Douglas Queen

A dressing history

Over the past 30 years as caregivers, clinicians have been exposed to a plethora of new advanced wound dressings. The moist wound care revolution began in the 1970s with the introduction of film and hydrocolloid dressings, and today these are the traditional types of dressings of the advanced dressing categories. Wound‐healing science has progressed significantly over the same period, as a result of intense clinical and scientific research around these product introductions. Today, the clinician understands moist wound healing, occlusion, cost effectiveness, wound bed preparation and MMP activity to name but a few of the many concepts in wound care that have flourished as a result of technology and product advancement. This review article presents a condensed history of dressing development over the past 30 years. However, in addition, such advancement is discussed in respect to its adoption in different parts of the world. The largest single markets of the world are generally the United States of America and Europe; as such, the development of both practice and technology generally begins there. Much has been written about these markets in previous review articles. For the purposes of this review, the development of wound care and the maturing of practice is discussed in respect to Canada, Japan and Australia representing smaller geographical areas where the development has been more recent but nonetheless significant.

Human pilot studies reveal the potential of a vitronectin: growth factor complex as a treatment for chronic wounds.

Several different advanced treatments have been used to improve healing in chronic wounds, but none have shown sustained success. The application of topical growth factors (GFs) has displayed some potential, but the varying results, high doses and high costs have limited their widespread adoption. Many treatments have ignored the evidence that wound healing is driven by interactions between extracellular matrix proteins and GFs, not just GFs alone. We report herein that a clinical Good Manufacturing Practice‐grade vitronectin:growth factor (cVN:GF) complex is able to stimulate functions relevant to wound repair in vitro, such as enhanced cellular proliferation and migration. Furthermore, we assessed this complex as a topical wound healing agent in a single‐arm pilot study using venous leg ulcers, as well as several ‘difficult to heal’ case studies. The cVN:GF complex was safe and re‐epithelialisation was observed in all but 1 of the 30 patients in the pilot study. In addition, the case studies show that this complex may be applied to several ulcer aetiologies, such as venous leg ulcers, diabetic foot ulcers and pressure ulcers. These findings suggest that further evaluation is warranted to determine whether the cVN:GF complex may be an effective topical treatment for chronic wounds.

The use of a novel oxygenating hydrogel dressing in the treatment of different chronic wounds.

A novel oxygenating hydrogel dressing, Oxyzyme Sterile Wound Dressing with Iodine (Insense, Ltd, Sharnbrook, UK) was evaluated during a 4-week trial in Toronto, Ontario, Canada, for its performance in the treatment of chronic wounds. The dressing has not yet received Food and Drug Administration approval in the United States. The authors present several cases demonstrating the flexibility in use of this new wound care treatment. Its demonstrated benefits include pain management, exudate management, and the creation of a healing environment.

Chronic Wounds and Their Management and Prevention is a Significiant Public Health Issue

Public health is defined as ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.’ (1920, C.E.A. Winslow) (1) It is concerned with threats to the overall health of a community based on population health analysis. There are two distinct characteristics of public health, firstly it deals with preventive rather than curative aspects of health and secondly it deals with population-level, rather than individuallevel health issues. The goal of public health is to improve lives through the prevention and treatment of disease. The United Nations’ World Health Organization defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ (2)

Wound bed preparation and oxygen balance – a new component?

Chronic wounds have traditionally been treated by conservative means. It was Winter’s moist wound healing research, in 1962, that stimulated a proliferation of a moist interactive dressing technologies. Even considering this advancement in thinking, chronic wounds continue to be a problem for many clinicians. An increasing delineation of the science of healing in the past 20 years has redefined the way in which we both evaluate and treat wounds. This scientific understanding has raised wound care from the clinical problem arena to that of clinical specialty, where many now cross refer patients to specialists in this field. Wound bed preparation (WBP) has played a significant role in this change in practice. The concept has changed an ‘art’ of switching at random from one dressing to another, into a clinical science. WBP has come to the forefront as a major educational aid to help others develop appropriate treatment of the underlying disease causing the wound and patient requirements. The concept of WBP evolved over the recent years, becoming more and more sophisticated with time. Recent adaptations have brought together many of the current components. This article proposes yet another element of WBP, that of ‘oxygen balance’.

