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Section Editor(s): Collins, Pat MSN, RN, ACNS-BC; Evans, Sharon MS, RN, CWOCN; Doughty, Dorothy MN, RN, CWOCN, FAAN; Falconio-West, Margaret RN, APN/CNS, CWOCN, DAPWCA
TITLE: Evidence-Based Management of Chronic Wounds
AUTHORS: Jones K, Fennie K, Lenihan A
SOURCE: Advances in Skin and Wound Care 2007; 20(11):591–600
ARTICLE TYPE: Research Report; Retrospective Chart Review
* 400 records from variety of care settings (acute care, home health, outpatient, and long-term care) were reviewed to determine whether wound care provided was consistent with current evidence-based guidelines.
* Review revealed significant "disconnect" between current practice and evidence-based guidelines, especially in the area of dressing selection.
* Authors recommend a structured assessment form for documenting wound status.
* WOC nurses need to focus staff development efforts on consistent and accurate wound assessment, and appropriate use of advanced wound dressings.
TITLE: Best Practice Recommendations for Preparing the Wound Bed: Update 2006
AUTHORS: Sibbald G, Orsted H, Coutts P, Keast D
SOURCE: Advances in Skin and Wound Care 2007; 20(7): 390–405
ARTICLE TYPE: Best Practice Recommendations; Clinical Practice Guidelines
* Provides review of current recommendations for wound bed preparation; emphasizes importance of holistic care; and includes evidence cited in the Registered Nurses' Association of Ontario's Best Practice Guidelines.
* This is an excellent article to share with other clinicians regarding evidence-based wound care; may be particularly beneficial to physicians since the primary author is an MD.
TITLE: Make Sense of Wound Care Billing: Turn Your Cents Into Reimbursement Dollars
AUTHOR: Vargo DM
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(2):186–196
ARTICLE TYPE: Integrative Literature Review; Tutorial
* This article provides billing guidelines, appropriate codes, and edits to enable proper billing and prevent inappropriate or ineffective billing in wound care centers. The author also provides information about online billing resources maintained by the United States Centers for Medicare & Medicaid Services.
* This is a very valuable resource for any wound nurse setting up an outpatient clinic or reviewing billing procedures.
TITLE: An Innovative Enterostomal Therapy Nurse Model of Community Wound Care Delivery
AUTHORS: Harris C, Shannon R
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(2):169–183
ARTICLE TYPE: Research Report; Retrospective Chart Review and Cost Analysis
* This study compared clinical outcomes and cost among 3 models of community based nursing, including one with no ET nurse involvement, one based on limited ET nurse involvement and one model with regular ET nurse care. Increasing involvement by the ET/WOC nurse resulted in shorter time to healing and lower costs than the models with less ET involvement.
* The study provides evidence that wound specialists contribute positively to the "bottom line"; this could be beneficial to WOC nurses who need to justify their roles in agencies, especially within the current economic recession when budgets are under particular scrutiny.
TITLE: Feasibility of Virtual Wound Care: A Pilot Study
AUTHORS: Wilkins E, Lowery J, Goldfarb S
SOURCE: Advances in Skin and Wound Care 2007; 20(5):275–278
ARTICLE TYPE: Pilot Study (No Control Group)
* Authors evaluated web-based telemedicine program for remote consultations (N = 56 patients with 208 "visits") by wound care nurses in Veterans Administration Outpatient Clinics.
* The majority of consultations resulted in a change in diagnosis or treatment.
* 76% of wounds decreased in size.
* Mean response time for consultation was 2.6 days; patient satisfaction was 98%.
* Results suggest that a "telemedicine" approach to wound care can provide positive outcomes; wound nurses practicing in the home health setting may find the data helpful in marketing telehealth as a viable option for extending their impact without significantly increasing costs.
TITLE: Skin Tears: A Review of Evidence to Support Prevention and Treatment
AUTHORS: Ratliff C, Fletcher K
SOURCE: Ostomy Wound Management 2007; 53(3): 32–42
ARTICLE TYPE: Systematic Literature Review
* Systematic review of meta-analyses, randomized controlled trials, prospective clinical trials, retrospective studies, and systematic reviews using MEDLINE and Cochrane Library databases for 1990–2006.
* Skin tears occurred most commonly on elbows, forearms, and hands in non-ambulatory patients, and on the shins of ambulatory patients. Caregiver education (regarding transfer techniques, stockinette wraps, and nonadherent dressings) had the greatest impact on the reduction of incidence of skin tears. In some states, reporting of skin tears is mandatory.
* Provides evidence-based guidelines for prevention and management of skin tears, with specific guidance and support for the importance of staff/caregiver education.
TITLE: Use of Negative Pressure Wound Therapy in the Treatment of Neonatal and Pediatric Wounds: A Retrospective Examination of Clinical Outcomes
AUTHOR: Baharestani M
SOURCE: Ostomy Wound Management 2007; 53(6): 75–85
* Review of records for 24 pediatric patients (aged 14 days to 18 years) whose wounds were managed with Negative Pressure Wound Therapy (Vacuum Assisted Closure, VAC).
* Author provides a table of recommended negative pressure levels when applying VAC to pediatric patients.
* This is an excellent resource article for wound nurses managing NPWT in the neonatal and pediatric population.
TITLE: Incontinence-Related Skin Damage: Essential Knowledge
AUTHOR: Gray M
SOURCE: Ostomy, Wound Management 2007; 53(12):28–32
ARTICLE TYPE: Integrative Literature Review
* The author provides a thorough review of the prevalence, pathology, differential assessment, and management of incontinence-associated dermatitis.
* This is an excellent resource for WOC nurses establishing protocols for prevention and management of incontinence-associated dermatitis; also provides helpful guidelines for differentiating incontinence-associated dermatitis and pressure-related damage.
TITLE: Discharge Knowledge and Concerns of Patients Going Home With a Wound
AUTHORS: Pieper B, Sieggreen M, Nordstrom C, Freeland B, Kulwicki P, Frattaroli M, Sidor D, Palleschi MT, Burns J, Bednarski D
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(3):245–259
ARTICLE TYPE: Research Report; Comparative Descriptive Study
* Patients and their families are often distressed with the myriad details of the discharge process and often do not fully comprehend the overall wound care plan or specific wound care instructions. The most commonly expressed concerns were: how active to be at home, wound pain, and monitoring for wound complications including infection.
* It is critical to repeat essential information regarding wound care and to provide written instructions as reinforcement.
* The WOC nurse can use this study to help justify the time spent on discharge planning.
TITLE: Preventing and Managing Skin Tears
AUTHOR: Roberts M
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(3):256–259
* Review of pathology and classification of skin tears, using the Payne-Martin Classification System. Principles of skin tear management include approximating the pedicle, maintaining a moist wound healing environment, and protecting the wound from maceration and trauma are described.
* Includes very helpful update on guidelines for topical therapy; for example, the author points out that transparent adhesive dressings are no longer recommended for skin tears.
TITLE: Antibacterial Properties of EMLA and Lidocaine in Wound Tissue Biopsies for Culturing
AUTHORS: Berg JO, Mossner BK, Skov MN, Lauridsen J, Gottrup F, Kolmos HJ
SOURCE: Wound Repair and Regeneration 2006; 14(5): 581–585
ARTICLE TYPE: Research Report; In Vitro Study of Isolates From Wound Cultures
* Study indicates that EMLA has potent antibacterial effects but that 1% lidocaine (preservative free) has minimal effects so long as specimen is collected within 2 hrs.
* Data from this study suggest that EMLA should not be used prior to obtaining a wound biopsy; 1% lidocaine is a better choice. However, the culture should be collected within 2 hours of lidocaine application.
TITLE: Preventing and Modulating Learned Wound Pain
AUTHOR: Sussman C
SOURCE: Ostomy Wound Management 2008; 54(11):38–47
* Provides review of pain pathology, to include pain that occurs without physical stimulation, learned pain (neuroplasticity), pain memories, and phantom pain.
* The author provides guidelines for assessment and prevention of wound-related pain.
* Prevention and management of wound-related pain is a key responsibility for WOC nurses. This article provides important insights into the pathology of chronic pain and effective strategies for prevention and management.
