[black small square] In This Issue of JWOCN

The July/August issue includes the typically wide variety of topics expected for a journal serving a group of clinical experts as broad as the WOC nurses. However, when reviewing this month's abstracts, I was struck by the growing number of articles that focus on the feasibility, safety, and effectiveness of combination therapies. From a strictly clinical perspective, there is nothing especially new about this concept. WOC nurses (as well as clinicians in every specialty) have a long tradition of empirically combining interventions, especially in complex cases. These innovative combinations form much of the discussion on the WOC forums, and they are the heart of Nightmares on WOC Street. Regulators and researchers are grappling with methods to measure the effectiveness of combination treatments, and this challenge, combined with a multitude of other factors associated with clinical research on the frail patients that comprise our daily practice, has led to a reexamination of the role of the randomized controlled study as the sole design for generating "level 1 evidence." I urge you to follow this discussion as it matures over the next several years; the implications for WOC specialty practice are potentially enormous.

This issue includes a View From Here written by Ivy Razmus who explores pediatric care within the WOC nursing specialty. You will want to read her thoughtful commentary on the need for an increasing cadre of nurses within the field of pediatrics, as well as her arguments that infants and children are a vulnerable population whose need for wound, ostomy, and continence care will only be partially met until we are able to increase the population of WOC nurses practicing in pediatric care settings.

Daniel J. Drake, Melvin Swanson, Gloria Baker, Marie Pokorny, Mary Ann Rose, Laurie Clark-Reed, Wanda Waters, Frank R. Watkins, and Martha Keehner Engelke evaluated the influence of body mass index on pressure ulcer prevalence. You will want to read this important study that reexamines and challenges traditional beliefs that body fat may protect the individual from pressure ulcer development. Tina R. Myers evaluated a heel protection device. You will want to read this clinically relevant study that examines both the intended outcome of the heel protection device (prevention of pressure ulcers) as well as a potential secondary benefit, prevention of plantar flexion contracture.

Debra Dunn examines the WOC nurse's participation in patients undergoing combination therapy for peritoneal surface malignancies. In this case, combination therapy including cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is increasingly recognized as an effective means of reducing the malignant burden and extending life in these aggressive, multifocal, and potentially deadly malignancies. The information in this article qualifies as must-read because of the insights Dunn provides into the wound and ostomy care needs of these patients.

In this issue's Ostomy section, Christoph Franklin describes a technique for isolating and containing effluent from small bowel fistulae within complex abdominal wounds. You will want to read this article to better understand how you might apply or adapt this technique to your management of enterocutaneous fistulae. You will also want to read Franklin's call for additional research to determine the comparative effectiveness of various treatment options for managing these especially complex cases. As you contemplate this challenges, you may want to consider why we have no randomized controlled trials in this area of care, and what alternatives may be exercised to generate reasonable evidence for the effectiveness and safety of these important interventions. Finally, you will also want to review the executive summary in the previous issue of the Journal1 and visit jwocnonline at http://journals.lww.com/jwocnonline/pages/default.aspx to obtain the CAET Best Practice Recommendations for Management of Enterocutaneous Fistulae.

Heidi Huddleston Cross and Patricia Hottenstein describe their experiences with an ostomy support group. This article contains must-read information about keys to success in maintaining an active ostomy support group since its inception in 1979. It also serves as an important reminder of our significant role in enabling ongoing health and maintenance of a strong quality of life following creation of an ostomy.

This issue's Continence section begins with a masterful review and CE offering from Dorothy Doughty and Joseph Kisanga that reviews strategies for ensuring your facility is in compliance with F-Tag 315. You will want to read this article and complete the attached continuing education test to increase your knowledge of how to aid you facility to ensure compliance with F-Tag 315 and ensure the best care for patients in your facility with urinary incontinence. Katherine N. Moore describes a case of a patient with multiple sclerosis, urinary incontinence, and incomplete bladder emptying who requests a suprapubic catheter for ongoing bladder management. You will want to read this fascinating case and thought-provoking questions and answers to sharpen your knowledge of the complex issues surrounding placement of a long-term indwelling catheter in a comparatively young adult with multiple sclerosis and neurogenic bladder.

This issue's Challenges in Practice also focuses on combination therapy for treatment of chronic wounds. Ivan Chernev, Paul A. Liguori, Sandra L. Senno, Kim L. Peters, and Jolene M. Bowers describe a series of cases in which they combine noncontact, low-frequency ultrasound with Manuka honey and sharp wound debridement for treatment of indolent chronic wounds. You will want to read their article to increase your knowledge of this intervention bundle and determine its potential application to your practice setting.

Donna Zimmaro Bliss, Director, the Society's Center for Clinical Investigation, authors this issue's Spotlight on Research. You will want to read her succinct and lucid discussion that provides practical and effective methods for obtaining letters of support when generating a successful research grant proposal.

Finally, I want to encourage you to visit jwocnonline often. As I noted previously, this newly enhanced Web page contains a variety of must-read information including a new blog from Web page Editor Lee Ann Krapfl (Getting the SKINny), J WOCN Early Edition that contains article published online before they appear in the printed Journal, collections of articles from the Journal's archives, and information for authors ensuring that your colleagues will soon be reading your contribution to our specialty practice's growing evidence base.

[black small square] Evidence From Other Publications

Wound Care

Is there seasonal variation in the incidence of venous leg ulcers? A retrospective analysis of 391 patients with venous leg ulcers suggests that the incidence of ulcer formation is increased during the warmest months of the year, followed by a decline during the late fall and winter.2 In addition, their analysis revealed that ulcers that developed during winter or summer healed slower than ulcers that developed during the spring or fall. Although these data are clearly provocative, the underlying mechanisms for this variation (such as seasonal variability in immune system function) remain speculative, as do the clinical implications of these observations.

Ostomy Care

Mechanical bowel preparation remains a widely used preoperative strategy that is intended to reduce the incidence of postoperative infection and anastomotic leakage within the bowel. In a recent issue of Annals of Surgery, Van Sant and coinvestigators3 compared the incidence of anastomotic leaks requiring diverting ileostomy in patients undergoing low anterior bowel resection. Forty-eight of 449 patients (10.6%) required diverting ileostomy. Twenty-seven received mechanical bowel preparation and 21 did not, a nonsignificant difference. The findings of this study are clinically relevant to WOC nursing practice because they provide additional data that mechanical bowel preparation is not effective for the prevention of anastomotic leakage during anterior bowel resection. For a more complete review of evidence related to bowel preparation, I urge you to review the Evidence Based Report Card by Colwell and Gray published in a previous edition of the Journal.4

Continence Care

Fecal or bowel management systems provide an important and effective option for transient management of fecal materials in selected cases. However, as with all indwelling devices, they also carry a potential of serious adverse side effects. A recent issue of Diseases of the Colon & Rectum includes a description of 3 cases where serious hemorrhage occurred in patients who experienced traumatic removal of a fecal management system (2 cases) or pressure ulceration associated with its presence (1 case).5 Each of the cases required endoscopic or surgical intervention to control blood loss. Although it must be remembered that fecal or bowel management devices are an effective means to prevent the substantial complications associated with uncontrolled exposure of the skin to fecal leakage, patients must be carefully monitored for clinically relevant blood loss, especially in the presence of traumatic removal or if there is an evidence of a pressure ulcer within the intestinal mucosa.

References