[Position paper of the Initiative Chronische Wunde (ICW) e. V. on the nomenclature of debridement in chronic wounds]. / Positionspapier der Initiative Chronische Wunde (ICW) e. V. zur Nomenklatur des Débridements chronischer Wunden.

The nomenclature used today in wound treatment varies widely across different disciplines and professions. Therefore, it is a mission of the professional association Initiative Chronische Wunde (ICW) e. V. to exactly and comprehensibly describe terms that were previously unclear. Therefore, the experts of the ICW defined in a consensus procedure debridement of chronic wounds as the removal of adherent, dead tissue, scabs or foreign bodies from wounds. There are various therapy options for this, which can be differentiated into autolytic, biosurgical, mechanical, osmotic, proteolytic/enzymatic and technical debridement. In the case of surgical debridement, a distinction is also made between sharp debridements that can usually be performed on an outpatient basis, such as minor surgical procedures, and surgical debridements with adequate anaesthesia in an operating theatre. Wound irrigation is defined by the ICW as the removal of non-adherent components on wounds with sterile solutions. Debridement and/or wound irrigation are often the first step in phase-appropriate modern wound treatment. Several methods are suitable for use in a combined or successive therapy. When deciding which therapeutic option to use, a number of individually different factors should be taken into account, depending on the patients to be treated but also on the therapists. The final individual decision for a method should be made together with the patient in each case and then adequately documented.

Multicomponent compression system use in patients with chronic venous insufficiency: a real-life prospective study.

OBJECTIVE: Compression therapy is the cornerstone of therapeutic management of patients with chronic venous insufficiency (CVI). This study aimed to evaluate the efficacy and safety of a multicomponent compression system in an unselected population of patients with CVI problems under real-life conditions. METHOD: A prospective, multicentre, observational study with a multicomponent two-bandage compression system (UrgoK2, Laboratoires Urgo, France) was conducted in 103 centres in Germany. Main outcomes included wound healing rate, wound healing progression, assessment of oedema and ankle mobility, local tolerability and acceptance of the compression therapy. RESULTS: A total of 702 patients with venous leg ulcers (VLU) and/or with lower limb oedema due to CVI were treated with the evaluated system for a mean (±standard deviation) duration of 27±17 days. By the last visit, 30.9% of wounds had healed and 61.8% had improved. Limb oedema was resolved in 66.7% of patients and an improvement of ankle mobility was reported in 44.2% of patients. The skin condition under the compression therapy was also considered as improved in 73.9% of patients and a substantial reduction of pain was achieved, both in number of patients reporting pain and in pain intensity. Compression therapy with the evaluated system was 'very well' or 'well' tolerated and 'very well' or 'well' accepted by >95% of patients. These positive outcomes were in line with the general opinion of physicians on the evaluated compression bandages, which were judged 'very useful' or 'useful' for >96.6% of patients. Similar results were reported regardless of the treated condition, VLU and/or limb oedema. CONCLUSION: Real-life data documented in this large observational study of non-selected patients receiving compression therapy in daily practice confirm the benefits and safety profile of the evaluated compression system. This study also confirms the high-level of performance and acceptability of the system, regardless of the characteristics of the wounds or patients at initiation of the treatment. The data support the use of this multicomponent compression system as one first-line intervention in patients with symptoms caused by CVI.

[Sucrose octasulfate-evidence in the treatment of chronic wounds]. / Sucrose Octasulfat ­ Evidenz in der Behandlung chronischer Wunden.

