinical trials of course need safe and well­defined
phages. Therefore a phage cocktail (BFC­1) that targeted
the most prevalent MDR P. aeruginosa and MRSA bacteria
was produced. The cocktail consisted of two phages
against P. aeruginosa and one against S. aureus (Fig. 1). It
was produced on a small scale and in accordance with basic
clinical­pharmaceutical standards (sterility, apyrogenicity,
pH, cytotoxicity, adequate shelf life and stability). In
addition, the phages in BFC­1 were proven to be exclusively
lytic and characterized at the genomic and proteomic
level. This specific production process was published by
Merabishvili et al. 32 and is actually used as a basic discussion
document for future adaptations in the regulatory
documentation process.
BFC­1 was applied, in a small pilot study, in the burn
unit of the Queen Astrid Military Hospital (9 patients,
10 applications) (Fig. 2). This was one of the first unconcealed
phage applications in modern Western medicine.
As expected, no adverse events or side effects were observed
based on clinical as well as laboratory­measurable param­
EWMA Journal 2012 vol 12 no 2

Figure 2.a.
The final product, a bacteriophage cocktail ready for use
in a human clinical trial. (Ref 26)
Figure 2.b.
Application of BFC-1 on an infected burn wound using a syringe
spray. (Ref 26)
Actually phages could be applied by a spray or a galenic ointment
formulation. Before application on wounds the wound bed should
always be cleaned, debrided and rinsed with bicarbonated
physiological water in order to provide a neutral pH environment.
This is to allow the phages to be stable. Too acidic or alkaline
environments cause phage degradation (protein denaturation).
Studies are warranted in order to optimize applications and
frequency of application as well as the type of the most suited
galenic formulation in function for the site of use.
eters. This small pilot safety trial, showing the innocuity
of phages when applied to burns, was discussed in a review
by Kutter and colleagues 27 . In addition, we successfully
applied (systemically, through a wound drain) large quantities
of BFC­1 (300 ml of 10 5 phage particles), under the
Declaration of Helsinki, in a critical pelvic trauma patient
with MDR P. aeruginosa and MRSA osteomyelitis.
Over the years, it has become clear that, in order to develop
phage therapy, an adapted regulatory framework
and eventually even a change in (medical/pharmaceutical)
mentality and developmental models needs to be achieved.
Especially the natural evolutionary and sustainability aspects
of the approach, not compatible with our current
bio/pharmaceutical business models where IP issues are at
the core, have to be taken into consideration when developing
phage therapy. The P.H.A.G.E. network allowed
us to discuss fundamental and practical issues such as the
Science, Practice and Education
status of phages (e.g. are they (classical) drugs?), exchange
information on applications and services and subsequently
to efficiently interact with authorities like the European
Medicines Agency (EMA).
In February 2011 we officially interpellated the EU
parliament: ‘what is the status of phage as antibacterial
agent’ which brought the discussion to the European
level. The question was put on the agenda by the Belgian
Christian democrat Ivo Belet and his colleague Catherine
Trautmann from the Socialist faction in France. The
Commission’s view was that the current regulatory framework
was sufficient for “phage therapy”, a standpoint we
clearly don’t share. Indeed if we consider the phage as a
static chemical substance we cannot develop phage therapy
as it should be developed in a sustainable efficacious way
and tailor made as discussed by Pirnay et al 29 .
Concerning the “false perception of viruses as enemies of
life” obstacle, which we feared when starting our clinical
trial, we found – to our surprise – that it was easily resolved
through clear and scientific communication with
the members of the ethical committee as well as the medical
and nursing staff of the hospital.
CONCLUSION
Natural phages are not straightforward inanimate and stable
substances, but rather lifelike evolvable natural biological
entities. The major obstacle hampering the further development
of phage therapy at large, in wound treatment
as well as in other clinical settings (otitis, osteomyelitis,
diabetic foot, diarrhoea, impetigo…) in our current medical/pharmaceutical
environment is mainly related to the
intellectual IP issues.
The existing relevant regulatory frameworks and business
models are not compatible with a dynamic sustainable
phage therapy concept. And this point of view is not compatible
with the current economic models that reduce the
pharmaceutical industry to ‘common button’ producers,
when their main societal role should be ‘providing people
with adequate products for a better health’. Therefore a
suitable environment should be worked out 28­29 . We need
to radically redesign our (pharmaceutical) economic models
to cater for more dynamic and sustainable approaches
that fit an eventual future green economy. We are actually
bouncing against our own ‘limits’ of growth 33­34 .
Any future sustainable phage therapy concept should,
based on scientific grounds, fully acknowledge the potentialities
of the co­evolutionary aspect of the couplet
phage/bacterium in its ecological environment, in casu the
human being 29 . Only then the inherent (positive) characteristics
of phages as natural biological bacterium controllers
can be put to use. Indeed, bacteria will inevitably
EWMA Journal 2012 vol 12 no 2 27
�

Science, Practice and Education
become resistant to phages, but due to the continuously
ongoing arms race between the two protagonists, specific
phages able to infect the formerly resistant bacterial strains
will quickly emerge 29 . In fact phage therapy fits well in
the new emerging field of Darwinian – evolutionary –
medicine (in contrast to a classical mechanistic – man
as a machine – view) where the insights of evolution are
fully taken into account. Viruses, among which phages are
included, were involved in the origin of life itself and play
a major role in biological evolution 35­36 . Hopefully they
will play a role in the future control of bacterial disease.
We feel that our plea for a more realistic approach, taking
into account the co­evolutionary aspect of the bacterium
and its phage is scientifically sound. Let’s hope that the
political and economic factors will adapt. m
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Presented at
EWMA 2011
Brussels · Belgium
Developing evidence-based ways of working:
Science, Practice and Education
Employing interdisciplinary team
working to improve patient outcomes in
diabetic foot ulceration – our experience
1. HISTORy AND INTRODUCTION
The treatment of wounds is an ancient area of
“specialization in medical practice”. Its origins
trace to ancient Egypt and Greece. The most profound
advances in the field came with the development
of microbiology and cellular pathology
in the 19 th century. In the 1870s, R.W Johnson,
the cofounder of Johnson & Johnson, began the
production of gauze and wound dressings with
Iodine. In the late 19 th century P.L. Friedrich
introduced the importance of wound excision, a
procedure that reduced the risk of infection and
thus surgery was on board….
The diabetic clinic at the Deaconess Hospital in
Boston can be considered as one of the first to
instigate a multidisciplinary approach in diabetic
wound care, bear in mind that the discovery of
insulin was still a few years ahead! The teaching
of diabetic foot care was considered so important
that by 1928 they had assigned one graduate nurse
and two pupil nurses to that duty. 1
From the moment we use the term “specialization
in different fields of wound care” we are
already speaking about multidisciplinarity.
2. DEFINITION OF A
MULTIDISCIPLINARy TEAM
We have found some different explanations/definitions
of a multidisciplinary team:
“…A group of people with different kinds of
training and experience working together, usually
on an ongoing basis. Professionals often use the
word “discipline” to mean a field of study such
as medicine, social work, or education…” (www.
dwp.gov.uk department for work and pensions).
“A group composed of members with varied
but complementary experience, qualifications,
and skills that contribute to the achievement of
the organization’s specific objectives” (Oxford
Dictionary).
“A multidisciplinary team is composed of
members from different healthcare professions
with specialized skills and expertise. The members
coordinate and communicate with each other to
provide quality patient care. Coordination and
teamwork among clinicians results in greater efficiency
and improved clinical outcomes” (Journal
of Healthcare Quality, March/April 2004). 2
In our further work we try to clarify why the use
of some words will play a major role and why
perhaps the terminology of multidisciplinarity is
not our favourite in our context of teams concerning
wound care.
3. WHy WE SHOULD USE
INTERDISCIPLINARy IN THE CONTExT
OF WOUND CARE?
A two-step approach
a. Difference between professionals and
disciplines.
We are privileged that an expert as respected as
Paul Gorman wrote several articles and books
about multidisciplinary teams. He helped us to
understand the differences and nuances between
professionals and disciplines. 3
It’s fascinating to question why we have developed
different disciplines in medicine. As human
beings we have learnt that specialization enables
us to know more about things. Receiving greater
depth of knowledge will give us greater control
over that part of our world and our environment.
At the same time, other people have specialist
knowledge about other things. Coming together
we will have an even greater area of knowledge.
Knowledge, but also status, reward and power, are
divided by the boundaries of professions and disciplines.
To demonstrate this Paul Gorman gave
us the following examples: doctors get paid better
than nurses and in some environments, have more
status and power. Gender too plays a crucial role
�
Kristien Van Acker
Diabetologist, Md, PhD
Chimay, Rumst,
Vice Chair DFP, IDF,
Consultant Trop Inst
Antwerp, Belgium
Correspondence:
stiebertje.viroin@
gmail.com
Conflict of interest: none
EWMA Journal 2012 vol 12 no 2 31

in the way professions operate internally and the way they
interact with each other. This lead to defining the mission
statements of the professional bodies (e.g. podiatry,
chiropody and nursing); in history we see the development
of professional bodies, acting as gatekeepers to the professions.
Those bodies control the right to practice and will
protect the public from charlatans, and this can only be
seen as an advantage. However an individual, namely a patient,
is not approached on a daily basis by the professional
bodies but by medical teams. For this reason, it’s preferable
to speak in terms of multidisciplinary teams (MTs) instead
of multi-professional teams. In MTs members of staff, like
auxiliaries, receptionists, and all the others also have a
central role. Another important point is that the patients
and their relatives have also a central place, which is not
in the case in a multi­ professional team.
b. Difference between multidisciplinary (MTs) and
interdisciplinary teams (ITs)
In 2007 Rebecca L Jessup from Australia was one of the
first to adopt the concept of interdisciplinary teams and
their skills and behavior 4 .
According to Paul Gorman, MTs utilize the skills
and experience of individuals from different disciplines,
with each discipline approaching the patient from its own
perspective. More often than not, this approach involves
separate individual consultations. These may occur in a
“one­stop­shop” fashion with all consultations occurring
as part of a single appointment on a single day. It is common
for this team to meet regularly, in the absence of the
patient, to “case conference” findings and discuss future
directions for the patient’s care. MTs provide more knowledge
and experience than disciplines operating in isolation.
ITs, however, integrate separate discipline approaches
into a single consultation, i.e. the patient­history taking.
The team, together with the patient, conducts assessment,
diagnosis, intervention and short­ and long­term management
goals at the one time. The patient is intimately
involved in any discussions regarding their condition or
prognosis and the plans about their care. Individuals from
different disciplines, as well as the patient themselves, are
encouraged to question each other and explore alternate
avenues, stepping out of discipline silos to work toward
the best outcome for the patient. In these processes, family
members and partners will also be involved in the plans
about the care of their family member. Those who have
experience in this approach will immediately recognize a
personal expression: “working in the order of chaos!” The
energy and general demands are huge but the rewards are
great, and perhaps the most important benefit is the richness
of the contacts of team members with the patients
and their family with, in return, the confidence the patient
gives back even when prognosis is poor.
32
4. WHAT CAN BE CONSIDERED AS
“PRACTICAL” GOLDEN RULES
For teambuilding and working in an interdisciplinary
team? 5-9
No­one anywhere can start such an Interdisciplinary Team
Project without a respectable time of preparation and a
clear concept of the project management in which he/she
has to take at least four characteristics into account: definite
duration, examine the logic relationship with other
activities in the project, study the resource consumption
of this team (information, energy, know how, time and
financial resources) together with the associated costs. This
means that at the very least, for long­term success, a person
must develop a business plan and management skills.
The initiative taker will define roles and boundaries.
Everyone needs clarity on his/her own role and it has to
be clear to each member what other team members do.
The team coordinator has to be aware of power dynamics
within the group, i.e. are certain members competing
for control? Or do some have more status than others?
The process of “taking decisions” must be analyzed on
a constant basis in the team; how, who and when is important.
Team members must learn to value each other’s
contributions and look at how the group communicates.
In addition, they have to be aware that “different professionals
have different views” and that this is the added
value of the concept.
Implementation of feed­back loops for self­evaluation
is helpful in detecting some barriers and is of utmost importance
to the success of ensuring members do not underestimate
the value of listening to service users (patients).
Often small details are huge barriers to team success. Some
of the biggest barriers include unclear goals, unhealthy
communication, playing it ‘safe’, individual goals and poor
leadership.
5. INTERDISCIPLINARy TEAMS IN DIABETIC
FOOT WOUND CARE
a. Rationale and evidenced based data
One example of where building an interdisciplinary team
is useful and effective is the diabetic foot team. We refer to
the International Consensus of the Diabetic Foot, audited
by Karel Bakker and first launched in 1996 and the fourth
edition recently launched at the International Diabetic
Foot Meeting in May 2011 in Noordwijkerhout 10 .
In this consensus the following statements can be
found: “If you have a foot problem, you should obtain
foot care from a multidisciplinary foot team. A multidisciplinary
approach has been shown to bring about a 45­85%
decrease in amputations”. This sounds impressive, so what
are the references and the associated evidence?
The first publication on multidisciplinary diabetic foot
clinics was published in 1986 by Mike Edmonds in which
EWMA Journal 2012 vol 12 no 2

he illustrated the improved survival of the diabetic foot
and the role of a specialized foot clinic. 11 In 2005 Lavery
LA published the outcome of a study of 2738 persons
with diabetes carried out over 28 months. Stratification
into low and high­risk groups was performed with the
implementation of preventive or acute care protocols.
The outcome was impressive: a 47% decrease of the incidence
of amputations; 38% reduction in foot­related
hospital admissions; 22% reduction of average hospital
days and 70% reduction in SNF (skilled nursing facilities)
admissions. 12 This model has been widely replicated; the
group of Gerry Ryman 13 illustrated a significant reduction
in total and major amputation rates in a defined U.K.
population measured over an 11­year period (1995­2005)
following improvements in foot care services including
multidisciplinary teamwork. Expressed as incidence per
10,000 people with diabetes, total amputations fell 70%,
from 53.2 to 16.0, and major amputations fell 82%, from
36.4 to 6.7. This was also the result of a continuous prospective
audit.
b. How to establish a diabetic foot clinic
Some years ago, the IWGDF convened a roundtable meeting
to discuss the principles of organizing a diabetic foot
clinic. We published these data in the Time to Act in the
year of the “Diabetic Foot”, 2005 14 . The idea of the working
group was to make a distinction between three models:
The minimal model or basic model, the intermediate
model, and the centres of excellence also called tertiary
referral centres model. In practice, the gradual process
towards excellence is initiated by a dedicated individual,
a “local champion”, working in a very small team. More
often than not, this person drives the project for many
years and he or she assumes much of the responsibility
from the start.
Please visit the IWGDF website for more information: www.iwgdf.org
Science, Practice and Education
In Table 1 we present the three models and refer to
the publication of Time to Act for more details. By accepting
the concept of this “Three Level Model”, we are
aware that referral patterns between these levels of care in
this global organization must be clearly defined. This will
only be possible if the organization in the country has a
well­established centre of excellence. Good structures will
have a positive influence on reducing delays in referrals!
c. The importance of feedback loops and benchmarking:
Quality control
Delivery of good diabetic foot care is also dependent on
the need for feedback and self reflection if we are to witness
improvements in the performance of the teams which in
turn lead to improvements in the delivery and outcome
of the medical care 15 . To evaluate the input, or the intervention
(e.g. “multidisciplinary diabetic foot clinic”)
and the process itself we have to register the outcome
parameters for our evaluation. There are many examples
of such processes. One of the modern techniques used is
benchmarking.
One of the first important studies to compare differences
by centre is the EURODIALE 16­18 . In this study (a
prospective cohort study of 1232 consecutive individuals)
we learned that treatment of many patients is not in line
with current guidelines and there are large differences between
countries and centres. At study entry, 77% of the
patients had inadequate or no offloading. During followup,
casting was used in 35% (0­68% variation between
countries!) of the plantar fore­ or midfoot ulcers. Vascular
imaging was performed in 56% (14­86%) of patients with
severe limb ischemia; while revascularization was (only)
performed in 43%.
At the current moment only two countries, namely
Germany and Belgium, are known to have this quality
control system. In the disease­management programme
in Germany, providers are obliged to refer high­risk feet,
ulceration and suspicion of diabetic osteoarthropathy to
specialized diabetic foot clinics at predefined interfaces.
Table 1: The Different Models of Diabetic Foot Care according to the IWGDF.
Minimal Model Intermediate Model Maximal Model
Staff Doctor/nurse or Doctor or General Physician
Diabetologist/surgeon/rehabilitation
podiatrist
Surgeon
specialist/microbiologist/dermatologist/
Podiatrist and/Nurse
Psychiatrist/nurse/educator/podiatrist/
Orthotist
casting technician/secretarial staff...
Aim Prevention and basic Prevention and basic curative care for Prevention and specialized curative care
curative care
all types of patients and advanced assessment
and diagnosis
provide training for other centres
Patients Own patients From the regional catchment area of National, regional or even international
the hospital with possibly some referrals
from outside the region
reference centre
Setting Small regional hospital, Hospital
health centres
Reference centre (Third line centre)
EWMA Journal 2012 vol 12 no 2 33
�

Science, Practice and Education
An interdisciplinary Diabetic Foot Team in action: Order in the Chaos. Diabetic Foot Clinic – Kristien Van Acker
Standards of Quality for Specialized Diabetic Foot Clinics
according to the Criteria of the Diabetic Foot Working
Group of the German Diabetes Association (DDG) are
based on Structural quality (equipment, documentation,
and staff); Structural­ and Process quality (interdisciplinary
cooperation by contract); Process quality (clinical
pathways/standard operation procedures (SOP); Hygiene
plans, (MRSA management plan); Audit (active and passive);
and Quality of performance (treatment results of 30
consecutive patients).
In Belgium, some opinion leaders together with Scientific
Institute of Public Health, Epidemiology in Brussels
developed an “Initiative for Quality of Care Promotion
and Epidemiology in Belgian Diabetic foot clinics”, the socalled
IQED centres. This prospective study is designed to
describe, evaluate and improve the Quality of Care in the
Belgian diabetic foot clinics (DFC) by collecting data and
providing benchmarking. In this study Off­loading was
used in 75% (variation from 42% to 100%) of the ulcer
patients, but a total contact cast was only used in 2.4%.
Of the patients with peripheral arterial disease, 42.8% underwent
revascularization and 59.4% were hospitalized 19 .
34
6. GENERAL CONCLUSIONS AND THE
CONCEPT OF INTERDISCIPLINARy TEAMS
FOR INTEGRATED WOUND CARE
In many countries and societies care facilities have come
a long way in developing their wound care programs,
especially where there is more effort towards an interdisciplinary
approach. They have moved away from the
approach of just having a single wound treatment nurse
and established a more integrated care approach. The most
successful teams are those that have a wound care team
involving all key departments within the facility. In hospitals
it starts with the medical director who facilitates
the necessary patient medical work­ups as, for example, a
therapy to apply specific services such as modalities and
wound debridement, and dietary services to ensure that
those with wounds have adequate nutritional intake. On
the other hand, well skilled home nurses who provide
primary patient care including wound dressings are also
important key players. But in this advanced situation the
key pitfall will be a good referral system and communication
between the first, second and tertiary line teams.
Ultimately, highly coordinated treatment plans are effective
in reducing average wound healing times, thereby
lessening patient suffering and costs of care.
EWMA Journal 2012 vol 12 no 2

