The great debate over iodine in wound care continues: a review of the literature

Angel DE, Morey P, Storer JG & Mwipatayi BP

Abstract
The use of iodine in wound management can be traced back hundreds of years and yet continues to divide and create debate amongst today's clinicians. Is there a place for this agent in either infected or non-infected wounds? The body of evidence and pharmacopeia of iodine-based products available can prove daunting. This review outlines the properties of iodine-based products and seeks to examine the relevant clinical studies in an attempt to provide an evidence-based structure to facilitate the choice of iodine-based product. The authors reviewed both animal and human studies. Over 50 studies have been conducted on the use of iodine in wound care. Analysis of the literature reveals that there does appear to be a place for iodine in wound management, particularly in the presence of infection. However, the literature highlights iodine may cause harm, therefore a sound knowledge of the factors that contribute to the activity of iodine and its potential for cytotoxicity is required for its judicious use.

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Clinician inter-rater reliability using a medical wound imaging system

Flowers C, Newall N, Kapp S, Lewin G, Gliddon T, Carville K, Martinelli D & Santamaria N

Abstract
The ability to determine the effectiveness of alternative treatments in the management of wounds is central to wound research and ultimately to the development of sound evidence on which to base clinical decision making. Measurement precision is therefore a critical factor in research which aims to determine the effects of treatment on healing rates, especially when the research is being conducted across sites and measurements are being made by different individuals. Additionally, as with any digital planimetric system, the quality of the measurement is dependent on the skill of the operator, therefore it is considered essential to measure the inter-rater reliability of the measuring system used.
This paper describes how the inter-rater reliability of the Alfred/Medseed Wound Imaging System, now known as the Advanced Medical Wound Imaging System (AMWIS) was established. Four clinicians involved in the trial were asked to independently trace (measure) the same 20 wound images using AMWIS. The data collected for each image included the total area and the various tissue characteristics for the wound. The results showed that there was high inter-rater reliability for the measures of total area, granulation and slough. Additional feedback suggested that better definitions and guidelines to assist in the differentiation and recording of tissue characteristics would be of value to the users.

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Does phenytoin have a role in the treatment of pressure ulcers?

Sinha SN & Amarasena I

Abstract
Pressure ulcers (PUs) are common in clinical practice. Apart from causing suffering to patients and at times contributing to their demise, they also result in increased length of hospital stay and increased cost of health care. Although prevention of PUs is the desirable goal, it may not always be possible. Skin, the largest organ of the body, is affected by the ageing process, nutritional deficiencies and systemic illnesses and, like other organs, can fail too. Phenytoin can play a significant role in reducing bacterial growth and improving the rate of healing of PUs. Topical phenytoin is simple to use, safe, inexpensive and readily available. We hope that this article will encourage other wound care specialists to engage in further research in this area.

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Diabetic peripheral neuropathy: pharmacological interventions or acupuncture an evidence-based perspective

Coats S

Abstract
This article demonstrates the practical application of the principles of evidence-based practice (EBP) to derive a solution to a clinical encounter, namely the management of painful peripheral neuropathy. The clinical scenario was analysed in accordance with EBP principles (PICO structure, generation of literature search strategy and citation reference list), concluding with the development of an evidence-based clinical response J. Elements of this paper were derived from various assessment components of the author's in the Evidence Based Practice Unit that is part of Monash University's graduate studies in wound care programmes.

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Abstracts

Evidence-based best practice in maintaining skin integrity

Gardiner L, Lampshire S, Biggins A, McMurray A, Noake N, van Zyl M, Vickery J, Woodage T, Lodge J& Edgar M

Abstract
The study reported here describes a 1 year programme to promote best practice in maintaining skin integrity, ensuring consistent clinical practices in relation to skin care, and managing skin breakdown. The analysis included baseline data on skin breakdown; comparisons of policy and practice with clinical guidelines and best practice locally, interstate and internationally; a quality improvement trial focusing on mobility, skin condition, diet and hydration, hygiene and elimination; and implementation of best practice, including analysis of the relative quality and clinical outcomes of products, practices and documentation strategies. Product evaluation by nurses and patients showed that all mattresses trialled were effective in minimising or preventing skin breakdown. All chair cushions were rated effective in preventing breakdown -some were easier to use than others, although all were rated highly by patients.
A retrospective chart audit indicated substantial improvements in consistent use of the Braden scale. and the number of risks identified. Completed risk assessments increased by 19.6% to 70%: Initial assessment increased from 16.5% to 44.6%, with identification of dietary insufficiency increasing from 3.4% to 10.6%. Hospital acquired pressure lesions were reduced from 6.4% to 5.8%. The most notable improvement (from 1.3% of patients to 43.9%) occurred in the completion of subsequent pressure risk assessments, with a modest increase in repositioning. The use of overlays and special mattresses increased with heel raisers increasing from 11% to 82.4%. The project demonstrated the value of a comprehensive team approach to clinical care and demystfied evidence-based practice (EBP).

