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OBJECTIVE

To discuss the role of the clinical nurse specialist in managing patients with ulceration caused by mixed venous arterial disease.

METHOD

A small scale retrospective audit study of eight mixed aetiology patients drawn from the caseload of leg ulcer patients within a specialist leg ulcer service in Ayrshire, Scotland was conducted by two specialist nurses with over 8 years' experience in specialist leg ulcer management. Patients were individually assessed using Doppler ultrasound and a rigorous set of validated risk factor criteria. Where Doppler ultrasound was considered to be unreliable, due to an inability to detect sounds, or where further diagnostic information was required in order to safely plan care, arterial duplex scanning was carried out by the cardiac department at Ayr Hospital. All patients were treated with a cohesive inelastic compression bandage system and closely observed by the specialist nurse.

RESULTS

All eight patients with mixed aetiology leg ulcers were reported to experience complete ulcer healing within 6-30 weeks after first application of the inelastic bandage system. The regimen was well tolerated by all patients and no adverse events were recorded.

CONCLUSION

With accurate assessment and treatment by a specialist team, patients with mixed venous arterial disease were safely and successfully managed where they may have remained unhealed.

DECLARATION OF INTEREST

This was an independent retrospective audit study conducted by two clinical nurse specialists, with educational support by Activa Healthcare to assist in bringing it to print.

Introduction:

Wound dressings with antimicrobial agents are increasingly utilized in the management of critical colonized or infected chronic wounds. The dressings’ antibacterial activities are mostly evaluated using in-vitro-tests. These may differ significantly in their properties and outcome. We have analyzed the antibacterial effect of PHMB- and silver-dressings using in-vitro-methods such as the agar diffusion test (ADT), contact tests like JISL1902:2002 or AATCC100, microplate-laser nephelometry (MLN) and luminometric quantification of bacterial ATP (LQb).

Materials & Methods:

Antibacterial activity of the dressings was tested against Staphylococcus aureus and Pseudomonas aeruginosa. ADT was performed according to DIN58940-3 with samples of 0.6 cm2. For AATCC100 samples sizes of 18 cm2 and for JISL1902:2002 of 400 mg were used. Dressing extracts were prepared corresponding to DIN10993-12 for MLN and LQb.

Results:

PHMB- and silver-dressings showed antibacterial activity in all tests. Yet, total effectiveness varied for single methods and properties of the basic dressing materials without active agent (such as alginate, cellulose, or polyurethane). Alginate, cellulose, or polyurethane alone had no effect in ADT. In contrast, alginate showed a strong antibacterial activity in the contact tests (JISL1902:2002, AATCC100) because it is able to sequester bacteria during gel formation. MLN and LQb only determined a bactericidal effect on S. aureus and P. aeruginosa for the agent-containing dressings.

Conclusions:

Using in-vitro-tests for the evaluation of the antibacterial activity allows quantification and direct comparison of dressings’ effectiveness under standard conditions. Various test methods are available that differ in their properties and hence in their outcome, this has to be taken into account when selecting a specific test and interpreting the results.

The effective management of bacterial bioburden is an essential element of wound care. Recent years have seen the increased use of topical antimicrobial dressings to control colonisation and infection, yet there is concern that some may inhibit wound healing and may have systemic sequelae (World Union of Wound Healing Societies (WUWHS), 2008). This article focuses on the safety and effectiveness of PHMB, an antimicrobial compound that is relatively underused in the UK, and argues that it is an effective option for the management of bacterial colonisation and infection.

OBJECTIVE

This study compares treatment with a polihexanide-containing biocellulose wound dressing (BWD+PHMB) versus the best local standard of silver dressings (Ag) in painful, critically colonised (wounds-at-risk) or locally-infected wounds.

METHOD

Patients with wounds of various aetiologies, a baseline VAS pain score >4 and a semi-quantitative bacterial load of ++ or higher were randomly allocated to receive treatment with either BWD+PHMB or Ag. Patients with systemic infections and/or using systemic antibiotics were excluded. The primary endpoint, patient-reported pain (VAS total pain, including the sub-scores pain at night, during the day, before, and 15min after dressing changes), was compared between treatment groups and scored on days 0, 1, 3, 7, 14, 21 and 28. Secondary outcomes of bacterial load, wound bed and periwound skin condition, quality of life and dressing handling were assessed at the same visits.

RESULTS

Thirty-eight patients (BWD+PHMB, n=21 [24 wounds]; Ag, n=17 [18 wounds]) were included in the analyses. Baseline variables showed no significant differences. Wound pain was reduced significantly in both groups, with a better pain reduction noted for BWD+ PHMB (p<0.001) before dressing changes. Compared with Ag, in the BWD+PHMB group critical colonisation and local wound infection had been reduced significantly faster and better (p<0.001) over the 28-day study period. Improved quality of life, good tolerability and no adverse events were demonstrated for both groups.

CONCLUSION

Both BWD+PHMB and AG were effective in reducing pain and bacterial burden. However, that BWD+PHMB was significantly faster and better in removing the critical bacterial load, makes this dressing an attractive therapeutic option to treat critically colonised and locally-infected wounds.

and a. This pair of parameters allows us to determine the maximum value of the observed events for tfi¥, as well as the period within which 50% of these events occur. This mathematic procedure is easy, clinically based and more precisely as Kaplan–Meier estimation, so we think that it has the potential to replace Kaplan–Meier curve.