In this philosophy we must consider today integrating
all the different “thematic” teams. Personally, I believe in
an integration of teams specialized in wound care of diabetic
foot ulcers, pressure ulcers, venous ulcers and others.
This is already the case in some countries, such as the U.S.
Finally, I would like to conclude that all worldwideknown
diabetic foot clinics, the so called ‘Centres of
Excellence’, were created one step at a time, beginning
with the basic model. This paper has reported the experience
of building one. This may be of use to those clinical
personnel who are considering the effectiveness of their
ways of working and the associated patient outcomes. We
have reported improved patient outcomes following the
implementation of this evidence­based model and would
encourage others to consider employing this approach.
‘A journey of a thousand miles begins with one step…’
Lao Tzu, China, 6 th century m
1. Joslin EP. The treatment of Diabetes Mellitus. Lea and Febiger: Philadelphia,
PA, 2nd edn, 1917: 423-427; 4th edn, 1928: 785-802.
2. Bernard J. Horak, PhD FACHE CPHQ; Joyce Pauig, RN; Ben Keidan, MD; Jennifer
Kerns, MD. JHQ 141 - Patient Safety: A Case Study in Team Building and Interdisciplinary
Collaboration. NAHQ, March/April 2004.
3. Paul Gorman. “Managing multidisciplinary teams in the NHS”. 1989. ISBN 0 7494
2787 6. Marston Lindsay Ross International Ltd, Oxfordshire.
4. Jessup RL. Interdisciplinary versus multidisciplinary care teams: do we understand
the difference? Australian Health review, August, 2007.
5. Logan K RN. Diabetes-The role of the multidisciplinary team in patient self
management. Standards of medical care in diabetes-2008. Diabetes Care. 2008.
3 Suppl S12-S54.
6. Multidisciplinary care. A model for achieving best practice cancer care.
A Victorian Government Initiative. www.health.Vic.gov.au/cancer
7. Fay D, BorrillC, Amir Z, et al. Getting the most out of multidisciplinary teams: a
multi-sample study of team innovation in health care. Journal of occupational and
Organizational Psychology, 2006
8. Gorman P. Excellent information is needed for excellent care, but so is good
communication. West j Med. 2000;172: 319-20.
9. Jenkins VA, Fallowfield LJ, Poole K. Are members of multidisciplinary teams in breast
cancer aware of each other’s informational roles? Quality in Health Care, 2001; 10:
70-75.
10. Nicolaas Schaper, William van Houtum, Andrew Boulton. Supplement: Proceedings
of the 6th International Symposium on the Diabetic Foot, May 10–14, 2011,
Noordwijkerhout, The Netherlands.Diabetes/Metabolism Research and Reviews,
February 2012,Volume 28, Issue Supplement S1, Pages 1–237
11. Mike Edmonds . Improved survival of the diabetic foot: the role of a specialized foot
clinic. Q J Med. 1986;232:763-771
12. Lavery LA, Wunderlich RP, Tredwell JL. Disease management for the diabetic foot:
effectiveness of a diabetic foot prevention program to reduce amputations and
hospitalizations. Diabetes Res Clin Pract. 2005 Oct;70(1):31-7.
13. Singhan K, Fiona N, Neil Baker, et al. Reduction in diabetic amputations over
11 years in a defined U.K. population. Diabetes Care. 2008;31:99-101.
14. Time to Act. Put feet first, prevent amputations: diabetes and foot care. Joint
publication of the International Diabetes Federation and the International Working
Group on the Diabetic Foot.2005
15. Edmonds ME. The Diabetic Foot, 2003. Diabetes Metab Res Rev. 2004; 20 Suppl 1/
S9-S12.
16. Prompers L, Huijberts M, Apelqvist J, et al High prevalence of ischaemia, infection
and serious comorbidity in patients with diabetic foot disease in Europe. Baseline
results from the Eurodiale study. Diabetologia. 2007 Jan;50(1):18-25.
17. Prompers L, Huijberts M, Apelqvist J, et al Optimal organization of health care in
diabetic foot disease: introduction to the Eurodiale study. Int J Low Extrem Wounds.
2007 Mar;6 (1):11-7.
18. Prompers L, Huijberts M, Apelqvist J, et al. Delivery of care to diabetic patients with
foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort
study. Diabet Med. 2008 Jun;25(6):700-7.
19. Billiet, A., Debacker, N., Beele, H., Daubresse, C., Deschamps, K., Deweer, S.,
Lauwers, P., Matricali, G., Nobels, F., Randon, C., Wanyama, S. (2009). Resultaten.
In: Billiet A., Debacker N., Nobels F., Van Acker K., Van Casteren V. (Eds.),
IKED-voet Initiatief voor kwaliteitsbevordering en epidemiologie bij multidisciplinaire
diabetes voetklinieken. (pp. 11-40). Brussels:Wetenschappelijk Instituut Volksgezondheid.
EWMA Journal 2012 vol 12 no 2
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Science, Practice and Education
Dr Jessica Walburn 1
John Weinman 1
Suzanne Scott 2
Kavita Vedhara 3
1 Institute of Psychiatry,
Department of Psychology,
King’s College London
2 Dental Institute,
Department of Dental
Practice and Policy, King’s
College London
3 Institute of Work,
Health and Organisations,
University of Nottingham
Correspondence:
jessicawalburn@
hotmail.com
Conflict of interest: none
36
Exploring the characteristics of a venous
leg ulcer that contribute to the emotional
distress experienced by patients
BACKGROUND
Venous leg ulcers (VLUs) are a common chronic
wound whose prevalence increases with age. A
number of studies across quantitative and qualitative
literature have found that living with an
ulcer can have a detrimental impact on healthrelated
quality of life (HRQoL) and elicit emotional
distress. Jones, Robinson, Barr & Carlisle,
(2006) reported that anxiety and depression were
positively associated with pain and malodour in
a survey of 190 patients with VLUs. This study
explored the negative emotions associated with
living with an ulcer and investigated the factors
that underpinned this distress.
METHODS
Design: A cross sectional design was used whereby
a series of in­depth semi­structured interviews
were conducted to explore distress, the lived experience
of having an ulcer, coping strategies, patients’
beliefs about their ulcer and its treatment,
and the impact on HRQoL.
Participants: This study had 14 participants being
treated in primary care leg ulcer clinics (Edgware
Community Hospital, Ravenscroft Medical Centre,
Vale Drive Primary Care Centre, Forest Primary
Care Centre) diagnosed with a VLU without
type II diabetes and taking part in a prospective
quantitative study investigating the determinants
of healing. At the time of interview four participants
had an open ulcer.
Analysis: A thematic analysis of the interviews
was conducted using Framework Analysis (Ritchie
& Spencer, 1994). Framework analysis involves
the organisation and interpretation of information
using a matrix or chart (Ritchie, Spencer, &
O’Connor, 2006). This approach was selected as
it easily enables comparison across participants and
themes. The quality and consistency of the analysis
was assessed by two independent researchers.
References
Jones, J.E., Robinson, J., Barr, W. & Carlisle,
C. (2008). Impact of exudate and odour from
chronic venous leg ulceration. Nursing Standard,
22(45), 53-4, 56, 58, 60-1.
Ritchie, J. & Spencer, L. (1994). Qualitative data
analysis for applied policy research. In A. Bryman
& P.G. Burgess (Eds.). Analysing Qualitative Data
(pp.173-194). London: Routledge.
Presented at
EWMA 2011
Brussels · Belgium
RESULTS
All participants described experiencing distress
associated with their ulcer. This was expressed
in terms of feeling depressed, angry, anxious,
ashamed and embarrassed. Dominant themes
associated with distress included: symptomatology
– pain, exudate and malodour; uncertainty
related to ulcer duration and outcome; intrinsic
revulsion at the appearance of the ulcer; dislike
of the compression bandages used to treat the
ulcer because of how they looked and how they
limited general mobility and other activities; social
impact of the ulcer relating to concerns about the
reactions of others to the appearance and smell of
the ulcer; strategies used to camouflage the compression
bandage (e.g., always wearing trousers in
warm weather) and manage the malodour (e.g.,
avoidance of unnecessary contact with others);
negative perceptions of the appearance of the ulcer
scar; concern about ulcer recurrence.
DISCUSSION
These findings highlight the range of negative
emotions experienced by patients associated with
having a VLU and are consistent with previous
research. Although patients described a variety of
factors related to their distress, appearance­related
issues and concerns about the reactions of others
were particularly significant. Quantitative research
is now required to establish the prevalence of these
concerns in a larger sample. In terms of improving
patient well­being, this research highlights
the variety of factors that could be contributing
to emotional distress for patients living with a
venous leg ulcer.
Thank you to the patients and staff of Edgware
Community Hospital, Ravenscroft Medical
Centre, Vale Drive Primary Care Centre, Forest
Primary Care Centre (Barnet and Enfield PCTs)
for taking part and assisting with this research. m
Ritchie, J., Spencer, L. & O’Connor, W. (2006).
Carrying out Qualitative Analysis. In J. Ritchie &
J. Lewis (Eds.). Qualitative Research Practice: A
Guide for Social Science Students and Researchers
(pp. 219-262). London: Sage Publication.
EWMA Journal 2012 vol 12 no 2

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Roy Lilley (Chair)
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and commentator, Surrey, United Kingdom
Prof. Julian Guest
Kings College London, United Kingdom
Prof. Jan Apelqvist
University Hospital of Malmö, Sweden
Dr. Bernhard Lange-Asschenfeldt
Charité Universitätsmedizin Berlin, Germany
Prof. Matthias Augustin
Universitätsklinikum Hamburg-Eppendorf, Germany
EWMA 2012
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Development of a wound healing
index for chronic wounds
SUMMARy
Objectives: to systematically review the literature
on healing measurement tools. To develop
a scale for measuring progress towards healing for
chronic wounds.
Material and methods: the study was conducted
in two phases:
Phase 1: Systematic review in major databases
of health sciences (MEDLINE, CINAHL,
WIDEN, SCIELO, LILACS, COCHRANE,
IME) from the start of the database until 2009.
Search strategy: instrument, tool, ulcer, chronic
wound, healing, assessment, validation, reliability,
and the same in Spanish, with their corresponding
formulations using Booleans AND, OR and truncation
term for some of them. The search took
place initially in the thesauri and if the word did
not exist, in free text. Study design not was taken.
GRADE system was used to quality appraisal.
Phase 2: modified Delphi study with a group
of experts in chronic wounds, to reach consensus
on variables that could measure the dimension
of “progress towards healing”. In the first round
started with all variables of the wound and the
patient found in the different instruments of the
systematic review. In the second round sent the
items that had obtained the highest score. Finally
sent the final version and experts were asked to
rate on a scale of 1 to 4 to obtain the content
validity index (CVI). Those variables that had
obtained more than 80% CVI were included.
Results: the systematic review revealed a number
of 8 healing tools as set out in 20 articles (10 articles
about PUSH, 3 PSST, 1 DESIGN, 1 PWAT,
1 Sessing Scale, 1 Scale Sussman, 1 WHS, COD­
ED 1, and finally, a literature review to collect 4 of
the above). Regardless of the number of items per
scale, scale PSST has the best research on validity
and reliability. However, most are for pressure ulcers.
Only 4 papers studied validity and reliability
of scales (PUSH, PSST, DESIGN and CODED).
The only scale that has been validated for venous
ulcers has also been the PUSH, in English and
Portuguese. The only scale found in Spanish is
coded, developed in the Basque Country in 2000,
but only presents a partial survey. That is why they
decided to develop a “de novo” scale for all types
of chronic wounds.
The scale developed, receives the provisional
name of “RESVECH V1.0. Expected results of
the assessment and evolution in the healing of
chronic wounds”. CVI scores obtained by the
experts above 80% on all items compose. Is
defined, pending the study of validity and reliability,
9 items: size of the lesion, depth/tissue
concerned, edges, maceration, perilesional, tunneling,
type of tissue in the wound bed, exudate,
infection/inflammation, frequency of pain (in last
10 days). The scale is scored numerically and can
score ranging from 0 to 40 points, wound healed
and the worst possible lesion respectively. Also
accompanied by operational definitions of each
item and its value­form.
Conclusions: we get a scale with, a priori, content
validity by expert’s assessment.
Key words: Wound healing assessment, measurement
tools, nursing, chronic wounds.
INTRODUCTION
From the beginning, medicine has always had two
basic aims: relieving pain and healing wounds.
Because of this, throughout the years the health
sciences have little by little stimulated their ability
to create new options for treatment and care 1 .
Historically, wounds and strategies for healing
them quickly have been linked to human progress,
and this gave rise to an almost infinite range of
treatment methods. It would be nearly impossible
to mention the great number of products
and agents put forward as beneficial for healing
wounds, from the most ordinary to the most esoteric
of substances thought to speed up the healing
process. For example: gentian violet, scarlet
red, Peruvian balm, cod liver oil and zinc sulfate,
among many others 2 . Most of the times the ultimate
goal was to prevent the occurrence of the
much­feared infection. But when it did occur,
fire was used to purify and cauterize wounds. The
discovery of healing in a moist environment by
�
Science, Practice and Education
Juan Carlos
Restrepo-Medrano
PhD, MSc Nurs, BSc Nurs
Universidad de Antioquia.
Medellín, Columbia
José Verdú Soriano
PhD, MSc Nurs, BSc Nurs,
DUE -RN
Universidad de Alicante.
Alicante, Spain
Correspondence:
jcrm6@alu.ua.es
This paper received the
GNEAUPP-Convatec SL
Sergio Juan Jordán
Memorial Award for
the best scientific paper
presented at the 8th
National Symposium on
Pressure Ulcers and
Chronic Wounds.
Santiago de Compostela.
November 2010.
First published in
GEROKOMOS 2011;
Vol. 22, no 4
Conflict of interest: none
EWMA Journal 2012 vol 12 no 2 39

Dr. Winter 3,4 was a revolution that led to a wide range of
advanced products for healing purposes.
Despite all the above and the breakthroughs in healthcare
systems, diagnostic methods and the assessment
and wound healing have not developed in the same way
through time. Healing is a process that has not been properly
approached in the case of wounds, especially chronic
wounds (CW). These lesions have not generally been of
interest to health­care professionals, who have always
considered them to be normal and inevitable in certain
conditions 5 , an attitude responsible for a certain kind of
lethargy in carrying out studies and research in this field.
Nonetheless, in recent years interest around these lesions
has gradually grown, focusing not only on appropriate
treatment but also on optimal preventive care 6 .
CW require continuous, direct care to prevent them
from occurring and/or healing them, which involves perseverance
on the part of both direct and indirect caregivers.
Adopting such an approach considerably increases
the care burden and leads to remarkably higher direct and
indirect costs in health­care services. The World Health
Organization (WHO) considers the presence of some of
these CW a measure of patient care quality 7 . Such is the
case of pressure ulcers (PU), which are thought to show
poor­quality patient care.
Few tools have been developed to measure the progress of
chronic wound healing, and these have generally focused
on a specific type of wound: PU. Some of the tools proposed
for assessing the healing process of PU are:
– the PSST scale (Pressure Sore Status Tool) 8,9,10 ,
– the PUSH scale (Pressure Ulcer Scale for Healing) 11 ,
– the Sussman scale (Sussman Wound Healing
Tool) 12 ,
– the Sessing scale 13 ,
– the WHS scale (Wound Healing Scale) 14 ,
– the PWAT scale (Photographic Wound Assessment
Tool ) 15 ,
– the CODED scale 16
– the DESIGN scale 17 .
Little research has been carried out with these tools, and
the methods used have varied enormously, to the extent
that it becomes difficult to establish their validity and
reliability. Some are widely used, even for wounds they
were not designed for, perhaps owing to the power of
individuals or scientific groups who wanted to see them
become a reality. Such is the case of PUSH, developed
by the NPUAP.
In practice therefore, clinicians are using these scales to
assess changes in wounds, but evidence needs to be gathered
to show that a scale has been validated and to make
it possible not only to evaluate the process of CW healing
40
but also the effectiveness of our intervention. Given the
foregoing, a reliable, valid tool would be needed to assess
and describe the current status of the CW and determine
whether it is progressing toward healing or worsening.
OBJECTIVE
n Systematic review of the literature on tools for measuring
healing to determine whether there is a valid,
reliable index or scale for all types of CW.
n Adapting and/or developing a scale to measure the
healing process of all types of CW.
MATERIAL AND METHOD
This study was carried out in two phases:
Phase 1: This stage involved a systematic review of publications
in the scientific literature that deal with the subject
of scales and/or tools for measuring wound healing. The
most relevant health and social science databases were
used: MEDLINE (PubMed), CINHAL, Web of Science,
LILACS, Sociological Abstracts, CUIDEN, EMBASE,
PsycInfo and ISI Web of Knowledge. The words included
in the search strategy were: instrument, tool, ulcer, chronic
wound, healing, assessment, validation, reliability, and their
equivalents in Spanish, using Boolean AND, OR operators
and the truncation term for some of them. In order
to find articles more precisely, the initial search for a term
was conducted in database thesauri and, when this was not
possible, it was used as free text. The search was limited
to paper titles and abstracts. The search period went from
the start of each database up to December 2009.
The inclusion criteria for selecting articles required that the
development or analysis of a wound healing tool and/or
scale be included in the objectives or hypothesis (the study
design was not taken into account for inclusion). The
exclusion criteria were: articles with no abstract available,
editorials, papers presented at conferences, book reviews
and animal studies.
Articles were initially selected by pertinence of the title
and abstract. The full text of articles chosen in this manner
was analyzed to decide whether they should be included
in the review. The GRADE system was used to evaluate
the quality of publications. Information of interest for
the study was extracted by means of an ad hoc chart that
collected information on the general characteristics of the
studies, the scale analyzed and the main results.
Phase 2: After completing the systematic review and establishing
the scales found in the literature, it was decided
whether it would be feasible to adapt a tool to make it valid
EWMA Journal 2012 vol 12 no 2

and reliable for all CW or whether it would be better to
develop a de novo tool.
If it were decided to adapt a scale or tool already developed,
the method of translation/back­translation of the
tool would be used and subsequently its cultural adaptation
to the Spanish language.
In the case of developing a de novo index, the prior studies
found would be taken into account to define the variables
that could describe CW healing. This first draft of the
index would undergo a content validity process involving
a consensus of experts using a modified Delphi method.
A group of 10 CW experts would evaluate the questionnaire
to determine whether the tool would respond to the
construct of “progress toward healing”.
A modified two­round Delphi method was used to
obtain the value of the content validity index (CVI). The
experts scored the list of items twice, first the initial version
of 12 items and then a final version with the items
included and their rating categories. This method ensures
that the scores will be based on the judgment of each
expert and not be influenced by external factors, such as
power relations, personal sympathies, desire to please or
not to feel in a minority, for example. This is achieved by
scoring the items in two rounds.
The content validity was determined by a panel of experts
as described by Polit and Hungler 18 based on two criteria:
pertinence, i.e., the item evaluates what it purports to
evaluate; and relevance, defined as the item’s significance
in evaluating healing. The following scale was used:
n Pertinence: 1) not pertinent 2) somewhat pertinent,
3) pertinent, 4) very pertinent
n Relevance: 1) not relevant, 2) somewhat relevant,
3) relevant, 4) very relevant.
Three calculations are made to determine content validity
with this method:
n Content validity index for each item in the tool
(CVI­i), calculated with the following formula:
Number of experts agreeing on the value of
relevance or pertinence of each item
(values between 3 and 4)
Total number of experts
n Content validity index for each expert (CVI­e),
by the following formula:
Number of items scored between
3 and 4 by an expert
Total number of items
n General content validity index for the tool
(CVI­total):
Sum of all experts’ individual CVI
Number of experts
A CVI of 0.80 or higher in any of the three above areas
was considered indicative of high content validity 18 , and
the minimum value required would be 0.62 according to
Lawshe 19 for a panel of 10 experts.
RESULTS
Phase 1
The article search and selection process is summarized in
Figure 1. Eight wound healing scales were identified in the
20 articles included in the review (10 articles on PUSH,
three on PSST, one on DESIGN, one on PWAT, one
on the Sessing Scale, one on the Sussman Scale, one on
WHS, one on CODED and, finally, a literature review
that included four of the above).
The main characteristics of the scales found were: PSST
which evaluates 13 wound categories 8,9,10 ; the PUSH tool
developed by the NPUAP that combines only three wound
categories 11 ; the Sussman Wound Healing Tool 12 , a scale
of 10 dichotomous categories; the Sessing Scale which
is a modified classification system with six categories 13 ;
Articles with no abstract
available:
6
Articles identified:
59
Articles included
in the study:
20
Editorials,
conference papers,
book reviews,
different languages:
6
Articles on scales
other than healing:
23 Articles aimed
at animal wounds:
4
Repeated articles:
3
Total articles excluded:
39
Fig. 1. Literature review process. Articles included and excluded.
Science, Practice and Education
EWMA Journal 2012 vol 12 no 2 41
�

EWMA DOCUMENTS
EWMA Documents on Debridement and Antimicrobials
EWMA are producing two documents in 2012:
The EWMA Document on Antimicrobials aims to meet
the on-going discussion across Europe concerning the
consequences of a biological mutation of infections
and the subsequent potential resistance to current
wound treatment. The document will describe the
related aspects of antiseptic, antibiotic treatment and
other relevant treatment methods.
In May 2010 the following EWMA Document was published:
Outcomes in controlled and comparative studies on
non healing wounds
– Recommendations to improve quality of evidence
in wound management
The document is written by members of the EWMA Patient
Outcome Group, based on common discussions in the group.
The document has been summaried in a pixi version.
In 2012-2013 the Patient Outcome Group is working
on a set of clinical study guidelines on non healing
wounds. With these guidelines the group aims to
support the recommendations included in the 2010
POG document on evidence and outcomes.
The guidelines will include a checklist with relevant
research questions, frequent mistakes and links to
other relevant sources of information.
Other EWMA documents e.g. Position Documents
can be downloaded from www.ewma.org
The EWMA document on Debridement aim
to provide an updated overview of the various
debridement options. It will offer a clarification
of the principal role of debridement and define
the possibilities and limitations for standard
and new debridement options.
Outcomes in controlled
and comparative studies
on non-healing wounds
Recommendations to improve the quality
of evidence in wound management
A EWMA Patient Outcome Group Document
EWMA front cover.indd 5 20/5/10 13:14:26
For further details contact:
EWMA Secretariat,
Nordre Fasanvej 113,
2000 Frederiksberg,
Denmark
Tel: +45 7020 0305
Fax: +45 7020 0315
ewma@ewma.org

the Wound Healing Scale, combining the four classification
stages with eight modifiers 14 . The only scale found in
Spanish was CODED, developed in the Basque Country
in 2000, but only a partial study was found 16 . The most recent
is the DESIGN scale, consisting of seven categories 17 .
The PUSH tool is the most commonly used by clinicians,
although the PSST is the one appearing most often in
studies of its measurement properties and application in
clinical practice which accredit its quality 8,9,10,11 , but its
complexity in clinical use is evidenced by practitioners
themselves.
Table 1. Content validity of each item
Item Content validity
1. Wound size 1
2. Depth/tissues involved 0.90
3. Edges 0.80
4. Perilesional maceration 0.80
5. Tunneling 0.90
6. Type of tissue in the wound bed 0.90
7. Exudate 1
8. Infection/inflammation (biofilm signs) 0.90
9. Incidence of pain 0.90
The PUSH tool, in contrast to PSST, is a much quicker,
more reliable scale to monitor the status and progress of
wounds through time, but the procedures used in developing
it are not clear in the literature. Even so, it has been
commonly used in the USA since it first appeared.
In Spain the GNEAUPP translated this tool into Spanish
and adopted it 20 after authorization by the NPUAP,
but no studies on the adaptation, validity and reliability
of this tool have yet been carried out in Spain. The DE­
SIGN scale is the most recent tool for assessing the healing
process, but there is only one published study that looks
at its validity and reliability 17 , involving inter­observer
reliability and in comparison with PSST to determine
its validity. Although the reliability and validity of this
tool are highly rated, the authors themselves point out
the need for more studies on the scale in other contexts
and other types of wounds. So far there is no record of
any such studies.
Regardless of the number of articles per scale, PSST is the
one with the best research on validity and reliability. Nevertheless,
most are measurement tools exclusively for PU.
Validity and reliability studies have been carried out for
only four scales (PUSH, PSST, DESIGN and CODED).
The only scale validated also for venous ulcers is PUSH,
in English and Portuguese 11,21 , which leads to the conclusion
that there is no scale suitable for the reliable, valid
assessment of healing in all CW.
Phase 2
It was decided to develop a healing progress index. Therefore,
the systematic review was used also to determine what
items should be included in developing the new scale.
Existing scales were reviewed and some of their items were
included in the initial drafts. This resulted in a lengthy list
of items related to the healing process, and it was decided
that the new scale should include only those items that
would potentially change throughout the healing process.
The outcome was a pencil­and­paper tool consisting of
12 variables: size/area/dimension, depth/tissues involved,
edges, perilesional area, tunneling, wound history, baseline
conditions, type and amount of tissue, exudate, infection/
inflammation (biofilm signs), treatment and pain. As mentioned
in the section on Material and Method, the experts
scored the item list twice, first in the initial 12­item version
and then in a final version with 9 items and their rating
categories. The CVI­i results are summarized in Table 1.
The CVI­e results demonstrated high content validity
for the most part, with scores of 0.80 or higher; some
even received the maximum CVI score (Table 2). The
CVI­total score was above 0.90, which indicates that the
questionnaire items measure a specific domain, based on
the scientific literature related to the evaluation of CW
healing, guaranteeing the general content validity. The
final outcome based on the foregoing and the CVI with
scores above 0.80 given by the experts for all the items
making up the de novo scale for all types of CW, was an
index with the provisional name of “RESVECH V1.0. Results
expected from the assessment and healing progress of
chronic wounds”, pending a study of validity and reliability
(Annex 1). It contains nine items: wound dimensions,
depth/tissues involved, edges, perilesional maceration,
tunneling, type of tissue in the wound bed, exudate, infection/inflammation
(biofilm signs), pain frequency (in the
past 10 days). The scale is scored numerically between 0
Table 2. Individual validity index for each expert (CVI-e)
Expert panelist
Number of items
scored between
3 and 4
Content validity
CVI-3 (according to
formula)
Expert 1 8 0.80
Expert 2 8 0.80
Expert 3 8 0.80
Expert 4 9 1
Expert 5 8 0.80
Expert 6 8 0.80
Expert 7 8 0.80
Expert 8 8 0.80
Expert 9 9 1
Expert 10 9 1
Science, Practice and Education
EWMA Journal 2012 vol 12 no 2 43
�

Science, Practice and Education
(wound healed) and 40 points (worst possible condition).
Additionally, operational definitions are provided for each
item, as well as the way of assessing them (Annex 1).
CONCLUSIONS
The systematic review confirmed that there is little research
on multidimensional tools for measuring healing
and more research is needed.
The RESVECH 1.0 index showed face value for the
clarity and ease of understanding of each item by the experts
who took part in the study. The overall content validity
index (CVI­total) was 0.98, greater than the required
minimum of 0.62 according to Lawshe for a panel of ten
experts, which ensures the content validity according to
the scientific literature relative to items for assessing the
healing process.
The validation process evidenced that this is a short
scale, and it is pending further analysis according to experts
and study population, comparing it with a disciplinary
theory.
The index entitled “RESVECH V1.0. Results expected
from the assessment and healing progress of chronic
wounds” is the first measurement tool applicable to chronic
wounds of all types and of any etiology that can be used
from the time the chronic wound is detected until healing
process is complete. It may undergo different types of validation
procedures to determine whether it measures what
it purports to measure, which emphasizes the significance
of continuing the improvement process.
In general, it can be concluded that the quantitative analysis
of the questionnaire shows that its content is valid both
in terms of pertinence and relevance.
BIBLIOGRAPHy
1. Calderón W. Historia de la cirugía plástica mundial.
Cirugía Plástica. Santiago. Sociedad de Cirujanos de
Chile 2001; 19-27.
2. Ladin D. Understanding wound dressings. Cl Plast
Surg 1998; 25: 433-41.
3. Winter GD. Formation of the Scab and the rate of
epithelisation of superficial wounds in the skin of the
young domestic pig. Nature 1962; 293 (4812):
293-4.
4. Winter GD, Scales JT. Effect of air drying and
dressings on the surface of a wound. Nature 1963;
197 (4862): 91-2.
5. Grupo de Trabajo sobre Úlceras Vasculares de la
AEEV. Consenso sobre Úlceras Vasculares y Pie
Diabético de la AEEV. Guía de Práctica Clínica.
Marzo 2004.
6. Grupo Nacional para el Estudio y Asesoramiento en
Úlceras por Presión y Heridas Crónicas. Mesa de
debate: “Las úlceras por presión, un reto para el
sistema de salud y la sociedad. Repercusiones a nivel
epidemiológico, ético, económico y legal”. Madrid.
Barcelona. Logroño: GNEAUPP, 2003.
7. Gutiérrez FF. Prevenir las úlceras por presión es
garantizar la calidad asistencial. Enfermería Científica
1993; 140: 7-10.
8. Bates-Jensen B. New pressure ulcer status tool.
Decubitus 1990; 3 (3): 14-5.
44
9. Bates-Jensen BM, Vredevoe DL, Brecht ML. Validity
and reliability of the Pressure Sore Status Tool.
Decubitus 1992; 5 (6): 20-8.
10. Bates-Jensen BM. The pressure sore status tool: an
outcome measure for pressure sores. Top Geriatric
Rehabil 1994; 9 (4): 17-34.
11. Thomas DR, Rodeheaver GT, Bartolucci AA, Franz
RA, Sussman C, Ferrell BA, Cuddigan J, Stotts NA,
Maklebust J. Pressure ulcer scale for healing:
derivation and validation of the PUSH tool. The
PUSH Task Force. Adv Wound Care 1997; 10 (5):
96-101.
12. Utility of the Sussman Wound Healing Tool in
predicting wound healing outcomes in physical
therapy. Adv Wound Care 1997; 10 (5): 74-7.
13. Ferrell BA, Artinian BM, Sessing D. The Sessing Scale
for assessment of pressure ulcer healing. Journal of
the American Geriatric Society 1995; 43: 37-40.
14. Krasner D. Wound Healing Scale, version 1.0: A
proposal. Adv Wound Care 1997; 10 (5): 82-5.
15. Houghton PE, Kincaid CB, Campbell KE, Woodbury
MG, Keast DH. Photographic assessment of the
appearance of chronic pressure and leg ulcers.
Ostomy/Wound Manage 2000; 46 (4): 20-30.
16. Emparanza JL, Aranegui P, Ruiz M y cols. A simple
Severity index for pressure ulcers. Journal of Wound
Care 2000: 9 (2): 86-90.
RESVECH SCALE V1.0 (SEE ANNEx 1.)
Scale of results from assessment and
progress of wound healing
Operational definitions of variables and
instructions for use
Below is a clear, systematic explanation of the items
making up the scale and the correct way to respond
to them according to your patient’s wound.
Indicate the score for each item in the box corresponding
to the time of measurement
(e.g., Measurement 0, Date ___________).
1. Ulcer dimensions
1.1. Dimensions: Indicate the measurements as
length x width, as follows:
n Length: Cephalocaudal measurement
(from head to feet)
n Width: Perpendicular to length
Express both measurements in cm. Then multiply
length x width to obtain the area in cm 2 .
Length
Width
Assign a score from 0 to 6 according to the area. For
example, an area of de 44 cm 2 would be scored as 4.
17. Sanada H, Moriguchi T, Miyachi Y, Ohura T, Nakajo
T, Tokunaga K, Fukui M, Sugama J, Kitagawa A.
Reliability and validity of DESIGN, a tool that
classifies pressure ulcer severity and monitors
healing. J Wound Care 2004; 13 (1): 13-18.
18. Polit DF, Hungler BP. Investigación científica en
Ciencias de la Salud: principios y métodos. 6ª. ed.
México: McGraw-Hill Interamericana, 2000, pp.
398-401.
19. Lawshe CH. Quantitative approach to content
validity. Personnel Psychology 1975; 28: 568.
20. Grupo Nacional para el Estudio y Asesoramiento en
Úlceras por Presión y Heridas Crónicas (GNEAUPP).
Instrumentos para la monitorización de la evolución
de una úlcera por presión (Documento VII.
GNEAUPP). En: Documentos GNEAUPP.
21. Santos VLCG, Sellmer D, Massulo MME. Transcultural
adaptation of the Pressure Ulcer Scale for
Healing (PUSH) to the Portuguese language, in
patients with chronic leg ulcers. Programme and
Abstract Book of the 15th Biennial Congress of the
World Council of Enterostomal Therapists 2004; (5):
16-19.
EWMA Journal 2012 vol 12 no 2

ANNEx 1. RESVECH SCALE V1.0
Items Measurement and dates:
0 1 2 3
1. Wound dimensions:
0. Area = 0 cm2 1. Area < 4 cm2 2. Area = 4 - < 16 cm2 3. Area = 16 - < 36 cm2 4. Area = 36 - < 64 cm2 5. Area = 64 - < 100 cm2 6. Area ≥ 100 cm2 2. Depth/tissues involved:
0. Intact skin healed
1. Dermis-epidermis involved
2. Subcutaneous tissue involved
(adipose tissue not reaching the muscle fascia)
3. Muscle involved
4. Bone and/or attached tissues involved (tendons,
ligaments, joint capsule or black scab blocking
view of the tissues underneath)
3. Edges:
0. Not distinguishable (no wound edges)
1. Diffuse
2. Delimited
3. Damaged
4. Thickened (“aged”, “everted”)
4. Perilesional maceration:
0. No
1. Yes
5. Tunneling:
0. No
1. Yes
6. Type of tissue in the wound bed:
4. Necrotic (dry or moist black scab)
3. Necrotic tissue and/or slough in the bed
2. Granulation tissue
1. Epithelial tissue
0. Closed/healed
7. Exudate:
3. Dry
0. Moist
1. Wet
2. Saturated
3. Leaking exudate
8. Infection/inflammation (biofilm signs):
8.1. Increasingly painful Yes = 1 No = 0
8.2. Erythema around the wound Yes = 1 No = 0
8.3. Edema around the wound Yes = 1 No = 0
8.4. Rising temperature Yes = 1 No = 0
8.5. Increasing exudate Yes = 1 No = 0
8.6. Purulent exudate Yes = 1 No = 0
8.7. Tissue is friable or bleeds easily Yes = 1 No = 0
8.8. Wound stationary, no progress Yes = 1 No = 0
8.9. Tissue compatible with biofilm Yes = 1 No = 0
8.10. Odor Yes = 1 No = 0
8.11. Hypergranulation Yes = 1 No = 0
8.12. Wound increasingly larger Yes = 1 No = 0
8.13. Satellite lesions Yes = 1 No = 0
8.14. Pale tissue Yes = 1 No = 0
ADD UP THE SCORES OF ALL SUB-ITEMS!
9. Frequency of pain (in past 10 days):
0. Never
1. When changing dressing
2. Often
3. All the time
TOTAL SCORE (Max. = 40, Min. = 0)
EWMA Journal 2012 vol 12 no 2
�
Management of
the Diabetic Foot
Theory & Practice
4 Day Course, 8 - 11 October 2012
Pisa, Italy
This 4 day theoretical course & practical
training gives participants a thorough introduction
to all aspects of diagnosis, management
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Lectures will be combined with practical
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Lectures will be in agreement with the
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& Practical Guideline on the Management
and Prevention on the Diabetic Foot.
· COURSE ENDORSED BY ·
EUROPEAN · WOUND · MANAGEMENT· ASSOCI
ATION
This course is endorsed by EWMA.
www.diabeticfootcourses.org

Science, Practice and Education
2. Depth/tissues involved: State the score for the greatest
involvement.
3. Edges: The edges are understood as the tissue bordering
the wound bed. Indicate the score that best defines the
edges of your wound:
• Not distinguishable: No borders seen, which may be
the case of a wound that is in the process of healing.
• Diffuse: It is difficult to distinguish them.
• Delimited: Clearly visible edges distinguishable from
the bed. Not thickened.
• Damaged: Well outlined edges, not thickened, that
may show maceration, lesions, etc.
• Thickened, aged or everted: Well outlined edges but
thickened or turned in towards the bed.
4. Perilesional maceration: Perilesional maceration is
defined as softening in the area between the edge and
outward from the wound (toward healthy skin). Indicate
5. Tunneling: Sinuous paths in the wound. Indicate
whether or not these are found in the wound.
6. Type of tissue in the wound bed: This refers to the
type of tissue present in the wound bed. Mark the worst
tissue found with an “x”, according to the following scale
from lesser to greater: necrotic­slough­granulation tissueepithelial
tissue­closed­healed.
6.1. Necrotic: This refers to devitalized, black or
brown tissue firmly adhered to the wound bed or
its edges, which may be harder or softer than the
surrounding tissue (skin); dry black scab.
6.2. Slough: Yellow or whitish tissue adhering to the
wound bed in the form of strands, filaments or
thin layers. It falls apart or is very difficult to remove
with pincers.
6.3. Granulation tissue: Pink or shiny, moist and
granular tissue.
6.4. Epithelial tissue: In ulcers or superficial wounds;
new pink tissue or shiny skin growing from the
edges or in islands around the ulcer/wound.
6.5. Closed/healing: The wound is completely covered
with epithelium (new skin).
7. Exudate: This is assessed when changing the dressing,
which may be:
7.1. Moist: Small amounts of fluid are visible when
removing the dressing; the primary dressing may
have slight spotting; the frequency of changing
the dressing is appropriate for the type of dressing.
Note: This is often the objective in the treatment
of exudate.
46
7.2. Dry: The wound bed is dry; there is no visible
moisture and the primary dressing is not stained;
the dressing may be stuck to the wound. Note:
This may be the environment of choice for
ischemic wounds.
7.3. Wet: Small amounts of fluid are visible when
the dressing is removed; the primary dressing is
very stained but there is no exudate flowing; the
frequency of changing the dressing is appropriate
for the type of dressing.
7.4. Saturated: The primary dressing is wet and exudate
is leaking through it; the dressing needs to
be changed more often than usual for this type of
dressing; perilesional skin may be macerated.
7.5. Leaking exudate: The dressing is saturated and
exudate is leaking from the primary and secondary
dressings toward clothing or further; the dressing
needs to be changed much more often than usual
for this type of dressing.
8. Infection/inflammation: Indicate if more than three or
four of the following signs or symptoms of inflammation
are present:
8.1. Increasing pain
8.2. Perilesional erythema
8.3. Perilesional edema
8.4. Rising temperature
8.5. Increasing exudate
8.6. Purulent exudate
8.7. Tissue that is friable or bleeds easily
8.8. Stationary wound that does not progress
8.9. Tissue compatible with biofilm
8.10. Odor
8.11. Hypergranulation
8.12. Increasing size of the wound
8.13. Satellite lesions
8.14. Pale tissue
9. Pain: In the wound area, divided in two
Frequency:
9.1. Never
9.2. When changing the dressing
9.3. Often
9.4. All the time
Intensity: Mark intensity on the VAS scale, according to
the following criteria:
0 = No pain, and 10 = Greatest possible pain
m
EWMA Journal 2012 vol 12 no 2

iabetic
lcer
non healing for 8 weeks
68 years
despair of wound deterioration
Activates healing naturally
Hyaluronic Acid & Iodine
Promotes granulation
Provides antimicrobial protection
Highly effective in diabetic ulcers*
49 % wounds completely healed
19 % wounds significantly improved
www.hyiodine.com
no social life
*SOBOTKA, L et al. Complex approach to the treatment of diabetic foot ulcers.
presented at EWMA 2006, May 19-20, Prague,
no walks with
grandchildren