Patients with chronic wounds should receive wound treatment in addition to causative therapy. In this context, the lack of adequate evidence for wound healing products has been repeatedly discussed. Using the example of TLC-sucrose octasulfate (TLC: technology lipido-colloid), the present review shows that there is significant data with good evidence and comparability in this area. One therapeutic approach to promote wound healing is the inhibition of matrix-metalloproteinases, for example by sucrose octasulfate. For wound products containing TLC-sucrose octasulfate, several sequential clinical studies have been conducted in recent years. The WHAT study was an open randomized controlled trial (RCT) with 117 patients with venous leg ulcers (VLU). The CHALLENGE study was a double-blind RCT with 187 patients with VLU. The SPID study was a pilot study with 33 patients with diabetic foot ulcers (DFU). The two prospective, multicenter clinical pilot studies NEREIDES and CASSIOPEE examined a total of 88 patients with VLU in different phases of healing. In the REALITY study, a pooled data analysis was performed on eight observational studies with 10,220 patients with chronic wounds of different genesis. In the double-blind, two-armed EXPLORER RCT, 240 patients with neuro-ischemic DFU were followed from first presentation until complete healing. In all studies, a significant promotion of wound healing could be shown by the use of wound healing products with TLC-sucrose octasulfate.

Clinical evaluation of polyabsorbent TLC-NOSF dressings on chronic wounds: a prospective, observational, multicentre study of 1140 patients.

OBJECTIVE: The superior wound healing properties and cost-effectiveness of TLC-NOSF dressings in the local treatment of chronic wounds have already been demonstrated by several randomised controlled trials (RCTs) at a high quality level. Therefore, this study aimed to evaluate the efficacy and safety of new TLC-NOSF dressings with polyabsorbent fibres in an unselected population of patients under real-life conditions. METHOD: A large, prospective, multicentre, observational study with two polyabsorbent TLC-NOSF dressings (UrgoStart Plus Pad and UrgoStart Plus Border, Laboratoires Urgo, France) was conducted in Germany between July 2017 and December 2018. Main outcomes included wound healing rate, clinical assessment of wound healing progression, local tolerability and acceptance of dressings. RESULTS: A total of 1140 patients with chronic wounds of various aetiologies (leg ulcers, diabetic foot ulcers, pressure ulcers, etc.) were treated with the investigated dressings in 130 centres, for a mean duration of 56±34 days. By the final visit, 48.5% of wounds had healed and 44.8% had improved. Similar results were reported regardless of wound aetiology or regardless of proportions of sloughy and granulation tissue at the start of treatment. According to the subgroup analysis by wound duration, the sooner the TLC-NOSF treatment was initiated, the better the clinical outcomes for all types of wounds. The dressings were very well tolerated and accepted by the patients. CONCLUSION: These results are consistent with those from RCTs conducted on TLC-NOSF dressings. They complete the evidence on the good healing properties and safety profile of these dressings, especially in non-selected patients treated in current practice, and regardless of the characteristics of wounds and patients. They support the use of the dressings as a first-line intervention and until wound healing in the management of chronic wounds, in association with appropriate standard of care.

Risk and clinical impact of bacterial resistance/susceptibility to silver-based wound dressings: a systematic review.

OBJECTIVE: To perform a systematic review of the literature on bacterial resistance, tolerance and susceptibility of silver within the context of wound therapy using silver-based dressings. METHODS: A literature search was carried out using PubMed, Embase and Cochrane Library databases, the focus was whether results from microbiological experimental in vitro tests with reference strains and clinical wound isolates are reflected in clinical practice with regards to their 'resistance' profiles, comparable with those observed for antibiotics. The search results were allocated to six categories: resistance and resistance mechanism, in vitro tests with standard strains and wound isolates, prevalence and incidence, impact on clinical practice and impact on antibiotic therapy as well as reviews, expert opinions and consensus. RESULTS: Based on all findings of the literature, it cannot be confirmed that a related clinical resistance to silver-ions in silver-based dressings has clinical impact, although endogenous and exogenous genetic resistance patterns have been described and intensively investigated. A translation of these genetic resistance-expression structures to phenotypic appearances, similar to those known for antibiotics, has not been demonstrated for silver in the literature. CONCLUSION: It can be concluded that there is no definitive evidence available and further studies should be conducted.

