In This Issue of JWOCN

This issue of the Journal includes a wide variety of hot topics in WOC nursing practice, from management of abdominal fistulae to glucose control management and implications for wound healing in hospitalized patients with diabetes mellitus. Our special focus is on larval debridement therapy. Three features focus on larval debridement. P. Steenvoorde and L.P. van Doorn present a case study of serious bleeding from a wound managed by maggot (larval) debridement therapy. They report that this unusual complication occurs in less than 1% of reported cases of larval debridement but can lead to serious clinical consequences unless promptly recognized and effectively managed. Read their article to learn more about this uncommon complication of larval debridement therapy and how to avoid or effectively manage bleeding should it occur in one of your patients. Our Challenges in Practice article by Laura Jean Van Veen also reports on a complex case managed with larval debridement therapy.

In View From Here, Susan Maditz addresses the ethics of relationships between industry representatives and the WOC nurse. This issue is basic to every WOC nurse's practice, but it is seldom discussed. Read her article for a summary of industry-generated ethical guidelines for interacting with clinicians, and her perspective on our responsibilities when meeting with a representative, handling samples, and bringing new products into a facility.

Barbara Hocevar, Paula Erwin-Toth, Judy Landin-Erdman, James Wu, Ann Navage, Ellen Duel, Shirley Dunbar and colleagues from the Cleveland Clinic, St Francis Hospital and Medical Center, Presbyterian Hospital of Dallas, University of Minnesota, and Morton Plant Health Care report on a new fistula and wound management pouching system. Read this article to learn about initial clinical experiences with a product designed to address a severely underserved clinical need, managing wound care and effluent containment needs of the patient with an abdominal fistula.

Brigid Lynch, Anna Hawkes, Suzanne Stegniga, Barbara Leggett and Joanne Atiken report on a population-based study of concerns among community-dwelling persons with an ostomy and colorectal cancer. Several strengths render their findings important to our understanding and management of this patient population, the robust sample (332 subjects), the use of a community-based sample, and serial evaluations at 5, 12, and 24 months after diagnosis. You will want to read this study to gain additional knowledge of long-term adjustment to an intestinal ostomy and the influence of colorectal cancer diagnosis.

In this issue's CE article, Karin Patel reviews the literature about hyperglycemia in patients with (and without) diabetes mellitus undergoing cardiothoracic procedures and especially coronary artery bypassing with grafts. All patients undergoing cardiothoracic surgery share some risk for sternal wound infections, but those with hyperglycemia are at especially high risk. She focuses on a novel prevention strategy, tight glucose control for the prevention of postoperative hyperglycemia. Read her article to refresh and expand your knowledge of the deleterious effects that hyperglycemia exerts on wound healing and infection risk, as well as the latest research about tight glucose control versus traditional management using a sliding-scale insulin regimen.

This issue's Wound Care section opens with a unique article that explores retrospective versus prospective research designs in the context of 2 studies focusing on pressure ulcer management. Dr Michael Clark contrasts the strengths and weaknesses of prospective designs, based on random assignment to treatment or control groups and maximal control of extraneous variables, to a retrospective study design with its emphasis on real-world study settings and the associated variability in outcomes. You will want to read this article to increase your ability to critically read research reports pertaining to wound, ostomy, and continence care, and to enhance your skills in applying this knowledge to an analytical evaluation of the strength and limits of applying clinical evidence to individual clinical decisions.

V.K. Shukla, Dinesh Shukla, Abhisek Singh, A.K. Tripathi, Sushil Jaiswal and Somprakas Basu report on a prospective study of pressure ulcer risk in 100 hospitalized patients. They used the Waterlow pressure ulcer risk assessment tool to classify patients as not at risk, at risk, at high risk, and at very high risk. All patients were placed on pressure ulcer preventive programs based on level of risk and outcomes measured. Read this article for a prospective evaluation of the effect of preexisting risk on pressure ulcer incidence and for a research-based evaluation of one of the hottest topics of 2008, "Are some hospital-acquired pressure ulcers avoidable?"