ABSTRACTS OF RECENT
COCHRANE REVIEWS
Publication in The Cochrane Library Issue 2, 2012
Aloe vera for treating acute and
chronic wounds
Anthony D Dat, Flora Poon, Kim BT Pham,
Jenny Doust
Citation example: Dat AD, Poon F, Pham KBT, Doust
J. Aloe vera for treating acute and chronic wounds.
Cochrane Database of Systematic Reviews 2010,
Issue 10. Art. No.: CD008762.
DOI: 10.1002/14651858.CD008762.
Copyright © 2012 The Cochrane Collaboration. Published
by John Wiley & Sons, Ltd.
ABSTRACT
Background: Aloe vera is a cactus-like perennial succulent
belonging to the Liliaceae Family that is commonly
grown in tropical climates. Animal studies have suggested
that Aloe vera may help accelerate the wound
healing process.
Objectives: To determine the effects of Aloe veraderived
products (for example dressings and topical
gels) on the healing of acute wounds (for example
lacerations, surgical incisions and burns) and chronic
wounds (for example infected wounds, arterial and
venous ulcers).
Search methods: We searched the Cochrane Wounds
Group Specialised Register (9 September 2011), the
Cochrane Central Register of Controlled Trials (CEN-
TRAL) (The Cochrane Library 2011, Issue 3), Ovid
MEDLINE (2005 to August Week 5 2011), Ovid
MEDLINE (In-Process & Other Non-Indexed Citations
8 September 2011), Ovid EMBASE (2007 to 2010
Week 35), Ovid AMED (1985 to September 2011) and
EBSCO CINAHL (1982 to 9 September 2011).
We did not apply date or language restrictions.
Selection criteria: We included all randomised controlled
trials that evaluated the effectiveness of Aloe vera,
aloe-derived products and a combination of Aloe vera
and other dressings as a treatment for acute or chronic
wounds. There was no restriction in terms of source,
date of publication or language. An objective measure
of wound healing (either proportion of completely
healed wounds or time to complete healing) was the
primary endpoint.
Data collection and analysis: Two review authors independently
carried out trial selection, data extraction
and risk of bias assessment, checked by a third review
author.
Main results: Seven trials were eligible for inclusion,
comprising a total of 347 participants. Five trials in
people with acute wounds evaluated the effects of Aloe
vera on burns, haemorrhoidectomy patients and skin
biopsies. Aloe vera mucilage did not increase burn
healing compared with silver sulfadiazine (risk ratio
(RR) 1.41, 95% confidence interval (CI) 0.70 to 2.85).
A reduction in healing time with Aloe vera was noted
after haemorrhoidectomy (RR 16.33 days, 95% CI
3.46 to 77.15) and there was no difference in the proportion
of patients completely healed at follow up after
skin biopsies. In people with chronic wounds, one trial
found no statistically significant difference in pressure
ulcer healing with Aloe vera (RR 0.10, 95% CI -1.59 to
1.79) and in a trial of surgical wounds healing by secondary
intention Aloe vera significantly delayed healing
(mean difference 30 days, 95% CI 7.59 to 52.41).
Clinical heterogeneity precluded meta-analysis. The
poor quality of the included trials indicates that the trial
results must be viewed with extreme caution as they
have a high risk of bias.
Authors’ conclusions: There is currently an absence of
high quality clinical trial evidence to support the use of
Aloe vera topical agents or Aloe vera dressings as
treatments for acute and chronic wounds.
Plain language summary: Aloe vera for treating acute
and chronic wounds
Aloe vera is a cactus-like, succulent plant which grows
in tropical climates. Aloe vera is widely used in a variety
of cosmetics including creams and toiletries. Some
studies conducted in animals have suggested that Aloe
vera may help wound healing. Aloe vera can be
applied topically as a cream or gel, or can be impregnated
into a dressing and applied to the wound.
The authors of this Cochrane Review wanted to find
evidence on whether Aloe vera encourages wound
healing in people with acute wounds (for example
lacerations, surgical incisions and burns) and chronic
wounds (for example infected wounds, arterial and
venous ulcers). The review found that there was not
enough research evidence to answer this question.
�
Cochrane Reviews
Sally Bell-Syer, MSc
Managing Editor
Cochrane Wounds Group
Department of
Health Sciences
University of York
United Kingdom
sembs1@york.ac.uk
Conflict of interest: none
EWMA Journal 2012 vol 12 no 2 49

Hydrocolloid dressings for
healing diabetic foot ulcers
Jo C Dumville, Sohan Deshpande, Susan O’Meara, Katharine
Speak
Citation example: Dumville JC, Deshpande S, O’Meara S, Speak
K. Hydrocolloid dressings for healing diabetic foot ulcers.
Cochrane Database of Systematic Reviews 2011,
Issue 5 . Art. No.: CD009099.
DOI: 10.1002/14651858.CD009099.
Copyright © 2012 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
ABSTRACT
Background: Foot ulcers in people with diabetes are a prevalent
and serious global health issue. Wound dressings are regarded
as important components of ulcer treatment, with clinicians and
patients having many different types to choose from including
hydrocolloid dressings. There is a range of different hydrocolloids
available including fibrous-hydrocolloid and hydrocolloid
(matrix) dressings. A clear and current overview of current evidence
is required to facilitate decision-making regarding dressing
use.
Objectives: To compare the effects of hydrocolloid wound dressings
with no dressing or alternative dressings on the healing of
foot ulcers in people with diabetes.
Search methods: We searched The Cochrane Wounds Group
Specialised Register (searched 4 January 2012); The Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane
Library 2011, Issue 4); Ovid MEDLINE (1950 to December
Week 3 2011); Ovid MEDLINE (In-Process & Other Non-
Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to
2011 Week 52); and EBSCO CINAHL (1982 to 30 December
2011). There were no restrictions based on language or date of
publication.
Selection criteria: Published or unpublished randomised controlled
trials (RCTs) that have compared the effects on ulcer healing
of hydrocolloid with alternative wound dressings or no dressing
in the treatment of foot ulcers in people with diabetes.
Data collection and analysis: Two review authors independently
performed study selection, risk of bias assessment and data
extraction.
Main results: We included four studies (511 participants) in the
review: these compared hydrocolloids with basic wound contact
dressings, foam dressings and alginate dressings. Meta-analysis
of two studies indicated no statistically significant difference in
ulcer healing between fibrous-hydrocolloids and basic wound
contact dressings: risk ratio 1.01 (95% CI 0.74 to 1.38). One of
these studies found that a basic wound contact dressing was
more cost-effective than a fibrous-hydrocolloid dressing. One
study compared a hydrocolloid-matrix dressing with a foam
dressing and found no statistically significant difference in the
number of ulcers healed. There was no statistically significant
difference in healing between an antimicrobial (silver) fibroushydrocolloid
dressing and standard alginate dressing; or an antimicrobial
dressing (iodine-impregnated) and a standard fibrous
hydrocolloid dressing.
50
Authors’ conclusions: Currently there is no research evidence to
suggest that any type of hydrocolloid wound dressing is more
effective in healing diabetic foot ulcers than other types of dressing.
Decision makers may wish to consider aspects such as
dressing cost and the wound management properties offered by
each dressing type e.g. exudate management.
Plain language summary: Hydrocolloid dressings to promote
foot ulcer healing in people with diabetes when compared with
other dressing types
Diabetes, a condition which leads to high blood glucose concentrations,
is a common condition with around 2.8 million people
affected in the UK (approximately 4.3% of the population).
Dressings are commonly used to treat foot ulcers in people with
diabetes. There are many types of dressings that can be used,
which also vary considerably in cost.This review (four studies
involving a total of 511 participants) identified no research evidence
to suggest that any type of hydrocolloid wound dressing is
more effective in healing diabetic foot ulcers than other types of
dressing.
Alginate dressings for healing diabetic
foot ulcers
Jo C Dumville, Susan O’Meara, Sohan Deshpande,
Katharine Speak
Citation example: Dumville JC, O’Meara S, Deshpande S,
Speak K. Alginate dressings for healing diabetic foot ulcers.
Cochrane Database of Systematic Reviews 2011, Issue 5 .
Art. No.: CD009110. DOI: 10.1002/14651858.CD009110.
Copyright © 2012 The Cochrane Collaboration.Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Foot ulcers in people with diabetes mellitus are a
common and serious global health issue. Dressings form a key
part of ulcer treatment, with clinicians and patients having many
different types to choose from including alginate dressings.
A clear and current overview of current evidence is required to
facilitate decision-making regarding dressing use.
Objectives: To compare the effects of alginate wound dressings
with no wound dressing or alternative dressings on the healing
of foot ulcers in people with diabetes mellitus.
Search methods: We searched The Cochrane Wounds Group
Specialised Register (searched 4 January 2012); The Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane
Library 2011, Issue 4); Ovid MEDLINE (1950 to December
Week 3 2011); Ovid MEDLINE (In-Process & Other Non-
Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to
2011 Week 52); and EBSCO CINAHL (1982 to 30 December
2011). There were no restrictions based on language or date of
publication.
Selection criteria: Published or unpublished randomised controlled
trials (RCTs) that have compared the effects on ulcer healing
of alginate dressings with alternative wound dressings or no
dressing in the treatment of foot ulcers in people with diabetes.
Data collection and analysis: Two review authors independently
performed study selection, risk of bias assessment and data
extraction.
EWMA Journal 2012 vol 12 no 2

Main results: We included six studies (375 participants) in this
review; these compared alginate dressings with basic wound
contact dressings, foam dressings and a silver-containing,
fibrous-hydrocolloid dressing. Meta analysis of two studies found
no statistically significant difference between alginate dressings
and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI
0.66 to 1.80). Pooled data from two studies comparing alginate
dressings with foam dressings found no statistically significant
difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08).
There was no statistically significant difference in the number of
diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid
dressing was compared with a standard alginate dressing
(RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up
times (six to 12 weeks), and small sample sizes.
Authors’ conclusions: Currently there is no research evidence to
suggest that alginate wound dressings are more effective in
healing foot ulcers in people with diabetes than other types of
dressing however many trials in this field are very small. Decision
makers may wish to consider aspects such as dressing cost and
the wound management properties offered by each dressing
type e.g. exudate management.
Plain language summary: Alginate dressings for healing foot
ulcers in people with diabetes mellitus
Diabetes mellitus, a condition which leads to high blood glucose
concentrations, is a common condition with around 2.8 million
people affected in the UK (approximately 4.3% of the population).
Wound dressings are widely used to treat foot ulcers in
people with diabetes. There are many types of dressings that
B. Braun Wound Care
Prontosan ® and Askina ® – a powerful team
can be used, which also vary considerably in cost. This review
(six studies involving a total of 375 participants) identified no
research evidence to suggest that alginate wound dressings are
more effective in healing diabetic foot ulcers than other types of
dressing. More, better quality research is needed.
Publication in The Cochrane Library Issue 3, 2012
Interventions for treating phosphorus burns
Loai Barqouni, Nafiz Abu Shaaban, Khamis Elessi
Citation example: Barqouni L, Abu Shaaban N, Elessi K.
Interventions for treating phosphorus burns.
Cochrane Database of Systematic Reviews 2010 , Issue 11.
Art. No.: CD008805. DOI: 10.1002/14651858.CD008805
Copyright © 2012 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Phosphorus burns are rarely encountered in usual
clinical practice and occur mostly in military and industrial settings.
However, these burns can be fatal, even with minimal
burn area, and are often associated with prolonged hospitalisation.
Cochrane Reviews
Objectives: To summarise the evidence of effects (beneficial
and harmful) of all interventions for treating people with phosphorus
burns.
�
B. Braun Wound Care products focus on every type of wound at each phase of wound healing. By providing innovative
solutions such as Prontosan ® Wound Irrigation Solution, bacterial biofilm can be efficiently removed thereby clearing the
way for application of advanced wound dressings from the Askina ® range, to assist in the complex task of tissue repair.
B. Braun Medical AG | Infection Control | Sempach | Switzerland
B. Braun Hospicare Ltd. | Collooney | Co. Sligo | Ireland | www.woundcare-bbraun.com
Royal Alliance

Search methods: We searched the Cochrane Wounds Group
Specialised Register (searched 30 September 2011); the
Cochrane Central Register of Controlled Trials (CENTRAL) (The
Cochrane Library 2011, Issue 3); Ovid OLDMEDLINE (1947 to
1965); Ovid MEDLINE (1950 to September Week 3 2011);
Ovid MEDLINE (In-Process & Other Non-Indexed Citations
29 September 2011); Ovid EMBASE (1980 to 2011 Week 38);
EBSCO CINAHL (1982 to 23 September 2011) and Conference
Proceedings Citation Index - Science (CPCI-S) (1990 to
30 September 2011).
Selection criteria: Any comparisons of different ways of managing
phosphorus burns including, but not restricted, to randomised
trials.
Data collection and analysis: We found two non-randomised
comparative studies, both comparing patients treated with and
without copper sulphate.
Main results: These two comparative studies provide no evidence
to support the use of copper sulphate in managing phosphorus
burns. Indeed the small amount of available evidence
suggests that it may be harmful.
Authors’ conclusions: First aid for phosphorus burns involves
the common sense measures of acting promptly to remove the
patient’s clothes, irrigating the wound(s) with water or saline
continuously, and removing phosphorus particles. There is no
evidence that using copper sulphate to assist visualisation of
phosphorus particles for removal is associated with better outcome,
and some evidence that systemic absorption of copper
sulphate may be harmful. We have so far been unable to identify
any other comparisons relevant to informing other aspects of
the care of patients with phosphorus burns. Future versions of
this review will take account of information in articles published
in languages other than English, which may contain additional
evidence based on treatment comparisons.
Plain language summary: Interventions for treating phosphorus
burns
Phosphorus is a chemical element sometimes used in a military
or industrial context. Phosphorus burns resulting from military or
industrial injuries are chemical burns that can be fatal. Although
rare, these burns are serious, often very deep and painful, and
can be associated with lengthy periods of time in hospital for
patients.
The usual procedure for dealing with phosphorus burns is to
remove any affected clothing and wash the wounds with water
or saline solution. In addition, copper sulphate can be used to
make the particles of phosphorus more visible and easier to
remove, however, copper sulphate is poisonous and can in itself
be fatal if absorbed into the body. This review found two retrospective
studies (88 patients) that compared burns treated with
or without copper sulphate. The review found no evidence that
using copper sulphate improves the outcome of the burn,
indeed, based upon the limited available evidence, the review
authors suggest that copper sulphate should not be used in the
treatment of phosphorus burns.
No other studies were identified that could be used to assess
other treatments for this type of burn.
52
Publication in The Cochrane Library Issue 4, 2012
Hyperbaric oxygen therapy for chronic wounds
Peter Kranke, Michael H Bennett, Marrissa Martyn-St James,
Alexander Schnabel, Sebastian E Debus, Irmgard Roeckl-Wiedmann
Citation example: Kranke P, Bennett MH, Martyn-St James M,
Schnabel A, Debus SE, Roeckl-Wiedmann I. Hyperbaric oxygen
therapy for chronic wounds. Cochrane Database of Systematic
Reviews 2004 , Issue 2 . Art. No.: CD004123. DOI:
10.1002/14651858.CD004123.pub2
Copyright © 2012 The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd.
ABSTRACT
Background: Chronic wounds are common and present a health
problem with significant effect on quality of life. Various pathologies
may cause tissue breakdown, including poor blood supply
resulting in inadequate oxygenation of the wound bed. Hyperbaric
oxygen therapy (HBOT) has been suggested to improve
oxygen supply to wounds and therefore improve their healing.
Objectives: To assess the benefits and harms of adjunctive
HBOT for treating chronic ulcers of the lower limb.
Search methods: For this first update we searched the Cochrane
Wounds Group Specialised Register (searched 12 January
2012); the Cochrane Central Register of Controlled Trials
(CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid
MEDLINE (1950 to January Week 1 2012); Ovid MEDLINE
(In-Process & Other Non-Indexed Citations, 11 July 2012);
Ovid EMBASE (1980 to 2012 Week 01); and EBSCO CINAHL
(1982 to 6 January 2012).
Selection criteria: Randomised controlled trials (RCTs) comparing
the effect on chronic wound healing of therapeutic regimens
which include HBOT with those that exclude HBOT (with or
without sham therapy).
Data collection and analysis: Three review authors independently
evaluated the risk of bias of the relevant trials using the
Cochrane methodology and extracted the data from the
included trials. We resolved any disagreement by discussion.
Main results: We included nine trials (471 participants). Eight
trials (455 participants) enrolled people with a diabetic foot
ulcer: pooled data of three trials with 140 participants showed
an increase in the rate of ulcer healing (risk ratio (RR) 5.20, 95%
confidence interval (CI) 1.25 to 21.66; P = 0.02) with HBOT at
six weeks but this benefit was not evident at longer-term followup
at one year. There was no statistically significant difference in
major amputation rate (pooled data of five trials with 312 participants,
RR 0.36, 95% CI 0.11 to 1.18). One trial (16 participants)
considered venous ulcers and reported data at six weeks
(wound size reduction) and 18 weeks (wound size reduction and
number of ulcers healed) and suggested a significant benefit of
HBOT in terms of reduction in ulcer area only at six weeks
(mean difference (MD) 33.00%, 95% CI 18.97 to 47.03, P <
0.00001). We did not identify any trials that considered arterial
and pressure ulcers.
EWMA Journal 2012 vol 12 no 2

