Wound Healing Southern Africa - Volume 8, Issue 2, 2015
Volume 8, Issue 2, 2015
Author Alan WidgerowSource: Wound Healing Southern Africa 8 (2015)More Less
This edition of Wound Healing Southern Africa (WHSA) is primarily dedicated to burn wound management and teaching from a physician and nurse perspective. The low figures in the burn unit in which I collaborate in a country like the USA, where I have spent the past few years, serves as a stark contrast to the great needs of countries such as South Africa, where burn injury figures are still high. Necessity is the mother of invention, and South African ingenuity has repeatedly proven itself. In that respect, Nikki Allorto, President of the South African Burn Society (SABS), and her team, have considered alternative means of procuring donor skin, examined the metabolic changes in burn injuries and new approaches to the control thereof, and provided insight to the important functions undertaken by the SABS.
Source: Wound Healing Southern Africa 8, pp 6 –21 (2015)More Less
Burns are among the most common and devastating forms of trauma. Increased morbidity and mortality accompany thermal injury, and survival is dependent on the correct assessment and management. Although acute treatment regimens and dressing selection have evolved to improve outcomes, deep burn injuries often leave patients with considerable cosmetic and functional disabilities, which may lead to a lifetime of challenges. Patients with major burns should be referred to a burn unit or multidisciplinary centre where the primary objective is to care for burn patients and to optimise their outcomes. Such centres comprise teams of specialist burn surgeons, plastic and reconstructive surgeons, physiotherapists, occupational therapists, dietitians, social workers and nursing staff, as well as other consultants, who all strive to obtain rapid wound closure and return burn survivors to a functional and well adapted life.
A pilot study of Cutimed® Sorbact® versus ACTICOATversus Silverlon® for the treatment of burn wounds in a South African adult burn unit : general reviewSource: Wound Healing Southern Africa 8, pp 22 –29 (2015)More Less
Background: Since significant clinical data are unavailable on the use of Cutimed® Sorbact® in burns, a decision was taken to test it againstthe best anti-infective dressings used in our burns unit.
Method: A random prospective study was conducted in which Cutimed® Sorbact® was compared with control products, ACTICOAT and Silverlon®. Selected patients had partial- or full-thickness burns.
Results: Thirteen patients were included in the pilot study. Fifty-seven dressing areas were tested. A statistical difference between the tested product and the control products was not found through either clinical observation or microbiological analysis.
Conclusion: This pilot study confirmed that the Cutimed® Sorbact® dressing was safe when treating burn wounds over a three-day period. In addition, the potential to use it on earlier or fresher burn wounds warrants the further study of Cutimed® Sorbact® as a potential skin substitute.
Source: Wound Healing Southern Africa 8, pp 30 –34 (2015)More Less
Since their introduction into medicine in the 1940s, antibiotics have been central to modern healthcare. Their role has expanded from treating serious infections to preventing infections in surgical patients, protecting cancer patients and people with compromised immune systems, and promoting growth and preventing disease in livestock and other food animals.Now, however, once-treatable infections are becoming difficult to cure, raising costs to healthcare facilities, and patient mortality is rising, with costs to both individuals and society. Decreasing antibiotic effectiveness has risen from being a minor problem to a broad threat, regardless of a country's income or the sophistication of its healthcare system. Many pathogens are resistant to more than one antibiotic, and new, last-resort antibiotics are expensive and often out of reach for those who need them.
ResistanceMap overview : the latest data on global antibiotic resistance embargoed until Sept 17, 2015 at 00:01 Hours GMT : CDDEP resistancemap overviewSource: Wound Healing Southern Africa 8, pp 35 –36 (2015)More Less
ResistanceMap is a web-based interactive tool that allows users to explore global trends in antimicrobial resistance (AMR) and antibiotic use using maps and other data visualizations. CDDEP first released ResistanceMap in 2010 with data from the United States, Canada, and over 30 European countries. This latest iteration now features data from low- and middle-income countries (LMICs) including India, Kenya, South Africa, Thailand, and Vietnam. Data from China, Nepal, Mozambique and the Philippines will be updated soon.
ResistanceMap features easy-to-use and quick-loading maps,charts, and trend graphs for both antibiotic use and resistance. Users can compare rates over time, between countries, and, for the United States, between states and census regions.
