Suppl.1 Vol.1

2012.

WOUNDSJournal

1st CONGRESS OF TREATMENT CHRONIC WOUNDS

WITH INTERNATIONAL PARTICIPATION

CHRONIC WOUNDS, CURRENT THERAPY-ANSWERS

Best Western Hotel M, BelgradeNovember 23-24. 2012.

Content — Wounds 3

Content

3 Content

4 Editorial

5 Introduction

6 The chronic wound: general, clinical and diagnostic aspect Z. Janjic, D. Momcilovic, J. Nikolic, M. Marinkovic

6 Microbiology of chronic wounds: the role of systemic antimicrobials in the treatment Brkić S.

6 Dermo-epidermal skin substitute Elia Ricci

7 Neurological aspects of chronic wounds Jovanovic Zagorka

7 Burns in Neonates Rytis Rimdeika, MD, PhD

8 The wounds in vascular surgery Nenad Ilijevski, Predrag Matić, Đorđe Radak

8 Chronic venous ulceration- trend growth mixed ulceration Javorka Delic

8 Surgical Treatment of Chronic Venous Insufficiency and Venous Leg Ulcers Dragan J. Milic, MD, PhD, FACS

9 Hemodynamic controversies over “in-flow” perforator veins in the etiology of chronic venous ulcers. Our experience in EVLA performing Petar Dragić MD

9 Indication and different materials for compression therapy for venous leg ulcers Nada Kecelj Leskovec, MD, PhD,

10 Treatment of chronic wounds using modern supportive covering Sandra Marinović Kulišić, Jasna Lipozenčić

10 Hard to heal chronic wounds – the role of lymphoedema Tanja Planinšek Ručigaj

10 Treatment of Venous Leg Ulcers with Reducing Terminal Reflux and EVLA. Andrej Šikovec, MD, MSc, Avelana Vein

10 Decubital ulceration - general aspects and risk factors Dubravko Huljev

11 Prevention and treatment of pressure ulcers Simon Pandjaitan, Saša Milićević

11 Application of topical negative pressure in healing wounds Sasa Borovic, Biljana Polic, Mirjana Nesovic

11 Conservative and active surgical treatment of pressure ulcers Saša Milićević, Nenad Stepić, Simon Pandjaitan

12 Necrotizing fasciitis, acute disease of contemporary man Z.Janjic, J.Nikolic, M.Marinkovic, N.Djermanov

12 Surgical treatment of Complications Dystrophic Epidermolysis Bullosa Rytis Rimdeika, MD, PhD

12 Chronic wounds in dermatology: new possibilitas of the treatment Jasmina Begic

13 Madura foot as cause of chronic wounds Radovanovic S, Delic J.

13 Tissue guided regeneration with allogeneic platelet gel, autologous cancellous bone graft and resorbtive collagene membrane Igor Frangez, Ciril Triller, Dragica Maja Smrke

13 Debrisoft - or how to simply do the wound debriman Borisav Mandić, Tijana Đurić, Marina Dišović

14 Calciphylaxis C. Triller, D. Huljev, D.M. Smrke

14 Application of iron preparations and recombinant human erythropoietin is a prerequisite for faster healing of chronic wounds in the cardiovascular surgery in anemic persons

Branko Čalija

14 Development Center for treatment of chronic wounds in the BH Heart Center Tuzla Softie M., Banjanovic B., Jahic M., S. Rajkovic

15 Reconstructive treatment of diabetic foot Jelena Jeremic, Cedomir Vucetic

15 Vacuum Assisted Wound Closure in Vascular Surgery – Experience of Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre

Marko Dragas, Igor Koncar, Lazar Davidovic

16 Organization of a specialized multidisciplinary Wound Center for Chronic Wound Management in Copenhagen Finn Gottrup

16 Organization of the Center of Chronic Wounds - Management in the Asklepios-Klinik-Hamburg-Harburg Dr. Harald Daum

16 Comprehensive treatment in the treatment of burns Nenad Stepić

17 Organisation of the Center for chronic wounds management- our experiences Aleksandar Gajić,

17 Presentation of the Swiss Wound Care Association (SAfW) Dr. Sebastian Probst

17 Intravenous Iron Administration For Acute and Chronic Wound Healing in Anemic Patients Branko Calija

18 Endovenous laser ablation veins in treatment of vsm, and prevention of recurrent venous ulcer Dario Jocić

18 Debrisoft-or how to simply do the wound debriman Borisav Mandić, Tijana Đurić, Marina Dišović

18 Mesotherapy in dermatocosmetology and regulation of reparative processes of the skin Nevenka Dokmanovic

19 Chronic wounds on postoperative cut – present cases Dijana Lukic, Gordana Kanjevac, Javorka Delic

19 Injuries In Children Sara Rowan

19 The Role of Nurse in Treatment of Chronic Wounds Anke Bültemann

20 Pressure ulcer-indicator for bad nursing care Kanjuh Ž.,Lazarević A., Dragin A.

21 2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014, BELGRADE, SERBIA

4 Wounds

Chronic wounds, with their presence, complexity of appearance and heal-ing, certainly are a great proffesional challenge. Various great resources need to be engaged and there are, also, significant costs. The existence of associations for wound healing, specialized professional magazine and professional meetings is an actual need. Following world’s professional and scientific streams, Serbian experts, through collaboration, tend to give a greater contribution in solving the daily problems of chronic wounds.

This issue of magazine (suplement) appears in time of I Congress of Serbian Wound Healing Association with international participation, having inten-tions to complete this meeting.

The need for congress about wound healing with international par-ticipation comes from enviable success in achieving high professional and organisational level. There is a dynaimic development in this area, so the doctors and medical stuff who do the chronic wound healing have plenty of possibilities in prevention and healing of chronic wounds. There is, also, an increasing number of these patients. But, existing procedures often do not give expectant results, the haealing is long and multidisciplinary. Congress is a professional meeting where professional achievements in various areas can be presented and evaluated. This Congress is, also, the result of collaboration and support of European Wound Management Association . Serbian Association is one of the oldest European associations for chronic wound healing. This meeting gathers eminent experts from Europe and Serbia, pharmaceutical industry, our doctors and nurses who do the healing of chronic wounds. Professional improvement is a need and also a duty. In our estimation, there are between 60000 and 80000 patients with chronic wounds in Serbia and this is a huge economic, healthy and social problem. Congress gives an opportunity for education, experience exchanging, for presentation of Serbian Helth System and puts Serbia together with European countries, which have high- level organization and systematic ap-proach in healing of chronic wounds. Congress is an opportunity for direct meetings and communication of participants, which will enable greater cooperation and exchange of knowledge and experience in aim of improv-ing chronic wounds healing and patients’ welfare.

Magazine Wounds publishes significant number of abstracts, in aim of in-troducing this works to as many professionals as possible on this congress. There is a constant need for improving praxis, knowledge and experience in chronic wound healing. Magazine Wounds tends to give the experts in this area an opportunity to present results in healing of chronic wounds. Hoping that our efforts will be useful to experts, patients and society, we are inviting you for collaboration in aim of a more successful work.

Editor- on-ChiefProf dr Čedomir Vučetić

Suppl.1 Vol.1 2012.