Authors’ conclusions: In people with foot ulcers due to diabetes,
HBOT significantly improved the ulcers healed in the short term
but not the long term and the trials had various flaws in design
and/or reporting that means we are not confident in the results.
More trials are needed to properly evaluate HBOT in people with
chronic wounds; these trials must be adequately powered and
designed to minimise all kinds of bias.
Plain language summary: Hyperbaric oxygen therapy for treating
chronic wounds
Chronic wounds, often associated with diabetes, arterial or
venous disease, are common and have a high impact on the
well-being of those affected. Hyperbaric oxygen therapy (HBOT)
is a treatment designed to increase the supply of oxygen to
wounds that are not responding to other measures to treat
them. HBOT involves people breathing pure oxygen in a specially
designed chamber (such as that used for deep sea divers
suffering pressure problems after resurfacing).
This review update of randomised trials found that HBOT
seems to improve the chance of healing diabetes-related foot
ulcers and may reduce the number of major amputations in
people with diabetes who have chronic foot ulcers. In addition
this therapy may reduce the size of wounds caused by disease to
the veins of the leg, but the review found no evidence to confirm
or refute any effect on other wounds caused by lack of blood
supply through the arteries or pressure ulcers.
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Negative pressure wound therapy for skin grafts
and surgical wounds healing by primary intention
Joan Webster, Paul Scuffham, Karen L Sherriff,
Monica Stankiewicz, Wendy P Chaboyer
Citation example: Webster J, Scuffham P, Sherriff KL, Stankiewicz
M, Chaboyer WP. Negative pressure wound therapy for skin
grafts and surgical wounds healing by primary intention.
Cochrane Database of Systematic Reviews 2011, Issue 8.
Art. No.: CD009261. DOI: 10.1002/14651858.CD009261
Copyright © 2012 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd.
ABSTRACT
Background: Indications for the use of negative pressure wound
therapy (NPWT) are broadening with a range of systems on the
market, including those designed for use on clean, closed incisions
and skin grafts. Reviews have concluded that the evidence
for the effectiveness of NPWT remains uncertain. However, this
is a rapidly evolving therapy. Consequently, a systematic review
of the evidence for the effects of NPWT on postoperative
wounds expected to heal by primary intention is required.
Objectives: To assess the effects of NPWT on surgical wounds
(primary closure or skin grafting) that are expected to heal by
primary intention.
Search methods: We searched the following electronic databases
to identify reports of relevant randomised clinical trials:
the Cochrane Wounds Group Specialised Register (searched 11
November 2011); the Cochrane Central Register of Controlled
Anatomy of a Heelift ®
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Cochrane Reviews
Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Database
of Abstracts of Reviews of Effects (The Cochrane Library
2011, Issue 4); Ovid MEDLINE (2005 to October Week 4 2011);
Ovid MEDLINE (In-Process & Other Non-Indexed Citations 8
November 2011); Ovid EMBASE (2009 to 2011 Week 44); and
EBSCO CINAHL (1982 to 04 November 2011). We conducted a
separate search to identify economic evaluations.
Visit EWMA
on our Social Media
platforms
Follow us and get the latest updates about
the EWMA 2012 Conference
as well as other EWMA activities:
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Remember to use #EWMA2012,
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54
ienna
EWMA 2012
Selection criteria: We included trials if they allocated patients at
random and compared NPWT with any other type of wound dressing
or compared one type of NPWT with a different type of NPWT.
Data collection and analysis: We assessed trials for their appropriateness
for inclusion and for their quality. This was done by
three review authors working independently, using pre-determined
inclusion and quality criteria.
Main results: We included five eligible trials with a total of 280
participants. Two trials involved skin grafts and three acute
wounds. Only one of the five trials reported the proportion of
wounds completely healed and in this study all wounds healed.
All five studies reported adverse events. In the four trials that
compared standard dressings with negative pressure wound therapy
(NPWT) the adverse event rate was similar between groups
(negative pressure 33/86; standard dressing 37/103); risk ratio
(RR) 0.97 (95% confidence intervals (CI) 0.33 to 2.89). There
was significant heterogeneity for this result, due to the high incidence
of fracture blisters in the NPWT group in one trial. One
trial (87 participants) compared a commercial negative pressure
device VAC® system with a negative pressure system developed
in the hospital (GSUC). The adverse event rate was lower in the
GSUC group (VAC® 3/42; GSUC 0/45); the RR was 0.13 (95%
CI 0.01 to 2.51). Results indicate uncertainty about the true
effect of either method on adverse events. The mean cost to supply
equipment for VAC® therapy was USD 96.51/day compared
to USD 4.22/day for the GSUC therapy (P = 0.01). Labour costs
for dressing changes were similar. Pain intensity score was also
reported to be lower in the GSUC group when compared with the
VAC® group (p = 0.02)
Authors’ conclusions: Evidence for the effectiveness of NPWT on
complete healing of wounds expected to heal by primary intention
remains unclear. Rates of graft loss may be lower when
NPWT is used; but evidence to date suggests that hospital-based
products are as effective in this area as commercial applications.
There are clear cost benefits when non-commercial systems are
used to create the negative pressure required for wound therapy,
with no reduction in clinical outcome. Pain levels are also rated
lower when hospital systems are compared with their commercial
counterparts. The high incidence of blisters occurring when
NPWT is used following orthopaedic surgery suggests that the
therapy should be limited until safety in this population is established.
Given the cost and widespread use of NPWT, there is an
urgent need for suitably powered, high-quality trials to evaluate
the effects of the newer NPWT products that are designed for use
on clean, closed surgical incisions. Such trials should focus initially
on wounds that may be difficult to heal, such as sternal
wounds or surgeries for obese patients.
Plain language summary: Negative pressure wound therapy for
acute surgical wounds.
Negative pressure wound therapy (NPWT) involves applying suction
to healing wounds. NPWT has been used for many years for
the treatment of chronic wounds, such as leg ulcers and bed
sores. More recently, the device has been modified for use on
clean surgical wounds, including skin grafts. We undertook a
review of studies that have compared NPWT with other wound
treatments. We found five trials which showed that evidence to
support the use of NPWT to promote faster healing and to
reduce complications associated clean surgery remains unclear.
m
EWMA Journal 2012 vol 12 no 2

Wounds Respond to
ragile Skin � Burns � Skin Tears � EB Wo unds � Full/Partial Thickness Wounds � Traumatic Wounds � Fragile
aumatic Wounds � Full/Partial Thickness W o u n d s � E B Wounds � Skin Tears � Burns � Fragile Skin � Bur
References:
1. Sessions R. Examining the Evidence for a Drug-free Dressing’s Ability to Decrease Wound Pain.
Poster Presentation. Clinical Symposium on Advances in Skin & Wound Care. October 2008. Las Vegas, NV USA.
2. Stenius M. Fast Healing of Pressure Ulcers in Spinal Cord Injured (SCI) People Through the Use of PolyMem ® Dressings.
Poster Presentation. EWMA. May 2008. Lisbon, Portugal.
3. Tamir J, Haik J. Polymeric Membrane Dressings for Skin Graft Donor Sites: 4 Years Experience on 800 Cases.
Poster Presentation. Clinical Symposium on Advances in Skin & Wound Care. October 2008. Las Vegas, NV USA.
PolyMem’s unique formulation
has the ability to reduce
patients’ total wound pain
experience while actively
encouraging healing 1,2,3
FERRIS MFG. CORP. | 16W300 83rd St., Burr Ridge, IL 60527 USA | International: +1 630.887.9797 | WWW.POLYMEM.EU
Unless otherwise indicated, all trademarks are owned by or licensed to Ferris. © 2010, Ferris Mfg. Corp., 16W300 83rd Street, Burr Ridge, IL 60527 USA MKL-383-I, REV-4, 0910

EWMA Journal
Previous Issues
The EWMA Journals can be downloaded free of charge from www.ewma.org
56
Volume 12, no 1, January 2012
How to rate the wound debridement trauma?
Jan Stryja
Ensuring equitable wound management education
within the Australian context
Jan Rice
Low wound prevalence and cost burden:
The impact of a multidisciplinary wound specialist team
Alison Hopkins, Fran Worboys, John Posnett
The results of a comprehensive wound audit in a
UK primary care trust
Alison Hopkins, Fran Worboys
Pressure ulcer programme of research – PURPOSE
Nixon J, Wilson L.M, Coleman S, Gorecki C, Muir D, Pinkney L,
Keen J, Briggs M, McGinnis E, Stubbs N, Dealey C, Nelson A
The skin’s own bacteria may aggravate inflammatory and
occlusive changes in atherosclerotic arteries of lower limbs
Waldemar L. Olszewski, Piotr Andziak, M. Moscicka-Wesolowska,
Bozenna Interewicz, Ewa Swoboda, Ewa Stelmach
Problem with the post burn wound pain: Chronic profiles
Laima Juozapaviciene, Rytis Rimdeika, Aurika Karbonskiene
Volume 11, no 3, October 2011
Challenges facing district nurses in the prevention
of pressure ulcers
Lynne Watret
Clinical application of stem cells in wound healing:
A near future?
Benoit I Hendrickx
Understanding the Patient Experience:
Does empowerment link to clinical practice?
Patricia Price
The Influence of Egyptian Propolis on Induced Burn Wound
Healing in Diabetic Rats – Antibacterial Mechanism
Emad T. Ahmed, Osama M. Abo-Salem, Ali Osman
PURSUN UK: The Pressure Ulcer Research Service User
Network for the UK
Delia Muir
Perspective of the European Patients’ Forum Developing
Collaboration
Nicola Bedlington
Volume 11, no 2, May 2011
The fight against biofilm infections:
Do we have the knowledge and means?
Klaus Kirketerp-Møller, Thomas Bjarnsholt, Trine R. Thomsen
Biofilms in wounds: An unsolved problem?
António Pedro Fonseca
Diabetic foot ulcer pain: The hidden burden
Sarah E Bradbury, Patricia E Price
Topical negative pressure in the treatment of deep sternal
infection following cardiac surgery: Five year results of first-line
application protocol
Martin Šimek
Wounds Research for Patient Benefit: A five year programme of
research in wound care
Karen Lamb, Nikki Stubbs, Jo Dumville, Nicky Cullum
Volume 11, no 1, January 2011
Who will take on
Ali Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi
Diabetic foot ulcer pain: The hidden burden
Sarah E Bradbury, Patricia E Price
The reconstructive clockwork as a 21st century concept in
wound surgery
Karsten Knobloch, Peter M. Vogt
Anaemia in patients with chronic wounds
Lotte M. Vestergaard, Isa Jensen, Knud Yderstraede
A survey of the provision of education in wound management
to undergraduate nursing students
Zena Moore, Eric Clarke
Caring for Patients with Hard-to-Heal Wounds – Homecare
Nurses’ Narratives
Camilla Eskilsson
Other Journals
EWMA wishes to facilitate the exchange of information
on wound healing in a broad perspective with
this section on International Journals.
Italian
English
Finnish
Spanish
Acta Vulnologica, vol. 10, no 1, 2012
www.vulnologia.it
Preliminary survey of the prevalence of chronic skin wounds in
the region of Marche
Pierangeli M., Grassetti L., Torressetti M., Bottoni E., Calamita R.,
Gioacchini M., Tartaglione C., Di Benedetto G. M., Scalise A.
Systematic review of the literature about wound management
Stiavetti E., Poli S., Romanelli M.
Extreme wound care: is it always the best choice?
Presentation of a case report
Palombi M., Fratto D., Cataldo F., Sortino A., Martinelli F.,
Palombi L.
Advances in Skin & Wound Care, vol. 25, no 5, 2012
www.aswcjournal.com
Eradication of Methicillin-Resistant Staphylococcus aureus
in Pressure Ulcers Comparing a Polyhexanide-Containing
Cellulose Dressing with Polyhexanide Swabs in a
Prospective Randomized Study
T. Wild, et al.
Systematic Review and Meta-analysis on the Use of
Honey to Protect from the Effects of Radiation-Induced
Oral Mucositis
J. J. Song, P. Twumasi-Ankrah, R. Salcido
Estimates of Evaporation Rates from Wounds for
Various Dressings/Support Surface Combinations
C. Lachenbruch, C. VanGilde
Exploring the Effects of Pain and Stress on Wound Healing
K. Y.Woo
Haava, no. 1, 2012
www.shhy.fi
Haava 1-2012
Infection or Inflammation?
Ansa Iivanainen, Esa Soppi
Criterions of Wound Infection
Tiina Pukki, Ansa Iivanainen (ed.)
Cost- effective Wound Care
Kielo Turtiainen
SIRO – Do we have the surgical side infections in Finland?
Outi Lyytikäinen
Antibiotics in Management of Infected Wound
Kirsi Skogberg
Wound Management Challenging the Skills of Hand hygienia
Carina Einimö
Wound Infection was Heal but the Patient was Succumb
Tiina Pukki
Wound Management in Home Care
Gunilla Lindholm
Succeeded Treatment of Infected Wound
Päivi Sinkkonen
Diary of the Treatment of Patient with Erysipelas
Mirja Pakkanen
Infection of trauma wound – traumatic experience
Eija Luotola
Individuality in Dermatologic Nursing
Helcos, vol. 23, no. 1, 2012
Quality assessment of the spanish clinical practyice
guidelines of pressure ulcers
Hernandez Martinez-Esparza E; Verdú-Soriano J.
Diaper rash. Local treatment with barrier products and
quality of life
Rueda Lopez J; Guerrero Palmero A; Segovia Gomez;
Muñoz BUeno AM; Bermejo Martinez M; Rosell Moreno C.
Pressure ulcer prevention and muscular and skeletal
injuries. Patient with stoke
Luque Moreno C; Peña Salinas M; Rodriguez Pappalardo F;
López Rodriguez L.
EWMA Journal 2012 vol 12 no 2

English
English
Int. Journal of Lower Extremity Wounds vol. 11, no 1, 2012
http://ijlew.sagepub.com
Wound Physicians: Lymphedema Is Not a Problem That Will Go
Away if Ignored
Miltos K. Lazarides and Raj Mani
Reporting an Alliance Using an Integrative Approach to the
Management of Lymphedema in India5
Terence J. Ryan and Saravu R. Narahari
From Lymph to Fat: Liposuction as a Treatment for Complete
Reduction of Lymphedema
Håkan Brorson
Multidisciplinary Lymphedema Treatment Program
Maria-Christina Papadopoulou, et.al.
Interdisciplinary Lymphology: The Best Place for Each Discipline in
a Team
Ethel Foeldi and Evangelos P. Dimakakos
The Madura Foot: Looking Deep
Sandhya Venkatswami, Anandan Sankarasubramanian, Shobana
Subramanyam
Diabetic Foot Screening: New Technology versus 10g Monofilament
Michelle C. Spruce and Frank L. Bowling
Management of Neglected Femoral Neck Fractures and Nonunions
using a Novel Triple Surgery Combination: An Indian Experience
Amit Kapoor, Lakshmi Venkatesh Deety, Vinith Zachariah John,
Sathish Devadoss, and A. Devadoss
Custom-Made Orthesis and Shoes in a Structured Follow-Up
Program Reduces the Incidence of Neuropathic Ulcers
in High-Risk Diabetic Foot Patients
Loredana Rizzo, et.al.
International Wound Journal, vol. 9, no 2, 2012
www.wiley.com
Wound management innovation cooperative research centre
– a new model for inter-disciplinary wound research
S Prowse, Z Upton
Prevalence of lymphoedema and quality of life among patients
attending a hospital-based wound management and vascular clinic
G Gethin, D Byrne, S Tierney, H Strapp, S Cowman
Split-thickness skin graft donor site management: a randomized
controlled trial comparing polyurethane with calcium alginate
dressings
L Higgins, J Wasiak, A Spinks, H Cleland
Multimodal therapy as an algorithm to limb salvage in diabetic
patients with large heel ulcers
EB Goudie, C Gendics, JC Lantis II
Elevated uric acid correlates with wound severity
ML Fernandez, Z Upton, H Edwards, K Finlayson, GK Shooter
Comparative study of the microvascular blood flow in the intestinal
wall during conventional negative pressure wound therapy and
negative pressure wound therapy using paraffin gauze over the
intestines in laparostomy
S Lindstedt, J Hansson, J Hlebowicz
Development of an evidence-based protocol for care of pilonidal
sinus wounds healing by secondary intent using a modified reactive
Delphi procedure. Part one: the literature review
CL Harris, S Holloway
Development of an evidence-based protocol for care of pilonidal
sinus wounds healing by secondary intent using a modified Reactive
Delphi procedure. Part 2: methodology, analysis and results
CL Harris, S Holloway
Improving wound score classification with limited remission spectra
J Schmidt, A Hapfelmeier, W-D Schmidt, U Wollina
Leczenie Ran Issue 1, vol. 9, 2012
Biofilm Based Wound Care: strategy for the treatment of chronic
wounds affected by the infection caused by microorganisms in the
form of biofilms
Marzenna Bartoszewicz, Adam Junka
Role of heat shock proteins in burns and systemic inflammatory
response
Beata Sosada, Marek Kawecki, Mariusz Nowak
High Voltage Stimulation for the treatment of hard-to-heal wounds
and oedemas
Krzysztof Materniak, Anna Nowak-Wró¿yna, Marek Kawecki,
Mariusz Nowak
Brachysyndactyly–hypospadiasis and other untypical correlation of
the congenital hand deformities
Anna Chrapusta, Jacek Puchaa
Patient with diabetic foot syndrome in the surgical ward
Katarzyna Cierzniakowska, Maria T. Szewczyk, Arkadiusz Jawieñ,
Karolina Szymañska, Paulina Moœcicka
English
English
German
Scandinavian
EWMA
Phlebologie, no 2, 2012
www.schattauer.de
The foam sclerotherapy: Observational study using air and
CO2-O2-sclerosing
Hesse
Histological changes after the circular varicose vein treatment
endoluminal thermal ablation (closure fast)
Brachmann
Prevalence of local complications and risk factors of Beinvarikose
in German general practices
Mueller-Buehl
Through the eyes of Laplace: The Role of wall tension in
varicose veins
Korff
Controlled studies comparing endovenous Therapppie of
varicose veins. If the stripping surgery still competitive?
Mumme
Schiller’s illness and his funeral, Part 2 (medical history)
Hach
Acute bilateral thrombosis of deep leg and pelvic veins
Diedrich
Wound Repair and Regeneration, vol. 20, no 2, 2012
www.wiley.com
Enhancing Braden pressure ulcer risk assessment in acutely ill
adult veterans
Linda J. Cowan, et.al.
The relationship between skin stretching/contraction and
pathologic scarring: The important role of mechanical forces
in keloid generation
Rei Ogawa, et.al.
Role of cytokines in lavage or drainage fluid after hemithyroidectomy
in wound healing: Involvement of histamine in the
acceleration and delay of wound healing
Miku Arai, et.al.
Impaired cutaneous wound healing in transforming growth
factor-b inducible early gene1 knockout mice
Keijiro Hori, et.al.
Selective release of cytokines, chemokines, and growth
factors by minced skin in vitro supports the effectiveness
of autologous minced micrografts technique for chronic ulcer
repair
Ginevra Pertusi, et.al.
Pyrvinium, a potent small molecule Wnt inhibitor, increases
engraftment and inhibits lineage commitment of mesenchymal
stem cells (MSCs)
Sarika Saraswati, et.al.
Wund Management, vol. 6, no 2, 2012
English abstracts are available from www.mhp-verlag.de
How to equip an obesity centre
P. Pick
Antimicrobial therapy of intra-abdominal infections due to
resistant bacteria in patients with morbide obesity
C. Eckmann, P. Kujath, H. Shekarriz
Chronic wounds and nutrition
U. Bonacker
The role of a point-of-care protease test in wound diagnostics
R. Strohal, J. Dissemond, G. Hastermann, K. Herberger,
S. Läuchli, G. Luch, D. Mayer, T. Neubert, M. Storck
Wounds (SÅR) vol. 20, no 1, 2012
www.saar.dk
Growth Factors for the Treatment of Chronic Wounds
Rasmus Lundquist
Interesting Alternative for Debridement of Wounds
Helen Skovgaard-Holm, Helle Simonsen
The History of Wound Infection
Svend Norn, Henrik Permin, Poul R. Kruse, Edith Kruse
Haderslev Makes the Processes More Efficient which have had
Positive Benefits in both Economy and quality
Jens Fonnesbech
Prevention of Pressure Ulcer in the Municipality of Køge
– A success!
Birgit Andersen
”Tele Wounds” for Copenhagen – A pilot project
Jens Fonnesbech
EWMA Journal 2012 vol 12 no 2 57

