Volume 54 - Issue 10 - October, 2008

Has the Pendulum Reached the Sun?

   In a recent issue of Ostomy Wound Management, Morris Magnan and JoAnn Maklebust observed, “Policy has an interesting way of shaping both science and practice.”1 They expressed the hope that recent Centers for Medicare and Medicaid Services (CMS) reimbursement changes for acute care facilities might provide the impetus to develop a theory of pressure ulcer prevention.

   The new CMS endeavor is rather unique in its timing — in most areas, the policy regulation pendulum has been moving toward deregulation. Policies that guide the regulation process shape our world. Recently, the magnitude of negative effects from certain policies has increased substantially. World markets are feeling the reverberations of changes in US economics from food (corn) subsidy to safety warnings and product recalls (children’s toys, pet food, infant formula, balloon catheters, and automatic external defibrillators) to manufacturing deficiencies (affecting more than 30 different generic drug products).2



A Clinical Trial to Investigate the Effect of Silver Nylon Dressings on Mediastinitis Rates in Postoperative Cardiac Sternotomy

Index: Ostomy Wound Manage. 2008;54(10):36-41.

Abstract

  Mediastinitis is a rare but serious postoperative complication of cardiac surgery that increases mortality rates, hospital length of stay, and medical costs. A clinical trial was conducted to investigate whether the type of postoperative surgical dressing (silver nylon or standard gauze) affects the rate of mediastinal infections. The sample consisted of 1,600 surgical cardiac patients.Infection rates in the standard gauze group (control, n = 1,235) were collected retrospectively from 24 months of infection control records. In the prospective treatment arm of the study, the wounds of all consecutive surgical patients (n = 365) were covered with a silver nylon dressing and patients were assessed during the 3-week postoperative visit. Thirteen (13) patients in the control group (1%) and none of the patients in the treatment group developed mediastinitis (chi2 [1, N = 1,600] = 3.88, P <0.05). Study findings support the need for a large, prospective, controlled clinical study to confirm the effects of these dressings on mediastinitis, resultant morbidity, and costs of care.

KEYWORDS: silver nylon fabric, mediastinitis, mediastinum infections



Managing Painful Venous Ulcers

   Patients with venous ulcers often report pain, which may be continuous or intermittent and often is associated with dressing changes. The pain may be perceived as generalized in the leg, focused in the ulcer or periwound, or both. Inflammation and edema resulting from the underlying venous disease are key factors in the patient’s pain.

   Appropriate wound care combined with continuous use of compression can help reduce pain and improve outcomes in patients with venous ulcers. Although compression therapy is the standard of care for resolving these wounds and reducing pain, patients often resist this approach — willingness to wear compression stockings depends on the patient’s understanding that managing pain and discomfort will improve quality of life.



My Career Chose Me

It’s choice — not chance — that determines your destiny. - Jean Nidetch (Weight Watchers® founder)

   Nursing is a vocation that reveals inner strength and courageousness that some men and women never knew they possessed. Wound/ostomy nursing in particular facilitates personal discovery and professional achievement. For Rosemary Kates, RN, MSN, CRNP, CWOCN, the nursing journey began in 1974 as a cardiovascular staff nurse specializing in critical care and cardiac rehab. After 15 years of working with postop open heart surgery patients, Rosemary wanted a change and eventually became a nurse educator at Our Lady of Lourdes Medical Center (OLLMC), Camden, NJ. One of her primary duties was to work with staff on patients’ skin issues and pressure ulcer prevention. Because Rosemary and the nursing staff lacked skin care knowledge, she paid close attention to WOCN consultant Nancy Tomaselli’s work. Nancy soon became Rosemary’s professional mentor, guiding and encouraging Rosemary on wound care issues.



Determining the Effect of an Oak Bark Formulation on Methicillin-resistant Staphylococcus aureus and Wound Healing in Porcine Wound Models

Index: Ostomy Wound Manage. 2008;54(10):16-25.

Abstract

  Control of wound infections, especially those associated with methicillin-resistant Staphylococcus aureus, is necessary for the wound healing process. Selection of topical agents should be based not only on their ability to eliminate pathogenic bacteria, but also on whether they may be detrimental to tissue repair. Two randomized, controlled in vivo studies using different porcine models were conducted to evaluate the effect of a topical oak bark ointment (treatment) on 1) methicillin-resistant Staphylococcus aureus in partial-thickness wounds, and 2) healing of second-degree burn wounds. Silver sulfadiazine, oak bark ointment vehicle control (polyethylene glycol), and no treatment (untreated wounds) were used as controls in both studies. In the first study, 108 partial-thickness wounds in three animals were inoculated with a methicillin-resistant S. aureus suspension (average 6.96±0.4 log CFU/mL) and covered for 24 hours with a polyurethane film. After polyurethane film removal, treatments were applied twice daily and nine wounds per day (three per animal) from each treatment group were cultured after 24, 48, and 72 hours. Methicillin-resistant S. aureus colonization was lowest in the active treatment group at all three assessment times and after 72 hours ranged from (5.01±1.1 CFU/mL) in the treatment to (6.20±0.8 CFU/mL) in the vehicle control treated wounds.



How Much Time Does it Take to Get a Pressure Ulcer? Integrated Evidence from Human, Animal, and In Vitro Studies

Index: Ostomy Wound Manage. 2008;54(10):26-35.