WOUNDSPublisher:Serbian Wound Healing Society Heroja Milana Tepića 1, Belgrade

Editor- on-Chief:Prof dr Čedomir Vučetić

Design, layout and printing:Dina Dizajn d.o.o.Kneza od Semberije 5a, Belgrade

Members of the editorial boardJavorka Delić Mirjana Dragašević Branko Čalija Željko Kanjuh Saša Borović Simon Panđaitan Zlata JanjićMilan MatićZagorka JovanovićJelena Jeremić Nenad Ilijevski Srećko Bosić

Members of the foreign editorial board Finn Gottrup Ellia RiciMarco RomanelliDubravko HuljevRytis RimdejkaZita Kiš DadaraSebastijan ProbstSara Rowan

WOUNDS — Wounds 5

Prim. dr Javorka Delić, specialist of dermatology and angiology

In formation of chronic wounds participate more causes (multifactoriality), so they should be familiarize beacouse “Hidden wounds are diffi cult to heal” (Hippocrates). This can be achieved through teamwork (multidisciplinarity, interdisciplinary), continuing professional education, using the latest advances in diagnosis and treatment, exchanging of knowledge and experience, which is the goal of the Congress. Using modern methods of treatment it shortens the healing time by 50%, it improves vitality of patients and reduce medical costs. In therapy is applied individual and holistic (comorbidities) principles. There are always the most important clinical parameters and good listening patients as active participants in the treatment, beacouse “Patients are our best teachers”(Hippocrates).

Prof. dr Čedomir Vučetić, specialist in orthopedic surgery and traumatology

Surgical treatment of chronic wounds is present in various types and causes of the condition, as wounds, as complications. Appropriate consideration of when and how to surgically treat, and the availability of this type of treatment is a continuing need in improving treatment. Surgery is, often, necessary in the prevention of chronic wounds and subsequent complications. Avaliable are very simple procedure, applicable in all situations (debridement), but also the most complex reconstructive surgery procedures (microsurgery).

Finn Gotrup, Vascular surgeon

Non-healing wounds are a signifi cant problem for health care systems all over the world. In the industrialized world, almost 1-1½% of the population has a problem wound at any one time and accounts for 2-4% of the health care budget-a fi gure which is likely to rise with an increasingly elderly and diabetic population (1-3)

6 Wounds — The chronic wound: general, clinical and diagnostic aspect

The chronic wound: general, clinical and diagnostic aspect

Z. Janjic, D. Momcilovic, J. Nikolic, M. Marinkovic, Clinic of plastic and reconstructive surgery, Clinical center of Vojvodina,

Medical faculty, University of Novi Sad, Novi Sad, Serbia.

Background: Chronic Wounds (CrW) are defined as wound that not healed after three months. ChW have also been defined as wounds do not decrease in size by 30% in three weeks or by 50% in 4-5 weeks with optimal surgical management. The authors to consider, in according to literature data and self experience, to give the up to date general, clinical and diagnostic aspect recommendations in doctrine of CrW.

Methods: This is descriptive, retrospective and comparative study of general characteristics, possibility of diagnostic and treatment of CrW in according on contemporary literature and self experience of surgeons from Clinic of plastic and reconstructive surgery, Clinical center of Vojvodina from Novi Sad, to found in 1964 year.

Results: In the past 40 year’s human population advancing in age, increasing in weight with the resultant comorbididities, an increase in the number of patients with ChW. Although the causes of ChW are numerous like diabetic, arterial, venous, and pressure sores, elderly and poor mobility constitute the majority of ChW. Infection is common problem in ChW, usu-ally resulting in nonhealing and significant patient morbidity end mortal-ity. The different diagnostic procedures are present in CrW now, while the surgical postulate is like that before. The most changes on the historical view were on local wound treatment in depending on socio-economic status of single person and society.

Conclusions: The authors of this study to have an opinion that avoid CrW are impossible but we to be able to reduce them with prophylactic treatment of acute wound in risk group of patients. The most important will be the education and coordination of patient, his or her family as well as medical and support staff. In according to experience of health care system over the world and in Serbia, the optimal way to improve prophylaxis and treatment of patients with ChW will be to create an independent multi-disciplinary wound-healing center and has outpatient clinic as well as an inpatient word.

Key words: Chronic wounds, diagnostic, treatment

Microbiology of chronic wounds: the role of systemic antimicrobials in the treatment

Brkić S. Clinical center Vojvodina, Clinic for infectious diseases, Serbia

Aims: The place and role of systemic antimicrobials in the treatment of chronic wounds, the choice and duration of treatment are the one of the most contraversional facts in complexicity of chronic wounds care. World-wide literature show that over 60% of patients received minimaly once cure of systemic antimicrobials.

Methods: Overview of new literature and guidelines with short retrospective study on the Clinic for Infectious Diseases, KCV, according to antimicrobial treatment of decubital ulcers with suspicion for moderate to severe infection.

Results: In 2 years od observation (2010,2011) on The Clinic for Infec-tious Diseases we treated 81 patient, average age of 59,92 godine (60%

≥65y.) with decubital ulcers and clinical diagnosis od potential local and/or systemic infection. Patients had been admitted with decubital ulcers or developed it during hospitalization. Statistically significant number of patients had neurological or osteomuscular disorders and 20% had mini-mally two or more co-morbidities. Significant number of patients expresed also laboratory signs of local infection (54%), following others with lab.findings for systemic infection (20%), and 26% patients didn’t have any lab. findings for infection at all, but also received antimicrobial treatment. 68% smears taken from wounds were positive with polymicrobial cultures (gram negative bacteria).

Conclusions: Systemic antimicrobials are indicated only in moderate to severe local infections (cellulitis, limfangitis, abscesses, osteomyelitis) and systemic complications (sepssis). In the presence of febrile state, for introduction of systemic antimicorbials laboratory findigs for infection are usefull and for systemic complication it is necessery that patients fullfay-ing the criteria for SIRS. Extensive use of systemic antimicrobials increase development of resistance and expose patients to other side effects.

Key words: chronc wounds, systemic antimicrobials

Dermo-epidermal skin substitute

Elia RicciDifficult Wound Healing Unit, St Lucas’ Clinic,

Pecetto Torinese, ITALY

The new development of Bioengineering made available to the operators a new category of products that promote tissue repair in chronic and acute wounds. Currently the indications of use are not well defined, the first documents are being drafted, but have found nothing in the operators, many supporters. an international consensus document published in 2011 defines three different types of extracellular matrices: biological, synthetic and composite. These materials are used as temporary coverings, their role is in the resumption of reparative processes, this takes place through the provision of a structure which, colonized by autologous tissues, allows the rapid filling of loss of substance. Also these tissues have the ability to inactivate MMPs, some authors have suggested this as real action of the scaffolds (table 1). There is a big push from Industries in terms of research of new products and in positioning it on the market, it is not simple classify all heads available. Should also consider the different regulations in force between nations and continents. In table 2 is reported a list of products available with the classification of J W T. The most evident advantage of this type of treatment is the reduction of aggressiveness of surgical treatment. This feature allows to extend to patients, not otherwise candidates for traditional surgery, the access to the operating room. even in the absence of trial extended and controlled, it is easy to predict that this type of technol-ogy will be more and more widely applied in the near future.