EWMA
EWMA
Teacher network
The EWMA Education Committee is currently working
to establish a network for wound management
teachers in Europe. This initiative arose from Pan­
European surveys and focus group interviews of education
providers and teachers of wound management. These activities
unearthed a desire by teachers for greater support in their
teaching of wound management.
The primary objectives of the network will be:
n To increase collaboration on objectives, structure and
content of future wound management education and
training in Europe;
n To explore the possibilities for establishing a sustainable
life­long learning training programme for nurse
teachers.
The EWMA 2012 conference which takes place in Vienna
23­25 May will host the initial meeting of the Teacher Network.
This meeting will take place on Wednesday 23 May
2012, 11:45-13:45.
Meeting Agenda
1) Welcome and introduction of participants
2) Approval of agenda
3) Rationale and background for establishing the network
4) Reflection and input for the network concept
• When reading the email invitation, what did you
have in your mind that a network might be?
• EWMA’s vision of what the network might be
5) Establish agreement on key objectives for the network
6) Establish short and long­term action plan to meet the
objectives
7) Agree on the establishment of communication forum
8) Next meeting
EWMA hopes that the meeting will attract teachers from
many different countries and institutions, as active participation
by all relevant institutions is crucial in ensuring that all
views and needs are addressed.
Teachers interested in joining the meeting or network during
the EWMA 2012 Conference are kindly asked to sign
up by email to the EWMA Secretariat, ewma@ewma.org
or come to the EWMA secretariat office during the Vienna
conference in May.
Zena Moore
58
ienna
EWMA 2012
23-25 May
Austrian
Diabetic Foot Symposium
Through the EWMA 2012 conference in Vienna,
EWMA, in collaboration with the Austrian
Wound Association (AWA), The International
Working Group on the diabetic Foot (IWGDF),
The Diabetic Foot Study Group (DFSG) of The
European Association for the study of Diabetes,
has arranged a symposium focusing on the implementation
of multidisciplinary diabetic foot
treatment.
During the presentations the symposium will set
out some of the basic principles of the IWGDF
consensus guidelines, following which the program
will proceed with a session aiming to present
examples of implementation of the multidisciplinary
treatment model from various different regions
across Europe. To wrap up the day an overview
of the current treatment results in Europe
will be given. This presentation will be followed
by a panel discussion aiming to give recommendations
for future strategies towards optimizing
diabetic foot treatment in Austria.
The symposium is an integrated part of a larger
project with the overall objective to support and
contribute actively to the implementation of the
IWGDF’s “Global consensus guidelines on the
management and prevention of the Diabetic
Foot” in Austria in order to allow diabetic foot patients
access to best practice standards of diabetic
foot care at specialised multidisciplinary diabetic
foot care clinics.
The Symposium takes place
Thursday 24 May 2012, 08:00-15:30.
The symposium is in English with simultaneous
translation into German.
EWMA Journal 2012 vol 12 no 2

International
Consensus on the
management and
prevention of the
diabetic foot 2011
Content:
n Definitions & Criteria
n Epidemiology of the diabetic foot
n Psycho-social and economic factors
n Pathophysiology of foot ulceration
n Diabetic neuropathy
n The diabetic foot ulcer management
and outcomes
n Interventions to enhance the healing
of chronic ulcers of the foot in
diabetes
n Infection in the diabetic foot
n Peripheral arterial disease and
diabetes
n Footwear and offloading
n Neuro-osteoarthropathy
n Amputations in people with diabetes
n How to prevent foot problems
n How to organize a diabetic foot clinic
n Implementation of guidelines
n P.E.D.I.S. a diabetic foot ulcer
classification system
And:
n Practical guidelines on the
management and prevention of
the diabetic foot 2011
n Specific guidelines on wound and
wound bed management 2011
n Specific guidelines for the treatment
of diabetic foot infections 2011
n Specific guidelines for the diagnosis
and treatment of pad in a diabetic
patient with a foot ulcer 2011
n Specific guidelines on footwear
and offloading 2007
Plus many pictures and three video’s.
Now available at: http://shop.idf.org
Price Euro 20.00 (+ shipping)

EWMA
·PATIENT OUTCOME GROUP·
EUROPEAN · WOUND · MANAGEMENT· ASSOCI
ATION
Pratricia Price
Chair of the
EWMA Patient
Outcome Group
1 Gottrup F, Apelqvist J, Price P:
Outcomes in controlled and comparative
studies on
non-healing wounds:
Recommendations to improve
the quality of evidence in
wound management,
Journal of Wound Care,
Vol 19, Iss 6,
6 June 2010, pp 237-268
The Patient Outcome Group
Following the publication of the EWMA
document on evidence and outcomes
within wound management 1 , the EWMA
Patient Outcome Group (POG) received a great
deal of interest and support from both European
and international stakeholders. The level of interest
supports the need for further activities to
develop and disseminate the key messages introduced
in this document.
In order to assist in the development of high
quality evidence across a range of research types
used in wound management, the POG is currently
working on a set of clinical study recommendations
covering the main types of non healing
wounds. Each document will include a short
checklist to assist in the development of relevant
research questions and identify frequent mistakes
made by novice researchers at each stage of the
research process including planning, conducting
and reporting RCTs and cohort studies. To
ensure consistency with existing standards and
regulations, a wide range of links will be included
to ensure that researchers can navigate their way
through the substantial amount of information
available on relevant topics.
The new documents are expected to be ready
for publication in 2012­2013.
Concurrent with these activities, the EWMA
POG is in the process of refining the objectives
for the group and prioritising future goals. The
focus will still be on addressing the various common
challenges that clinicians and industry face
by providing a forum for discussion, exchanging
knowledge and generating ideas for the benefits
of EWMA’s work and objectives.
Current members of the EWMA Patient Outcome Group are:
Clinicians:
Patricia Price, Chair
Martin Abel
Jan Apelqvist
Matthias Augustin
Industry representatives:
Brigitte Espirac
Finn Gottrup
Luc Gryson
Deborah Klestadt
Harald Kuhlmann
Hans Lundgren
Robert Strohal

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Active healing that’s out of sight.

EWMA
Jan Apelqvist
EWMA President
62
We want
to make a difference!
– EWMA future projects
EWMA has a number of projects in which we
are obliged to participate or on which we have
an opinion.
For a long time the challenge has been to raise
awareness of wounds in the political arena. However,
the wider focus on the increasing elderly
population and the demographic challenges across
Europe have increased the focus on the burden
of wounds; not only to patients but to the whole
health care system.
EWMA is participating actively in these discussions.
Most recently, we were invited to speak in
the European Parliament as one MEP is particularly
concerned about the burden of wounds and
the need for increased political focus. (Read about
this on page 64).
Some of the focus areas of EWMA for the next
year will be:
n EWMA is becoming more involved in the
EU’s institutions and through this involvement
being heard and actively participating
in working groups
n EWMA will participate in EU applications
as part of larger consortiums
n EWMA has decided to set down a Patient
Panel/Focus Group. As a multidisciplinary
organisation, EWMA believes that the patient
is a valuable resource in the multidisciplinary
team. We need to increase the focus
and thereby better understand the potential
of this. EWMA will increase the focus on
multidisciplinary teams with a project focussing
on how to organise the treatment;
how to work together across disciplines,
specialities and health care sectors. Read
EWMA’s point of view on multidisciplinary
teams on page 66.
n Telemedicine or E­Health is becoming more
and more important as a way of securing the
multidisciplinary approach to care as well as
the patients’ self­management. EWMA will
address this issue this year as well as next
year and there will be a session on this in
Copenhagen next year. The focus will be on
sharing information within multidisciplinary
teams, collecting scientific data and furthering
the education of health care personnel,
patients and relatives. EWMA will develop
the existing focus on home care and how to
improve the quality of life for patients with a
wound by securing that the right treatment
is given to the patient at all times.
n One of EWMA’s key objectives is to assist/
facilitate the creation of new national wound
management associations. Russia and its
neighbouring countries have for a long time
been at the heart of EWMA’s work to meet
this objective. Prof. Rytis Rimdeika, member
of EWMA Council, has been appointed
by the EWMA Council to head this process
and much progress has already been made –
for example, there will be special focus on
this area during the conference this year in
Vienna, Austria, where a large number of
activities in Russian are planned. EWMA
wishes to continue these efforts and will
follow up on the activities in numerous ways
including, amongst others, a Russian spoken
sym posium at EWMA 2013, Copenhagen,
Denmark.
EWMA Journal 2012 vol 12 no 2

100 years on
The
future
of podiatry
11-13 October 2012
Glasgow, SECC
100 th Anniversary
Conference & Exhibition
2012 is the 100th anniversary of organised podiatry
in the UK. This year’s conference will be a special
celebratory event, bringing members together in
Glasgow to celebrate this unique and exciting occasion.
The conference committee is producing an exceptional programme of events that will
offer delegates a one-off experience and a conference not to be missed!
We are extremely excited to announce that the hugely popular
physicist and BBC television presenter, Professor Brian Cox OBE,
will be attending the conference as a special guest, with a keynote
presentation on Thursday morning.
Don’t miss the opportunity to present at this year’s conference by submitting an
abstract of your scientific research, practical innovations and areas of general practice
for poster or oral presentation.
The top scoring papers will be presented in the relevant concurrent sessions on their
topic and will also be published in the Journal of Foot & Ankle Research (JFAR).
Cash prizes will be awarded for the best papers.
Oral submissions deadline 29 April 2012
Poster submissions deadline 31 August 2012
To submit an abstract or for further information visit
www.scpconference.com
or call 020 88327311

EWMA Document on
Antimicrobials
The document form will be developed from a
Health Technology Assessment, where elements of
health economics and patient perspectives will be
represented as well as a comprehensive technological
review.
The document will include political, organisational
and economic points of view in addition to the
clinical discussion regarding when to use which
categorised product. Furthermore, as EWMA is a
multidisciplinary organisation, we will take all specialities
into consideration. This is also reflected in the
composition of the author group. The document will
result in recommendations. We expect that one of
the main focus areas of the document will be antimicrobial
resistance.
Members of the working group are:
n Finn Gottrup, Surgery,
Bispebjerg Hospital, Denmark
n Jan Apelqvist, Endocrinologist (health economy),
University Hospital of Malmö, Sweden
n Zena Moore, Nursing,
Royal College of Surgeons in Ireland, Ireland
n Sebastian Probst, Nursing, Zurich University of
Applied Sciences, Switzerland
n Rose Cooper, Microbiology,
Cardiff Metropolian University (UWIC), Wales
n Thomas Bjarnsholt, Microbiology/biofilm,
Copenhagen University, Denmark
n Edgar Peters, Infection, University Medical
Center, Amstersdam, The Netherlands
Finn Gottrup
Supporting Companies
64
AWCS group
EU ‘WEEK FOR LIFE’
Prof. Jan Apelqvist, Mr. Alojz Peterlé, Dr. Bernard Thill
and Mr. Vittorio Prodi
On 26 March 2012 EWMA was invited by Member
of the EU Parliament, Mr Vittorio Prodi, to
present in a seminar during the ‘week for life’
event under the theme: Europe against Cancer –
the spirit of care. The invitation was based on the
strong profile of EWMA within multidisciplinarity
and organisation of treatment.
EWMA President, Jan Apelqvist, described the
importance of a multidisciplinary approach to
wound management and applied this approach to
any kind of treatment. The EWMA presentation
also related wound management to the organisation
of palliative care for cancer patients, stressing
that the multidisciplinary approach is essential
with regards to the quality of life of the patient
as well as efficiency within the health care system.
The primary message of EWMA was the importance
of removing barriers for collaboration
between different specialists and groups of staff.
Failure to remove these barriers is likely to cause
an expensive treatment of poor quality.
MEP Prodi expressed his gratitude for the presence
of EWMA at the meeting and confirmed his
great interest in wound management.
EWMA Journal 2012 vol 12 no 2

EWMA’s communication strategy was discussed at the
latest EWMA Council meeting in March. The Council
decided that it would be possible to make some small
changes to the overall communication which EWMA has
with its members. These include: EWMA Journal as a
member magazine, EWMA Newsletter, the EWMA website
and the communicative activities at the EWMA conference.
Technology and the number of communication tools
available is ever increasing and improving. This offers
EWMA many new opportunities to communicate more
efficiently with the EWMA stakeholders.
EWMA Journal is primarily designed to be a membership
journal, with a specific focus on promoting activities
and sharing wound relevant news, scientific knowledge
and clinical experience between the target groups:
EWMA members, EWMA Cooperating Organisations,
other partner organisations, sponsoring companies and
health administrators/decision-makers. At the same time
this meets another EWMA objective of facilitating the
spread of knowledge on wound care and educating new
generations of wound care professionals.
EWMA Council has decided to reduce the number of
issues of the EWMA Journal to two per year, published in
May and October. This decision will support the unique
profile of the EWMA Journal with the objective of supplementing
existing wound journals rather than competing
with them. Finally, a reduction in the number of issues of
the EWMA Journal from 2013 give capacity for activities
covering other communication tools.
The EWMA Journal will continue to reflect EWMA’s
knowledge and expertise with respect to wound management
activities across Europe. Sue Bale
ienna
EWMA 2012
23-25 May
EWMA Document on
Debridement
The EWMA document on Debridement will provide an
updated overview of the various debridement options.
It will offer a clarification of the principal role of debridement
and define the possibilities and limitations for
standard and new debridement options.
The document is expected ready for publication by the
end of summer 2012 and will be written by an author
group consisting of: Robert Strohal, Editor,
Jan Apelqvist, Co-editor, Joachim Dissemond,
Julie Jordan O’Brien, Alberto Piaggesi, Rytis Rimdeika
and Trudie Young.
A key session on Debridement at the EWMA 2012
Conference in Vienna will present the main topics of
the document:
Key session: Debridement
Wednesday 23 May 16.45-18.00
• R. Strohal: The position of debridement in
wound healing: An introduction
• T. Young: Bedside options for debridement
• R. Rimdeika: Surgical debridement and technical
solutions
• J. Apelqvist: Challenges and health-economy
• R. Strohal: The process of debridement and a
clinical algorithm
Robert Strohal
The EWMA Debridement Document is supported by:
EWMA 2012: Russian spoken Symposium in Vienna
Following the success of the Russian symposium during
EWMA 2009 in Helsinki, a full day symposium in Russian will
take place on Wednesday 23rd May, 10:00-19:00.
The symposium includes 25 presentations from Russia, Ukraine and Belarus,
including a round table discussion with representatives from the national
wound management organisations. Among the topics are:
Pediatric Wounds, Burns, Evidence-based approach and Chronic Wounds.
The symposium is organized by EWMA and AWA. It is held in Russian with
simultaneous translation into English.
A number of sessions on Thursday 24 May will also be translated
from English into Russian.
EWMA Journal 2012 vol 12 no 2 65
EWMA

EWMA focus on multidisciplinarity
in wound management
EWMA is a multidisciplinary association working to
secure the best possible treatment of the patient, provided
in a cost efficient manner to the benefit of society.
For these reasons, it is important for EWMA to
stress the significance of securing a multidisciplinary
approach to wound management throughout Europe.
The key messages of EWMA are:
n The multidisciplinary approach to wound management
improves healing rates, prevents adverse events
and increases patients’ quality of life1,2,3,4,5 n Outcome studies support that the multidisciplinary
approach reduces the overall cost to society4,5,6 n Multidisciplinary wound centers secure a high level
of expertise within the group of staff, resulting in a
fast and correct diagnosis and treatment of the patient1,3
n Existing barriers for collaboration between different
specialists and groups of staff must be defined and
removed.
MULTIDISCIPLINARITy – A DEFINITION
Multidisciplinary collaboration is established with the
objective of producing outcomes that cannot be achieved
without collaboration. A multidisciplinary approach brings
together experts from the various relevant disciplines to
collectively address a complex problem 7,8 .
Within wound management in general the relevance of
multidisciplinarity lies in the need to integrate knowledge
of different aspects of treatment such as wound healing,
tissue repair, wound care, long term scarring and specialist
knowledge about the various etiologies.
The multidisciplinary approach to wound management
is often expressed in the establishment of wound
healing expert groups in hospitals or wound healing centers
3 .
References:
1. Apelqvist, J, Larsson, J: What is the most effective way
to reduce incidence of amputation in the diabetic
foot?, Diabetes/metabolism research and reviews,
Diabetes Metab Res Rev 2000; 16 (Suppl 1);
pp. 75-S83.
2. McCabe, C.J., R.C. Stevenson, A.M. Dolan: Evaluation
of a diabetic foot screening and protection
programme, Diabetic Medicine, January 1998, vol. 15;
Issue 1; pp. 80–84.
3. Gottrup, F, Holstein, P, Jørgensen, B, Lohmann, M,
Karlsmark, T.: A New Concept of a Multidisciplinary
Wound Healing Center and a National Expert Function
of Wound Healing, Arch. Surgery. July 2001; vol.136;
pp. 765-772
66
EWMA
4. Kadriye A, Mehlika I, Karakaya J, Gürlek A: Change in
amputation predictors in diabetic foot disease: effect of
multidisciplinary approach, Endocr (2010) 38: 87-92
5. Driver Vickie R, Fabbi M, Lavery L A, Gibbons G: The
cost of diabetic foot: The economic case for the limb
salvage team, Journal of vascular surgery, September
Supplement 2010
6. Matricali G A, Dereymaeker G, Muls E, Flour M,
Mathieu C: Economic aspects of diabetic foot care in a
multidisciplinary setting: A review, Diabetes/metabolism
research and reviews, review article Diabetes
Metab Res Rev 2007; vol 23; pp. 339-347.
The Diabetic Foot Example
Diabetic foot ulcers represent a large percentage of the
chronic wounds. Due to the total situation of the diabetes
patient, these ulcers are characterised by a complexity that
necessitates a multifactorial approach in which aggressive
management of infection and ischemia is of major importance.
For the same reason, a process­oriented approach
in the evaluation of prevention and management of the
diabetic foot is essential.
Thus, correct diagnosis and treatment requires a multidisciplinary
team including diabetologists, orthopedic
surgeons, vascular surgeons, diabetes nurses, wound care
nurses, podiatrists and orthotists. A close co­operation
with primary health care is also important 1 .
The negative consequences of diabetic foot ulcers on
quality of life include not only morbidity but also disability
and premature mortality. Costs for healing ulcers are high.
For ulcers resulting in amputation they are even higher,
due to prolonged hospitalisation, rehabilitation, and need
for home care and social service.
One of the most important steps to reduce cost in the
management of the diabetic foot is to avoid amputations.
A cost­effective management should not only be focused
on the short­term cost until healing but also on the longterm
cost related to increased re­ulceration rate and lifelong
disability caused by foot ulcers and amputations. A
multidisciplinary approach including a preventive strategy,
patient and staff education, and multifactorial treatment of
foot ulcers has been reported to reduce the amputation rate
significantly and in some cases by more than 50% 1,4,5,9 .
Currently various barriers for collaboration between different
specialists and groups of staff exist. Failure to remove
these barriers is likely to result in an expensive treatment
of poor quality.
Jan Apelqvist
7. Gottrup F, Nix DP, Bryant RA.: The Multidisciplinary
Team Approach to Wound Management
In: Acute and chronic wounds. Current management
concepts. (Third edition). Eds. Ruth A. Bryant, Denise
P. Nix. Mosby (Elsevier), St. Louise, 2007; pp. 23-38.
8. Davey L, Solomon JM, Freeborn SF: A multidisciplinary
approach to wound care, Journal of Wound Care.
1994; vol. 3; pp. 249-252.
9. Ragnarson-Tenvall G, Apelqvist J. Prevention of
diabetes-related foot ulcers and amputations: a
cost-utility analysis based on Markov model simulations.
Diabetologia. 2001; vol. 44; pp. 2077-2087
EWMA Journal 2012 vol 12 no 2

23 rd Conference of the
European Wound Management Association
EWMA 2013
15-17 May · 2013 · Copenhagen · Denmark
New abstract deadline: 1 January 2013
ORGANISATION AND
COOPERATION IN COPENHAGEN
Organised by the European Wound Management Association
in cooperation with the Danish Wound Healing Society · www.saar.dk
WWW.EWMA.ORG / EWMA2013

