Rachel Webb

A chronic case of confusion

T his month’s Journal of Wound Care (JWC) focuses on infection and biofilm—a subject that seems key to treating many chronic wounds. The consensus in both the wound care and infection fields is that all chronic wounds are infected and that chronic infection is caused by biofilm. Over the past two decades, there has been an increasing research emphasis on biofilm and wound healing. A quick search on PubMed for the key words ‘wound’ and ‘biofilm’ identified four articles in 1997, 33 in 2007 and, so far, 133 in 2017. This puts us roughly on par with 2016, which saw 214 articles on these topics. These numbers seem rather low to me, but they are consistent with what we have seen in JWC. Our understanding of the role of biofilms in chronic wounds has improved thanks to this increase in research. Our thinking is no longer about planktonic bacteria floating around happily on their own, but of a fortress of bacteria using extracellular substances to fight off invaders, such as antibiotics and even the immune system. Randy Wolcott’s schematic diagram of biofilm (page 425) is an excellent representation of the reactions, interaction and workings within and around biofilm. Yet, with all the information available, there are still major issues with how we identify biofilm and then how to treat these wounds in practice. If we are to improve wound healing rates, we need to address these questions quickly. The first, and perhaps the biggest, issue is identifying biofilm. Is it visible to the naked eye? Many experts say biofilm can only be seen with high resolution microscopy; some say they can see biofilm and critical colonisation (a term recently discarded by the International Wound Infection Institute (IWII) as part of the infection continuum)1 by eye. This is an argument that must be resolved by evidence. In this issue, Swanson et al. (page 426) highlight the problem of identification, reporting on the responses of health professionals (all of whom treat wounds to a greater or lesser extent), when asked which were the primary/clinical signs of biofilm. Of eight questions asked, five had a correct response rate between 40–60%, suggesting uncertainty among the 2641 respondents. However, around 70% responded that stalled wound healing was a symptom of biofilm presence, while only about 20% thought that biofilm infection must have the classic signs of infection; 20% thought that microbial culture would be negative when biofilm is present. These results show the huge level of confusion in this area. Identifying biofilm by eye, although not impossible, will not be possible for all infected wounds. Furthermore the classic signs of infection and inflammation are not always present. What seems to be the most recognised sign of biofilm infection is stalled wound healing. So, if we say all stalled chronic wounds are infected, thus inhibiting healing, and that infection is caused by biofilm, is chronicity enough to start biofilm based wound care? Yes. Do we need any other signs and symptoms? No. The problem becomes: by the time wound is defined as chronic have we waited too long? JWC

The Olympians of wound care

T he summer is almost over, and as we enter September we have a very busy month ahead. The big event is the World Union of Wound Healing Societies (WUWHS) conference, which takes place at the end of the month (25–29 September). As the official journal of the WUWHS we have a number of events at the conference. At the meeting in Florence, we will be holding the JWC WUWHS Awards ceremony, a new event that aims to honour the work of groups and individuals over the 4-years since the Japan conference—the Olympics of wound care, if you like. We had a large number high-quality nominations in every category, and like the JWC awards, judging between the short-listed candidates will be hard. The general categories are Innovation in Wound Care, Contribution to Clinical or Preclinical Research, Outstanding Achievement in Patient Care, Contribution to Education in Wound Care, Cost-Effective Wound Management, Infection and Biofilm, and Advances in Pressure Care. From these, I am particularly pleased that two of the those short-listed, Jennifer Hurlow (Infection and Biofilm) and Charmaine Childs (Innovation in Wound Care), have papers in this issue of JWC related to the work for which they have been nominated. On page 499, Childs et al. describe their work using non-invasive thermal imaging techniques to identify surgical site infection before any of the normal visual signs become apparent. Previous work published in JWC has already shown that infected and non-infected wounds could be distinguished on the basis of a specific thermal signature,1 while this study extends the work into women undergoing an elective caesarean section. Hurlow et al (page S11, in the WUWHS Supplement) use scanning electron microscopy to confirm the presence of biofilm in wound debridement samples, from patients with suspected bioflim. There are also five special awards—the first two are aimed at industry (Most Innovative Dressing and Most Innovative Product)–again these are for developments over the past four years. The most progressive society, which honours the work done by the WUWHS many collaborating and sister societies. The Lifetime Achievement Award, for a lifetime’s contribution, passion and commitment to wound care ,while having a major impact on practice or research in their field, possibly received the most nominations for worthy individuals. Finally we have our X-Factor style award, The Rising Star. This award will be decided on the evening by those attending the awards ceremony. There will be three of the WUWHS Rising Stars invited to attend the event and give a short 3 minute presentation on their work, after which the audience will vote. This will all take please along with food, drink and entertainment at Scherma Hall, Fortezza da Basso. Finally, I hope you enjoy our new WUWHS Supplement showcasing some of the best work in wound care from around the world. JWC

From decubitus ulcers to pressure injury: what is in a name?