The emergence of a clinical specialty in wound care

Chronic wounds affect hundreds of thousands of patients, particularly older individuals. The wounds are frequently long term, painful and debilitating, resulting in extreme loss of quality of life for sufferers. For many patients living with non-healing wounds, amputation of an affected limb may be the only option. In the United Kingdom chronic wounds conservatively cost the National Health Service £2–3 billion per year in direct costs alone, yet the issue receives little attention from the media, policy makers and research funding agencies. They are a silent epidemic as described in a recent publication funded by the Smith & Nephew Foundation. ‘Skin breakdown in its various forms affects hundreds of thousands of people a year in the UK and has a huge knock-on effect on their relatives and carers. The commonest forms of skin breakdown include leg ulcers, pressure ulcers and diabetic foot ulcers. These conditions are often long term and disabling. They increase social isolation and reduce quality of life. The prevalence of skin breakdown will continue to grow as the population in the UK ages. Most importantly, the cost of the health service and the taxpayer of these conditions is escalating, with current estimates of coast at around £2.3–£3.1 billion per year’’. (Ref: Skin Breakdown – The silent epidemic. The Smith & Nephew Foundation. 2007: www.snfoundation.org.uk). This publication also highlighted a number of recurring key messages emerge from this silent epidemic. These are:

Wound registries -- a new emerging evidence resource.

Wound healing as a speciality is in its orphan stages, and it remains important that all clinical information is recorded and evaluated, including ‘real-life’ experience. While clinical studies remain important, with the randomised controlled trial being the gold standard, ‘reallife’ experience is often more useful and practical for clinicians on the front line. The creation of a registry will allow the capture and more importantly the use of this data as validation of a clinical approach. To aid the development of wound care as a clinical specialty we believe the registry approach will become accepted as an additional model for collecting data for new treatments for patients with wounds. When collected and stored in a registry the data can be examined for a variety of parameters, including usage statistics, adverse event reporting and successful outcome data. This robust economic and epidemiological data on wounds and wound prevention and treatment, both nationally and internationally, is essential for effective evidence-based decision making leading to the adoption of cost-effective wound prevention and treatment solutions and planning for service delivery in the future, in particular for cost-strained healthcare systems. The provision and uptake of best prevention and treatment for acute and chronic wounds are hampered by the fragmentation of health funding and health service provision globally. Treatments that may reduce cost to the health system as a whole are not embraced as the increased cost to those delivering the treatment is not directly compensated. The savings are therefore not realised. A more global view of the benefits of improved healing needs to be embraced and for this to happen, policy and decision makers need robust data and evidence. This requires the demonstration that health interventions are effective at reducing the problem, and critically, that these are costeffective. Until this information is obtained, allocation of resources to wound prevention and treatment at an appropriate level, and with appropriate treatments and interventions, will not occur. National and International Wound Registries will allow the combined epidemiology and economics of wound prevention and treatment across the global diverse healthcare landscapes for the first time. This activity will highlight the gaps in knowledge and inform future clinical trials to be managed within the healthcare environments. Such registries exist in many other clinical areas and geographies. Now it is time for this to become a reality in wound care. The input of data however has to be cognisant of the environment in which wound carers work. It has to be both practical and sensible. The creation of such a registry and input process should be user defined and driven, opposed to technologically driven. For clinicians involved in this subject as you see the emergence of this type of activity it is in your best interest to become involved and participate. If we are going to emerge from the orphan subject we are today we need data – hard and fast!

Can 2015 be a transformative year for diagnostics in wound care

Progress in wound care is slow at best. Often clinicians are slow to embrace and adopt new approaches to both treatment and diagnosis. Attempts have been made in recent times to provide diagnostic tools but the clinical community was slow to embrace them and added to their frustration, one significant barrier to adoption was that of funding. Payers and those responsible for reimbursement make it more difficult for wound care to progress by introducing significant ‘proof’ barriers. Can diagnostics turn the corner in 2015? Can we at last have a diagnostic suite that helps move wound care towards the clinical specialty it needs to be if progress is to be achieved in the management of the silent epidemic that will be upon the healthcare systems of the world? Most attempts at the provision of diagnostic tools, for wound carers, come from smaller more ‘start-up’ companies or from Universities, where funding for research and product support/registration is generally low. This poses significant time and financial pressures on organisations that do not necessarily have the means to provide the ‘burden of proof’ asked for by clinicians and regulators. So, little, if any, progress is likely unless we can change this environmental component to open innovation in this very important area, to ensure continued progress towards clinical specialization of wound care. Several players in the diagnostic arena have approached us to ask if a mechanism can be found to open the environment within wound care to better embrace diagnostics: To provide an environment where smaller players can work together leveraging the synergies of intellect, finances and resource to better serve their joint needs. Surely this is possible as we have seen such a collaboration in the area of infection with the advent of the International Wound Infection Institute. Perhaps we need the same in the diagnostics arena to move the environmental impactors into a more positive trajectory. Interested? If so we would like to hear from you, whether from the research, commercial or clinical arenas. If this is an area of interest for you then let us know and surely we can build some momentum to positively influence the research and development and subsequent clinical use of important tools for the care of patients with wounds.

Professor Keith Harding, Editor-in-Chief of the International Wound Journal, honoured for his services to healthcare.