EWMA
EWMA participation in EU Conference on
Antimicrobials Resistance – it’s time to take joint action!
On 14 March 2012 Rytis Rimdeika, Member of the
EWMA Council, represented EWMA at a high level
EU presidency Conference: Combating Antimicrobials
Resistance – Time for Joint Action. EWMA was selected
amongst leading expert groups across Europe to take part
in the conference. The conference was held in the Bella
Centre in Copenhagen, Denmark, which coincidentally
is also the venue of the next EWMA conference in 2013.
The conference was jointly hosted by the Ministry of
Health and the Ministry of Food, Agriculture and Fisheries
of Denmark and by the EU­Commission. Participation
in the conference is linked to the EWMA Document on
Antimicrobials which is expected to be ready for publication
by the end of 2012.
EWMA considers the conference invitation a significant
accomplishment as regards reaching out to national
authorities as well as to the European Union. This is part
of EWMA’s long term strategy – to place wound management
high on the political agenda both nationally and in
the EU Institutions.
The conference was opened by Her Royal Highness Crown
Princess Mary of Denmark. Key speakers at the first session
were Dr. Margaret Chan, Director­General of the World
Health Organisation (WHO) and Dr. Marc Sprenger, Director
of the European Centre for Disease Preventions and
Control (ECDC). All the speakers spoke of the dangers
of excessive use of antimicrobials in medicines for both
humans and animals. The microbial resistance to antibiotics
is emerging in all the countries of the EU and beyond.
Research has indicated a link between the consumption
of antibiotics in animals and resistance development in
humans. Overuse of antibiotics in medicine, both in primary
health sector and hospitals is exacerbating the problem.
This calls for collaboration between the human and
veterinary sectors across the EU and non­governmental
organisations to combat the growing problem of antibiotic
overuse. The sharing of innovative ideas and the exchange
of best practices are needed.
The two day conference consisted of theoretical lectures
and practical workshops. Presentations were given by many
well­known specialists in veterinary and human medicine
and public health and by politicians. Best practices and
initiatives to reduce antimicrobial resistance in Denmark,
the UK and France were presented to the audience. The
Workshops were focused on three topics: Stop the overuse
of antibiotics both in humans and animals; reduce the
68
use of Critically Important Antimicrobials (CIA), and the
surveillance and collection of compatible data. Participants
of the conference stressed the need for surveillance and
reduction of irrational use of CIAs – Fluoroquinolones,
Cephaslosporins (these two groups widely used in both
human and veterinary medicine), Cholestin (used only
in veterinary) and Carbapenems (authorised for human
use). Antimicrobial resistance against the CIAs is particularly
worrying, as they are “the last resort” treatment for
a number of very serious diseases. A strictly prudent use
of CIAs should therefore be implemented internationally
as resistant microbes can spread worldwide through the
global movement of persons and food products of animal
origin.
Participants of the conference outlined these final statements
and conclusions:
1. Antibiotics in animal health should only be used in
context of biosecurity, good nutrition, good housing
and vaccinations being in place.
2. Good examples of best practice are extremely important
for promoting the prudent use of antibiotics.
3. Guidelines should be established for the prudent use
of antimicrobials in the primary health sector and
the hospital sector. Better control of use of antibiotics
in long care institutions is also important.
4. It is very important to raise awareness among the
publics regarding the overuse and improper use of
antibiotics and the risks for the individual arising
from that over / improper use.
5. Clear legal framework both in the EU and at national
levels is needed to fight the problem.
6. Collection, analysis and real time reporting of data
is essential for the understanding of the problem and
the planning of means to combat the problem.
The dangers of excessive use of antimicrobials have been
known for decades. Raising awareness and taking action
against microbial resistance is not new to the European
Union, but taking further action within the Union and beyond
is now necessary in order to effectively meet the challenges
of that growing resistance. And non­governmental
international organisations such as those in the wound
management field like EWMA and its cooperating partners
will play an important role in helping to implement
the very important tasks required for a positive outcome.
In other words – it’s time to take joint action!
Rytis Rimdeika
EWMA Journal 2012 vol 12 no 2

Submit your next paper to Phlebologie
iris.weiche@schattauer.de

The Eucomed Advance Wound Care Sector
Group is currently involved in
many activities and initiatives at the
European Union level. A number of these are
where AWCS and EWMA are currently working
together. These are listed below.
To begin with I will elaborate on the EU 2020
goals and strategy which are highly relevant to
the work we are currently conducting. The Eucomed
/ AWCS group is involved in the
projects italicized.
EU 2020 GOAL & STRATEGy
Woundcare reflections
on the EU 2020 strategy
– Eucomed Advanced Wound Care Sector Group (AWCS) perspectives
Hans Lundgren
Chair of the Eucomed
Advanced Wound Care
Sector Group
Correspondence:
Hans.Lundgren@
molnlycke.com
70
The five targets for the EU in 2020
(and how to measure progress)
Policies and Commission initiatives are driven by
these overall goals:
1. Employment
• 75% of the 20­64 year­olds to be employed
2. R&D / Innovation
• 3% of the EU’s GDP (public and private
combined) to be invested in R&D / innovation
3. Climate change / Energy
• greenhouse gas emissions 20% lower than
1990
• 20% of energy from renewables
• 20% increase in energy efficiency
4. Education
• reducing school drop­out rates below
10%
• at least 40% of 30­34 year­olds completing
third level education
5. Poverty / Social exclusion
• at least 20 million fewer people in or at
risk of poverty and social exclusion
The seven flagship initiatives
(new engines to boost growth and jobs)
Smart growth:
1. Digital agenda for Europe
2. Innovation Union
3. Youth on the move
Sustainable growth:
4. Resource efficient Europe
5. An industrial policy for the globalisation era
Inclusive growth:
6. An agenda for new skills and jobs
7. European platform against poverty
DIGITAL AGENDA FOR EUROPE
This is a strategy to ensure a flourishing digital
economy by 2020. It outlines policies and actions
to maximize the benefit of the Digital Revolution
for all. One of the planned actions of the Digital
Agenda is Information and Communication
Technology (ICT) for Social Challenges. This is
where the Commission aims to increase access
to online medical data2 and assisted living programmes3
and the uptake of eHealth solutions1
through EU wide standards,.
AWCS and EWMA are involved in e­health solutions
and access to online medical data as well as
assisted living programmes.
INNOVATION UNION
This aims to increase the innovation potential of
Europe by removing obstacles to innovation and
revolutionizing the way the public and private sectors
work together4. The first pilot partnership is
the European Partnership on Active and Healthy
Ageing (AHAIP)5 which aims to bring together
stakeholders from the supply and demand sides4
to identify and overcome barriers to innovation in
the health sector with the intended goal of adding
two quality years to the lives of European citizens
by 2020.
EWMA Journal 2012 vol 12 no 2

AWCS and EWMA are involved in the organisation of
care and the referral of patients between different sectors.
As part of the Active and Healthy Ageing Partnership
AWCS and EWMA are following the proceedings closely
and are very involved.
PATIENT SAFETy CAMPAIGN
The Council Recommendations on patient safety including
the prevention and control of HCAIs (Health Care
Acquired Infections) were adopted in 2009 and provide
non­binding recommendations for Member States regarding
patient safety. As part of the recommendations, the
European Commission is mandated to review the progress
made by member states since 2009. The implementation
of the recommendations is being evaluated through a questionnaire6
sent out to member states in April 2011, which
includes a general safety section and a portion dedicated
specifically to HCAIs. A report on the responses must be
published by 2012.
Additionally, a Joint Action on Patient Safety and Quality
of Care is being organized to assist the Commission
with implementation of certain aspects of the Council
Recommendations, particularly concerning coordination
and exchange of best practices within the member states.
For example, AWCS / EWMA will aim to ensure the adoption
of patient safety recommendations for the prevention
of wounds/infections and to make sure that exchange of
best practice with regards to wound care is considered
within the Joint Action. This can be seen as a follow up
on the activities conducted in 2011, where EWMA and
AWCS submitted questions for the member states’ questionnaire
on patient safety.
ACTIVITIES/INITIATIVES WHERE
AWCS/EWMA ARE CURRENTLy INVOLVED
1. Wound treatment in patient’s own home by
collaboration between hospital and home care:
A Health Technology Assessment
In December 2011, the Danish National Board of
Health published an HTA with the above title.
The HTA concluded, amongst other things, that
patients with pressure ulcers which are treated by
a wound care nurse from the hospital wound care
centre, are healed equally well in their own home as
at the hospital.
2. Transcontinental Wound Registry (TWR)
The AWT (Academy of Wound Technology), together
with supporting partners from the industry,
EWMA
has started a pilot project of a worldwide registry
on wound healing and tissue repair. Nine facilities,
with expertise in wound management and located in
Europe, the USA and Asia, are participating in a 52
week pilot phase. The TWR pilot phase results will
be presented at the WUWHS meeting on Yokohama
in September 2012.
3. Innovation in the sector of demographic ageing
A first step has been taken through the contact with
AAL (Ambient Assisted Living) which has a seat at
the European Innovation Partnership: Pilot on Active
& Healthy Ageing. For advanced wound care,
potential topics are telemedicine, monitoring devices
and patient specific data.
4. Collaboration between the industry and academia
Since June 2007, Eucomed AWCS has held twenty
meetings in partnership with EWMA, which reflects
the spirit of the Innovation Partnership.
5. European Innovation Partnership on Active and
Healthy Ageing (AHAIP)
Adoption of the Strategic Implementation Plan
(SIP) and call for stakeholders to populate the five
task forces. A letter has been sent from Mr Prodi
inviting EWMA to become a member of the Task
Force responsible for implementing actions in the
area of developing, disseminating and promoting
successful innovative integrated care models for
chronic diseases amongst older patients.
6. Questionnaire about Patient Safety sent out by
the European Commission
AWCS/EWMA have the opportunity to support
the European Commission with questions related
to wound care. The engagement raises awareness in
the Commission of AWCS/EWMA’s interest in this
dossier and provides an avenue for future discussions
with the Commission – particularly the use of
adequate wound care treatments to increase patient
safety through prevention and control of infections.
7. Joint Action on Patient Safety and Quality of Care
The Joint Action is being organized by HAS (Haute
Autorité de Santé) in France and there are more than
40 Associated Partners (EPF, European Patient’s
Forum is one) participating, in addition to the 17
Collaborating Partners. In order to take a seat in
this Joint Action, AWCS/EWMA need to highlight
any substantial public health issue. We think the
ongoing debate on antibiotic­resistance is a potential
opening to raise awareness on issues of patient safety
related to wound care, specifically in terms of surgical
wounds, pressure ulcers and diabetic foot ulcers.
Therefore EWMA has taken the initiative to write a
EWMA Antimicrobial Document. m
EWMA Journal 2012 vol 12 no 2 71

Corporate A
ConvaTec Europe
www.convatec.com
Covidien (UK) Commercial Ltd.
Paul Hartmann AG
www.hartmann.info
Corporate B
3M Health Care
www.mmm.com
Abbott Nutrition
www.abbottnutrition.com
Absorbest
www.absorbest.se
Advanced BioHealing, Inc.
www.AdvancedBioHealing.com
AOTI Ltd.
www.aotinc.net
72
Corporate Sponsors
KCI Europe Holding B.V.
www.kci-medical.com
Lohmann & Rauscher
www.lohmann-rauscher.com
Mölnlycke Health Care Ab
www.molnlycke.com
Ferris Mfg. Corp.
www.PolyMem.eu
ArjoHuntleigh
www.ArjoHuntleigh.com
B. Braun Medical
www.bbraun.com
BSN medical GmbH
www.bsnmedical.com
www.cutimed.com
Chemviron
www.chemvironcarbon.com
Curea Medical GmbH
www.curea-medical.de
www.drawtex.com
Flen pharma NV
www.flenpharma.com
Nutricia Advanced
Medical Nutrition
www.nutricia.com
Organogenesis
Switzerland GmbH
www.organogenesis.com
Wound Management
Smith & Nephew Medical Ltd
www.smith-nephew.com/wound
Sorbion AG
www.sorbion.com
Systagenix Wound Management
www.systagenix.com
Phytoceuticals
www.1wound.info
Argentum Medical LLC
www.silverlon.com
Söring
www.soering.com
Laboratoires Urgo
www.urgo.com
Welcare Industries SPA
www.welcaremedical.com
EWMA Journal 2012 vol 12 no 2

Conference Calendar
Conferences Theme 2012 Days City Country
Chronic Wounds Initiative (ICW) Annual Congress May 9-10 Bremen Germany
Congress of the Swiss Association for Wound Care (French section) May 10 Morges Switzerland
22nd Conference of the
European Wound Management Association
13th European Federation of National Associations of Orthopaedics
and Traumatology (EFORT) Congress
German Society of Wound Healing and Wound Treatment (DGfW)
Annual Meeting
Wound healing – different
perspectives, one goal
May 23-25 Vienna Austria
May 23-25 Berlin Germany
Jun 14-16 Kassel Germany
The 2nd Euro-Asian Forum of Association for Wound management Jun 24-29 Sarajevo Bosnia and
Herzegovina
International Lymphoedema Framework 2012 Conference (ILF) Jun 28-30 Montpellier France
4th Congress of the World Union of Wound Healing Societies Better care – Better Life Sep 2-6 Yokohama Japan
The Annual Spring Symposium on Advanced Wound Care (SAWC/WHS) Sep 12-14 Baltimore USA
15th Annual European Pressure Ulcer Meeting (EPUAP) Sep 18-21 Cardiff United Kingdom
SAfW Symposium Swiss Association for Wound Care (SAfW)
Symposium (German section)
Sep 20 Zürich Switzerland
31st Annual meeting of the European Bone and Joint Infection Society Sep 20-22 Montreux Switzerland
The 12th Annual Leg Club Conference Sep 26-27 Worcester United Kingdom
11th National Congress of Italian Association for the Study of
Cutaneous Ulcers (AIUC)
Sep 26-29 Rimini Italy
10th Scientific Meeting of Diabetic Foot Study Group (DFSG) Sep 28-30 Berlin-Potsdam Germany
National Congress of the Belgian Federation of Wound Care (BEFEWO) Oct Uccle Belgium
4th Scientific Congress of the Polish Wound Management Association (PWMA) Oct 3-6 Bydgoszcz Poland
1st National Multidisciplinary Congress for Wound Professionals Oct 8-9 Ede Netherlands
Pisa International Diabetic Foot Courses Oct 8-11 Pisa Italy
Croatian Wound Association (CWA) Symposium Oct 24-26 Primosten Croatia
Sympoisum APTFeridas 2012 Oct 25-26 Portugal
GNEAUPP Biennial Meeting Pressure Ulcers and
Chronic Wounds
Nov 14-16 Sevilla Spain
The Neuropathic Osteoarthropathic Foot (Charcot Foot Course) Nov 15-17 Rheine Germany
Danish Wound Healing Society (DSFS) Annual Meeting Nov 22-23 Kolding Denmark
International Congress for Wound Management of
the Serbian Wound Healing Society SWHS
The French and Francophone Society of Wounds and Wound
Healing annual conference
Chronic Wounds, Current
Treatment – Outcomes
Nov 23-24 Belgrade Serbia
2013
Jan 20-22 Paris France
23rd Conference of the European Wound Management Association May 15-17 Copenhagen Denmark
For web addresses please visit www.ewma.org
Organisations
EWMA Journal 2012 vol 12 no 2 73

Contact:
Pam Landaiche
pam@DFCon.com
The next DFCon meeting
is set for
March 21-23, 2013,
again at the
Renaissance Hollywood
Hotel in Los Angeles.
For further information,
visit www.DFCon.com.
Diabetes and diabetic foot experts from around the
globe met March 15-17, 2012, at the tenth DFCon
Global Diabetic Foot Conference in Los Angeles to
share ideas on how to prevent lower limb amputations
due to the complications of diabetes.
10th DFCon
Global Diabetic Foot Conference
EWMA President Jan Apelqvist receives Diabetic Foot Award
2012 Edward James Olmos Award for Advocacy in
Amputation Prevention winner Jan Apelqvist, MD, PhD of
Malmö, Sweden (seated9. Also pictured are (previous
honorees and the actor for whom the award was named):
Benjamin A. Lipsky, Peter R. Cavanagh, Gary W. Gibbons,
Edward James Olmos; Karel Bakker, Andrew J.M. Boulton,
Joseph L. Mills Sr., and conference co-chairman George
Andros.
Diabetic foot experts attend global meeting
to share ideas on amputation prevention
EWMA is proud to announce that the EWMA
President, MD, PHD Jan Apelqvist, received the
“2012 Edward James Olmos Award for advocacy in
amputation prevention” at the Diabetic Foot Global
conference in Los Angeles 15-17 March 2012.
Motivating the choice of Jan Apelqvist as this years
winner the conference co-chairs Dr. David G. Armstrong
and George Andros said that: “Dr. Phd Jan
Apelqvist Senior Consultant, Department of Endocrinology,
Skåne University Hospital, Malmö, Sweden
is one of the world’s most distinguished experts
on the diabetic foot, diabetes- related complications
and wound management, a noted researcher, a
skilled clinician, a prolific author and a respected
educator.”
In his speech of thanks Dr. Jan Apelqvist stressed
the role of the whole team from the Diabetic foot
unit at the Endocrinological department in Lund
and Malmö, Sweden. He also expressed his understanding
of the value of the award as being not primarily
the honoring of various experts – but rather
the fact that the diabetic foot care gains attention
through this award.
Specialists from 39 U.S. states and 35 foreign
countries attended DFCon 2012.
Portal Education broadcast educational
sessions of the meeting live worldwide, and video
of the education will be streamed on the DFCon
website at www.DFCon.com.
DFCon conference co-chairmen Drs. David G. Armstrong and George Andros lead a panel discussion on the opening day of DFCon 2012.
74
EWMA Journal 2012 vol 12 no 2

AAWC
Association for
the Advancement
of Wound Care
Terry Treadwell, MD
President, AAWC
www.aawconline.org
EWMA international
Partner Organisation
The Association for
the Advancement of Wound Care
Greetings from your wound care colleagues at the
Association for the Advancement of Wound Care,
the AAWC, in the United States. This is an exciting
time for us in that we are helping celebrate the
25th Anniversary of the Symposium on Advanced
Wound Care, our multidisciplinary wound care conference
which is being held in Atlanta, Georgia,
USA, this month. This conference has had a great
impact in providing multi-specialty wound care education
to practitioners in the United States.
We know that education is indispensable for us to
be able to help people with wounds. In an attempt
to determine the educational needs of the healthcare
providers practicing wound care, an exam asking
basic questions about wound care was developed
and given in selected areas around the United
States in 2011 which one hundred ninety-five practitioners
including nurses, physicians, physical therapists,
and nurse practitioners took. Deficiencies
were most apparent in the areas of wound infection,
compression therapy, and diabetic foot ulcer
management. It was very eye-opening to see the
lack of knowledge of the people who take care of
patients with wounds.
It is obvious that we must strive to correct these
educational deficiencies in our colleagues. In my
last communication to you, I mentioned the
AAWC’s involvement in providing web-based educational
modules for our members. This program
has been well received and is due for expansion this
EWMA 2013
15 -17 May 2013
year; however, it is obvious that many other types of
educational programs must be developed and distributed
to educate those who take care of patients
with wounds.
In addition to education, it is important for us to
take advantage of opportunities to help wound care
providers in countries with few resources. The Global
Volunteers program of the AAWC directed by
Dr. Tom Serena has been instrumental in sending
volunteers to selected locations around the world to
teach local healthcare providers the basics of good
wound care. The program has recently added a site
in Haiti where volunteers can visit, work, and teach
in addition to our sites in India and Cambodia. This
program is available to all of you who wish to volunteer
and work with us.
The AAWC has recently partnered with the Debra
Foundation to provide assistance and support to
patients and families suffering from epidermolysis
bullosa. Involvement with this program will give our
members a chance to share their knowledge to
help patients with this terrible disease and to provide
support to their families.
We strive to accomplish both of these goals—to
provide wound care education to wound care providers
here and around the world and to serve
wound patients and their families who will benefit
from our knowledge and service. Won’t you join us
in this project?
Danish Wound
Healing Society
COPENHAGEN
Denmark
WWW.EWMA2013.ORG
Organisations
EWMA Journal 2012 vol 12 no 2 75