Evidence From Other Publications

WOUND CARE

The risk of foot ulcers is widely recognized among wound care clinicians and WOC nurses. Multiple factors associated with diabetes mellitus are commonly cited, such as peripheral polyneuropathies, angiopathies, and anatomic deformities including Charcot foot.1 Rheumatoid arthritis is also known to involve the foot, affecting more than 90% of sufferers over the course of this chronic disease, resulting in anatomic defects of the joints of the toes or ankle.2 In a recent issue of Arthritis & Rheumatism, Firth and coinvestigators2 report the prevalence of foot ulcerations among patients with rheumatoid arthritis as 9.73%. Ulcers tended to occur on the toes (51%) including the dorsal aspect of hammer toes and metatarsal heads, other locations on the forefoot (57%), or the rear aspects of the foot (15%). In addition, 33% of patients with rheumatoid arthritis reported multiple ulcerations (median number of ulcers 2, range = 2-30 episodes). Only 40% of these patients reported receiving care from a wound care or foot care specialist and slightly less than half of respondents with active ulcers at the time the research was completed wore special footwear. WOC nurses and wound care clinicians lead the way in counseling persons with diabetes mellitus to engage in routine and ongoing self-management programs designed to reduce the risk of foot ulceration, and aggressively manage ulcerations when they occur. This article provides evidence that we should include both patients with rheumatoid arthritis and their healthcare professionals when teaching foot care and self-monitoring for ulcerations.

In a recent issue of the Archives of Surgery, Gregor and colleagues3 report on a systematic literature review and meta-analysis of negative pressure wound therapy (NPWT). They searched electronic databases MEDLINE, CINAHL, EMBASE, and the Cochrane Library for randomized clinical trials, and quasi-experimental trials comparing NPWT to conventional wound therapies. They identified 255 citations and 17 studies that met inclusion criteria, as well as 19 unpublished trials. Seven of the studies that met the authors' inclusion criteria were randomized clinical trials and 10 were quasi-experimental studies that compared NPWT to other therapies but did not employ randomization when assigning treatments. They found significant differences in time to wound closure in 2 of 5 RCTs and 2 of 4 quasi-experimental trials. They also performed a meta-analysis of 4 of the randomized controlled trials and 2 of the quasi-experimental studies also favored NPWT. Nevertheless, the authors concluded that insufficient evidence exists to clearly demonstrate a clinical benefit of NPWT. Their rationale for this statement rises from the overall poor methodologic quality of the studies included in the review and meta-analysis and the large number of unpublished and prematurely discontinued trials as sources for concern. While it is impossible to deny the considerable enthusiasm associated with NPWT, this critical analysis of the existing evidence serves as a sobering reminder that the evidence supporting the benefits of this therapy remains weak, and the need for well-designed, completed, peer-reviewed, and published trials is more urgent than ever.

OSTOMY CARE

In addition to concerns over hospital-acquired pressure ulcers, changes in the prospective payment policies of the Centers for Medicare & Medicaid Services have generated considerable interest in nosocomial infections including catheter-associated urinary tract infections and ventilator-associated pneumonia. When examining nosocomial infections rates in a critical setting, Beyersmann and associates4 have attempted to distinguish between nosocomial infections acquired from endogenous sources (ie, the patient himself or herself) versus transmission-acquired nosocomial infections (TANI). TANI are defined by the authors as hospital-acquired infections caused by transmission of pathogens from staff to patient or from patient to patient. Common examples of TANI pathogens identified in the critical care setting include Acinetobacter baumannii, Staphylococcus aureus, and Clostridium difficile. Multivariate analysis of 1,876 patients managed in intensive care units was analyzed to determine the incidence of TANI (8.8%) and factors associated with an increased risk for TANI. The presence of a colostomy was the only factor found to significantly increase the hazard ratio for TANI (hazard ratio, 3.8; 95% CI, 1.0-14.3; P = .047), although its presence did not alter the risk for subsequent death. This finding is important because it identifies persons with a colostomy as at increased risk for TANI and underscores the necessity of a WOC nurse consultation for every patient with a new or existing colostomy managed in a critical care setting.

CONTINENCE CARE

Painful bladder syndrome (interstitial cystitis) remains one of the greatest challenges to continence management. Persons with painful bladder syndrome suffer from both pelvic pain and lower urinary tract symptoms (LUTS) including urinary frequency and nocturia. Botulinum toxin A is under investigation for possible use in the treatment of overactive bladder syndrome and neurogenic detrusor overactivity associated with reflex or urge urinary incontinence caused by neurologic disease or spinal cord injury. In a recent report in the Journal of Urology, Giannantoni and coworkers5 report on intravesical injection of botulinum toxin A for the management of LUTS in 15 patients with painful bladder syndrome. Approximately 87% reported improvement in LUTS at 1 and 3 months, including statistically significant decreases in daytime and nighttime voiding frequency. However, these benefits diminished at 5-month follow-up, with only 27% reporting persistent LUTS relief. LUTS and pain recurred in all patients by 1 year. As this pilot study demonstrates, the search for effective and durable treatment options for painful bladder syndrome persists, but answers remain elusive.

References