Neurological aspects of chronic wounds — Wounds 7

Chronic wounds contain high levels of MMPs which can:* Degrade the ECM and growth factors* Increase inflammatory response* Reduce cell responsiveness in the wound* Delay wound healing

Enhanced wound healing environment, where matrix has been replaced by new collagen with remodelling of ECM

Treat using an acellular matrix that closely resembles native ECM. This may act as a scaffold for:* MMPs to bind to and break down collagen in the product* Epithelial cells, fibroblasts and vascular endothelial cells to migrate into and proliferate* Reduced levels of MMPs to be released back into wound as collagen matrix breaks down, rebalancing protease and growth factor levels in the wound

↓

↓

Table 1: Role of acellular matrix in wound Healing (HardingK W Int 2011)

Type SUB TYPE BRAND NAME

Non cellularized dermal substitute Bi layer IntegraHyalomatrix PA

PelnacRenoskin

Single layer AllodermEpiflex

Ez dermGammagraft

GlyadermIntegra single layer

MatridermSurederm

Human fibroblast derived dermalsubstitutes

Living cells / Cells products

DermagraftDermagen

Advanced biological skinrepair therapy

Apligraft

KERATINOCYTES COLTURE EpicelEpibaseRecell

Laserskin

HELPS FIBROBLAST GROWTH BiobraneGraftygen derma

OasisUnite

HELPS EPIDERMAL GROWTH SupratelVeloderm/graftigen

epidermis

Table2: Classification of bioengineering tissues

BIBLIOGRAPHY:· Harding K., Kirsner R, Lee D, Mulder G, Serena T. “Acellular matrices for the treatment of

wounds”

Wounds International 2011.

· VVAA “Bioengineered Alternative Tissue” J Wound Tecn 4, 2009

Neurological aspects of chronic wounds

Jovanovic ZagorkaClinic of Neurology Clinical Center of Serbia, School of Medicine,

University of Belgrade, Serbia.

The role of the nervous system is important in maintaining of trophic, tone and skin perfusion. which participate in The structure of the central and peripheral nervous system, especially the autonomic nervous system participate in these functions. In a number of neurological diseases there are the disorders of motor function, autonomic control of sensitivity and vascular systems, which are particularly pronounced for difficult moving patients. Immobility associated with chronic pressure on the skin leads to chronic wounds. These diseases are stroke, Parkinsonism and Parkinson’s syndrome, motor neuron disease, multiple sclerosis, myelitis, spinal cord injury, polyradiculoneuritis, polyneuropathies et al. Dementia and depres-sion contribute to the development of chronic wounds.

The prevalence of chronic wounds due to pressure (pressure ulcers)varies in different studies from 12% to 27% of nonselected patients. The selection of patients in relation of pathology showed the highest number of severe pressure ulcers (classification by European pressure ulcer advisory panel) in surgical patients (12%), geriatric (8%) and neurological patients (2%) after 7 days of hospital admission. The structure analysis of neurologic disease with pressure ulcers showed one examination of 592 neurological patients, of which 16 had decubitus on admission: 2 with motor neuron disease, 5 with Parkinson’s disease and 9 with other neurological diseases. In another study of older patients the most common risk for pressure ulcers was the previous stroke (60% patients). The study of risk for pressure ulcers in patients in intensive care showed the highest risk in patients who have had a stroke (OR = 1.96), followed by trauma (OR = 1.83) and cognitive decline (OR = 1.26). In patients with spinal cord trauma, pressure ulcers occured in 30% - 40% of cases, with the recurrence after surgical treatment in 17.3% of patients.

In neurological practice, trigeminlni trophic ulcer can be seen, as a result of damage to the central or peripheral trigeminal system, with anesthesia, paresthesia and persistent or recurrent skin ulcers.

In diabetic senso-motor polyneuropathy, the chronic wounds are categorized as neuropathic in 50% of patients, ischemic in 15% and neuro-ischemic in 35%. There is a loss of perception of pain in the feet, which along with other internal and external biomechanical factors, are leading to chronic wounds.

Prevention should be started early, in the form of daily skin care, avoiding pressure, good nutrition, optima physical and mental activity. Early treat-ment with medication includes nutritional resources, antibiotic prepara-tions, growth factors and extracellular matrix products, using pulsed electromagnetic fields, and surgery at the end.

Burns in Neonates

Rytis Rimdeika, MD, PhDLithuanian University of Health Sciences,

University Hospital Kauno Klinikos

Although burns in neonates are rare they still occur incidentally. The im-maturity of skin renders infants susceptible to burns of various etiologies: following relatively brief exposure to disinfectants, phototherapy lamps and blankets, adhesive dressings, etc. Burns in neonates have major implications in terms of morbidity. Author will give an overview of various

8 Wounds — The wounds in vascular surgery

etiologic factors of burns in neonates and will illustrate the presentation with own clinical experience based on treatment of eleven patients.

First clinical case is on treatment of preterm neonate twins who sustained burn injuries on the warming blankets in 30 December 2001. Major full thickness burn injuries were diagnosed with a 15 and 20 % TBSA respec-tively. Patients were treated by eschar excisions and wound split skin grafting with an allograft overlay (sandwich technique). Ten year follow-up is presented. Other cases represent chemical burns in nine infants caused by solution of benzalkonium chloride. This disinfectant often used for the skin antisepsis prior to injections, punctures and surgical procedures in hospitals, with no restriction to use or obstetric practice. Nine infants (5 females and 4 males) were gestated normally in regional hospital on 10th -11th December, 2009. During 24 hours after gestation skin was wiped with benzalkonium chloride prior to puncture of vein or for hygienic purposes. Inflammation of wiped zones was followed by blistering and ulceration. Affected areas included scalp, neck, armpits, thorax, abdomen, groins. All infants were transferred to University Hospital immediately . 2-15 % TBSA chemical burn injuries were diagnosed. Two of them sustained 15 % TBSA injuries complicated by infection. In University Hospital wounds were debrided and dressed with advanced dressings. Two sustaining 15 % TBSA burn injuries had wound debridement under general anesthesia. For these infants hydrophilic base antiseptic creams were used and wounds were dressed by non-occlusive dressings.

Author concludes that the cases highlight the importance of having a clear policy for nursing in every neonatal unit and measures to avoid errors by vigilant checking of all medication and technical devices.

The wounds in vascular surgery

Nenad Ilijevski, Predrag Matić, Đorđe RadakInstitut of Cardiovasculare Disease, Institut “Dedinje”, Belgrade,Serbia

The wounds on legs were often the reason for thi patient ,s visit to vascular surgeon. The treatment of the wounds is the burden for health system .The most of them are vascular etiology,vhronic and reccurence. The wounds can be the consequences of the disease of arterial or veins systems, or theirs combinations. Also, the patients with chronic wounds have the risk factor for the amputation of the extremities.

The examinations presented that the prevalence of chronic wounds ,aproxi-matelly 1% (adult populations) and that 80% of the wounds were veins eiology.

Conservative method for tretament is consisted –the realisation adequate conditions for wounds healing , dressings ,but the operative method for wounds therapy is also very importante. The operative treatment is pre-sented by debridment , arterial revascularisation and operation on vains systems on extremities.