Evidence of emergent silver-resistance in clinical bacteria : a major implication for wound care and the use of silver-dressings : finley SAWC posterSource: Wound Healing Southern Africa 8, pp 37 –39 (2015)More Less
Concerns of emergent widespread silver resistance in clinical bacteria have been raised due to the increased utilization of inorganic silver in wound dressings. Although the molecular basis for silver-resistance has been previously characterized, to date, phenotypic expression of these genes has not been observed in clinical settings. Here we identified the first strains of clinical bacteria expressing silver-resistance at a level that could significantly impact wound care and the use of silver-dressings. After IRB approval, preliminary screening of 859 isolates identified 67 samples potentially harboring silver-resistant genes. Colony PCR confirmed 31 isolates had at least 1 silver-resistant gene. Next, we investigated whether the bacteria possessing silver-resistant genes expressed this trait phenotypically. Despite carrying silver-resistant genes, minimal inhibitory concentration (MIC) testing revealed that most of the bacteria displayed little or no increase in resistance to ionic silver (200 - 300µM Ag+). However, 2 isolates (Klebsiella pneumonia and Enterobacter cloacae) were capable of luxuriant growth at exceedingly high silver concentrations with MIC values reaching 5,500µM Ag+. An examination of the extracellular DNA of these two strains revealed small cryptic plasmids roughly sized 1.5, 2, and 2.5kb which were not present in the other bacteria with lower MIC values. We hypothesize these unanticipated DNA products are potential promoters for phenotypic expression of silver-resistance. Scanning Electron Microscopy images revealed the presence of silver nanoparticles embedded in the extracellular polymeric substance of both isolates. This finding suggested the isolates may neutralize ionic silver via reduction to elemental silver. Additional antimicrobial testing revealed these isolates to be at least 1,000 times more resistant to many commercially-available silver dressings when compared to control bacteria. Taken together, these findings provide the first evidence of emergent silver-resistance in clinical bacteria. The development of acute silver-resistance would have significant consequences on wound care and patient outcomes.
Silver resistance identified in clinically isolated enterobacteriaceae : major implications for burn and wound care : finley SAWC posterSource: Wound Healing Southern Africa 8, pp 40 –42 (2015)More Less
During the last 40 years, inorganic silver has become a popular additive for many medical devices including burn and wound dressings. As a result, concerns of widespread silver-resistance emerging in clinical bacteria have been raised. Previously, we identified the first clinical bacteria (Klebsiella pneumoniae and Enterobacter cloacae) capable of luxuriant growth at exceedingly high concentrations of silver. Additional DNA sequence analysis revealed PCR products from these isolates had a high degree of similarity to other plasmids containing genes which encode for heavy metal resistance. These plasmids included pKPN3, pMG101, and many mega plasmids in the Klebsiella taxid. This finding suggests the existence of many genetically similar plasmids all with potential capabilities of expressing high levels of silver-resistance. Further antimicrobial testing against commercially-available silver dressings showed after 24 hours of dynamic contact, the silver-resistant isolates were largely resistant to many of the dressings. Data from a corrected zone of inhibition (CZOI) assay supported these findings. Neither of the silver-resistant isolates produced significant zones of inhibition after contact with the dressings, while the non-resistant organisms yielded a measureable zone of inhibition. Swabs from underneath the dressing post-incubation revealed the silver-resistant bacteria remained viable. Research revealed non-silver based wound dressings maintained high antimicrobial efficacy against these clinical bacteria without the risk of resistance. The development of acute silver- resistance would have significant consequences on wound care and patient outcomes. There is a significant need for non-silver based dressings that can effectively manage bio-burden while minimizing resistant risks. Due to a current lack of antimicrobial stewardship practices for silver-based treatments, continued monitoring for silver-resistance is warranted.