O ver the years ‘pressure ulcers’ have been known by many different names including, decubitus ulcers, bed sores and pressure sores, with the current trend towards pressure ulcers. When I started in wound care two years ago the term pressure ulcer seemed to be the preferred one; however, you may be surprised at the regularity with which we receive papers from clinical heath professionals involved in pressure ulcer prevention, who refer to decubitus ulcers and bed sores. These are individuals—who didn’t get the memos about the name changes— who are extremely competent at implementing new and successful pressure ulcer prevention strategies and writing up their work for publication. Last year the National Pressure Ulcer Advisory Panel (NPUAP), made the decision to use the term pressure injury rather than pressure ulcer.1 As expected this has caused a great deal of debate at conferences and in editorials, including in the Journal of Wound Care, where Ruth Byrant, argues this decision is flawed:2

Sniffing out the problem: is odour the answer?

Dr Rachel Webb – Editor Rachel Webb, PhD, Editor Journal of Wound Care N ot so long ago I saw a article in the news about a woman who could smell Parkinson’s disease.1,2 Joy Milne had noticed a difference in her husband’s ‘odour’ eight years before he was diagnosed with the disease. However, it wasn’t until 17 years after his diagnosis, having spent a large amount of time around others with the disease, she asked at a Parkinson’s UK awareness lecture, why people with Parkinson’s disease smell different. After realising what Joy was saying, Dr Tilo Kunath, a Parkinson’s UK fellow at the school of biological sciences at Edinburgh University, tested Joy’s ability. She was asked to smell 12 T-shirts, six from people who had Parkinson’s disease and six from those who did not. She identified seven Parkinson’s sufferers, making 11/12 correct, a pretty good result. However, several months down the line, the owner of the seventh T-shirt was diagnosed with the disease. Joy can smell the symptoms of Parkinson’s way before diagnosis—in her husband’s case eight years. Scientists now believe a particular odour is associated with the disease, a theory undergoing testing.1 Research is underway to see if dogs can smell certain cancers. The results of a recent study looking at detecting hepatocellular carcinoma from breath concluded:

How has our view of pressure ulcers changed and what does the future hold

At this years European Pressure Ulcer Advisory Panel (EPUAP) conference, the Journal of Wound Care met members of manufacturer ROHO Inc.s scientific advisory board. We discussed the changes in thought on pressure ulcer aetiology and care and what the future might look like. Here we describe deep tissue deformation and how this concept is changing the way scientists and clinicians look at pressure ulcers. The future for pressure ulcer prevention could be the use of microsensors allowing, among other things, home monitoring of those at risk

Having an impact

How time flies. The first issue of Nature Climate Change appeared in April 2011, and the journal — a monthly publication — is now well into its third volume. By the time this issue goes to press, we should have received our first impact factor from Thomson Reuters1. The impact factor is one of the most recognized metrics and is a measure of a journal’s influence. It is calculated on two years’ worth of citation data. The impact factor released in 2013 is for 2012; it is calculated on citation counts in 2012 of papers published in 2010–2011, divided by the number of ‘citable items’ published in that period. Citable items — typically considered to be research papers and review articles — may not include all of the journal content that has been cited, Commentary and Policy Watch pieces would be excluded, for example. The importance of impact factors is much debated, with a feeling that too heavy an emphasis is placed on this single number. A small number of very highly cited papers can strongly influence the final number, and the citation is not rated on being positive or negative, so a highly criticized paper may inflate the value. Further criticisms of the impact factor include the timeframe — it only looks at the first two years of citations for any given paper, so the longer-term impact of work is not measured; and coverage — citations in books, conferences, reports, policy documents, working papers and the media — is not taken into account. Different dynamics, including publishing timelines and formats, across research disciplines result in different citation rates, meaning that comparison across fields is not possible. The social sciences are not well represented by impact factors; a study has shown that they often have artificially low numbers and are better ranked by other metrics2. Thomson Reuters recognises this and there is a Social Science Citation Index, covering over 4,000 journals and 50 disciplines in the social sciences, for better comparison in these fields3. Another tool for measuring journal performance is the h5-index used by Google Scholar, which provides greater coverage of citations including books, conference and working papers4,5. One advantage of the h5-index is that it is based on five years’ worth of data, rather than just two, which should make it more reliable; on the other hand a new journal would have to wait this period of time before receiving its first h5-index ranking.