Key words: wounds, arterial, veins, therapy

Chronic venous ulceration- trend growth mixed ulceration

Javorka DelicCity Institute for Dermatology, Belgrade Serbia

Chronic venous ulceration (CMA) is the most common, is 65% of all ulcers of vascular etiology (46%-75%, Wells 2004; Korber 2008; Control study 2006; Delic 2004, 2008; Debus 2009).

In recent years, the distribution of the CMA increased tendency of mixed ulceration, i.e. association of CMA with peripheral artery disease, diabetes, vasculitis, lymph edema, trauma. Mixed CMA represent 10-22% of all ulcers (Schultz, Debus, Delic, Control).

The primary objective of the study was the incidence of mixed CMA, secondary clinical presentation, time of healing, complications, treatment methods. In the study 91 patients - 60 women, average years (59 yr.), 31 men (56 years). CMA (post thrombotic) is present in 59 (65%) showed mixed ulceration in 32 (35%) patients.

Average healing time of mixed CMA is 6 months, with complications (infec-tions, cellulites, pain, bleeding), change in localization to the front and side of the lower leg and foot, and more than 5 co morbidities and risk factors. Arterial-venous ulcers, affect the choice of compression therapy (CT), when the ABI below 0.8, when the ABI below 0.6 KT is not recommended, as the ulcer is treated artery. Mixed ulcers are difficult healing ulcers, treated with combined therapy (CB, HBO, NDT, laser stimulative, grafts, surgery, hospitalization), and the treatment of multiple expensive compared to “pure” venous ulceration.

The tendency of increasing mixed CMA explains the increase of the popula-tion over 70 years, an increase in cardiovascular, neurological diseases, injuries, and the application of standardized diagnostics.

Because clinical and localization of mixed CMA is often defined as atypical. Initial survey of patients with CMA includes Color Doppler, ABI, co mor-bidities control, i.e. a holistic approach, enabling accurate diagnosis and treatment.

Key words: venous ulcers, Ulcus mixtum

Surgical Treatment of Chronic Venous Insufficiency and Venous Leg Ulcers

Dragan J. Milic, MD, PhD, FACSClinic for Vascular Surgery, Clinical Centre Nis, Serbia

Background: Chronic Venous Insufficiency and Venous Leg Ulcers (VLU) are a major health problem because of their high prevalence and associated high cost of care. The cost of venous leg ulcers is estimated to be $1 billion per year in the United States, and the average cost for one patient over a lifetime exceeds $40 000 because the natural history of this disorder is slow healing and high recurrence rate. It is estimated that 0.3% of entire population in Western European countries has an active venous ulcer.

Etiopathology: Ambulatory venous hypertension is a key factor in the development of chronic venous insufficiency and venous ulcers. Basi-cally there are two possible mechanisms involved in the development of venous hypertension:

1) venous reflux which could be axial or segmental, deep or superficial; and/or 2) venous obstruction.

Hemodynamic controversies over “in-flow” perforator veins in the etiology of chronic venous ulcers. Our experience in EVLA performing — Wounds 9

Surgical treatment: In the treatment of Venous Leg Ulcers main postulate is to correct underlying venous lesion. The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. Surgical options for treatment of venous insufficiency include ablation of the saphe-nous vein; interruption of the perforating veins with subfascial endoscopic surgery, laser or radiofrequency ablation or sclerotherapy; treatment of iliac vein obstruction with PTA and stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser and radiofrequency therapy, skin grafting....There is no evidence demonstrating the superiority of surgery over compression treatment in the healing of venous ulcers, but ESCHAR study clearly demonstrated that surgery reduces the rate of recurrences compared to compression therapy.

Conclusion: For venous leg ulcers surgical management should be considered in order to correct underlying venous lesion. Although more research is needed regarding the comparative efficacy of various surgical approaches, options include debridement; human skin grafting; and surgery for venous insufficiency, which is associated with a reduced rate of ulcer recurrence and may be helpful for severe or refractory cases. Artificial skin grafting with human skin equivalent may be effective when used with compression therapy, but there are concerns regarding infection transmis-sion.

Hemodynamic controversies over “in-flow” perforator veins in the etiology of chr onic venous ulcers. Our experience in EVLA performing

Petar Dragić MDJelica Malešev MD

Introduction: The causes of the occurrence of chronic venous ulcers are the following hemodynamic changes:

• Insufficiency of superficial venous system and

• Insufficiency of deep venous system with consequential occurrence of “out-flow” perforators.

Aim: To point at the fact that hemodynamic importance of in-flow perforators in the occurrence of venous ulcers in an isolated insufficiency of superficial venous system is a minor one and also frequently overestimated by physicians dealing with the issue.

Method: Last decade brought some important novelties in the field of venous diseases treatment, therefore contemporary phlebology currently has an array of minimally invesive methods.

Since 2008 until present day, we treated by laser 47 patients with venous ulcres occurred due to insufficiency of superficial venous system. We have not treated ulcers of other etiology so far. We used duplex scan to exclude DVT, insufficiency and post-thrombotic syndrom of deep veins and artherial insufficiency...

Chronic venous ulcers of our patients were treated by a combined therapy:

• endovenous laser ablation of insufficient superficial venous system with or without adjuvant procedures, e.g. the application of Aethoxisclerola foam and/or microphlebectomy,

• transcutaneous laser iradiation and

• elastic compression.

Results: The success of laser procedure is based upon the main trunk oc-clussion of superficial venous system and absence of flow in control duplex check-up. Subjectively, patients feel the reduction of pressure and gradual disappearance of symptoms immediately after the first intervention. In all the treated patients there occurred the healing of chronic venous ulcer during a follow-up period lasting for a few weeks up to several months post intervention.

Conclusion: In-flow preforator veins represent closing part of the course of superficial venous insufficiency, i.e. the entering point of reflux into deep venous system. In most cases we speak of Cockett’s preforator veins, but frequently they can also be other preforator veins. Their hemo-dynamic importance in conditions of venous ulcer presence in an isloated venous insufficiency of superficial venous system is a minor one. By solving the problem of insufficiency of superficial venous system we also solve the problem of preforator veins, therefore their further treatment is not necessary for ulcer healing. Contrary to in-flow, out-flow perforators are connected to insufficiency of deep venous system (usually as a consequence of secondary insufficiency of deep venous system), therefore for ulcer heal-ing their treatment is necessary.

Indication and different materials for compression therapy for venous leg ulcers

Nada Kecelj Leskovec, MD, PhD, Department of Dermatovenereology, University Medical Centre Ljubljana, Slovenia

Aim: The aims of compression therapy are to accelerate vein, lymph and microcirculation flow and therefore to reduce chronic nonbacterial inflam-mation and oedema of the limb and to improve venous ulcer healing.

Methods: According to the degree of extensibility, short-stretch (exten-sibility 10% to 100%) and long-stretch (extensibility >100%) compression materials are distinguished. The former generate very high sub-bandage pressures during exercise due to contraction of muscles and stiffness of the material (passive compression) and maintain low pressures during rest due to their low elasticity. By contrast, long-stretch bandages exert moderately high pressures, which are almost the same at rest and during walking and are unaffected by changes in calf circumference, e.g. due to a decrease in oedema (active compression). Stiffness tells us how pressures under the bandage change during walking. It can be expressed with the static stiffness index (SSI), which is the difference in pressure between active standing and lying.