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The issues surrounding the continued use of saline soaked gauze dressings

Ryan M

Abstract
Saline soaked dressings are often used on wounds healing by secondary intention within the acute care sector. Nurses need to act as patient advocates with other healthcare providers and use evidence-based practice from reliable research findings to guide practice towards care that is effective, feasible, appropriate and meaningful for the patient. As such, the levels of research-based evidence into the efficacy of saline soaked gauze dressings are discussed. This article identifies many potential issues with the use of these dressings such as patient discomfort, prolonged inflammation, localised hypothermia, infection risk and increased costs.

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The use of OPAL001 filtrate and cream in the treatment of chronic pressure ulcers

Graves N & Ashby AE

Abstract
Residents at the Quadriplegic Centre located in Perth, Western Australia, were studied. The Quadriplegic Centre is a 100-bed hospital for the specialist management of people with paralysis as a consequence of spinal cord injury or diseases of the spinal cord. Clinical staff at the Quadriplegic Centre became aware of the OPAL001 filtrate and cream, derived from pawpaw (papaya) and peach, and the apparent efficacy in healing various types of ulcers. Staff initiated a trial involving patients that had suffered Stage II-IV pressure ulcers, including some of more than 5 weeks' duration that were difficult to heal. Daily treatment consisted of application of the filtrate to the ulcer and the cream to the surrounding skin with non-adherent dressing. Treatment appeared to be effective, and persistent large and deep ulcers were healed. There was improved mobility among patients, as well as less turning and bedside care. A retrospective cost analysis shows savings arose from reduced nursing care and fewer products being used for wound care. The preliminary data presented show some evidence for OPAL001 therapy reducing costs and improving outcomes; the situation where costs decrease and health outcomes improve is both unusual and highly desirable for healthcare decision makers. A randomised clinical trial is required to show that these observations are real effects from therapy.

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Introduction of the Lanarkshire Oximetry Index in community nursing

Blanchfield D

Abstract
The aim of this project was to improve access to appropriate, timely and safe application of high compression bandaging for clients with suspected venous leg ulcers (VLUs) with the use of the Lanarkshire Oximetry Index (LOI) when an ankle-brachial pressure index (ABPI) has not be done. An additional aim was to decrease concerns generalist community nurses (GCN) had in relation to the application of high compression bandaging and its effect on blood flow in the lower limbs. This clinical practice improvement project builds on the work done by Field 1 researching why district nurses in the United Kingdom do not apply high compression bandaging. This current project involves community nurses in NSW.
The literature review highlighted that there was no research that specifically investigated nurses' concerns and confidence in their ability to apply high compression bandaging without interfering with the client's blood supply. Bianchi et al. 2 published a paper that demonstrated a method of increasing nurses' confidence in their ability to apply high compression bandaging without placing the patients' limb at risk. This method of detecting the arterial status, the LOI, is conducted by the use of a pulse oximeter.
Following the implementation of the LOI project, the survey results showed that use of the LOI is achieving a reduction in the time delay for investigations to be performed to ensure safe application of high compression bandaging for clients who have not already had an ABPI. Use of the LOI is results in an increase in nurses' confidence that high compression bandaging has been applied in a safe manner. In summary, the project highlighted the benefits of the LOI method. This method can be used to assess the arterial status of the limb in combination with a complete assessment of the client and the wound before high compression bandaging is applied.
Since the conclusion of this project, the LOI has become standard practice in SESIH SHN CH and GCNs have now preformed 300 LOIs. Using this tool three clients with critical limb ischemia have been picked up and had urgent surgical intervention. The LOI is now being introduced into the public hospital system.

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Preventing venous leg ulcer recurrence: a review

Kapp S & Sayers V

Abstract
Preventing venous leg ulcer recurrence is of prime importance to the individuals who live with these wounds and the health care providers participating in their care. Though the manifestation of these wounds is well understood, there are gaps in current understandings of how to prevent them. A survey of advanced clinical nurses in a Victorian home nursing service found a range of preventative practices employed and a subsequent review of the literature identified diverse approaches to the prevention of venous leg ulcer recurrence. The results from this survey and the accompanying review are of interest to multidisciplinary wound management practitioners who seek to promote best practice in this area of wound care.