Lords-a-leaping put wound care centre stage

ISSN 0969-0700 Printed by Pensord Press Ltd, Blackwood, NP12 2YA O n 22 November, there was a debate in the House of Lords, the upper house of the UK Parliament, titled ‘Improving the standard of wound care in the NHS’. This is an issue that deserves much attention from the UK government and health-care bodies worldwide. The debate itself gave a platform for wound care that is incredibly important in today’s society. Although I hear and read the phrase ‘with an increasingly ageing population’ all too often, there is no getting away from the truth and this fact alone should put wound care to the front of any health-care agenda. As we know, an ageing population is prone to wounds, ulcers and slow healing. The debate started a little after 19:00 in the main chamber, with its gold, statues, red seats and history. After an opening statement, Baroness Wheeler asked what plans the Government has ‘... to develop a strategy for improving the standards of wound care ...’ This was followed by several other questions from all shades of the political spectrum, culminating in a response by a representative of Her Majesty’s Government (Lord O’Shaughnessy). Paul Browning has summarised the key points on page 707. A national strategy should provide three things, all of which were mentioned in the debate. First, sufficient nurses (health professionals); second, sufficient knowledge to either be able to treat a wound or to recognise a problem and refer it to a relevant health professional; and third, access to the right treatment/therapy/devices. In the UK, the majority of wound care is carried out by nursing staff, often in the community. The reduction in nursing numbers, as well as the lack of provision for training were both questioned. Baroness Watkins explained, we need more district nurses—there are 4000 in England compared with 7000 in the mid 70s.1 The Government has also cut budgets for continuing professional development (CPD),2 making extra training and keeping to-date with the latest techniques and research almost impossible. Without enough time or training, skin issues, wounds, and ulcers will remain unidentified and untreated, increasing costs and suffering. Access to appropriate treatment is already an area of discussion. Following the Carter report,3 a clinical evaluation team began an exercise to reduce the number of products available through the NHS Supply Chain and, although it seems that has not affected wound care products, there is still great concern that in a rush to save costs by bulk buying, treatment options may disappear. Choices have to be based on clinical effectiveness, and what that looks like in wound care is also a matter of debate. Randomised controlled trials often exclude most difficult-to-heal wounds, while a single case study is not a strong evidence base on which to make a decision. In a letter by Cutting et al. (page 788) the authors suggest that all levels of evidence should be acknowledged. However, if the Government wants to reduce costs, the saving will come from reduced nursing time, as shown by Guest et al.4 This study clearly demonstrated that it does not matter how much the dressing or product costs: as long as it quickens healing time (reducing costs associated with staff time), you will save money. Furthermore, as prevention is better (and cheaper) than treatment, we need to identify and monitor those at risk. For example, the investment in health professionals to check the feet of people with diabetes, which could identify ulcers earlier, has got to be cheaper in the long term than an amputation? These are my thoughts, I am sure you have your own. At the Journal of Wound Care Conference on 2 March 2018 Julian Guest will give his in a talk titled ‘Is it feasible to introduce a national strategy for improving wound care in the NHS?’ Putting wound care on the political agenda is a great step forward; we now have to make sure it stays there, and, try and get the resources required to reduce the financial and social burden. JWC Rachel Webb, PhD, Editor Journal of Wound Care