Use of a TLC-Ag dressing on 2270 patients with wounds at risk or with signs of local infection: an observational study.

OBJECTIVE: A description of wounds treated with a poly-absorbent silver dressing (with technology lipido-colloid with silver ions, TLC-Ag), and evaluation of the short-term clinical impact of the dressing on the wound healing process, under real-life conditions. METHOD: A large, prospective, multicentre, observational study of patients in 81 centres in Germany, presenting with an exuding wound at risk or with clinical signs of local infection for whom the evaluated TLC-Ag dressing (UrgoClean Ag, Laboratoires Urgo, France) has been prescribed. Main outcomes included: reduction in number of wound infections diagnosed and clinical signs of local infection, wound healing rate, clinical assessment of wound healing progression, relative wound area reduction (RWAR), local tolerability, handling and acceptance of the dressing. RESULTS: A total of 2270 patients with acute and chronic wounds of various aetiologies were treated with the evaluated dressing for a mean duration of 22±13 days. All clinical signs of local infection and the diagnosed wound infections were substantially reduced at two weeks after the treatment initiation. All wound infection parameters continued to reduce until the last visit. In the meantime, clinical improvement in wound healing was reported in 98.9% of acute wounds, with a wound closure rate of 68.5%. In chronic wounds, a median RWAR of 57.4% was achieved, with an improvement in healing process documented by clinicians in 90.6% of cases, stabilisation in 6.1% and worsening in 3.2%. Similar results were reported, regardless of exudate level and proportion of sloughy and granulation tissues in the wound bed at baseline. The dressing was well tolerated and well accepted by both patients and health professionals. CONCLUSION: These results, documented in a large cohort of patients treated in current practice, support and complete the clinical evidence on the healing properties and safety profile of the TLC-Ag dressing in the management of wounds at risk or with clinical signs of local infection, regardless of wound and patient characteristics. Declaration of interest: This study was supported by a grant from Laboratoires Urgo. UM, EB, LT and SB are employees of Laboratoires Urgo. JD, KCM and MD provided advisory and speaking services to pharmaceutical and other healthcare organisations including, but not limited to, Laboratoires Urgo. Data management and statistical analyses were conducted independently by INPADS GmbH, Germany.

Efficacy of MMP-inhibiting wound dressings in the treatment of chronic wounds: a systematic review.

OBJECTIVE: Matrix metalloproteinases (MMPs) substantially contribute to the development of chronicity in wounds. Thus, MMP-inhibiting dressings may support healing. A systematic review was performed to determine the existing evidence base for the treatment of hard-to-heal wounds with these dressings. METHODS: A systematic literature search in databases and clinical trial registers was conducted to identify randomised controlled trials (RCTs) investigating the efficacy of MMP-inhibiting dressings. Studies were analysed regarding their quality and clinical evidence. RESULTS: Of 721 hits, 16 relevant studies were assessed. There were 13 studies performed with collagen and three with technology lipido-colloid nano oligosaccharide factor (TLC-NOSF) dressings. Indications included diabetic foot ulcers, venous leg ulcers, pressure ulcers or wounds of mixed origin. Patient-relevant endpoints comprised wound size reduction, complete wound closure, healing time and rate. Considerable differences in the quality and subsequent clinical evidence exist between the studies identified. Substantial evidence for significant improvement in healing was identified only for some dressings. CONCLUSION: Evidence for the superiority of some MMP-inhibiting wound dressings exists regarding wound closure, wound size reduction, healing time and healing rate. More research is required to substantiate the existing evidence for different types of hard-to-heal wounds and to generate evidence for some of the different types of MMP-inhibiting wound dressings.

Handling properties of a superabsorbent dressing in the management of patients with moderate-to-very high exuding wounds.