TITLE: Chronic Wounds: Factors Influencing Healing Within 3 Months and Nonhealing After 5–6 Months of Care
SOURCE: Wounds 2007; 19(3); URL: http://www.woundsresearch.com/article/6978, accessed April 2, 2009
ARTICLE TYPE: Research Report; Multisite, Retrospective Review of Medical Records and Electronic Database
* Medical records and data from electronic database of 400 patients with pressure, venous, or diabetic ulcers and at least 3 months of data were reviewed. Patients received routine wound care delivered by typical staff across a variety of care settings.
* Wounds were less likely to heal if they were larger, deeper, infected, highly exudative, or necrotic. Medicaid/nonwhite status and inappropriate management of exudate and necrosis were also associated with poorer healing outcomes. Nonhealing wounds were less likely to be managed with moist wound healing dressings. Pressure ulcers were least likely to heal; venous ulcers were most likely to heal. Wounds located on the iliac crest/trochanter were less likely to heal; lower extremity wounds were more likely to heal.
* Provides an overview of data regarding factors that affect healing. These findings may be beneficial to the wound care nurse in assessing an individual patient's prognosis for healing.
* Provides support for prompt management of necrosis and infection and appropriate use of advanced wound care dressings.
TITLE: The Role of Moisture Balance in Wound Healing
AUTHORS: Okan D, Woo K, Ayello EA, Sibbald G
SOURCE: Advances in Skin and Wound Care 2007: 20(1):39–52
* Reviews current literature concerning the role of moisture balance in wound healing. The authors also discuss dressings that support moist wound healing. The synthesis is based on the DIME conceptual framework: Debridement; Control of Infection and Inflammation; Moisture Balance; and Edge effect.
* This review focuses on the importance of moisture balance; two companion articles addressed the concepts of debridement and control of inflammation (see subsequent reviews).
* Excellent article for distribution to other team members regarding evidence based wound management; provides summary of data regarding importance of effective management of wound exudate and maintenance of a clean, moist wound surface.
TITLE: The Edge Effect: Current Therapeutic Options to Advance the Wound Edge
AUTHORS: Woo K, Ayello EA, Sibbald RG
SOURCE: Advances in Skin and Wound Care 2007; 20(2): 99–117
* Reviews current literature related to the role of the wound edge in wound healing (edge effect refers to ability of epithelial cells at wound edge to migrate across stable bed of granulation tissue).
* This is one of four articles based on DIME conceptual model (see subsequent reviews).
* Excellent article for distribution to other team members regarding evidence based wound management, specifically the impact of the wound edge and current evidence regarding implications for wound management.
TITLE: Water for Wound Cleansing
AUTHORS: Fernandez R, Griffiths R
SOURCE: Cochrane Database of Systematic Reviews 2008; 23(1):CD003861
ARTICLE TYPE: Systematic Review; Meta-analysis
* Seven studies were identified that compared infection and/or healing of wounds using water vs saline; 3 were located that compared water and no cleansing; one study compared procaine vs water.
* Pooled data revealed no evidence that saline is more effective than tap water in reducing infection or improving healing. Rather, some evidence suggests the opposite. The authors conclude that there is insufficient evidence to determine whether cleansing reduces the risk of infection or promotes wound healing.
* Supports use of water for wound cleansing, which is frequently more practical in the home environment. (However, clinician should avoid recommending water for wound cleansing if the water is not safe to drink.)
TITLE: Impact of Tight Glucose Control on Postoperative Infection Rates and Wound Healing in Cardiac Surgery Patients
AUTHOR: Patel K
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(4):368–381
* This article provides an overview of postoperative infections and wound healing in diabetic patients undergoing cardiac surgery, with a focus on the current ADA Guidelines for postoperative glucose control.
* Tight blood glucose control (serum glucose levels between 80 and 150 mg/dL) has been shown to provide better outcomes following cardiac surgery—reduced mortality and fewer wound complications.
* It is critical to establish a program for tight glucose control postoperatively among cardiac surgery patients; it is likely that such a program would promote healing among all surgical patients.
TITLE: Prevention of Projectile and Aerosol Contamination During Pulsatile Lavage Irrigation by a Wound Irrigation Bag
AUTHORS: Angobaldo J, Sanger C, Marks M
SOURCE: Wounds 2008; 20(6); URL: http://www.woundsresearch.com/article/8881, accessed April 4, 2009
ARTICLE TYPE: Research Report; Randomized Clinical Trial
* Aerosolization of bacteria is a major concern with use of pulsed lavage. The authors compared standard pulsed lavage to lavage using a wound irrigation bag. Use of the wound irrigation bag reduced the amount of aerosolized bacteria within a 3-foot circumference of the procedure.
* Clinicians using pulsed lavage should ask their vendors about containment units and data regarding their effectiveness.
TITLE: Polyhexamethylene Biguanide (PHMB): An Addendum to Current Topical Antimicrobials
AUTHORS: Mulder GD, Cavorsi JP, Lee DK
SOURCE: Wounds 2007; 19(7); URL: http://www.woundsresearch.com/article/7494, accessed April 4, 2009
* The authors review research pertaining to bacterial species commonly involved in wound infections and topical therapy options.
* A number of pathogens involved in wound infections can produce biofilms (Pseudomonas, Klebsiella, S. aureus, E. coli).
* Silver and iodine are the most commonly used antimicrobial dressings. Silver can eradicate bacteria either by binding to the cell wall and disrupting its membrane or by binding to DNA and preventing replication.
* Iodine "works" by destabilizing cell walls.
* PHMB works by causing increased permeability of cell walls, leading to cell death; it exerts maximum bactericidal activity at pH 5–6. No toxicity to fibroblasts has been demonstrated.
* In 1 small study of venous ulcers that did not respond to either silver or iodine, PHMB produced 42% reduction in CFU in 25 days (N = 7).
* PHMB may be effective in wounds that do not respond to silver or iodine (PHMB is the active ingredient in Kerlix AMD, Telfa AMD, X Cell AM).
TITLE: Diagnostic Validity of Three Swab Techniques for Identifying Chronic Wound Infection
AUTHORS: Gardner SE, Frantz RA, Saltzman CL, Hillis SL, Park H, Scherubel M
SOURCE: Wound Repair and Regeneration 2006: 14(5): 548–557
ARTICLE TYPE: Research Report; Observational, Cross-sectional
* Wound surface swabs harvested from non-arterial, full thickness wounds using 3 techniques were analyzed: (1) swab of wound exudate obtained immediately after dressing removal and before cleansing; (2) swab of entire cleansed wound surface using zig-zag technique; and (3) swab using Levine's technique. Concurrent biopsy was taken using a 4–6 mm punch to obtain viable tissue; biopsy was used as a comparative standard. Eighty-three patients participated in the study.
* Data analysis revealed statistically significant agreement between biopsy results and all swab techniques; BEST concordance was with Levine's technique.
* Levine's technique remains the recommended approach to obtaining a swab culture (1-square cm of viable tissue swabbed with enough force to produce exudate after wound cleansed with saline).
TITLE: Antibacterial Honey (MediHoney). In-vitro Activity Against Clinical Isolates of MRSA, VRE, and Other Multi-Resistant Gram-Negative Organisms Including Pseudomonas
AUTHORS: George NM, Cutting KF
SOURCE: Wounds 2007; 19(9); URL: http://www.woundsresearch.com/article/7751, accessed April 5, 2009.
ARTICLE TYPE: Research Report; In Vitro Study of Isolates Obtained From Clinical Isolates
* Not all honeys are the same; "honey" is not a generic term.
* Antibacterial honeys are primarily sourced from Leptospermum species (Manuka Honey).
* The concentration of honey needed to achieve a bactericidal effect varies significantly based on the bacterial species and strain.
* Use of honey in wound care should be limited to honeys shown to be potentially therapeutic. Off the shelf honey products should never be used in wound care.
* The clinician must be aware that there are limited data regarding the bactericidal efficacy of honey and the concentration required for positive results.
TITLE: Outcomes Research: Measuring Wound Outcomes
AUTHORS: Romanelli M, Dini V, Bertone M, Brilli C
SOURCE: Wounds 2007; 19(11); URL: http://www.woundsresearch.com/article/7986, accessed April 5, 2009
ARTICLE TYPE: Integrative Review
* This article reviews wound assessment parameters most commonly identified as predictors of healing for venous, diabetic foot, and pressure ulcers.