The hypermetabolic response to burn injury and modulation of this response : an overview : general reviewSource: Wound Healing Southern Africa 8, pp 44 –46 (2015)More Less
Burn injuries are followed by a profound hypermetabolic response, which is characterised by circulatory, physiological, catabolic and immune system changes. This response can persist for up to 24 months post burn. It is mediated by a 50-fold elevation in plasma catecholamines, cortisol and inflammatory cells. This leads to whole body catabolism, significantly elevated resting energy expenditure (REE) and multi-organ dysfunction. These patients have a number of metabolic derangements, including increased REE, increased cardiac work, increased myocardial oxygen consumption, marked tachycardia, severe lipolysis, liver dysfunction, severe muscle catabolism, increased protein degradation, insulin resistance and growth retardation. Early excision and grafting is the cornerstone of management. No treatment modality supersedes early wound coverage. Early enteral nutrition, thermoregulation and resistance training are other components of care. Basic management should be correctly executed before pharmacological agents are employed.
Source: Wound Healing Southern Africa 8, pp 59 –69 (2015)More Less
Objective: This article forms part of the findings of a thesis titled, The management of burn wounds by nurses. The purpose was to describe current practice to identify strengths, weaknesses and gaps in this regard.
Design: A qualitative, descriptive research design was used.
Subjects and setting: The population included nurses providing care to patients admitted to a burn unit.
Outcome measures: Semi-structured interviews were selected for data collection. Data collection took place from August to October 2012 and from April to June 2013. Data saturation was achieved after eight interviews.
Results: The description of current practice identified strengths, weaknesses and gaps in current practice with regard to the management of burn wounds from the participants' perspective.
Conclusion: The interviews augmented the findings of structured observation. Certain hypotheses were proved and disproved, for example,that wound care is ritualistic as the same words were repeated by nurses to describe certain phenomena. Heating cleaning solutions and hand washing were identified as areas that needed development. Participants' responses suggested a need for training, following assessment and diagnosis. The tissue, infection and inflammation, moisture balance and edge of wound (TIME) framework was not adopted for the management of burn wounds. The nursing process and the TIME framework were not used during documentation, which indicates a need for a more structured approach to reporting. These results indicate that guidelines on the management of burn wounds by nurses are required.
Sixty-second screening for diabetic foot disease : a comparison of two Nigerian teaching hospitals : original researchSource: Wound Healing Southern Africa 8, pp 65 –69 (2015)More Less
Objectives: This study identified diabetic patients at high risk of diabetic foot disease, using a 60-second screening tool in two Nigerian teaching hospitals. This is important as diabetic foot is the most common reason for diabetic-related hospitalisation and often requires amputation. It is known that patients who undergo any form of amputation are at increased risk of further amputations. However, when patients are diagnosed early and offered adequate care using a multidisciplinary approach, the rate of amputation decreases significantly.
Design: This was a cross-sectional study. Consecutively consenting patients with diabetic mellitus who present at both hospitals (University of Ilorin Teaching Hospital and Lautech Teaching Hospital) were recruited into the study.
Subjects and setting: The patients had diabetic mellitus and were attending the endocrinology clinic at both hospitals. Sixty-five patients were recruited from the University of Ilorin Teaching Hospital, Ilorin, while 64 patients were recruited from the Lautech Teaching Hospital, Ogbomoso, for the study.
Outcome measures: The patients were screened using the 60-second screening tool. This identified patients at high risk of developing diabetic foot who would therefore need further intervention.
Results: The study patients were predominantly in the sixth and seventh decade of life (60% at the University of Ilorin Teaching Hospital, and69% at Lautech Teaching Hospital). Fifteen per cent of patients with a previous ulcer were at the University of Ilorin Teaching Hospital, and 28% at Lautech Teaching Hospital. Deformity was recorded in some patients. Eleven per cent of the patients experienced loss of protective sensation at the University of Ilorin Teaching Hospital, and 30% at Lautech Teaching Hospital. Overall, there was at least one risk factor for 35% of patients at the University of Ilorin Teaching Hospital, and 55% at Lautech Teaching Hospital.
Conclusion: Screening for diabetic foot is paramount in reducing the morbidity and mortality associated with the condition. This identifies high-risk patients who require further care. Therefore, efforts should be concentrated on Screening.
Source: Wound Healing Southern Africa 8, pp 69 –75 (2015)More Less
Objectives: This article forms part of the findings of a thesis on the management of burn wounds by nurses. The aim of the study was to describe the current practice by nurses of managing burn wounds.
Design: A mixed-method, quantitative and qualitative, non-experimental, explanatory, sequential, descriptive design was used.
Subjects and setting: The population was nurses providing care to adult patients with superficial- to partial-thickness burn wounds, admitted to a single burn unit in a tertiary academic hospital in Gauteng.