OBJECTIVE: Exudate control is an important aspect of wound management in both acute and chronic wounds. Exudate can be an indicator of the wound bed condition, specifically inflammation and infection. This study aimed to evaluate the performance, in terms of usability, handling properties, exudate management, user satisfaction and patient comfort, in daily clinical practice, of a superabsorbent dressing, Vliwasorb Pro (Lohmann & Rauscher), suitable for the management of moderate-to-very high exudate levels. METHOD: The user test was conducted between September 2016 and July 2017, with clinicians from different specialisms in 55 centres across Germany. Both the dressing and user test were supplied by the sponsor. The superabsorbent dressing was used for at least three dressing changes, with frequency dependent on the patient and wound condition. RESULTS: A total of 55 clinicians recruited 171 patients with various wound types. The clinicians rated dressing application as 'easy' for 163 (95.3%) of the patients. The dressing was rated as easy to remove (168 (98.3%) and, according to clinicians, did not soil patients' clothing in 165 (97.1%) of cases. The dressing demonstrated a 'good absorbent capacity', as noted by clinicians in 167 (98.2%) of cases. Clinicians also commented that the dressing reduced foul odour, maceration and improved periwound skin condition. CONCLUSION: The evaluated dressing was easy to use, comfortable and reliable for patients with moderate-to-very high exuding wounds. In view of these results, superabsorbent dressings seem to be interesting for both clinicians and patients. Clinical studies are required to confirm these results.

Evidenz von Silber in der Wundbehandlung - Metaanalyse der klinischen Studien von 2000-2015.

HINTERGRUND: Da die wissenschaftliche Evidenz für Silber in der Wundbehandlung meist als unzureichend angesehen wird, besteht für die Anwender eine Unsicherheit hinsichtlich des klinischen Einsatzes. MATERIAL UND METHODIK: Von einer Expertengruppe wurden die publizierten klinischen Studien zu Silber in der Wundbehandlung für den Zeitraum 2000-2015 ausgewertet. ERGEBNISSE: Es konnten 851 Artikel identifiziert werden, von denen 173 Artikel eingeschlossen und kategorisiert wurden. Hierbei fanden sich 31 randomisierte kontrollierte Studien (RCTs) und acht Kohortenstudien. Bei 28 dieser Studien fanden sich statistisch signifikante Endparameter zugunsten von Silber. Thematisch waren dies neun Studien zu Verbrennungen, 20 Studien zu anderen Indikationen (9 x Ulcus cruris venosum, 3 x Dekubitus, 2 x chronische Wunde, 1 x diabetisches Fußsyndrom und 5 x andere Wunden), 16 Studien mit dem Parameter Heilung, zwölf Studien bezogen sich auf Lebensqualität inklusive Schmerz, acht Studien mit Kosteneffektivität und drei Studien mit Reduktion der bakteriellen Keimlast. Auf der Basis dieser Ergebnisse wurde ein Behandlungsalgorithmus für Silber in der Wundbehandlung entwickelt. SCHLUSSFOLGERUNGEN: Diese aktuelle Metaanalyse zeigt, dass die Evidenzlage für Silber in der Wundbehandlung deutlich besser ist, als in der derzeitigen wissenschaftlichen Diskussion wahrgenommen wird. So ergeben sich bei gezieltem und zeitlich begrenztem Einsatz neben den antimikrobiellen Effekten unter anderem auch Hinweise auf eine Verbesserung der Lebensqualität sowie eine gute Kosteneffektivität.

Evidence for silver in wound care - meta-analysis of clinical studies from 2000-2015.