Results: In the first phase of compression therapy in a calf with venous ulcer, erythema and oedema we advise short stretch bandages or very stiff compression systems. After the reduction of limb oedema, improvement of skin changes and healed venous ulcer, the maintain phase of compression therapy is proceeded with long stretch compression bandages or stockings.

Conclusions: Compression therapy is indicated in all stages of CVI. Short-stretch compression systems are suitable for advanced forms of the disease associated with cutaneous changes and ulceration. Long-stretch compression bandages and stockings are recommended for maintain therapy.

10 Wounds — Treatment of chronic wounds using modern supportive covering

Treatment of chronic wounds using modern supportive covering

Sandra Marinović Kulišić, Jasna Lipozenčić

The goal: Treatment with modern supportive covering is today the most effective and pharmacoeconomic justified. The main role of a supportive lining provide optimum physical and chemical conditions for wound healing, and today their role is becoming ever more demanding, in terms of prevention of the development of infection control exudate, painful atraumatic bent down and eventually “cost benefit” compared to conventional treatment.

Method: The modern concept of treatment today includes general and local treatment. General measures are aimed at correcting any associated diseases and conditions that hinder the healing process and that local treat-ment consists of cleaning the wound and removal of pus, necrotic layers, and to encourage the process of granulation and epithelialization.

supportive covering are divided into:

- covering that help with autolytic processes in the wound: gels, alginates

- coverings that accelerate granulation with creating moist, warm environment and absorbing excess secretions (hydrocolloids, hidrofiber, hidrocapilar and silicone coverings)

- coverings that accelerate epithelization: membrane, acrylic, lining with collagen, cellulose hidrobalans coverings, films and nets

- covering which affect on infection: the addition of silver linings and coal, iodine, and poliheksanida medical honey.

Results: Of the 1750 patients in 2011 with chronic wounds, 980 were venous ulcers, 215 ischemic ulcers and 565 ulcers of various etiology (vasculitis, polyarteritis nodosa, calciphylaxis, necrobiosis lipoidica). Treat-ment was carried out with modern supportive liner, and it was measured by assessing the status of the wound, chronic wound classification (previ-ously made Biopsy specimen for microbiological treatment of ulcers and histopathological analysis) and Doppler veins and arteries of the lower extremities.

Conclusion: The modern supportive covering are an integral part of care for patients with wounds of various origins. In keeping with the indica-tions and proper application, along with an individualized approach each patient, we can achieve faster, better, and better treatment for wounds.

Hard to heal chronic wounds – the role of lymphoedema

Tanja Planinšek Ručigaj

Lymphoedema of lower limb presents as persistent and progressive swell-ing of the leg. In many patients venous and lymphatic insufficiency coexist. Even more, at many patients with chronic wounds venous etiology, the significance of lymphatic failure has not been recognized. The presence of lymphoedema influence on ulcers healing and in the other way, the chronic venous ulceratios will also damage local lymphatics and that will increasing the potential for develop and worsening the lymphoedema. In later second and third stage of lymphoedema, where the oedema is very big, the skin is stretched and fragile so the risk of appearence of ulcers is biger. We can find the chronic oedema at 35-55 % of patients with leg ulcerations. When the lymph drainage is compromised, the fluid will accumulates and remains

proteins will influence on proliferation of macrofages. The inflammatory responce will efect on fibroblasts and collagen fibres. All of those process cause the skin problems and risk of infections and ulcerations.

At our study, where patients with lymphoedema and patients with lymphoedeama and chronic venous insufficiency, both group with ulcers, were inclouded, we find, that in group with mixed aethiology of ulcers, the healing rate is lower versus healing rate at ulcers only lymphatic ethiology.

Treatment of Venous Leg Ulcers with Reducing Terminal Reflux and EVLA.

Andrej Šikovec, MD, MScAvelana Vein

Center Otočec, Slovenia

Aim: Venous leg ulcer is the end stage result of chronic venous insufficiency. About 1% of mainly elder population is affected by this condition. The changes that are the result of high venous pressure cause the inflammation cascade that ends up in hypoxia and necrosis of the tissue. A compression therapy and care of ulcer remain the pillars of the therapy but reducing the superficial venous reflux may boost the healing process. The immediate distal vein reflux abolishing relives symptoms and improves the condition to that stage that endovenous thermal therapy of superficial reflux is feasible.

Method: After the duplex scan we started immediately with ultrasound guided foam therapy of the venous network around the ulcer with 1% Aethoxysclerol foam. After some weeks we continued the treatment with endovascular laser ablation of the refluxing trunk vein and perforators if feasible.

Results: In 2 years we have treated 12 leg ulcer in this way and we achieved healing of all ulcers in 2 month period.

Conclusions: Immediate reducing of terminal vein reflux boost the healing process of the venous ulcer. In this way the infection and inflam-mation are reduced and the symptoms are relived. So the endovenous laser ablation of safenous vein and perforator can be safely performed in short time period.

Key words: venous leg ulcer, terminal venous flow reduction, EVLA

Decubital ulceration - general aspects and risk factors

Dubravko Huljev

Decubitus is a significant phenomenon, especially in the elderly years, which is constantly growing and it is one of the most common complica-tions of poorly moving people. This is an important gerontology public health problem that also represent big health and economic problems for the patient, his environment, and the facility in which it is located. Decubitus (Latin decumbere = lying) is a condition that occurs due to tissue ischemia or circulatory in some area of the body, caused by a stronger and longer-lasting pressure on a certain part of the body (most commonly over bony promination) lying or sitting. It occurs in patients who are immobile or hardly moving, and in which it does not perform adequate.

The most important risk factor for decubitus is patients immobility, (general bad condition, paralysis, injury or illness that is requiring bed rest or use a wheelchair, coma, recovery after major surgery). Additional factors that

Prevention and treatment of pressure ulcers — Wounds 11

influence the development of decubitus are age, contractures, loss of feel-ing, malnutrition, inadequate hydration, urinary and fecal incontinence, bacterial contamination, and so on. Prevalence in hospitalized patients, depending on the severity of the disease and the department, is ranging from 3.5% up to 69%. In home care that range is from 2.6% to 24%.

There are three main mechanisms for formation decubitus, and they are pressure, shear and friction. Pressure is the most important factor in the development of decubitus. If the external pressure is higher than the capil-lary pressure, then arises occlusion of blood vessels. Capillaries are closed when the pressure rises above 32 mm Hg. Shearing occurs when the patient slides on the surface. Shear forces result in damage to the blood vessels, with resultant cessation of circulation. Friction is a force that occurs when two surfaces slide over one another (eg, between the skin of patients and sheets). On that way occurs a superficial skin abrasions. Clinically we distin-guish 4 stages decubitus. I stage - erythema with edema. It occurs after a few hours and disappears when the pressure is removed. II stage - bubbles in the affected region or partial lack of skin. III stage - with the entire loss of necrosis of skin and subcutaneous tissue to the fascia and muscle, with or without undermined parts. Stage IV - ulcer affects the muscles, tendons and bones.

The most common location is the sacrum, gluteal region, pertrohanterna region, heel and back. Bottom of decubitus is often deep necrosis that often extends all the way to the bone, which can be affected by infection (osteo-myelitis). The edges are often undermined, secretion is often purulent, and the surrounding skin is often atrophic with marked signs of cellulitis.