* In reports to date involving multiple assessment parameters, the percent reduction in wound surface area during the first two weeks of care is the most reliable indicator for complete healing.
* Wounds should be carefully monitored for progress during the first two weeks of care; wounds that fail to show expected progress should be identified as potentially refractory and the clinician should consider active wound therapies.
TITLE: Operational Definition of Moist Wound Healing
AUTHOR: Bolton L
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(1):23–29
* This evidence-based report card provides an extensive literature review that supports application of moist wound healing principles in the management of both acute and chronic wounds.
* Excellent article to share with other clinicians who challenge the concept and evidence behind moist wound healing.
TITLE: New Topical Agents for Treatment of Partial-Thickness Burns in Children: A Review of Published Outcome Studies
AUTHORS: Dorsett-Martin W, Persons B, Wysocki A, Lineaweaver W
SOURCE: Wounds 2008; 20(11); URL: http://www.woundsresearch.com/content/new-topical-agents-treatment-partial-thickness-burns-children-a-review-published-outcome-stu, accessed April 5, 2009
* Studies to date suggest that advanced wound care products (Biobrane, Transcyte, Duo-derm, Mepitel) are associated with reduced infection rates, reduced pain, and faster healing in partial thickness burns among pediatric patients (as compared to topical antimicrobials such as silver sulfadiazine).
* There is insufficient evidence to establish product or treatment superiority.
* Wound care nurses may be involved in management of small burns and should be aware that moist wound healing dressings are as effective or more effective than products such as silver sulfadiazine creams.
TITLE: Prevention and Treatment of Moisture-Associated Skin Damage (Maceration) in the Periwound Skin
AUTHORS: Gray M, Weir D
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(2):153–157
ARTICLE TYPE: Systematic Literature Review (Evidence-Based Report Card)
* The use of periwound skin protectants decreases the incidence of maceration; however, available data suggests there is no significant difference between the various barriers.
* Existing evidence suggests that a silver foam may prevent maceration better than a non-silver foam in wounds that are draining.
* It is critical to protect the periwound skin from maceration, but the decision regarding which protectant to use should be based on the characteristics of the surrounding skin, the dressing protocol, and cost/availability issues. For example, copolymer films are usually a better choice with adherent dressings, whereas a moisture barrier ointment can be effective with extremity wounds where the dressing is secured with wrap gauze.
TITLE: Enzymatic Wound Debridement
AUTHORS: Ramundo J, Gray M
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(3):273–280
ARTICLE TYPE: Systematic Review (Evidence-Based Report Card)
* This evidence-based report card examines evidence related to the use of enzymatic debriding agents in selected patients. Existing evidence suggests that collagenase is more effective than a placebo ointment for removal of necrotic tissue from pressure ulcers and leg ulcers.
* Enzymatic debridement is a viable option for patients with necrotic wounds who are not surgical candidates. The clinician should be aware that collagenase products remain available, although papain-urea products were pulled from the market by the United States Food and Drug Administration in late 2008.
TITLE: Is Larval (Maggot) Debridement Effective for Removal of Necrotic Tissue From Chronic Wounds?
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(4):378–384
ARTICLE TYPE: Literature Review (Evidence-Based Report Card)
* This report examines research focusing on the efficacy of maggot debridement therapy (MDT) and its role in wound management. The concept of wound bed preparation is discussed.
* Clinical experience supports the efficacy of MDT for debridement of necrotic tissue from wounds. The author points out that there is insufficient evidence to determine whether MDT is more effective than other means of debridement or that MDT increases healing or reduces bioburden.
* The clinician should be aware that MDT is supported by anecdotal evidence, but there are no data that indicate superiority to other methods of debridement.
Title: Is Ultrasound Mist Therapy Effective for Debriding Chronic Wounds?
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(6):579–583
* This review summarizes available evidence regarding the role of devices using ultrasonic energy for removal of necrotic tissue and the promotion of wound healing.
* The authors include current evidence regarding contraindications, use of personal protective equipment, and ultrasound's possible effects on bioburden. Limited evidence suggests that non-contact devices may have a greater role in promotion of wound healing than in debridement.
* Clinicians considering use of ultrasound devices should review the company's data to determine the best utilization of the device.
TITLE: Skin Substitutes and Alternatives: A Review
AUTHORS: Shores J, Gabriel A, Gupta S
SOURCE: Advances in Skin and Wound Care 2007; 20(9): 493–508
* The authors review currently available skin substitutes and provide guidelines for their application.
* Excellent resource for current data regarding use of skin substitutes.
TITLE: Extracellular Wound Matrices: Novel Stabilization and Sterilization Methods for Collagen-Based Biologic Wound Dressings
AUTHORS: Nataraj C, Ritter G, Dumas S, Helfer FD, Brunelle J, Sander TW
SOURCE: Wounds 2007; 19(6)(supplement); URL: http://www.woundsresearch.com/article/7374, accessed April 5, 2009
* Review of mechanisms of action, indications, and factors affecting clinical outcomes for extracellular matrix (ECM) products, such as SIS Wound Matrix (OASIS) and Graft Jacket.
* The ECM plays a critical role in repair. It acts as a functional matrix that provides a scaffold over which cells can migrate. The ECM regulates communication among cells critical to wound repair, and generates signals to cells to migrate and synthesize new matrix.
* While chronic nonhealing wounds may differ in terms of specific etiology, there are marked similarities in the wound environment that contribute to their failure to heal.
* The absence of a functional ECM is an impediment to both granulation tissue formation and epithelial resurfacing.
* The ECM plays a critical role in the wound healing process, and lack of a functional matrix may be one of the factors contributing to failure to heal.
* A number of products are being developed and evaluated for their ability to function as a "replacement, substitute" ECM; these products may promote healing of refractory wounds.
TITLE: Extracellular Wound Matrix (OASIS): Exploring the Contraindications. Results of Its Use in 32 Consecutive Outpatient Clinic Cases
AUTHORS: Barendse-Hofmann M, Steenvoorde P, van Doorn L, Jacobi CE, Oskam J, Hedeman PP
SOURCE: Wounds 2007; 19(10); URL: http://www.woundsresearch.com/article/7892, accessed April 5, 2009
ARTICLE TYPE: Research Report; Case Series
* Thirty-two patients with wounds that had been debrided and were granulating but not epithelializing were treated with weekly application of a wound matrix product. Patient and wound characteristics were compared to established contraindications for the ECM product.
* 74.2% closed completely; the two most common adverse events were infection and hypergranulation tissue. ECM was discontinued in patients who developed infection; hypergranulation tissue was treated with AgNO3 and ECM was continued. Analysis of patient and wound characteristics revealed that only 77% would be deemed ineligible for therapy owing to current contraindications. Based on this clinical experience, the authors concluded that the established criteria are excessively strict.
* Extracellular matrix products such as OASIS should be considered for management of wounds that are granulating but not epithelializing. Clinical experience suggests that adverse effects are limited and easily managed.
TITLE: New Opportunities to Improve Pressure Ulcer Prevention and Treatment: Implications of the CMS Inpatient Hospital Care Present on Admission (POA) Indicators/Hospital-Acquired Conditions (HAC) Policy. Consensus Paper From International Expert Wound Care Advisory Panel
AUTHORS: Armstrong D, Ayello EA, Capitulo K, Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, Sibbald RG, Smith AP
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(5):485–492.
ARTICLE TYPE: Integrative Literature Review; Consensus Statement
* A group of clinical experts reviews recent CMS decisions about reimbursement for hospital-acquired pressure ulcers. They especially focus on admission assessment and documentation of skin status (to meet present on admission requirements), risk assessment, and implementation of aggressive prevention protocols to minimize the incidence of hospital-acquired pressure ulcers. They emphasize the need for a multidisciplinary approach with total team involvement, including ongoing education targeting patients, families, and caregivers.
* Provides excellent synopsis of the changes in CMS reimbursement related to hospital-acquired pressure ulcers, along with implications for wound care nurses in the acute care setting.
TITLE: Risk Assessment Scale for Pressure Ulcer Prevention: Systematic Review
AUTHORS: Pancorbo-Hidalgo P, Garcia-Fernandez F, Lopez-Medina I, Alvarez-Nioto C
SOURCE: J Advanced Nursing 2006: 54(1):94–110
ARTICLE TYPE: Systematic Literature Review; Meta-analysis
* Fourteen databases were searched for evidence related to pressure ulcer risk assessment based on the Braden Scale, Norton Scale, Waterlow Scale, and clinical judgment.