BACKGROUND: Given that the scientific evidence for silver in wound care is generally considered insufficient, there is uncertainty among users regarding its clinical use. MATERIAL AND METHODS: A group of experts evaluated the clinical studies on silver in wound management published from 2000-2015. RESULTS: Overall, 851 articles were identified, 173 of which were included and categorized. There were 31 randomized controlled trials (RCTs) and eight cohort studies. Twenty-eight of these studies showed statistically significant outcome parameters in support of silver. While nine of these studies investigated burn injuries, 20 addressed other indications (venous leg ulcers: 9; pressure ulcers: 3; chronic wounds: 2; diabetic foot ulcer: 1; other types of wounds: 5). In 16 studies, the primary parameter was wound healing, whereas quality of life including pain was assessed in twelve studies; cost-effectiveness, in eight studies; reduction of bacterial load, in three studies. Based on these results, a treatment algorithm for the clinical use of silver in wound care has been developed. CONCLUSIONS: The present meta-analysis shows that the evidence base for silver in wound management is significantly better than perceived in the current scientific debate. Thus, if used selectively and for a limited period of time, silver not only has antimicrobial effects but is also characterized by an improvement in quality of life and good cost-effectiveness.

Quality of life in patients with primary and secondary lymphedema in the community.

Lymphedema is a complex and burdensome medical problem and requires continuous specific therapy. The aim of this cross-sectional study of community lymphedema care in the metropolitan area of Hamburg, Germany, was to evaluate health-related quality of life (QoL) in lymphedema patients. Generic as well as disease-specific health-related QoL was assessed using EQ-5D and FLQA-LK, respectively. Pain was assessed using a visual analogue scale (VAS). About 301 patients (median age of 60.5 years, 90.8% female) with lymphedema of any origin were included. About 66.4% had lymphedema, 24.1% combined lipolymphedema, and 9.5% lipoedema. Mean disease-specific QoL (FLQA-LK) was 2.4 (range 0 = no to 4 = maximum burden). The highest impairment values were observed in subscales for physical complaints, everyday life, and emotional well-being. Mean EQ-5D VAS was 70.4, mean EQ-5D score 63.3. Lymphedema was associated with major impairments in QoL, which differed for subgroups of pain, clinical severity, and comorbidity. Pain as a common problem for lymphedema patients seemed to be underestimated and undertreated. Early diagnosis and structured treatment strategies are urgently needed.

Erratum to: Education in wound care: Curricula for doctors and nurses, and experiences from the German wound healing society ICW.

[This corrects the article DOI: 10.1186/s40779-016-0094-1.].

Compression therapy - current practice of care: level of knowledge in patients with venous leg ulcers.

BACKGROUND AND OBJECTIVES: Compression therapy is a mainstay in the causal treatment of patients with venous leg ulcers. It facilitates healing, reduces pain and recurrences, and increases quality of life. Up until now, there is a scarcity of scientific data with respect to the level of care and the specific knowledge of patients with venous leg ulcers. PATIENTS AND METHODS: At first presentation, patients with venous leg ulcers anonymously answered a standardized questionnaire. Participating facilities nationwide included 55 outpatient care services, 32 medical practices, four wound centers, and one specialized care center. RESULTS: Overall, 177 patients (mean age of 69.4; 75.1 % women) participated in the study. The average duration of florid venous leg ulcers was 17 months. With regard to compression therapy, 31.1 % of patients received none; 40.1 % used bandages; 28.8 % used stockings. Of the latter, 13.7 % were treated with compression class III; 67.4 %, with compression class II; and 19.6 %; with compression class I. While 70.6 % put on their stockings after getting out of bed in the morning, 21.1 % wore them day and night. In 39.2 % of individuals, the stockings caused them discomfort. Merely 11.7 % owned a donning device. On average, bandages were worn for 40.7 weeks, and 69 % were used without underpadding. In 2.8 % of patients, ankle and calf circumference was measured to monitor therapeutic success. 45.9 % reported doing leg exercises. CONCLUSIONS: Although it is considered a basic therapeutic measure in venous leg ulcers, one-third of all patients received no compression treatment. Moreover, given the long duration of ulcers, adequate product selection and correct use have to be questioned, too. Our findings indicate that improvements in the level of knowledge among users and prescribers as well as patient training are required.