There are often complications, but the most common of these are: infections, cellulitis, sepsis, osteomyelitis, malignant transformation ulcer (Marjolin ulcer).

Prevention and treatment of pressure ulcers

Simon Pandjaitan1, Saša Milićević2

1Plastic surgery office Pandja and Maraš,2Military Medical Academy, Clinic for plastic surgery and burns,

Belgrade, Serbia

Objectives: Pressure ulcer is a disease that occurs as a result of poor care. Decubital ulcerations caused by action of the continuous pressure on a particular part of the body which lead to interruption of the circulation in the superficial layers of the skin and soft tissues. The aim of this paper is to present the prevention of pressure ulcers occurrence, and to show the ways of pressure ulcers treatment.

Methods: Pressure ulcer prevention methods are: prolonged pressure release - turning the patient at regular time intervals, the use of different types of mattresses (for better distribution of the pressure), the use of bridges in the positioning of patients, as well as various types of splint joints. In addition, it can also be used Clinitron bed with constant pumping hot air. Conservative and surgical methods could be applied in the treatment of pressure ulcers. Non surgical methods are: improved nutritional status, treatment of infection and adequate care. Surgical treatment includes application of split skin and local flaps in the definitive coverage of defects of the skin caused by pressure sores covering ulceration.

Results: The paper gives a schematic view of prevention, the presenta-tion looks mattress and advantages of using bridges. Application of surgical methods in the treatment of pressure ulcers is presented with clinical cases, with a final postoperative result.

Conclusion: Prevention of pressure ulcers is a key factor in care of patients with chronic illnesses. The treatment of pressure ulcers requires a good estimate for the application of the appropriate methods that will promptly lead to the complete coverage of defects of the skin cover.

Keywords: pressure sores ulcers, prevention, treatment

Application of topical negative pressure in healing wounds

Sasa Borovic, Biljana Polic, Mirjana Nesovic

Introduction: Deep sternal infections and mediastinitis are the worst forms of surgical site infection after cardio surgery operations.This paper presents the results of use of topical negative pressure in patients with postoperative mediastinitis

Methods: Retrospective study that analyze the results of treatment of 10 patients using topical negative pressure in mediastinitis after cardio-surgery operation. Patients were treated in the period from march 2010. until may 2012. in Institute of Cardiovascular diseases “Dedinje.” We used Renasys (Smith & Nephew) and V.A.C (KCI) apparatus.

Results: Of 10 patients, 5 (50%) were female. The average age of treated patients was 66 years (range 56 to 79). On average, 22 days passed from cardiosurgery operation to the diagnosis of infection and the start of treatment (interval ranged from 9 to 60).Topical negative pressure is used on average 37 days (range 18 to 120). After treatment, the wound in 5 (50%) patients were sewn without reconstruction technique, in 4 (40%) were used reconstructive procedures, and at 1 (10%) patient wound is not closed. At 7 (70%) patients the treatment was successful, and of that number 4 was without recurrence, and at 3 patienst were recurrent, and that was locally treated until healing. In 3 (30%) patients there was a death that was associated with infection of surgical site.

Conclusion: By using of topical negative pressure are achieved a good results, hospitalization time is much shorten and material costs are reduced.

Conservative and active surgical treatment of pressure ulcers

Saša Milićević1, Nenad Stepić1, Simon Pandjaitan2

1Military Medical Academy, Clinic for plastic surgery and burns,2Plastic surgery office Pandja and Maraš,

Belgrade, Serbia

Objectives: Defects of the skin covering in pressure ulcers usually cover using active surgical approach, use of split skin graft or local flaps. The aim of this paper is to present comparative characteristics of the conservative and active surgical treatment.

Methods: In application of active surgical treatment, it is necessary preoperative conditioning of patients for specific positioning, as well as evaluation and assessment of the general state of health for the upcoming surgery. In patients who do not accept an active surgical treatment, method of choice is conservative treatment, with the implementation of prevention, adequate antibiotic therapy and positioning. This paper describes the characteristics of both approaches.

Results: Conservative treatment is a less invasive approach, which is characterized with debridement and necrectomy, with the use of appropriate medications for local treatment and wound dressing for the

12 Wounds — Necrotizing fasciitis, acute disease of contemporary man

treatment of chronic wounds. Conservative treatment often requires more active during treatment. Active surgical treatment is a method that is often characterized by active short time of treatment, but that depends on the general condition of the patient, postoperative course, and the need for more intervention, depending on the localization of pressure ulcers and surgical wounds healing time.

Conclusion: The decision regarding the application of certain methods of treatment of patients with decubitus depends on the characteristics of pressure ulcers, and general condition of the patient and his or her willing-ness to accept the most appropriate method of treatment which will in a short period of time to give better results.

Keywords: pressure sores ulcers, conservative treatment, active surgi-cal treatment

Necrotizing fasciitis, acute disease of contemporary man

Z.Janjic, J.Nikolic, M.Marinkovic, N.Djermanov, Clinic of Plastic and reconstructive surgery, Clinical center of Vojvodina,

Medical faculty, University of Novi Sad, Novi Sad, Serbia

Background: Necrotizing fasciitis (NF) was in the past an uncommon, progressive infection of the superficial fascia and soft tissue with thrombosis of skin vessels, associated with ischemia and necroses of all tissue and with high possibility of death. The correct epidemiological data was unknown because of the other admit diagnosis on surgical department (cellulitis, abscessus, phlegmons). The aim of this study was to represent debridement as the surgical procedures the most important for treatment NF patients with recommendation for the rest therapy for this life-threatening disease.

Methods: Authors to reviewed the retrospective, one year clinical study, with statistical analysis of data and photodocumentad patients with NF treated in Emergency Center and Clinic of Plastic and Reconstructive Surgery, Clinical Center of Vojvodina from Novi Sad (Serbia).

Results: A total of 46 patients with NF underwent surgery for one year, which is the 30% more than in our last study from 2006 year. The most common diagnosis for admitted patients was phlegmons (21 patients\ 45, 65%), while NF was admitted diagnosis for 14 patients (30, 43%). Except for that diagnosis, patients were hospitalized as abscessus or as cellulitis. The more common were male patients (78%) with localization on the lower extremity (39%). The acute course of disease was the most diagnosticated (50%) with sepsis (68%), as the most common complication in postopera-tive course of disease. Unfortunate, five patients (10, 86%) were to die due NF.

Conclusions: NF is a serious life-threatening infection of soft tissue. The incidence of this disease is growing. The early diagnosis and the fast and aggressive surgical excision of all necrotic tissue (the majority of pa-tients required repeated debridement) with parenteral antibiotics therapy and systemic support to be in the recent time imperative for successful treatment of NF.

Key words: Necrotizing fasciitis, debridement, diagnosis, treatment.