Tulips from Amsterdam: making the most of EWMA

B ritain is in bloom, the sun is shining and the spring appears to have arrived. Last weekend I visited a local flower market where one of the most popular items—selling like hotcakes as we say—were tulips, which made me think of the upcoming European Wound Management Association (EWMA) conference in Amsterdam (3–5 May). This was already on my mind to be fair, as for several months now we have been preparing, as many of you have, for the meeting. So far this year the Journal of Wound Care (JWC) has published the first of two EWMA documents1 which are to be launched at the meeting. The second on oxygen therapy will be hot off the press as we are currently putting the final editorial touches to the document. Both have dedicated sessions at the meeting and are available free at www.magonlinelibrary.com/page/jowc/resources. As in previous years we are producing the EWMA Daily newspaper for the event. For three days members of our editorial team will be running around writing up sessions, taking photos and asking you about your highlights of the meeting. It is something we are very proud of and the editor Peter Bradley and team do an amazing job putting together the day’s coverage and meeting the print deadline each night. Along with session coverage, EWMA and society updates there will be some amazing tourist pages, details of the day’s events and of course if you have a few minutes to spare a games section. If want to be in the paper look for our roving reporter and photographer getting your thoughts and a picture for Vox Pops or if you’re attending EWMA—or reading this while there—tell us what you’re up to by tweeting us @EWMADaily using the hashtag #EWMA2017. However, there was one thing we have discussed in the office this week that I thought may be of interest to you and that is how to get the best out of a conference. A number of suggestion were put forward; here are the best: Pick the talks that interest you personally, not the ones that you think will just be the most beneficial to go to. If you’re passionate about something, you’re more likely to learn than if you’re taking notes because it might come up one day. Go grab every journal on offer as soon as you arrive, and read them between talks when you’re waiting for the room to fill up. You never know when you might want to go talk to the editor about something that springs to mind. JWC is at stand 3E08. Don’t be afraid! Ask the questions you want in sessions: if you are thinking it, the chances are so are other people in the audience. Take yourself out of your comfort zone and meet new people, you never know who and what they might know, conferences are also about networking. Talk to people on the stands if you want to try something, make the most of the people and information in front of you. Finally, if you are lucky enough to have expenses save your receipts and don’t stay out too late with your work colleagues... Enjoy Amsterdam and EWMA. The JWC and EWMA Daily teams are very much looking forward to seeing you there!

Waiting for change

A t the time of writing this editorial, we are waiting for the General Election to be held when future plans for health-care funding in the UK will be announced. By the time you read it, the result will be known. The Conservative party has stated that it will ensure real-term increases in NHS spending—an extra £8 billion per year by 2022/2023. In addition, it has promised to help the NHS provide exceptional care in all parts of England, making clinical outcomes more transparent so that clinicians and frontline staff can learn from the best units and practices. In tissue viability, we are already going a long way to achieving this through initiatives including React to Red, Stop Pressure Ulcer Days and Commissioning for Quality and Innovation (CQUIN). Labour has pledged more than £30 billion in extra funding over the next Parliament; it also stated it will repeal the Health and Social Care Act and aim for integration of all health and social care services. All parties recognise the changing demographics of the UK with an ever-increasing ageing population. However, no party identifies skin integrity or tissue viability services or indeed recognises that tissue viability services span all aspects of clinical need. In this issue of the Journal of Wound Care (JWC) Julian Guest and colleagues (see page 292) report on the costs of managing wounds within a typical clinical commissioning group (CCG)/ health board. They predict £50 million per CCG/health board for managing wounds and associated comorbidities will be required by 2019/2020 if we do not increase the rate at which we heal wounds. On page 353, White et al. discuss the implications of this paper and the reasons they feel many wounds are not healed in a reasonable time. They state budgets are one reason and as we see from the Guest paper, unless we start to heal wounds quicker the strains on budgets will only get worse. Another cause identified by White et al. is lack of consistency in training. Indeed a recent letter,1 a response to it in this issue (see page 353) and an editorial2 have pointed out inconsistency in practice and poor treatment due to lack of training. Accessing education and training is essential if knowledge and skills are to be up-to-date; however, with clinical demands it can be difficult to secure time away. We are delighted that the Institute of Skin Integrity and Infection Prevention, University of Huddersfield, in collaboration with JWC and the National Institute for Health Research WoundTech Healthcare Technology Co-operative, is hosting the second International Skin Integrity conference on the 26–27 June. The conference recognises and celebrates the fact that tissue viability requires an interdisciplinary approach (including health professionals, microbiologists, biologists and engineers) to manage impaired skin integrity. We need to address inconsistency in treatment and learn from others to reduce the burden on both the health service and the patients and their families. As clinicians working in tissue viability, you must continue to research and produce evidence that promotes effective and timely interventions to maintain and improve quality of life outcomes. Finally, whoever is leading government, we have to make the importance of wound healing understood— if not, the financial and personal burdens will only increase!

Celebrating the best in wound care

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