Kompressionstherapie - Versorgungspraxis: Informationsstand von Patienten mit Ulcus cruris venosum.

HINTERGRUND UND ZIELE: Eine Säule der kausalen Therapie bei Patienten mit Ulcus cruris venosum ist die Kompressionstherapie. Sie unterstützt die Abheilung, reduziert Schmerzen und Rezidive und steigert die Lebensqualität. Bislang existieren kaum wissenschaftliche Daten zu dem Versorgungsstand und fachspezifischem Wissen von Patienten mit Ulcus cruris venosum. PATIENTEN UND METHODIK: Standardisierte Fragebögen wurden bundesweit in 55 Pflegediensten, 32 Arztpraxen, vier Wundzentren und -sprechstunden sowie einem Pflegetherapiestützpunkt von Patienten mit Ulcus cruris venosum bei Erstvorstellung anonym ausgefüllt. ERGEBNISSE: Insgesamt nahmen 177 Patienten (Durchschnittsalter 69,4 Jahre; 75,1 % Frauen) teil. Ein florides Ulcus cruris venosum bestand im Mittel 17 Monate. 31,1 % hatten keine Kompressionstherapie, 40,1 % Binden und 28,8 % Strümpfe. Bei der Bestrumpfung hatten 13,7 % Kompressionsklasse III, 64,7 % Kompressionsklasse II und 19,6 % Kompressionsklasse I. 70,6 % legten die Strümpfe nach dem Aufstehen an, 21,1 % trugen sie Tag und Nacht. 39,2 % bereiteten die Strümpfe Beschwerden. Lediglich 11,7 % hatten eine An- und Ausziehhilfe. Die Binden wurden im Mittel 40,7 Wochen getragen und bei 69 % nicht unterpolstert. Bei 2,8 % wurde der Knöchel- und Waden-Umfang zur Erfolgskontrolle gemessen. Venensport machten 45,9 %. SCHLUSSFOLGERUNGEN: Ein Drittel hatte keine Kompressionsversorgung, obwohl diese eine Basismaßnahme der Therapie des Ulcus cruris venosum ist. Zudem ist deren korrekte Auswahl und Anwendung angesichts der langen Bestandsdauer der Ulzerationen zu hinterfragen. Weiterführende Fachkenntnisse bei Anwendern und Verordnern sowie Patientenschulungen sind erforderlich.

Education in wound care: Curricula for doctors and nurses, and experiences from the German wound healing society ICW.

The German wound healing society ICW (Initiative Chronische Wunden) started a training program for nurses in 2005. Certified by TÜV Rheinland the courses are regularly audited and the quality is ensured. More than 30,000 nurses attended these courses in Germany. In three Chinese hospitals the ICW courses have been adopted. A close collaboration between Chinese and German experts in wound healing let to their further development and improvement. The article reviews the need for education in the treatment of chronic wounds for medical personnel-nurses and doctors. Experiences and perspectives are discussed.

Quality of care in chronic leg ulcer in the community: introduction of quality indicators and a scoring system.

BACKGROUND: Treatment of chronic wounds is complex, particularly as a standard for the assessment and evaluation of quality of care is missing. OBJECTIVES: To develop indicators for quality of care in chronic wounds in general, and to evaluate the quality of care in leg ulcers in Hamburg, Germany, in particular. METHODS: Twenty indicators were derived from a national Delphi expert consensus to compute a single index of quality of care. This index was applied in a cross-sectional study involving a large spectrum of care providers and leg ulcer patients in the community. Trained wound experts interviewed and examined the patients, who had to complete standardized questionnaires. RESULTS: On average, 64% of the quality criteria were met in the consecutive sample of 502 patients with chronic leg ulcers of any origin; 75% of the patients were satisfied with their wound care. Predictors of quality of care are presented. CONCLUSIONS: This instrument is feasible, valid and ready for comparisons of patient groups, regions and care systems, and for optimization processes in wound care.