Surgical treatment of Complications Dystrophic Epidermolysis Bullosa

Rytis Rimdeika, MD, PhDLithuanian University of Health Sciences,

University Hospital Kauno Klinikos

The term Epidermolysis Bullosa (EB) refers a group of disorders best characterized by blister formation as the result of skin fragility. Clinical manifestations range widely, from localized blistering of the limbs to generalized blistering of the skin and oral cavity, and injuries to multiple internal organs. EB subtypes are known to arise from mutations within the genes encoding for several different proteins, each of which is intimately involved in the maintenance of adhesion of the keratinocyte to the underly-ing dermis or structural keratinocyte stability. EB is best diagnosed and subclassified by the collective findings obtained via detailed personal and family history, in concert with the results of various laboratory findings. All types and subtypes of EB are rare; the overall incidence and prevalence of the disease is approximately 50 per one million live births and 9 per one million population. Out of these 92 percent are cases referred to EB Simplex and 5 percent of referred to Dystrophic EB. Optimal patient management requires a multidisciplinary approach, and involves the injury prevention of susceptible tissues, use of advanced wound dressings, nutritional support, and adequate medical or surgical interventions to correct whenever pos-sible the extracutaneous complications. Prognosis varies considerably and is based on both EB subtype and the overall health of the patient.

The hands and foots due to intensive use during normal daily activity are especially exposed to blistering, with secondary scarring leading to pseu-dosyndactily, adduction contracture of the thumb, and flexion or extension contracture of the fingers. The standard surgical approach for the correction of these deformities is based on the degloving of affected limb, combined blunt-to-sharp release of pseudosyndactily and contractures, skin grafting of the secondary wounds.

Author will give a short overview on classification, etiology, epidemiology, diagnostics of various subtypes of EB, as well as personal approach to surgi-cal techniques of dissolving syndactily and contractures, intraoperative splinting of separated fingers, wound management after the surgical release of deformations and post op nursing. Author conclude that an in-dividual surgical attitude, along with an adequate intra and post-operative rehabilitation, ensures a good restoration of function and a satisfying delay of inevitable recurrence.

Chronic wounds in dermatology: new possibilitas of the treatment

Jasmina Begic Dermatovenerology Clinic, Clinical Center University Sarajevo

Bosnia and Herzegovina

Introduction: The incidence of the skin and soft tissue infection (SSTIs) has increased due the to the ageing of the general population, the increased number of critically ill patients, the increased number of immunocompromised patients (HIV infection, cancer, immunosuppressive therapy) and recent emergence of multi-drug resistant pathogens. Unusual number of nonhealing wounds, noticed in the people with autoimmune disorders.One of the reasons at the autoimmune disorders is that they may have low-grade vasculitis-inflammation affecting the small blood vessels in the skin. People with normal skin is heavily colonized by bacterial flora.

Madura foot as cause of chronic wounds — Wounds 13

Normal flora of skin is classified on the resident flora, transient flora and transient or temporary residents. The infection may arise as primary infec-tions in minor superficial breaks in the skin or as secondary infections of preexisting dermatosis. Carriers of S.aureus and GAS are at increased risk for pyodermas and skin and soft tissue infection (SSTIs).

Aim: Aim is to present new possibilitas of the treatment patients with skin and soft tissue infections (SSTIs).

Methods: Three contemporary problems conforming the clinical evaluation of patients with skin infection are diagnosis, severity of infec-tions and pathogen-specific antibiotic resistence. In the six months we made at patients with inflammatory dermatoses, bullous disease, ulcers, dermatopphytosis and bites,microbiological tests, microbiological swab and the culture techniques , the amount leucocytes in the complete blood count, CRP and local clinical symptoms of infections( induration, erythema, warmth and pain).RESULTS: during the six months most frequently isolated bacteria were S.aureus, Pseudomonas aeruginosa, MRSA( in the nose at the skin). At the patients with SSTIs accompanied by signs and symptoms of systemic toxicity we sow at the patients with bullous disease and the patients with immunosuppressive therapy, and they treated with systemic, topic and supplemetary therapy.Patients without this symptoms were treated with topic and supplementary therapy. Like supplementary therapy we used Bioptron polarized light (480-3400nm).

Conclusion: In the case of skin and soft tissue infections (SSTIs) we treated patients with systemic, topic and Bioptron polarized light (480-3400nm) and we reduce infection, reduce time of hospitalization and antibiotic therapy.

Madura foot as cause of chronic wounds

Radovanovic S1, Delic J.2

1Nyangabgwe Referral Hospital, Francistown, Botswana2City Institute for Dermatology, Belgrade, Serbia

Madura foot is rare cause for chronic wounds formation and in endemic areas it offenly remains unrecognized. This disease is morphological entity, etiologically there can be eumicetoms which are evoked by pathogen fungi or actinomicity caused by microaerophyl actinomicity.

Clinically, there is trio: 1. Tumefaction 2. Fistulas (and fistula scars) 3. Colored “grains” in escudat-agregation of the cause. Disease is asymptomatically in good condition even at very destructive neglected changes.

We had two patients with actinomicity and results of their therapies which consists of two 5 week treatments with mix of antibiotics and antimicotics.

For correct therapy it is essentially important to make difference between eumicetoms and actinomicetom, histological and microbiological.

Key words: Madura foot, micetom, atypical chronic wounds

Tissue guided regeneration with allogeneic platelet gel, autologous cancellous bone graft and resorbtive collagene membrane

Igor Frangez1, Ciril Triller2, Dragica Maja Smrke2

University clinical centre Ljubljana, Department of Traumatology 1 and Department of Surgical Infections 2, Ljubljana, Slovenia.

Background: Chronic osteitis is a serious complication in open frac-tures. Therapy is usually long and demanding. It is one of the most difficult complications in open fracture treatment and appears in about 20 % of cases. Approach must be multidisciplinary with surgical basis. At the end of the infect erradication there is often a large bone defect. Tissue guided regeneration with allogeneic platelet gel, autologous cancellous bone graft and resorbtive collagene membrane is one of the possibilities how to bridge bone defect.

Case report: 26 years old male sustained open fracture of distal cruris with steel wire. He was urgently operated – necrectomy of bone and soft tissue, revision of wound and external fixation was performed. We replaced external fixator with intramedulary nail. After 6 weeks we covered wound with Tiersch transplant. Four months later he came with clinical sign of infection on distal part of the cruris and chronic osteitis was diagnosed. Intramedulary nail was replaced with external fixator, radical necrectomy of bone and soft tissue was performed, VAC was changed every three days. Antibiotic therapy was adjusted to antibiogram. In two months osteitis was healed and soft tissue defect was grafted with surralis and one month later we performed tissue guided regeneration with allogenic platelet gel and autologous cancellous bone graft and resorbtive collagene membrane. The essential idea of this therapy was to combine the healing capacities of platelet-derived growth factors and osteogenic stem cells and the modeling capacity of the gel. After operation we performed photobiomodulation with LED (light emitting diode) of the operated area to enhance healing potential. After 4 months the graft was incorporated, the bone defect was fully bridged and full weight-bearing capacity was achieved.

Conclusion: Our case presents the example, where tissue guided regeneration with allogenic platelet gel, autologous cancelous bone graft, collagene resorbtive membrane in addition with photobiomodulation with LED can improve and shorten treatment outcome.

Debrisoft - or how to simply do the wound debriman

Borisav Mandić, Tijana Đurić, Marina DišovićHealth centre “Dr Ristić” Novi Beograd, Srbija

Aim: Demonstration of fast and easy wound debridman by Debrisoft utilization. It is an active system which removes debris, necrotivc tissue, fybrin sediments, escudat and even hyperceratotic sediments on the edge of the wound. It is provided by milions of polyester microfybrin fibers in the Debrisoft.