To those outside of wound care he is a son, husband, father, grandfather, friend or neighbour. To most of us involved in wound care, Keith Harding needs no introduction and his achievements are legendary. However, whether you personally know or know of Keith, you are certainly aware of his passion and commitment to wound care and its ultimate evolution into a true clinical specialty. Indeed he has devoted the majority of his professional career to this goal and coined the phrase ‘woundologist’ of which he is a prime example. In recognition of his effort and passion, Her Majesty the Queen has conferred Professor Harding with a CBE (Commander of the Order of the British Empire) in the New Year’s Honours List 2013, for his services to healthcare. This is recognition of an outstanding career, promoting the clinical specialty of wound care, benefiting those who suffer from both acute and chronic wounds not only in Wales but from other regions of the UK. Professor Harding will be invited to the Buckingham Palace in the next 6 months to receive his CBE from a member of the Royal Family at an investiture ceremony. The following is an abbreviated recap of the career of a professional wound care giver: Professor Keith Harding CBE MB ChB MRCGP FRCP FRCS has had a longstanding interest in wound healing. He has undergone training in both general surgery and general practice. He was appointed as the first Director of the Wound Healing Research Unit in 1991. From 2002 to 2005 he was also the Head of the University Department of Surgery and is currently the Director of the TIME Institute, School of Medicine, Cardiff University; Head of the Wound Healing Research Unit, Cardiff University; and Clinical Director of Wound Healing in the Cardiff & Vale NHS Trust. His clinical practice is exclusively focused on treating patients with wound healing problems having a wide range of aetiologies. He has authored over 300 publications in the field of wound healing and has written a number of chapters and books in this area, including the ABC of Wound Healing published in the British Medical Journal in 2006 which is to be updated in 2013. He is the Editor-in-Chief of the International Wound Journal published by Wiley-Blackwell. He was the First President of the European Pressure Ulcer Advisory Panel, First Recorder of the European Wound Management Association and is a Past President of the European Tissue Repair Society. He was Chair of the International Working Group on Wound Healing in Diabetic Foot Disease in 2003, Chair of the Expert Working Group that produced the World Union of Wound Healing Societies (WUWHS) Consensus Document in 2004 on minimising pain during wound dressing related procedures. He was Chair of the WUWHS Expert Working Groups on Exudate in 2007 and on Compression, VAC therapy and Wound Diagnostics in 2008. He was also Chair of International Consensus Document on wound infection in 2008. He chaired an International Working Group on Pressure Ulcer Prevention, Prevalence and Evidence in Context, which was published in 2009. He has obtained funding of over £30 million from a range of academic, commercial and clinical sources since the Wound Healing Research Unit was created in 1991. Much has been achieved over the past three decades but being awarded this high honour is recognition of true dedication and lifetime achievement in a field close to the hearts of our readership. Please join me in congratulating Keith on this fine achievement, which I know he will say he is accepting on behalf of his team, as nothing is really achieved without a true professional multi-disciplinary approach.

Maximising use of social media for patient and professional interaction.

Social media is commonplace in everyday life, particularly with the younger generation. This generation uses social media applications to both communicate and also to be connected to friends and family alike. In health care, individuals, especially patients with chronic conditions such as diabetes, can feel isolated and alone, feeling like the only person who has such health-related issues. This often drives such individuals to Internet-based resources to inform, educate and engage. Clinicians only become aware of the dangers of such information when patients who come seeking help are armed with their latest ‘Internet wisdom’. Today, such individuals sometimes use Twitter and Facebook for social connection to feel a sense of belonging and less anxiety of loneliness, as well as to share their collective experiences and ‘Internet wisdom’ – peer to peer. As professionals in this arena, is the time right for specific ‘social interaction’ vehicles to allow connectivity for persons with wounds, including professionals involved in their care? Can such an approach provide a more directive ‘Internet wisdom’, where the sharing of experiences and wisdom would be more appropriate? Can we use a social media approach, which allows connectivity, discussion and sharing of experiences within a private community? Can such an approach allow connectivity, and also the sharing and ranking of information within the system, providing information relevancy and legitimacy? Can such an approach allow integration to both Twitter and Facebook to allow ‘viral’ marketing of new and important content and events? Perhaps a more profound question is if we need to increase the engagement between patients and their caregivers: do we need to influence their ‘social interaction’ when it comes to wound care? For example, if a person with a wound, or a professional caregiver, discovers an important piece of information that could be of use to others, how should this be validated and then communicated to others? All these are important questions to consider, but in this age of social media and Internet information, we may have little choice if we are to ensure a more informed wound care environment, particularly as the current youth becomes the next generation of health care providers. And those of us not fully engaged in the current social media trend will become the patients requiring the knowledge and interaction. It is a changing world requiring a change in approach.