* The Braden Scale provided optimal predictive power: 67% correct based on 16 studies that enrolled 5847 patients. The Norton Scale was found to provide the second strongest predictive power: 60.2% correct based on 5 studies enrolling 2008 patients.
* This systematic review supports use of the Braden Scale as the most powerful of the currently available risk assessment tools for predicting pressure ulcer risk.
TITLE: Prevention and Early Detection of Pressure Ulcers in Hospitalized Patients
AUTHORS: Padula C, Osborne E, Williams J
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(1):66–75
ARTICLE TYPE: Quality Improvement Project
* The authors describe a comprehensive staff education program with follow-up at the bedside that achieved a positive impact on pressure ulcer incidence.
* The authors emphasize the importance of a comprehensive and interdisciplinary approach to pressure ulcer prevention. However, they point out that some pressure ulcers appear to be unavoidable, even with appropriate preventive care.
* This article provides insight into measures that may reduce nosocomial pressure ulcers; it also provides support for the position that some ulcers are unavoidable.
TITLE: Does Regular Repositioning Prevent Pressure Ulcers?
AUTHORS: Krapfl L, Gray M
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(6):571–577
* This report card reviews available evidence on routine repositioning for pressure ulcer prevention.
* The authors conclude that there is limited evidence to suggest that turning every 4 hours combined with a pressure redistribution surface is as effective as turning every 2 hours in patients placed on a standard hospital mattress.
* There was no evidence found to support the 30-degree lateral tilt is superior to a 90-degree turn.
* Excellent review of studies done on repositioning frequency, including studies regarding impact of pressure redistribution surfaces on turning frequency.
* Provides support for modifying turning frequency for patients managed on pressure redistribution surfaces.
TITLE: Evaluation of a Protocol for Prevention of Facility-Acquired Heel Pressure Ulcers
AUTHORS: Walsh J, Ploczynski D
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(2):178–183
* A pressure ulcer prevention protocol that included vigilant use of the Braden Scale and pressure reducing devices contributed to the reduction of facility-acquired pressure ulcers of the heel.
* The project included a comparative evaluation of two heel elevation devices, Waffle Boots and Prevalon Heel Protectors.
* This is an excellent source for WOC nurses addressing the problem of nosocomial heel ulcers; provides evidence regarding importance of heel elevation and comparative data regarding two commonly used devices.
TITLE: The Effect of a Pressure Ulcer Program and the Bowel Management System (BMS) in Reducing Pressure Ulcer Prevalence in an ICU Setting
AUTHORS: Benoit RA, Watts C
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(2):163–175
* Using the Braden Scale subscale related to moisture (specifically bowel incontinence) and implementation of an internal bowel management system (Zassi BMS, Hollister, Libertyville, IL), the authors demonstrated a marked reduction in skin breakdown.
* This article addresses role of bowel management systems in reducing skin breakdown. It is valuable for the WOC nurse because of its useful policies, procedures, and protocols for effective use of bowel or fecal management systems in the critical care setting.
TITLE: Education and Empowerment of the Nursing Assistant: Validating Their Important Role in Skin Care and Pressure Ulcer Prevention, and Demonstrating Productivity Enhancement and Cost Savings
AUTHOR: Howe L
SOURCE: Advances in Skin and Wound Care 2008; 21(6):275–281
* The authors describe experiences with a quality improvement project that included education of non-licensed personnel and change in protocols for routine skin care and incontinence care.
* An outcomes analysis demonstrated a clinically relevant reduction in agency-acquired pressure ulcers.
* This article provides guidelines and support for education of nursing assistants as a critical component of a process improvement project related to pressure ulcer prevention. It addresses other useful measures to reduce nosocomial breakdown.
TITLE: Pressure Ulcer Prevention and Management in Spinal Cord Injured Adults: Analysis of Educational Needs
AUTHORS: Schubart JR, Hilgart M, Lyder C
SOURCE: Advances in Skin and Wound Care 2008; 21(7): 322–329
ARTICLE TYPE: Research Report; Qualitative Narrative Analysis (Needs Assessment Study)
* Sixteen persons with spinal cord injuries and eight professional care providers were interviewed to determine educational needs related to pressure ulcer prevention and early detection.
* Analysis of narratives revealed significant gaps in knowledge, suggesting a need for more intensive long-term education about skin care for adults with spinal cord injuries.
* Provides valuable data regarding the need for long-term and repetitive education regarding pressure ulcer prevention for spinal cord–injured patients. Results of this study could be beneficial in demonstrating the need for outreach/outpatient educational programs.
TITLE: Pressure Ulcers in Neonates and Children: An NPUAP White Paper
AUTHORS: Baharestani M, Ratliff CR
SOURCE: Advances in Skin and Wound Care 2007: 20(4): 208–219
ARTICLE TYPE: Integrative Literature Review; Clinical Practice Guideline
* Provides a review of current evidence regarding prevention and management of pressure ulcers among pediatric population. The authors include AWHONN (Association of Women's Health, Obstetric, and Neonatal Nurses) recommendations for topical therapy.
* Wound care nurses need to be aware that many products used for adolescents and adults may be inappropriate for neonates and infants due to the greater permeability and fragility of their skin.
* AWHONN has now published updated evidence-based guidelines for neonatal skin care. They can be purchased from their web site, www.AWHONN.com.
TITLE: Reducing Hospital Acquired Pressure Ulcers Through a Focused Prevention Program
AUTHOR: McInerney JA
SOURCE: Advances in Skin and Wound Care 2008; 21(2): 75–77
* Authors report on results of a multi-intervention pressure ulcer prevention program in a 548-bed health system composed of 2 community based acute care facilities. Pressure ulcer incidence was reduced by 81%; incidence of heel ulcers was reduced by 90%.
* Key prevention strategies included use of the Braden Scale for risk assessment, use of air overlays for patients with Braden scores less than 16, and WOC nurse consult for patients with Braden scores less than 13.
* This article provides insight and guidance into strategies that can be effective in reducing nosocomial pressure ulcers.
TITLE: Multisite Web-Based Training in Using the Braden Scale to Predict Pressure Sore Risk
AUTHORS: Magnan M, Maklebust J
SOURCE: Advances in Skin and Wound Care 2008: 21(2): 14–133
ARTICLE TYPE: Research Report; Prospective Before-After Single Group Study
* The authors use web-based training to try to improve accuracy in pressure ulcer risk assessment using the Braden Scale.
* Accuracy in risk assessment is a key element of an effective prevention program, and this article addresses staff nurse training in the accurate use of the Braden Scale.
* The authors suggest a combination of training and clinical experience as opposed to training alone.
TITLE: Certification and Education: Do They Affect Pressure Ulcer Knowledge in Nursing?
AUTHORS: Zulkowski K, Ayello EA, Wexler S
SOURCE: Advances in Skin and Wound Care 2007; 20(1): 34–38
ARTICLE TYPE: Research Report, Cross-sectional Survey and Knowledge Test
* Four hundred nurses certified in wound care, specialty areas other than wound care and nurses without specialty practice certification provided demographic information and completed a standardized test measuring pressure ulcer knowledge (Pieper Pressure Ulcer Knowledge Tool).
* The mean score for nurses certified in wound care on the standardized test was higher than for nurses certified in other specialty areas or those without certification.
* This article provides support for the benefits of education and certification and may be helpful to wound care nurses who are trying to justify their roles to administration.
TITLE: Are All Pressure Ulcers the Result of Deep Tissue Injury? A Review of the Literature
AUTHORS: Berlowitz DM, Brienza D
SOURCE: Ostomy, Wound Management 2007; 53(10):34–38
* Provides review of current theories regarding pressure ulcer pathology and contributing factors (pressure, shear, friction, and moisture).
* Authors point out that superficial lesions caused by friction and maceration are frequently "mis- diagnosed" as pressure ulcers.
* Excellent review of pressure ulcer pathology compared to pathology of superficial lesions; helpful resource to wound care nurses in educating nurses re: pathology and characteristics of ischemic (pressure) injuries versus traumatic (friction) injuries.
TITLE: Intraoperative Acquired Pressure Ulcers: Are There Common Risk Factors?