Abstract

  Severe pressure ulcers and deep tissue injury are associated with higher mortality rates, longer hospital stays, and costly treatment. Time is a critical factor in commonly employed measures (eg, pressure redistribution for wheelchair users and patient turning schedules) to prevent pressure ulcers and deep tissue injury. Surprisingly, information regarding the timeframe for pressure ulcer onset, particularly for deep tissue injury onset, is scant. To create a timeframe for the development of pressure ulcers and deep tissue injury, available evidence from the following study types was obtained and reviewed: 1) studies involving patients who underwent surgeries of known duration and subsequently developed a serious pressure ulcer with subcutaneous tissue damage or deep tissue injury; 2) animal studies in which loads were applied on soft tissues of anesthetized animals and tissue viability monitored in real time or using histology post-euthanasia; and 3) in vitro models in cell cultures and tissue-engineered constructs. Findings from the three models indicate that pressure ulcers in subdermal tissues under bony prominences very likely occur between the first hour and 4 to 6 hours after sustained loading. However, research examining these timeframes in sitting patients is not available. Further fundamental research, employing animal and cell culture models, is required to narrow this range further and to correlate the time factor to the extent of tissue damage.

KEYWORDS: pressure ulcer, deep tissue injury, animal model, tissue engineering, injury threshold



Practice Recommendations for Preventing Heel Pressure Ulcers

Index: Ostomy Wound Manage. 2008;54(10):42-57.

Abstract

  Heels are the second most common anatomical location for pressure ulcers. A combination of risk factors, including pressure, may cause ulceration. Heel pressure ulcers are a particular concern for surgical patients. A review of the literature, including poster presentations, shows that controlled clinical studies to assess the effectiveness and cost-effectiveness of available interventions are not available. Case series (with or without historical controls) as well as pressure ulcer guideline recommendations suggest the most important aspect of heel ulcer prevention is pressure relief (offloading). It also has been documented that the incidence of heel ulcers can be reduced using a total-patient care approach and heel offloading devices. Guidelines, observational studies, and expert opinion intimate that reducing heel ulceration rates can be expected to improve patient outcomes, decrease costs associated with their care, and avoid costs related to hospital-acquired pressure ulcers. The heel pressure ulcer prevention strategies reviewed should be implemented until the results of prospective, randomized controlled studies to compare the effectiveness and cost-effectiveness of these strategies are available.

KEYWORDS: heel pressure ulcer,, perioperative pressure ulcer, heel protector device, heel offloading device



Low-frequency, Therapeutic Ultrasound Treatment for Congenital Ectodermal Dysplasia in Toddlers

Abstract

  Hay-Wells Syndrome is a rare genetic disorder characterized by ankyloblepharon, ectodermal dysplasia, and cleft palate. Recalcitrant scalp wounds with secondary infections are common. This case series describes the use of acoustic pressure wound therapy in 3-year-old fraternal twins (male and female) with HWS-associated scalp wounds. Present since infancy, the wounds were severe and extensive at presentation to the authors’ wound clinic. Previous management consisted of standard topical treatments, including foam; oxidized, regenerated-cellulose/collagen with silver; calcium alginate; silver sulfadiazine cream; and biologic tissue matrix. Following admission to the authors’ wound clinic, acoustic pressure wound therapy was administered one to three times weekly for 3 to 10 minutes for 7 months in addition to standard topical treatments to provide nonsurgical debridement and reduce wound bioburden without inflicting additional pain. Substantial improvements occurred during the first 5 weeks of consistent treatment. When treatments became sporadic due to health and family issues, wound deterioration occurred. After 7 months, wound sizes decreased by 31.3% in the boy and 1.1% in the girl, 70% of the wound surface in both children was covered with granulation tissue, and no clinical signs of infection were evident. The treatments were well tolerated. So far, the twins each received a total of 37 treatments. Consistent, long-term acoustic pressure wound therapy improved the status of severe, recalcitrant, Hay-Wells Syndrome-associated scalp wounds.

KEYWORDS: acoustic pressure wound therapy, AEC Syndrome, ectodermal dysplasia, Hay-Wells Syndrome, wounds



New Products/Industry News

Clinical trial affirms honey’s healing benefits for venous leg ulcers

     Medihoney™, Derma Science Inc’s (Princeton, NJ) Wound & Burn Dressing with Active Leptospermum Honey, was recently found in a large randomized and controlled clinical trial to significantly improve the healing rates of stalled venous leg ulcers. Before this study, no other advanced wound care dressing under compression therapy demonstrated improved healing rates of leg ulcers.

     In the 108-patient randomized and controlled clinical trial, venous leg ulcers that had been proven to be non-healing under standard treatment (compression therapy) were examined. Half of the patients had a common advanced wound care gel added to the standard treatment, while the other half of the patients had Active Leptospermum (Manuka Honey) added. After 4 weeks, the mean reduction in size of the wounds was 34% in the honey group and 13% in the control group. After 12 weeks, there was a 44% complete healing rate in the honey group compared to only 33% in the control group. Since the launch of the honey in Europe, the United States, and Canada, clinicians have consistently reported its effectiveness on stalled ulcers of various etiologies.

     For more information, visit www.dermasciences.com.