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Abstracts

Chronic wound research: an integrated approach

Wallace HJ & Stacey MC

Abstract
For 20 years a significant research component has been integrated into the clinical services provided for patients with chronic leg wounds at Fremantle Hospital. The development of a team of clinicians, nurses and scientists has enabled a broad range of clinical and laboratory wound research to be undertaken on human subjects, which is only possible in a small number of centres worldwide. The key areas of research focus have been chronic wound epidemiology, clinical investigations, exercise and venous disease, pathophysiology of venous leg ulceration and clinical trials. Research on the pathophysiology of venous leg ulceration has been facilitated by the development of a human model of non-healing and healing venous ulcers. More recently, a genetic approach has been used to identify key molecules in venous ulcer pathogenesis through the investigation of gene polymorphisms as risk factors for the development of venous leg ulceration.
Genetic studies and randomised control trials for chronic wound therapies require large numbers of subjects to provide adequate statistical power. Additional funding and leadership is required to increase the number of centres across Australia with the capacity to participate in multi-centre chronic wound studies, and to facilitate effective collaborations between hospital- and community-based wound care providers, research institutions and industry.

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Matrix metalloproteinases and their roles in poor wound healing in diabetes

McLennan SV, Min D & Yue DK

Abstract
The prevalence of diabetes is increasing worldwide and has been forecasted to double in the next 20 years. The major increase in morbidity and mortality of diabetes is due to the development of complications, including failure of the wound healing process. Foot ulcers occur in 25% of all patients with diabetes and failure of healing eventually leads to deep-seated infection and amputation. Impaired wound healing is therefore the pivotal event responsible for most of the morbidity (and mortality) of diabetic foot disease. Consequently, a detailed understanding of the wound healing process in diabetes and how it can be improved is of great importance. However, efforts to develop new therapies are hampered by a lack of knowledge of the molecular mechanisms responsible for the poor wound healing.
Our laboratory is examining the role of matrix metalloproteinases (MMPs) in this regard. These proteolytic enzymes are important in normal wound repair and have been shown to be abnormally expressed in diabetic wounds. Our studies focus on evaluating MMPs as both markers and mediators of impaired wound healing in diabetes. Information will lead to a better understanding of poor wound healing in diabetes and ultimately more optimal therapeutic interventions.

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The duplicitous nature of inflammation in wound repair

Rajan V & Murray RZ

Abstract
Skin plays a key role in protecting the body from the onslaught of pathogens and toxins we meet during our lifetime; thus, out of necessity, we have developed a rapid repair mechanism that quickly plugs any holes in this vital organ. Upon injury, a series of highly coordinated overlapping events, that include inflammatory, proliferation and maturation phases, result in the hasty closure of the wound and restoration of skin integrity. Over the past decade it has become clear that a number of immune cells that regulate the inflammatory phase, whilst important for removal of invading pathogens, are not necessary for repair and in fact may be responsible for the subsequent scar formation that seems to have resulted from having such a rapid repair process. The magnitude and length of inflammation in the wound not only appears to dictate the extent of scar formation but also in some cases may even prevent wound closure. In this review we will explore the two sides of inflammation in wound healing and review current and future drug therapies that target inflammation to modulate the healing outcome.

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c-myb proto-oncogene is up-regulated in hypertrophicscars and correlates with increased collagen I

Kopecki Z, Adams D & Cowin AJ

Abstract
Hypertrophic scar formation is a serious medical problem involving an excess fibro-proliferative response; it is particularly observed in burns patients and patients with a variety of diseases including keloids and scleroderma. Type I collagen is the major form of collagen produced in response to wounding and is involved in cutaneous fibrosis and scar formation. A recently discovered function of the well known c-myb proto-oncogene, previously reported to be involved in regulating cell growth and development, is its ability to regulate type I collagen protein production. Previously we have shown that c-myb plays an important role in wound repair, by regulating collagen synthesis and cellular proliferation and migration. Here we examine the involvement of c-myb in different human wound and scar tissues. Human tissue collected from hypertrophic scars, keloid scars, acute wounds and chronic venous leg ulcers were immunostained for c-myb and collagen I.
Our results reveal a significant increase in c-myb protein levels in hypertrophic scars but not acute wounds, keloids or chronic ulcers. Interestingly, this increase in c-myb expression corresponded to the increased expression of collagen I in hypertrophic scars. These findings suggest that c-myb may be an important modulator of collagen synthesis in hypertrophic scar formation and may be important in wound fibrosis and scarring. Manipulation of c-myb levels may be of value in promoting improved wound healing and reducing scar formation.