AUTHOR: Aronovitch SA
SOURCE: Ostomy Wound Management 2007; 53(2):57–69
ARTICLE TYPE: Research Report; Cross-sectional Survey
* Data collected on surgical patients to determine incidence of pressure ulcers appearing immediately following surgery and risk factors associated with ulcer development.
* The incidence of pressure ulcers among participating patients was 3.5%; their median OR time was 4.48 hours. Associated factors included age; type of surgery; intraoperative positioning; and number of anesthetic agents.
* Currently available risk assessment tools did not accurately predict intraoperative pressure ulcers in this study.
* Standard risk assessment tools do not accurately measure risk for intraoperative pressure ulcers, and specific risk factors for intraoperative ulcers have not yet been definitively identified. Research is ongoing.
TITLE: National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System
AUTHORS: Black J, Baharestani MM, Cuddigan J, Dorner B, Edsberg L, Langemo D, Posthauer ME, Ratliff C, Taler G
SOURCE: Advances in Skin and Wound Care 2007; 20(5): 269–274
ARTICLE TYPE: Consensus Statement
* NPUAP has revised the pressure ulcer staging system in an attempt to clarify each stage and reduce number of wounds that were incorrectly staged or classified.
* Primary revisions included clarification of Stage 2 and clear statements that non-pressure wounds should not be staged. The panel also clarified that a wound whose bed is partially obscured by necrotic tissue but where muscle, tendon, or bone remain visible and can be identified can be staged as Stage 4. New categories, deep tissue injury and unstageable, were defined.
* The official staging system has been modified; wound care nurses can use this article as a reference in updating the documents and staff education programs in their agencies.
TITLE: Evaluation of Pressure Ulcers in 202 Patients With Cancer: Do Patients With Cancer Tend to Develop Pressure Ulcers? Once Developed, Are They Difficult to Heal?
AUTHORS: Masaki F, Riko K, Seiji H, Shuhei Y, Aya Y
SOURCE: Wounds 2007; 19(1); URL: http://www.woundsresearch.com/article/6706, accessed April 5, 2009.
ARTICLE TYPE: Research Report; Retrospective Comparison Cohort Study
* Medical records of 419 patients who developed pressure ulcers were reviewed; 202 also had a diagnosis of cancer and 217 did not. Pressure ulcer risk was measured using the OH scale.
* Patients with cancer more likely to develop pressure ulcers despite "lower" risk scores than were patients without cancer.
* No differences were found when healing time for subjects with cancer was compared to those without cancer.
* Study results suggest that cancer may be an independent risk factor for pressure ulcer development.
TITLE: Best Practice Recommendations for Prevention and Treatment of Pressure Ulcers: Update 2006
AUTHORS: Keast DH, Parslow NE, Houghton PE, Norton K, Fraser C
SOURCE: Advances in Skin and Wound Care 2007; 20(8): 447–460
ARTICLE TYPE: Clinical Practice Guidelines
* The article is reprinted from Wound Care Canada, the Official Publication of the Canadian Association of Wound Care (2006;4[1]:31–43). It provides a review of current "best practice" recommendations for pressure ulcer prevention and management.
* Provides level of evidence for various recommendations, as cited by Registered Nurses' Association of Ontario guidelines.
* Includes discussion of becaplermin (Regranex) for treatment of pressure ulcers. Readers should be aware that in the US, becaplermin is indicated for the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. The efficacy of becaplermin has not been established for the treatment of pressure ulcers and venous ulcers.
* Provides comprehensive compilation of current guidelines for pressure ulcer prevention and management, along with "level of evidence" for each recommendation.
TITLE: Dressings for Healing Venous Leg Ulcers
AUTHORS: Palfreyman S, Nelson EA, Lochiel R, Michaels JA
SOURCE: Cochrane Database of Systematic Reviews: 2006;(3):CD001103
* Compared dressings' effect on time to healing, proportion healed, and rate of healing. 42 RCTs involved 3001 pts; HCD vs foam; alginate vs HCD; HCD vs other HCD; HCD vs low-adherent; foam vs foam; hydrogels vs low-adherent.
* No significant difference was found between the healing effects of any 2 dressings.
* Provides support for principle-based wound care, i.e., dressing selection based on wound characteristics, and provides evidence that there is no one "best" dressing.
TITLE: Antibiotics and Antiseptics for Venous Leg Ulcers
AUTHORS: O'Meara S, Al-Kurdi D, Ovington LG
SOURCE: Cochrane Database of Systematic Reviews 2008; 23(1):CD003557
* Twenty-two studies were identified that focused on antibiotic or antiseptic use in the management of patients with venous leg ulcers. Five involved systemic antibiotics; 10 involved cadexomer iodine; six used other agents.
* Pooled analysis revealed no evidence supporting the routine use of systemic antibiotics to promote healing of venous leg ulcers. Limited evidence was identified that supports the use of cadexomer iodine, but further research is needed before definitive conclusions can be made.
* Routine use of systemic antibiotics should be discouraged; some data support use of topical antimicrobials such as cadexomer iodine in the management venous ulcers.
TITLE: Prospective Randomized Controlled Study of Hydrofiber Dressing Containing Ionic Silver or Calcium Alginate Dressings in Non-Ischaemic Diabetic Foot Ulcers
AUTHORS: Jude EB, Apelqvist J, Spraul M, Martini J, Silver Dressing Study Group
SOURCE: Diabetic Medicine 2007; 24(3):280–288
* A hydrofiber dressing with silver was compared to a calcium alginate dressing in a multisite study involving 134 patients with non-ischemic diabetic foot ulcers. Inclusion criteria included a diagnosis of Type 1 or 2 diabetes mellitus with a hemoglobin A1c ≤ 12%, adequate lower limb perfusion, and neuropathic or neuroischemic Wagner Grade I or Grade II >1 sq cm in area. Ulcers were surgically debrided until the wound bed was covered by <5% necrotic tissue. Supportive care included accommodative footwear and offloading.
* Ulcers randomized to the silver hydrofiber dressing had a greater reduction in wound depth and fewer required systemic antibiotics for wound infections. Wound healing outcomes were otherwise comparable.
* Silver dressings may be of benefit in the management of diabetic foot ulcers.
TITLE: Lack of Reliability of Clinical/Visual Assessment of Chronic Wound Infection: The Incidence of Biopsy Proven Infection in Venous Leg Ulcers
AUTHORS: Serena T, Robson MC, Cooper DM, Ignatius J
SOURCE: Wounds 2006; 18(7); URL: http://www.woundsresearch.com/article/5944, accessed April 6, 2009
ARTICLE TYPE: Research Report; Secondary Analysis of Randomized Clinical Trial
* Six hundred fourteen patients were screened for evidence of infection based on the following indicators: delayed healing; friable and/or discolored granulation tissue; undermined wound edge; foul odor; wound deterioration; and increased pain. Wounds were biopsied using a 6 mm punch and biopsy results were compared to clinical assessment.
* Biopsy results supported clinical assessment in 74% of cases. The majority of cases (95%) involved only one organism, most commonly Staphylococcus aureus. Polymicrobial culture results were more likely to occur in patients who had previously been diagnosed with an infection and treated with antibiotics.
* Clinical indicators of wound infection accurately reflect biopsy results in most (but not all) venous ulcers. These results support the importance of meticulous serial wound assessments to determine evidence of surface wound infection or critical colonization.
TITLE: NPWT After Partial Diabetic Foot Amputation: A Multicenter Randomized Controlled Trial
AUTHORS: Armstrong DG, Lavery LA
SOURCE: Lancet 2005; 366(9498):1704–1710
ARTICLE TYPE: Research Report; Randomized Controlled Trial
* This 16-week study evaluated outcomes of 162 patients randomly assigned to either standard care (offloading) plus NPWT using the VAC device or standard care (offloading) plus moist wound dressings.
* 56% in NPWT group healed either with or without surgery vs 39% in moist wound dressing group (P = 0.04).
* 40% in NPWT group healed by secondary intention (did not require surgery), as compared to 29% in the group managed with moist wound dressings (P = 0.005).
* Partial amputation sites healed in 56 days in NPWT group as compared to 77 days in the group managed with moist wound dressings.
* The wound care nurse should consider use of NPWT to promote healing among patients with diabetic foot ulcers after partial amputation.