Method: The quantitative data were collected initially through an integrative review, followed by the parallel collection of quantitative data through structured observations, and qualitative data through semi-structured interviews. This article presents the findings from the structured observations. Multiple dressing changes were observed, using a checklist as a data-collection tool. Data were collected from August to October 2012, and from April to June 2013. Descriptive statistics were used to summarise, categorise and order the data. The positivity index (PI)percentage was used for analysis. A total of 303 dressing changes were observed.
Outcome measures: The outcome measure was a description of current practice according to the themes of the nursing process using aquantitative checklist.
Results: The findings revealed that communication between nurses and patients was ineffective, with PIs of 18% for the nurses introducing themselves to patients, and 14% for giving an explanation of the procedure to be carried out to patients. Failing to heat the cleaning solution before applying it, and not washing their hands were also identified as areas needing improvement. On assessment and diagnosis, the nurses scored below the 70% mark required for a quality assessment. The lowest scores were observed for the use of the TIME (tissue management, control of infection and inflammation, moisture imbalance, and advancement of the epithelial edge of the wound) framework. This suggests that the framework had not been adopted as a frame of reference for the management of burn wounds in the observed setting. Satisfactory scores were obtained for certain elements of the dressing execution, namely the aseptic field being maintained, a logical sequence being followed throughout the procedure, and consideration being given to complaints by the patients about their pain. However, the way in which the environment was not adequately prepared prior to dressing execution, the way in which packages were not opened asceptically, the failure of the nurses to check the expiry dates of the cleaning materials, and the cleaning technique used were identified as gaps in competence. The need for a more structured approach to reporting was identified from lack of use of the TIME framework during documentation. A PI of 62%was obtained for the referral pathways, which is below the benchmarked score of 70% for quality.
Conclusion: The results obtained from the structured observations in this study indicate that there is a need for guidelines on the management of burn wounds by nurses.
Source: Wound Healing Southern Africa 8, pp 76 –77 (2015)More Less
Burn injuries place a significant burden on the healthcare system in South Africa. Early excision and management is the standard of care, and impacts upon survival in cases of large total body surface area burns. If the use of an autograft is limited owing to extensive burn injuries, cadavre skin is the gold standard for temporary management. A cadavre skin bank is needed in South Africa, and has not existed until very recently. Organ donation is increasing, while tissue donation is largely unknown, although tissue banking has been established in South Africa for cornea, bone and heart valves. The availability of tissue remains difficult. The high demand for tissue is not being met by current donations. South Africa is a rainbow nation, and varied cultural and religious considerations impact upon organ and tissue donation. A small number of healthcare workers were surveyed in order to gauge their willingness to become skin donors as part of research into the development of a campaign to raise awareness about skin donation.
Source: Wound Healing Southern Africa 8, pp 78 –81 (2015)More Less
Chronic wounds refer to wounds that fail to progress through an orderly and timely sequence of repair, where healing has not been realised in a predictable time frame, i.e. when wounds fail to heal within three months, when the wound's size hasn't decreased by30% within four weeks, when the wound is not 30% smaller after one month and will not heal by week 12. A perception exists that chronic wounds are associated with old age, but every chronic injury has the potential to develop into a chronic wound. The prevalence of patients living with chronic wounds globally is high. Approximately 120 patients per 100 000 are aged 45-65 years. With increased age, the prevalence increases to more than 800 patients per 100 000 who are aged 75 years and older.
Author Nikki AllortoSource: Wound Healing Southern Africa 8, pp 82 –83 (2015)More Less
The time has come for the "Cinderella" field of burns to be transformed as the South African Burn Society (SABS) grows, and we reach the critical mass needed to fulfil the role of the SABS in an environment in which there is a high burden of disease, and which has been neglected for so long. When I took over as President, the SABS had a mere 30 members. We now have a record 340 members as a result of a successful membership drive this year, launched through our new website (saburnsociety.co.za) which offers easy online application, as well as through visits to burn units around the country. It is important to build a network among professionals working in burns in order to share knowledge and support, and to work together for change. Membership is free for these reasons, in the interests of encouraging as many professionals as possible to join.
Source: Wound Healing Southern Africa 8 (2015)More Less