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Acceleration of wound healing using electrical fields: time for a stimulating discussion

Ly M & Poole-Warren LA

Abstract
Chronic wounds have a significant effect on patient morbidity and also result in high cost to both affected individuals and the healthcare system. Several engineering approaches have been devised to combat chronic cutaneous wounds; these can be broadly divided into chemical, biological and physical wound management. This review discusses the various approaches, with an emphasis on physical wound management, in particular the application of electric fields to accelerate wound healing.

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Bilateral heel ulcers: a complex case for vacuum assisted closure

Freeman A

Abstract
The heels are the second most common area of the body for pressure wound development, accounting for 20-30% of all pressure lesions 1, 2. Successful treatment, including offloading of heel pressure wounds, can be challenging, particularly in the patient with diabetes and associated complications of neuropathy, peripheral vascular disease and increased susceptibility to infection. Topical negative pressure wound therapy (TNPWT) has the potential to accelerate healing of diabetic foot ulcers and decrease incidence of amputation. This paper discusses one case of the successful use of TNPWT in a complicated case of diabetic foot ulceration.

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Management of a pressure ulcer in the presence of arterial disease and MRSA infection

Higgins N

Abstract
This is a case study of an elderly lady with a Stage IV heel pressure ulcer. The ulcer was complicated by underlying arterialdisease and wound swabs revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA).

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Case study: maggot debridement therapy

Fenn-Smith P

Abstract
This case study looks at the use of maggot debridement therapy on a non-healing wound in a middle-aged lady.

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Collaboration the key to successful wound healing

Geard D

Abstract
The focus of this case study was to demonstrate the importance of collaboration between all care providers to achieve optimum outcomes for all clients, despite being constrained by the system of waiting lists for specialist intervention.

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Consider the whole patient, not just the hole: healing a wound cavity by secondary intention

Cartlidge-Gann L

Abstract
This case study demonstrates the effective management of an infected wound cavity by the use of an antimicrobial wound product, Aquacel Ag. This helped to promote wound healing by secondary intention in a time effective manner, thereby achieving best patient outcomes. Selecting a wound dressing product depends on accessibility, ease of use, the location of the wound, the type of tissue present on the wound bed, the depth of the wound, exudate levels and the condition of the peri-wound skin. The impact on wound healing from inappropriate selection of wound dressing products, for example Betadine-soaked gauze, and the subsequent effect on the wound healing process, is discussed.

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Healing a chronic venous ulceration using the Southland Snail, an innovative pressure device

Pagan A

Abstract
Recalcitrant venous ulcers pose a myriad of challenges for healthcare professionals managing them. Patient and wound related factors affect the healing process and need to be identified and managed appropriately, with adequate resources and by experienced healthcare professionals 1. This case report illustrates the effectiveness of applying an inexpensive supplemental pressure device under compression bandaging to a recalcitrant ulcer to achieve wound closure.

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Case report on a non-healing venous ulcer utilising a cellulose / super polymer dressing for exudate control

Bain G

Abstract
Controlling exudate is a key issue in the management of large venous leg ulcers. Dressings need to provide sufficient absorbency to prevent local tissue maceration, to remove inflammatory fluids from the wound bed and to limit strikethrough onto retentive dressings and clothing. These same dressings need to perform these tasks under some form of limb compression. In this case report, DryMax dressings were used to contain the persistent drainage of a non-healing ulcer and to assist in improving the patient’s quality of life.

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Measurement system for the evaluation of alternating pressure redistribution mattresses using pressure relief index and tissue perfusion – a preliminary study

Twiste M & Rithalia S

Abstract
Clinicians who are selecting dynamic support surfaces such as alternating pressure redistribution mattresses (APRMs) for the prevention and treatment of pressure ulcers are faced with commercial literature that predominantly reports on magnitudes of interface pressures, rather than on additional parameters. The aim of this preliminary study was to generate a pressure relief index (PRI) to evaluate dynamic support surfaces using the magnitude of interface pressures as well as their duration. Data for generating a PRI were captured from 11 subjects on two different dynamic support surfaces using three different, arbitrarily selected, interface pressure thresholds. Tissue perfusion measurements were used to evaluate the reliability of the calculated PRI. The results demonstrate a good relationship (r=0.7) between PRI and tissue perfusion values. The generated PRI appears to be a reliable indicator of the recovery time allowed below a given interface pressure and is therefore a useful parameter for selecting appropriate dynamic support surfaces.

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