TITLE: SAWC Oral Abstracts Summary: Role of High-Voltage Pulsed Electrical Stimulation in Limb Salvage for Diabetic Patients
AUTHORS: Burdge J, Hartman J, Wright M
SOURCE: Wounds 2008; 20(3); URL: http://www.woundsresearch.com/article/8459, accessed April 5, 2009
ARTICLE TYPE: Abstract Only
* Thirty patients with 45 full-thickness diabetic foot and lower extremity wounds who failed standard therapy (vascular evaluation, surgical intervention if indicated, offloading, debridement, and infection control) were treated with high voltage pulsed electrical stimulation. The mean number of treatments was 22.3. The mean age of the wounds was 25 weeks.
* 35 (77.8%) of wounds healed; mean healing time was 14.2 weeks.
* 31 (68.9%) of wounds remained healed at follow-up (mean time to follow-up 39.4 wks).
* Electrical stimulation can promote healing and limb salvage for diabetic patients who fail standard therapy. The wound care nurse should collaborate with physical therapy to provide appropriate therapy for these patients.
TITLE: SAWC Oral Abstracts Summary: Living Cells or Collagen Matrix: Which Is More Beneficial in Treatment of Diabetic Foot Ulcers?
AUTHORS: Landsman A, Roukis TS, DeFronzo DJ, Agnew P, Petranto RD, Surprenant M
SOURCE: Wounds 2008; 20(5); URL: http://www.woundsresearch.com/article/8705, accessed April 6, 2009
ARTICLE TYPE: Research Report; Randomized Controlled Trial (Nonblinded)
* Twenty-six subjects with diabetic foot ulcers that had been under treatment for at least 4 weeks were randomized to standard therapy (debridement, offloading) plus OASIS (acellular, collagen-based dressing) or Dermagraft (living skin equivalent with human fibroblasts seeded onto polyglactin mesh scaffold). In both groups, the active wound agent was covered with damp saline gauze.
* There was no statistically significant difference in time to closure between the 2 groups.
* The average cost for the extracellular matrix dressing was $807; the average cost for the living skin substitute was $3505.
* While both OASIS and Dermagraft promoted healing in these diabetic wounds, OASIS achieved similar outcomes at a lower cost. The wound care nurse should consider OASIS as initial therapy for diabetic foot ulcers that fail to heal with standard therapy.
TITLE: Role of a Silver Releasing Lipido-colloidal Contact Layer in Venous Leg Ulcers Presenting Inflammatory Signs
AUTHORS: Lazareth I, Meaume S, Sigal-Grinberg ML, Combemale P, Guyadec TL, Zagnoli A, Perrot J, Sauvadet A, Bohbot S
SOURCE: Wounds 2008; 20(6); URL: http://www.woundsresearch.com/article/8880, accessed April 6, 2009.
* One hundred two subjects were randomized in a clinical trial comparing a silver-containing contact layer dressing to the same contact layer dressing without the silver. All subjects had venous ulcers with at least 3 of the following 5 indicators of high bioburden: (1) pain between dressing changes; (2) periwound erythema; (3) edema; (4) foul odor; (5) heavy exudate. Ninety-nine subjects completed the study.
* All patients received compression therapy in addition to the topical therapy described above.
* Patients were managed with their assigned protocol for 4 weeks, at which point all patients were converted to the control protocol (compression and the non-silver contact layer dressing) for 4 weeks.
* Median reduction in wound area for the silver group was 5.9 cm2 (47.9%) as compared to 0.8 cm2 (5.6%) for the non-silver group.
* This study provides support for use of silver dressings in venous ulcers with clinical indicators of critical colonization.
TITLE: Improving Limb Salvage in Critical Ischemia With Intermittent Pneumatic Compression: A Controlled Study With 18-Month Follow-up
AUTHORS: Kavros SJ, Delis KT, Turner NS, Voll AE, Liedl DA, Gloviczki P, Rooke TW
SOURCE: Journal of Vascular Surgery 2008; 47(3): 543–549
ARTICLE TYPE: Research Report; Retrospective Cohort Study
* Medical records of forty-eight patients were retrospectively analyzed. Twenty-four patients were managed by weekly debridement plus biologic dressings for open wounds. A second group of 24 patients received the same therapy plus intermittent pneumatic compression (IPC).
* No statistically significant differences in clinically relevant arterial or wound characteristics were found when groups were retrospectively analyzed.
* Fourteen patients (58%) treated with debridement, biologic dressings, and IPC healed as compared to 4 patients (17%) treated with debridement and biologic dressings alone.
* The wound care nurse should consider use of pneumatic compression therapy in management of patients with critical limb ischemia.
TITLE: Are Ankle and Toe Brachial Indices (ABI-TBI) Obtained by a Pocket Doppler Interchangeable With Those Obtained by Standard Laboratory Equipment?
AUTHORS: Bonham PA, Cappuccio M, Hulsey T, Michel Y, Kelechi T, Jenkins C, Robison J
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2007; 34(1):35–44
ARTICLE TYPE: Research Report; Comparison Cohort Study
* Thirty patients underwent both bedside ankle brachial index (ABI) and toe brachial index (TBI) testing and testing in a vascular laboratory using two instruments, a standard laboratory based Doppler and a handheld battery operated pocket Doppler device.
* Differences between ankle brachial indices were within the 15% limit of variability established as acceptable prior to the research. In contrast, differences between toe brachial indices exceeded this level of agreement.
* Handheld Dopplers can be effectively used to obtain valid ABI results at the bedside; if TBI is required, the patient should be referred to the vascular lab.
TITLE: Lymphedema in the Morbidly Obese Patient: Unique Challenges in a Unique Population
AUTHORS: Fife C, Carter M
SOURCE: Ostomy Wound Management 2008; 54(1): 44–56
* Concise review of the pathology of venous edema, lymphedema, and lipedema in the morbidly obese patient, with guidelines for differential assessment and management.
* Authors stress importance of accurate assessment and holistic approach to management, including weight loss strategies.
* The WOC nurse must be able to differentiate between venous edema, lymphedema, and lipedema in order to manage patients effectively and make appropriate referrals. This article provides valuable tips for accurate assessment and management.
TITLE: Compression in Venous Ulcer Management
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(1):40–49
* This article provides a review of the evidence base for currently available treatment options for venous ulcers. Substantial (Level 1 or Level A) evidence exists to support moderate to high level elastic or inelastic 2-layer and 4-layer sustained graduated compression bandages, and single-layer compression products for management of venous ulcers.
* Substantial evidence indicates that compression promotes healing better than no compression.
* In selecting compression therapy for an individual patient, the WOC nurse should know that current data support multilayer elastic compression systems as being more effective than inelastic products and Unna's Boots (with Unna's Boots, sub-bandage pressure drops below therapeutic levels within 8 hours).
TITLE: Impact of a Preventive Program on Amputation Rates in the Diabetic Population
AUTHOR: King L
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(5):479–482
* The author described experiences when establishing a Foot Care Clinic that focused on routine screening and aggressive education related to preventive foot care.
* The author provides specific guidelines for preventive care, and reports a reduction in lower extremity amputations following implementation of this program.
* Provides valuable guidelines for establishing a comprehensive limb preservation program and also provides documentation of the clinical benefits of such a program (which could be helpful to wound care nurses trying to market a similar program).
TITLE: The Case for Evidence in Wound Care: Investigating Advanced Treatment Modalities in Healing Chronic Diabetic Lower Extremity Wounds
AUTHOR: Lyon KC
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(6):585–590
ARTICLE TYPE: Research Report; Retrospective Review of Medical Records
* Medical records of 89 patients with diabetic ulcers refractory to standard care and subsequently managed by comprehensive care plan that included use of advanced therapies growth factor therapy and/or hyperbaric oxygen therapy (HBO).
* Patients receiving HBO therapy healed faster than those receiving standard care alone or standard care plus growth factor therapy.
* Emphasizes importance and impact of comprehensive wound care that includes attention to etiologic factors, systemic support, appropriate topical therapy, and use of hyperbaric oxygen and growth factors when indicated.