Organisations
AWMA
The Australian
Wound Management
Association
Dr Bill McGuiness
President
www.awma.com.au
www.awma2012.com
EWMA international
Partner Organisation
76
The Australian Wound Management
Association national conference
The Australian Wound Management Association
(AWMA) national conference is held every two
years in different capital cities in each state.
The principal aim of the conference is to establish
an agenda that the Association will prosecute over
the next two years.
The 9th conference was recently held at The Sydney
Convention Centre using the theme “Harbouring
Wound Care – integument, integrity and innovation”
Some 700 delegates from seven different
countries attended. It was the first national conference
held since AWMA assumed a single national
identify and logo. The aim to be recognised as a
national peak body for wound care was established
at the 2010 conference and culminated at the
above conference with the launch of the new logo.
More details can be found at our web site
(www.awma.com.au).
The scientific program for the 2012 conference
(www.awma2012.com) was designed to focus on
four integrated concepts:
n Principles don’t’ change only resources
n Resources are garnished by demonstrating
efficacy via evidence
n Ethical practitioners change patients situation by
adopting best practice and lobbying government
for resources
n Wound care in 2020.
On day one participants were reminded via a
number of plenary and concurrent sessions that
principles such as keeping the wound bed clean,
maintaining a moist interface and controlling
oedema were essential platforms for wound
management. Recent research and innovations
regarding the reduction of biofilms, lymphatic
drainage and proteolytic indicators supported this
theme. Maintaining the principles in resource poor
countries was also visited by presentations from clinicians
working with disadvantaged cohorts both
internationally and within the Australasian context.
Using evidence to garnish resources was a common
theme on the second day of the conference. It built
on the recent release of the Pan Pacific Pressure
Injury Guidelines and the Australian and New
Zealand Venous Leg Ulcer Guidelines in October
2011. Plenary sessions by Dr Zena Moore, Prof
David Leaper and Prof Keith Harding set the scene
to explore a definition of evidence, the use of
evidence in practice and research required in the
future. It also encouraged participants to become
active lobbyists to ensure that government provided
required resources to implement best practice. To
support this theme a preconference workshop was
dedicated to the development of a consensus paper
on conservative sharp debridement in the Australian
context.
The day also introduced the 2012 AWMA wound
awareness campaign; “hop into compression”
aimed at obtaining subsides for compression therapy.
To strengthen the campaign AWMA is joining
forces with the Australian Lymphology Association.
The final day was devoted to future trends in wound
care. Presentations about new research being
undertaken by the Australian Wound Innovation
CRC provided some exciting insights into new technologies
and interventions on the horizon. New
approaches to service delivery models and alternative
models for education were also explored. The
final session was dedicated to some crystal ball
gazing and exploring the impacts on wound care in
2020.
In true Australian tradition the conference was not
all work. Several social activities ensured that participants
had the correct work-life balance. The dinner
cruise also hosted the inaugural “AWMAs got
talent contest” which is set to become a regular
forum for state to state rivalry in the future.
The AWMA 2012 to 2014 agenda is now set.
Increasing awareness that wound management
principals don’t change-only resources, effective
lobbying for resources via the generation of new
evidence and an active campaign to influence
government, in particular for subsidised compression
therapy.
The next conference will be held at the Gold Coast,
Queensland in 2014 so I would encourage all
EWMA members to joins us in the sun and set the
AWMA agenda for 2014 to 2016.
EWMA Journal 2012 vol 12 no 2

See the complete details online including continuing education statements,
learning objectives, session descriptions, faculty credentials, information
for submitting oral and poster abstracts, and registration information.
2-K041

Organisations
DEBRA
International
John Dart
DEBRA House
www.debra.org.uk
www.debra-
international.org
debra@debra.org.uk
or
john.dart@debra.org.uk
DEBRA International
actively seeks collaboration
with health care
professionals and industry
and would welcome
contact with any EWMA
members who are
interested in our work.
EWMA international
Partner Organisation
DEBRA International
DEBRA International is the international association
of epidermolysis bullosa (EB) patient support
groups and, since the characteristic feature of EB is
severe wounds that are frequently very hard to heal,
the synergies with the work of EWMA are obvious.
Consequently, we were delighted to be invited
to become an International Partner Organisation
and to have had the opportunity to present our
clinical work at at the last two annual conferences
and to have this chance to describe our current
activities. The Centre of Expertise in Austria, the EB
House in Salzburg, will be hosting a session on EB
at the Vienna EWMA conference and there will be
a DEBRA International stand in the exhibition area
so we look forward to seeing many of you then.
DEBRA International is currently working in over 40
countries, through national EB patient groups, with
strong representation in Europe, North and South
America and Australasia and with a growing membership
in Asia. The objectives of the organisation
are to do together those things that are best
achieved on a regional or world level and to assist
member groups to do better those things that can
only be done nationally and locally.
Our current priority areas of work are:
n funding and facilitating research to develop
innovative treatments including gene, cell,
protein and small molecule therapies; DEBRA
International is unusual in that it has a single
system of international peer review used by all of
the National DEBRAs that fund research so that
best use can be made of the € 3-5 M invested
each year by member groups. A research
planning conference is held every three years,
involving the leading research teams worldwide,
to identify opportunities and barriers to therapy
development.
n Identifying potential partners in industry and
venture capital, whose involvement will be
needed to successfully translate the promising
work in a number of potential therapies from the
laboratory into the clinic.
n the generation of best clinical practice guidelines
in various areas of importance to people with
EB; a guideline on best practice in dental care
has been completed and guidelines on cancer
management, pain management, nutrition,
physical therapies and wound care are in
preparation.
n the establishment of a clinical training programme
for professionals interested in establishing,
or improving, a specialist EB clinical service
in their own countries, including an online,
modular course coupled with mentoring.
n creating stronger clinical networks of specialist
EB centres to promote sharing of expertise and
facilitate clinical trials
n creating an international database of patients
with EB to understand better the natural history
of different types of EB and the costs of living
with the condition.
Submit your paper to EWMA Journal
78
Published by
EUROPEAN
WOUND MANAGEMENT
ASSOCIATION
www.ewma.org
EWMA Journal 2012 vol 12 no 2

Journal of Tissue Viability
Journal of Tissue Viability is a quarterly journal concerned
with all aspects of the occurrence and treatment of wounds,
ulcers and pressure sores including patient care, pain, nutrition,
wound healing, research, prevention, mobility, social problems
and management.
The Journal particularly encourages papers covering skin and
skin wounds but will consider articles that discuss injury in any
tissue. Articles that stress the multi-professional nature of
tissue viability are especially welcome. We seek to encourage
new authors as well as well-established contributors to the fi
eld - one aim of the journal is to enable all participants in tissue
viability to share information with colleagues.
We are excited to invite you to publish in Journal of Tissue
Viability, an international, peer reviewed journal.
For more information visit: www.journaloftissueviability.com
TYPES OF PAPERS
• Clinical Study
• Basic Research Study
• Case Report
• Review Articles
• Letters to the Editor
ABSTRACTED & INDEXED IN:
• BioInfoBank Library
• Medline
• PubMed
• Science Direct
• Scopus
Call for Papers
Submit your paper online now! http://ees.elsevier.com/jtv
ISSN: 0965-206X
Offi cial Journal of the Tissue Viability Society.
Editor in Chief:
D. Bader, Southampton, UK
International editorial board:
C. Dealey, UK
L. Edsberg, USA
A. Gefen, Israel
S. Hagisawa, Japan
A. Nelson, UK
J. Nixon, UK
H. Partsch, Austria
M. Romanello, Italy
L. Schoonhoven, Netherlands
L. Stockton, UK
J. Swaine, Australia
T. Young, UK

EPUAP
European
Pressure Ulcer
Advisory Panel
Michael Clark
President, EPUAP
www.epuap.org
80
News from the
European Pressure Ulcer Advisory Panel
The European Pressure Ulcer Advisory Panel
(EPUAP) will hold its 15th Annual Meeting in
Cardiff, Wales over September 18th - 21st 2012.
The theme of this year’s meeting will be ‘Identifying
research gaps and clinical needs in pressure ulcer
prevention and management’.
Who cares about pressure ulcers? – We do!’
During the conference several areas will be
explored including:
n The new PUCLAS classification on line tool
n Microclimate and moisture lesions
n Incontinence-associated dermatitis (IAD)
n Pressure ulcer guideline implementation:
clinical drivers versus financial drivers
n International guideline adaptation
– the Belgian, Netherlands & UK experience
n Superficial versus deep infection in pressure
ulcers, diagnosis and management
n Pain and pressure ulcers
Important new sections of the conference will provide
an opportunity for EWMA and the EPUAP to
collaborate together upon a joint session. The
conference will close with a live link to the Cardiff
Complex Wound Clinic when delegates will be able
to interact with complex wound management in
action.
Cardiff has been chosen as the venue for the
EPUAP 2012 conference venue for two main reasons
– the first President of the EPUAP, Professor
Keith Harding has been based in Cardiff throughout
the majority of his professional life in wound
healing and it was fitting on our 15th anniversary to
visit the city where many development and initiatives
in wound management began. Secondly there
is vibrant research, clinical and commercial activity
in Wales related to pressure ulcers and wider
wound healing with the Welsh Government recognising
wound healing as a major success in the
country’s bio-science activities. So the 2012 EPUAP
conference is coming to a city that has been long
associated with the EPUAP and will help contribute
to the growing awareness of wounds as a strength
of Wales.
One topic that will be discussed during the Cardiff
conference is the EPUAP’s role in promoting a Stop
Pressure Ulcer Day across Europe. In recent years
we have seen ’Stop Pressure Ulcer’ Days occurring
in Spanish and Portuguese speaking countries and
last year organisations in Europe and Latin America
created a Declaration in Rio speaking out against
people developing pressure ulcers (www.silauhe.
org/es/?file=kop1.php).
In 2012 there will again be a Stop Pressure Ulcer
Day to be held on November 16th 2012. The European
Pressure Ulcer Advisory Panel applauds the
efforts of such events to bring pressure ulcers to the
public, the professionals and our politicians and has
decided to participate in this even in 2012. During
the Cardiff 2012 conference there will be a meeting
with other interested wound organisations to help
co-ordinate the Stop Pressure Ulcer Day. Let’s take
the opportunity to remind colleagues, the public
and our politicians about the need to reduce the
burden of pressure ulcers across Europe.
To find more information on the project
please visit the website:
www.epuap.org/news/stop-pressure-ulcer-day/
EWMA Journal 2012 vol 12 no 2

Latin American Activities on Prevention of Pressure Ulcers
Last October, the executive of the Ibero Latin-American Society
for Ulcers and Wounds (Sociedad Iberolatinoamericana
sobre Úlceras y Heridas, SILAUHE) gave a “green light” to
two projects, both directly related to the Prevention of Pressure
Ulcers:
Firstly, the “Declaration of Rio de Janeiro”, requires, as a
universal right of all people, prevention of these episodes and
discussion of the lines of action to undertake.
Secondly, the announcement of a “World Day for Prevention
of Pressure Ulcers”, scheduled for next November
16th. On this topic, SILAUHE would like to invite all scientific
organizations and Health Care Officials from Latin America
and Europe, to adopt this event as yours, as formal recognition
that the problem of Pressure Ulcers is evident and
important as regards the implications for the quality of life of
Organisations
people who suffer from ulcers, the increased risk of morbidmortality
and the high economic impact on society; and in
particular, to bring to everyone’s attention that today it is
possible, with the right treatment, to prevent almost all cases.
It is hoped that these two projects have resonance and
impact on the first World Prevention of Pressure Ulcers Day,
and we hope that, in the future, we will have many more
issues and projects and that many national and international
organizations in the field of health and human rights, scientific
societies and society as a whole will participate as partners
or stakeholders in the fight against pressure ulcers.
Written by Jose Verdú Soriano,
on the executive of GNEAUPP, trustee at EPUAP and
a member of EWMA Council
EWMA Journal 2012 vol 12 no 2 81

Cooperating Organisations
AFIScep.be
French Nurses’ Association in Stoma Therapy,
Wound Healing and Wounds
www.afiscep.be
AISLeC
Italian Nurses’ Cutaneous Wounds Association
www.aislec.it
AIUC
Italian Association for the study of Cutaneous Ulcers
www.aiuc.it
APTFeridas
Portuguese Association for the Treatment of Wounds
www.aptferidas.com
AWA
Austrian Wound Association
www.a-w-a.at
BEFEWO
Belgian Federation of Woundcare
www.befewo.org
BWA
Bulgarian Wound Association
www.woundbulgaria.org
CNC
Clinical Nursing Consulting – Wondzorg
www.wondzorg.be
CSLR
Czech Wound Management Society
www.cslr.cz
CWA
Croatian Wound Association
www.huzr.hr
DGfW
German Wound Healing Society
www.dgfw.de
Associated Organisations
Leg Club
Lindsay Leg Club Foundation
www.legclub.org
LSN
The Lymphoedema
Support Network
www.lymphoedema.org/lsn
For more information about
EWMA’s Cooperating Organisations
please visit www.ewma.org
82
Danish Wound DSFS
Healing Society Danish Wound Healing Society
www.saar.dk
FWCS
Finnish Wound Care Society
www.suomenhaavanhoitoyhdistys.fi
GAIF
Associated Group of Research in Wounds
www.gaif.net
GNEAUPP
National Advisory Group for the Study of Pressure
Ulcers and Chronic Wounds
www.gneaupp.org
ICW
Chronic Wounds Initiative
www.ic-wunden.de
LBAA
Latvian Wound Treating Organisation
LUF
The Leg Ulcer Forum
www.legulcerforum.org
LWMA
Lithuanian Wound Management Association
www.lzga.lt
MASC
Maltese Association of Skin and Wound Care
www.mwcf.madv.org.mt/
MSKT
Hungarian Wound Care Society
www.euuzlet.hu/mskt/
International Partner Organisations
AWMA
Australian Wound Management
Association
www.awma.com.au
AAWC
Association for the Advancement
of Wound Care
www.aawconline.org
Debra International
Dystrophic Epidermolysis Bullosa
Research Association
www.debra.org.uk
EFORT
European Federation of National
Associations of Orthopaedics
and Traumatology
www.efort.org
MWMA
Macedonian Wound Management Association
ILF
International Lymphoedema
Framework
www.lympho.org
NZWCS
New Zealand Wound Care
Society
www.nzwcs.org.nz
SOBENFeE
Brazilian Wound
Management Association
www.sobenfee.org.br
EWMA Journal 2012 vol 12 no 2

Other Collaborators
NATVNS
National Association of Tissue Viability Nurses,
Scotland
NIFS
Norwegian Wound Healing Association
www.nifs-saar.no
NOVW
Dutch Organisation of Wound Care Nurses
www.novw.org
PWMA
Polish Wound Management Association
www.ptlr.pl
SAfW
Swiss Association for Wound Care (German section)
www.safw.ch
SAfW
Swiss Association for Wound Care (French section)
www.safw-romande.ch
SAWMA
Serbian Advanced Wound Management Association
www.lecenjerana.com
SEBINKO
Hungarian Association for the Improvement in Care
of Chronic Wounds and Incontinentia
www.sebinko.hu
SEHER
The Spanish Society of Wounds
www.sociedadespanolaheridas.es
SFFPC
The French and Francophone Society
f Wounds and Wound Healing
www.sffpc.org
SSiS
Swedish Wound Care Nurses Association
www.sarsjukskoterskor.se
SSOOR
Slovak Wound Care Association
www.ssoor.sk
DFSG
Diabetic Foot Study Group
www.dfsg.org
EADV
European Academy of Dermatology and Venereology
www.eadv.org
EBA
European Burns Association
www.euroburn.org
EPUAP
European Pressure Ulcer Advisory Panel
www.epuap.org
E T R S ETRS
European Tissue Repair Society
www.etrs.org
STW Belarus
Society for the Treatment of Wounds
(Gomel, Belarus)
www.burnplast.gomel.by
SUMS
Icelandic Wound Healing Society
www.sums-is.org
SWHS
Serbian Wound Healing Society
www.lecenjerana.com
SWHS
Swedish Wound Healing Society
www.sarlakning.se
TVS
Tissue Viability Society
www.tvs.org.uk
URuBiH
Association for Wound Management
of Bosnia and Herzegovina
www.urubih.ba
UWTO
Ukrainian Wound Treatment Organisation
www.uwto.org.ua
V&VN
Decubitus and Wound Consultants, Netherlands
www.venvn.nl
WMAI
Wound Management Association of Ireland
www.wmai.ie
WMAK
Wound Management Association of Kosova
WMAS
Wound Management Association Slovenia
www.dors.si
WMAT
Wound Management Association Turkey
www.yaradernegi.net
Organisations
Eucomed
Eucomed Advanced Wound Care Sector Group
www.eucomed.org
ICC
International Compression Club
www.icc-compressionclub.com
MSF
Médecins Sans Frontières
www.msf.org
WAWLC
World Alliance for Wound and Lymphedema Care
www.wawlc.org
WUWHS
The World Union of Wound Healing Societies
www.wuwhs.org
EWMA Journal 2012 vol 12 no 2 83

5 Editorial
Science, Practice and Education
7 A structured approach to surgical treatment in deep
infection in diabetic foot
Cedomir S Vucetic, Javorka B Delic, Zoran S Vukasinovic,
Goran Dz Tulic, Ivan K Dimitrijevic, Cedo Dj Vuckovic,
Vesna K Kalezic
15 Endothelial progenitor cells, a unipotent stem cell, involved
in neovascularization of wound healing in diabetic foot ulcer
Jacqueline Chor Wing Tama, Chun Hay Ko, Ping Chung Leung,
Kwok Pui Fung, Clara Bik San Lau
23 Bacteriophages for the treatment of severe infections:
– a ‘new’ option for the future?
Daniel De Vos, Gilbert Verbeken, Thomas Rose, Serge Jennes, Jean-
Paul Pirnay
31 Developing evidence-based ways of working:
– Employing interdisciplinary team working to improve patient
outcomes in diabetic foot ulceration – our experience
Kristien Van Acker
36 Exploring the characteristics of a venous leg ulcer that contribute
to the emotional distress experienced by patients
Jessica Walburn, John Weinman, Suzanne Scott, Kavita Vedhara
39 Development of a wound healing index for chronic wounds
Juan Carlos Restrepo-Medrano, José Verdú Soriano
Cochrane Reviews
49 Abstracts of Recent Cochrane Reviews
Sally Bell-Syer
EWMA
56 EWMA Journal Previous Issues and other Journals
58 EWMA Teacher network
Zena Moore
58 Austrian Diabetic Foot Symposium, EWMA 2012
60 EWMA Update, The Patient Outcome Group
Patricia Price
62 We want to make a difference! – EWMA future projects
Jan Apelqvist
64 EU ‘Week For Life’
Jan Apelqvist
66 EWMA focus on multidisciplinarity in wound management
Jan Apelqvist
68 EWMA participation in EU Conference on Antimicrobials
Resistance – it’s time to take joint action!
Rytis Rimdeika
70 Eucomed, Woundcare reflections on the EU 2020 strategy
Hans Lundgren
Organisations
72 EWMA Corporate Sponsors
73 Conference Calendar
74 10th DFCon Global Diabetic Foot Conference.
EWMA President Jan Apelqvist receives Diabetic Foot Award.
Diabetic Foot Experts Attend Global Meeting to Share Ideas
on Amputation Prevention
75 AAWC, The Association for the Advancement of
Wound Care
Terry Treadwell
76 AWMA, The Australian Wound Management Association
national conference
Bill McGuiness
78 DEBRA International
John Dart
80 EPUAP, News from the European Pressure Ulcer Advisory
Panel – Latin American Activities on Prevention of Pressure
Ulcers
Michael Clark
82 EWMA Cooperating Organisations