OBJECTIVE

Postsurgery dressing changes in diabetic foot amputation wounds and surgical wounds healing by secondary intention are often conducted in the operating room under general anesthesia. A prospective comparative cohort study was performed in 60 patients (n = 60: n = 30/n = 30) with secondary-intention surgical wounds (82% had forefoot and/or digit[s] amputations) to compare 2 different dressing types.

METHOD

Patients at the study center gave informed written consent, after which they were randomly allocated to one of the treatment groups. Group A received a biocellulose dressing with polyhexanide, and group B a hydrophobic dressing with dialkyl-carbamoyl-chloride. In both groups, gauze was used as secondary dressing and fixed with a film dressing. One day after surgery, the dressings were removed by the surgeon and patient-reported pain and dressing adherence/integrity were evaluated. The number of patients that required general anesthesia was determined during the procedure and afterward.

RESULTS

All patients (n = 60; n = 30/n = 30) were included in the intention-to-treat analysis. Pain levels in group A were significantly (t (59) = 4.026, P < .000) lower upon dressing removal, when compared with group B; in group A, n = 21 reported no pain versus n = 8 (26%) for group B. In group A, the dressing adhered in 7 subjects (23%) versus n = 27 (90%) of cases in group B (P = .000). No anesthesia was required for the patients in group A, contrary to group B, where 16% of patients received general anesthesia for dressing removal.

CONCLUSION

Pain levels were significantly lower and the dressing adhered significantly less in group A, compared with group B, demonstrating a better quality of life for the patients in group A.

The TIME acronym (tissue, infection/inflammation, moisture balance and edge of wound) was first developed more than 10 years ago, by an international group of wound healing experts, to provide a framework for a structured approach to wound bed preparation; a basis for optimising the management of open chronic wounds healing by secondary intention. However, it should be recognised that the TIME principles are only a part of the systematic and holistic evaluation of each patient at every wound assessment. This review, prepared by the International Wound Infection Institute, examines how new data and evidence generated in the intervening decade affects the original concepts of TIME, and how it is translated into current best practice. Four developments stand out: recognition of the importance of biofilms (and the need for a simple diagnostic), use of negative pressure wound therapy (NPWT), evolution of topical antiseptic therapy as dressings and for wound lavage (notably, silver and polyhexamethylene biguanide) and expanded insight of the role of molecular biological processes in chronic wounds (with emerging diagnostics and theranostics). Tissue: a major advance has been the recognition of the value of repetitive and maintenance debridement and wound cleansing, both in time-honoured and novel methods (notably using NPWT and hydrosurgery). Infection/inflammation: clinical recognition of infection (and non infective causes of persisting inflammation) is critical. The concept of a bacterial continuum through contamination, colonisation and infection is now widely accepted, together with the understanding of biofilm presence. There has been a return to topical antiseptics to control bioburden in wounds, emphasised by the awareness of increasing antibiotic resistance. Moisture: the relevance of excessive or insufficient wound exudate and its molecular components has led to the development and use of a wide range of dressings to regulate moisture balance, and to protect peri-wound skin, and optimise healing. Edge of wound: several treatment modalities are being investigated and introduced to improve epithelial advancement, which can be regarded as the clearest sign of wound healing. The TIME principle remains relevant 10 years on, with continuing important developments that incorporate new evidence for wound care.

BACKGROUND

Acne vulgaris is a common skin disease with a large quality of life impact, characterized by comedones, inflammatory lesions, secondary dyspigmentation, and scarring. Although traditionally considered a disease of adolescence, reports suggest it is also a disease of adults, especially adult women. Our objectives were to determine acne prevalence in a large, diverse group of women and to examine acne by subtype and in relation to other skin findings, measurements, and lifestyle factors.

METHODS

We recruited 2895 women aged 10-70 from the general population. Photographs were graded for acne lesions, scars, and dyspigmentation. Measurements were taken of sebum excretion and pore size, and survey data were collected.

RESULTS

Of the women studied, 55% had some form of acne: 28% had mild acne, and 27% had clinical acne, 14% of which was primarily inflammatory and 13% of which was primarily comedonal. Acne peaked in the teenage years, but 45% of women aged 21-30, 26% aged 31-40, and 12% aged 41-50 had clinical acne. Women with inflammatory acne were younger than those with comedonal acne (p≤0.001), and postmenopausal women had less acne than age-matched peers (p<0.0001). Acne was associated with facial hirsutism (p=0.001), large pores (p=0.001), and sebum excretion (p=0.002). Smokers had more, primarily comedonal, acne than nonsmokers.

CONCLUSIONS

The cross-sectional design precludes conclusions about progression of acne with age. Participation was restricted to women. The photographic nature of the study imposes general limitations. Techniques used in this study were not sufficiently sensitive to identify cases of subclinical acne. More than a quarter of women studied had acne, which peaked in the teens but continued to be prevalent through the fifth decade.