TITLE: Treatment of Ischemic Wounds With Noncontact, Low-Frequency Ultrasound: The Mayo Clinic Experience 2004–2006
AUTHORS: Kavros S, Miller J, Hanna S
SOURCE: Advances in Skin and Wound Care 2007; 20(4): 221–225
ARTICLE TYPE: Research Report, Randomized Controlled Trial
* Compared standard care alone vs standard care + noncontact low-frequency ultrasound in management of nonhealing leg/foot ulcers associated with critical limb ischemia.
* Found significant improvement in healing rates among treatment group.
* The wound care nurse should consider noncontact low-frequency ultrasound for patients with critical limb ischemia and nonhealing wounds.
TITLE: Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers: Update 2006
AUTHORS: Burrows C, Miller R, Townsend D, Bellefontaine R, Mackean G, Orsted HL, Keast DH
SOURCE: Advances in Skin and Wound Care 2007; 20(11): 611–621
ARTICLE TYPE: Systematic Literature Review; Clinical Practice Guidelines
* The authors summarize "best practice" recommendations for treatment of venous leg ulcers.
* The supporting systematic literature review was adapted from the Registered Nurses' Association of Ontario evidence-based guidelines for assessment/ management of venous ulcers.
* Comprehensive compilation of current guidelines for venous ulcer management, along with "level of evidence" for each recommendation.
TITLE: Best Practice Recommendations for the Prevention, Diagnosis, and Treatment of Diabetic Foot Ulcers: Update 2006
AUTHORS: Orsted H, Searles GE, Trowell H, Shapera L, Miller P, Rahman J
SOURCE: Advances in Skin and Wound Care 2007; 20(12): 655–669
ARTICLE TYPE: Systematic Literature Review/ Evidence-Based Guidelines
* The authors summarize "best practice" recommendations for treatment of diabetic foot ulcers, with a particular focus on multidisciplinary management and systemic interventions.
* The supporting systematic literature review was adapted from the Registered Nurses' Association of Ontario evidence-based guidelines for assessment/ management of diabetic foot ulcers.
* Comprehensive compilation of current guidelines for management of diabetic foot ulcers, along with "level of evidence" for each recommendation.
TITLE: Frostbite
AUTHOR: Varnado M
SOURCE: Journal of Wound, Ostomy and Continence Nursing 2008; 35(3):625–630
ARTICLE TYPE: Case Study
* This author reviews the epidemiology, pathophysiology, clinical manifestations, immediate care, emergency department care, long-term care, and alternative options for treating frostbite.
* Factors affecting severity are discussed, as well as the importance of rewarming rates and a watchful waiting approach.
* Excellent review of principles of frostbite management; excellent resource article for WOC nurses who do not typically treat this condition.
Copyright © 2009 by the Wound, Ostomy and Continence Nurses Society
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Paintball Guns
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are the makers of many marker accessories that people use to upgrade and maintain their paintball guns. Hater Paintball produces oil and lube, marker specific accessories, and DMS Accessories. Hater Paintball also produces clothing that players can use on and off the field. They sell T-shirts with Hater logos and artwork and wear such as the Hater Paintball Trucker Hat.
Hater Paintball also make other accessories that are designed to sharpen the look of your paintball gun. They make a Hater Paintball Gun Graffiti Band. The Graffiti Band is made of neoprene and it is water proof so that if won't get heavy or wear out during rough weather. This band will make your gun look sharp, and it will easily slide on and off the barrel.
Hater makes Angel upgrades such as the Lucky Angel Un1 Board. The Lucky Angel Un1 Board is compatible with 67, A4FLY, A4, IR3, and Angel LCD markers. This board allows the user to use any chip made for the DM4/5/C. This board accepts Virtue Chips, Tadao Chips, and Hater Chips. Hater also makes an Activated Series Hater Chip. This chip is easy to install, drop in replacement chip for the DM4, DM5, DMC, and all Un1 Boards. This activated series chip is available at a competitive price wish a number of impressive features. Some Activate Series Hater Chip features include tournament locks, low battery indicator via LED Flasher on Bootup, Adjustable Rebounce, Duel, ROF, AMB, ABS, Eye Delay, and Fire Modes, and every chip has a custom activation code for cheater modes. The Hater Chip features the most advanced shot processing engine and eye logic in the industry. The Activated Series Hater Chip is a very high performance DM5 Accessory. Other DM5 Accessories include the X-95 Bolt Kit from Evolve Paintball, Thump Board from Tadao Technologies, and the DM5 Grip Frame from Sith
Hater Paintball produces two marker specific accessories: the Quest Texas Storm Code and the Quest Malicious Intent Code. The Quest Malicious Intent Code is specifically designed for the FEP Quest marker. The intent code includes seven firing modes: PSP Breakout, NPPL Breakout, Discrete Ramping, Fast Ramping, Auto Response, PSP and the NPPL Semi. The Quest Malicious Intent Code is engineered with anti-mechanical bounce AMB algorithms that solve the problem of physical switch bounce. The Quest Texas Storm Code is designed to operate at 8 possible firing modes, including PSP, PSP Breakout, Discrete Ramping, and Fast Ramping. The Quest Texas Storm Code is engineered with a blazing fast trigger logic, which constantly monitors the trigger switch to ensure that all pulled shots register and are processed. Other marker specific accessories produced by other manufacturers include Gold Member Bolt from First Endeavor Paintball and the ICD Pressure Balance Valve from Empire.
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Playing a game of table tennis will require you to really get those muscles moving. On top of that, your table tennis racket will also experience a vigorous adventure on its own. Therefore, making sure that your ping pong paddles stay in good shape at all times is very important for a table tennis player, beginner and pro alike.
The durability of the racket rubbers rely on three factors: friction, flexibility and tension. After prolong use, flexibility and tension will diminish, but you can prevent the loss of friction by practicing a daily cleaning routine. Friction is vital as it controls the contact of the ball to the rubber surface – allowing a good spin onto the ball.
In the previous articles, you have learned the basic grips and strokes you can do with your ping pong rackets. Now, it's time to give those paddles a breather. Read these simple guides on how to look after your table tennis paddle.
- Table tennis racket case – You can store your paddle in a racket case to protect it from dirt, from direct heat, and from getting wet. Make sure to purchase a racket case that is made from high quality material, else you will compromise the safety of your paddle.
- Commercial cleaners – Apply it on the rubber and wipe it off with a sponge. These cleaning solutions could come in a spray or a foam type. They are said to restore the rubber's natural coarse state.
- Sponge and water – This is what most players prefer as a cleaning method. Just moisten a sponge with water and use it to clean your rubbers off. You can use a commercial sponge that has a plastic container which keeps the sponge damp all the time, or a regular kitchen sponge will do.
- Detergent – Add just a small amount of detergent to water, soak a sponge into it, and wipe away. It can remove oil build up from sweat in contact with the rubber.
- Breath and hand – Some professional players do this technique – they breathe on the rubber and wipe it with their hand. But experts recommend doing this only when no other cleaning solution is available and if you don't mind changing rubbers frequently.
Other players like it better when their rubbers are unclean – they feel that dirt and dust might just be the thing they need to have that power spin. But whatever cleaning method you prefer, taking good care of your table tennis equipments is a must. The tips above are sure-fire ways to get that dirt off your ping pong paddles, all the while protecting the racket rubbers and helping you top your game.
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Seybold, Cathy A.; Harms, Deborah S.
Abstract: Water retention at −1500 kPa is a crucial parameter in soil survey interpretations and in many hydrologic, agronomic, and ecological applications. Because it is impractical to measure −1500 kPa water contents everywhere in a soil survey area, it is often estimated using a model that is considered rule of thumb. The objectives are to validate this model and determine if a superior model can be developed using general linear models. Validation results indicate a consistent bias between the measured and predicted values. The 1500 kPa model was found to overestimate the contribution of organic matter, and the 1500 kPa water-to-clay ratio (WCR) of 0.4 was shown to be in agreement with measured ratios from a wide range of soils. For soils dominated by specific clay minerals, the 1500 WCR ratios varied from 0.25 for soils containing gypsum to 0.50 for soil clays containing hydroxy-interlayered vermiculite. The accuracy of the model could be improved if the clay mineralogy is known and the corresponding 1500 WCR is used instead of 0.4. The development of a new model resulted in total clay, organic carbon, and cation exchange capacity explaining 91% of the variation in water contents retained at −1500 kPa. The new model had the lowest root mean square error of 1.967, indicating a more accurate model than just using total clay or total clay and organic carbon as predictor variables. On a wide range of soils, validation of the newly developed model indicated no bias and was superior to the rule of thumb model in accuracy. The new model will be useful in soil survey as an approximation when data are lacking and is not intended to replace measured values.
© 2012 Lippincott Williams & Wilkins, Inc.
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Fulton Focus On WCLK Features Vendor Opportunities, Voting, Citizen's University and Diet
By Rob Maynard • Mar 15, 2014
Fulton Focus is a production of WCLK and Fulton County Communications. This month on Fulton Focus we feature Rholanda Stanberry with a discussion of the upcoming Vendor Opportunity Day March 27. Ericka Davis discusses the upcoming Fulton County Citizen's University. Fulton County Director of Registration and Elections Richard Barron discusses the registration deadline (April 21) and early voting opportunities in the upcoming May 20 Primary Election. And in honor of March being Nutrition Month, Fulton County Registered Dietician Rachel Agnew stops by to talk about making healthy choices.
For more information on these and other Fulton County programs and initiatives, you can go to their website by clicking here.


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When was the last time you stepped out for the evening thinking, I can't wait to hail a cab? The process isn't exactly enjoyable, but it could soon get a lot easier for millions of New Yorkers. The New York City Taxi and Limousine Commission just approved a year-long pilot program that will allow startups such as Uber, Hailo, and GetTaxi to legally operate apps that will let passengers use their smartphones to electronically hail rides with one of the city's 14,000 yellow cabs, starting in February.
The pilot is a huge win, at least temporarily, for players in the on-demand car service industry. When companies such as Uber and Hailo began cropping up a few years ago, offering on-demand rides that you could order right from your smartphone, they helped eliminate a lot of the uncertainty that comes with standing curbside, one hand flailing in the air, and not knowing exactly what you're going to get.
But the for-hired rides industry isn't without problems of its own. One big issue with smartphone-enabled, pre-arranged rides is it's very easy for both drivers and passengers to drop out of their digital commitment. If a would-be customer orders a car, then spots a free cab a minute later, what's to stop her from jumping in and simply hitting "Cancel" on her phone? It's the same for drivers—en route to a pre-arranged pickup destination, they're bound to run into curbside hailers who could have meant extra cash.
And although the number of companies in the space continues to grow, none of them have yet figured out how to crack the code so everyone wins and the company profits. It's a constant state of trial and error and slowly figuring out what resonates with both drivers and riders, says Steve Humphreys, the CEO of e-hailing company Flywheel, formerly known as Cabulous.
One observation Humphreys noticed is that drivers and passengers who talk to each other as the driver is en route are substantially less likely to abandon each other. So the new Flywheel app includes a calling feature that allows passengers and drivers to talk to each other without exchanging numbers. A cancellation fee that charges based on how far the driver has already traveled keeps passengers more accountable and likely to follow through on their orders. And Flywheel's system allows it to lower priority for drivers who are abandoning requests, not accepting hails, or staying within a very limited radius.
The Flywheel app also no longer has a feature of the old Cabulous app called "jump the line," which let impatient passengers essentially bribe drivers with an extra $5, $10, or $15 incentive to pick them up first. Humphreys said that feature irked customers, who didn't want to feel like they had to pay extra up front to get from the same Point A to Point B.
Flywheel competitor Uber uses a surge pricing mechanism to incentivize drivers and quell demand during peak hours, but the feature has gotten it in trouble in past with customers on the receiving end of "sticker shock." So in the new Uber 2.0 app, which it released this week, Uber's included an "instant quote" feature that provides an instant estimate of how much your ride will cost.
Humphreys says transparency will play a critical role in which apps ultimately gain customers' trust. "It's a stranger and you're about to get in their car," he says. "How do you build trust and comfort in that? It's risky and stressful every single time."
But Humphreys also has faith that as the market matures, consumers will start to think about on-demand cars as the go-to option for how to get around town.
"In 18 months, people won't recognize the hired ride market because it's going to be so much better and cleaner and smoother and more reliable," he says.
It's too early to tell who will get it right. We'll just have to, er, ride it out.
[Image: Flickr user TitoRo]
Slideshow Credits: 01 / [[i]Image: Flickr user [url=http://www.flickr.com/photos/rfreixas/3726979227/in/photostream/]TitoRo[/url][/i]];


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ATV Supporters React to Forest Rule
Laramie, WY – As the forest service drew up its new off-road vehicle, or O-R-V, rule, ORV enthusiasts and industry representatives kept a hand in the process. O-R-V advocacy group the Blue Ribbon Coalition provided input on the new rule. Effective shortly, national forests must tally their O-R-V routes and designate which can officially be used. Coalition founder and director Clark Collins says his group wants to influence that process.
Collins says some O-R-V users enjoy forging their own routes. But, in the medicine bow national forest, an environmental group recently won a case forcing the forest service to close off these kinds open routes. The alliance claimed O-R-V users were harming sensitive landscapes.


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A number of notable 2010 all-conference selections from Big Ten secondaries will return this season. This is in direct contrast to the defensive lines and linebackers.
For the former, only three second-team players are returning, and for the latter, no all-conference players came back. Nebraska does have one all-conference lineman and one all-conference linebacker amongst its returning players, but that was in the Big 12.
In effect, when one looks to analyze the holes in 2011 conference defense, one might be inclined to look for running teams to have a slight advantage.
Either way, this is the way the Big Ten teams stack up in the secondary.
A few notes
The players in italics are returning starters. A "returning starter," for my purposes, is any player that has started four or more games in his career.
Players in italics and bold denote multi-year starters.
Players with an asterisk next to their names were first- or second-team, media or coaches, all-conference last season.
Players with three asterisks next to their names would be returning consensus All-Americans, but as there are none this season, this is irrelevant.
Finally, I have not factored true freshmen into this projection. Nonetheless, while true freshmen can fill out a depth chart and have important roles to play, if a true freshman is starting, that is rarely a good sign.


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Give the Cham credit for being the most optimistic ski in the category. It expects to find powder every day and is built accordingly. Testers warned that it's an indifferent hard-snow carver—too wide for quickness, too drastically rockered for positive rebound. But throw soft snow at it, and it comes to life—No. 1 in Flotation, No. 1 in Crud Performance. The Cham is more than willing to sacrifice the edginess of Dynastars past and fully embrace the loose, smeary performance of new- school powder boards. Gleason: "The float of the forebody gives it a distinctly Western flavor."
MSRP $800 flat
DIMENSIONS 133-97-113 (178 cm)
RADIUS 16 m (178 cm)
Check out this ski and others in the 2013-14 Gearfinder.


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|Look, Mom!!! I DO TWO!!!
|Ummmm...how the hell did he do that? This seems much harder than it should.
|Wait...is this it? Did I do TWO??
|I did it, didn't I? You know I did...just tell me...did I do TWO?
|Oh SNAP!!! Hailey did TWO!
Raise your glass to the Crazies...who make everything seem harder than it really is!
BTW, don't be too jealous of their talent...they've been calling me in after bedtime to show me that they "did two."


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The options are endless with this casual must-have. The tunic features a notched neckline that's accented with silver-tone and shiny coral plastic beading in a floral design. The front of the tunic has long pin tucks on each side of the neckline for added feminine flair. You'll find a sheer zebra print through out the body, in your choice of navy or natural along with full length sleeves and a hem that sits below the waist.
Additional Information:
Made of 100% viscose. Machine wash cold, gentle cycle, with like colors. Do not bleach. Reshape and line dry. Cool iron if necessary. Do not iron on decoration. Do not dry clean. Made in China.
To determine your size, Click Here.
Garment Measurements:
Below are actual measurements for this garment. Use the above link to find the best size for your figure.
Small: Bust: 39-1/4", Center Back: 30"
Medium: Bust: 41-1/4", Center Back: 30-1/2"
Large: Bust: 44-1/4", Center Back: 31"
XL: Bust: 47-1/4", Center Back: 31-1/2"
1X: Bust: 50", Center Back: 31"
2X: Bust: 54", Center Back: 31-1/2"
3X: Bust: 58", Center Back: 32"
Please Note:
Sizes S-XL are considered missy/standard and sizes 1X-3X are considered womens/plus. Each set is graded separately and sizing may overlap.