It simultaneously allows the newformed granulated tissue and epithel to remain unharmed. Debrisoft is ised at vein ulcus, decubitus, diabet foot, acut wounds and postoperative wound that heal secondary.

Methods: We have analized efect of Debrisoft use at hard-to-heal vein ulcuses in which treatment of interactive compresses is also used. We have presented several cases in which Debrisoft was used for its efficeancy

14 Wounds — Calciphylaxis

in entirelly painless wound debridman after which speed of healing was accelerated.

Results: Single use of Debrisoft in 2-4 min. period provided very good result in removal of debris, necrotic tissue of fibrin sediments. For similar effect by classic methods it was needed 3-7 days!

In some cases, particulary with thick necrotic particle, parts of the dead tissue have to be removed by invasive methods (surgery) and after that treat with Debrisoft.

Conclusion: Debridman is neccessary treatment which enables heal-ing of chronic wounds. By Debrisoft use, it is accomplished fast, east and effectivly. Also, the whole procedure is very comfortable for the patient since it is completely painless.

Key words: Debrisoft, debridman, painless

Calciphylaxis

C. TRILLER¹, D. HULJEV², D.M. SMRKE¹¹ University Medical Centre Ljubljana, Slovenia, Division of Surgery,

Department of surgical Infections ² Sveti Duh University Hospital, University Department of Surgery,

Centre for Plastic and Reconstructive Surgery, Zagreb, Croatia

Calciphylaxis is a form of extra-skeletal calcification characterized by calcium deposites in arterial tunica media and vascular thrombosis, which leads to tissue ischaemia including skin ischaemia with consequential skin necrosis. Necroses may also develop in the subcutaneous adipose tissue and skeletal muscle. The cause of this disorder remains unknown. It was first described by Bryant and White as early as 1989 in association with uremia, and the syndrome remained clinicaly inadequately recognizable until 1976. Then, Gipstein and coworkers described the disorder in more detail, followed ba a great number of calciphylaxis case reports since then, includ-ing data on morbidity and therapeutic dilemmas. Calciphylaxis has been reported in association with renal insufficiency treated by hemodialysis, hepatic cirrhosis, diabetes mellitus, obesity, Mb. Crohn and some other sistemic diseases like cholangiocarcinoma, lupus erithematodes and carci-noma of breast. The authors present the clinical procedure of identifying and treating major ulcerations on both legs in a patient with polymorbidity and recognized calciphylaxis wich caused skin necroses with consequential chronic leg ulcers.

Key words: calciphylaxis, calcific uremic arteriolopathy, renal insuf-ficiency, hemodialysis

Application of iron preparations and recombinant human erythropoietin is a prerequisite for faster healing of chronic wounds in the cardiovascular surgery in anemic persons

Branko ČalijaInstitute for Cardiovascular Diseases Dedinje, Belgrade, Serbia

Introduction: Treatment of chronic ulceration of the skin lower extremities resulting from various diseases and pathological changes in modern medicine requires a large investment, patience and persistence for both patients and health care professionals. It is well known that within the European Union, the USA, Canada and Australia for the treatment of

chronic wounds spends about 2% of the planned budget to treat popula-tion. Unfortunately in Serbia the concept of code list of medical services and treatment of chronic wounds there.

As in most cases, patients with early chronic anemia and a wound heal-ing process is even more difficult and complicated. This is indicated by numerous data in the literature and our experience over the last twenty years gained in the transfusion management of patients undergoing heart surgery, arteries and aorta.

When the concentration of hemoglobin in the circulation of patients was lower than 100 g / L healing of chronic wounds or ulcers on the extremities was slow and difficult due to the lack of peripheral oxygenation. Anemia in most cases is caused by iron deficiency or a consequence of chronic diseases (diabetes, insufficient renal function, systemic disease, malignancy), or is caused by the inflammatory cytokines on progenitor cells of the erythrocyte lineage.

Method: Repeated infusions of iron supplements (Ferri sucrose, 1 mg vials contains100 Fe3 +), in the interval of 3-4 weeks (total of 1000 mg), raises the level of Hb 30%, compared to baseline (≤100 g / L). When the iron infusion combined with subcutaneous application of recombinant human erythropoietin (repo), erythropoiesis is significantly faster, and the level of Hb in the circulation increases by 40% and maintained for longer. Usually it is applied to 10 000 IU of alpha or beta repo, or 100 mcg of darbepoetin alfa once a week, a total of 30 000 IU or 300 mcg of darbepoetin alpha.

Results:Following the introduction of strategies to correct preoperative anemia hypochromic iron supplementation and repo, the need for al-logeneic red blood cell transfusions in Institute for Cardiovascular Diseases Dedinje was reduced from year to year. Durable are reduced postoperative complications that include chronic wounds and sternum and lower extremi-ties (the place extirpation of vein grafts).

Conclusion: Treatment of anemia in pre, peri and postoperative iron supplementation and r-EPO in cardiovascular surgery in addition to medical and has also economic importance.

Development Center for treatment of chronic wounds in the BH Heart Center Tuzla

Softic M., Banjanovic B., Jahic M., S. RajkovicSpecial Hospital BH Heart Center Tuzla

Introduction: The Center for treatment of chronic wounds was organ-ized in early May 2012 as part of the BH Heart Center Tuzla. In daily contact with patients, we had a growing influx of patients with problems and severe complications occurred as a result of chronic venous insufficiency, arterial occlusive disease, or diabetes mellitus. Practically there were no institutions where these patients receive adequate assistance. This was the reason why we accepted the cooperation and under the supervision of col-leagues from Germany and Austria, launched a project of the Center for the treatment of chronic wounds. Identificran space within our facility, which consists of two clinics and outpatient clinic with 5 beds. The team is trained and is composed of four doctors and six nurses. Center currently operates as the day hospital. In future hospitalization of these patients. During the first six months in our clinic were examined over 70 patients. After presenting our protocol for treatment in our institution, 38 patients consented.

Patients and Methods: 38 patients consented to be treated in our institu-tion by protokolu.18 patients (47.36%) had a chronic wound as a result of chronic venous insufficiency, in 7 patients (18.42%), the wound was the result of Diabetes mellitus , 4 patients (10.5%) due to arterial occlusive

Reconstructive treatment of diabetic foot — Wounds 15

disease, vasculitis, allergic etiology was verified in 3 patients (7.9%), Rheumatiod arthritis in 1 patient (2.63%), as the primary cause of injury was verified in 2 patients (5.26%), and peripheral neuropahtia as a result of previous surgery for a variety of foot deformities in 3 patients (7.8%). After the first examination, and treatment of vascular clinic patients is explained mode and Approximate length of treatment. Procjelini we found that 90 days period when we should expect the first results of treatment.

Results: 13 patients (34.2%) had less than 6 treatments at our institu-tion, which was expected. In 25 patients, the treatment is carried out according to the protocol for a period of 90 days. In 7 patients with chronic venous ulcer healing was observed, the remaining 4 patients with diabetic foot were recorded at one healing, and in the remaining three patients, a drastic reduction in the wound and infection control, two of the remaining patient in whom verificran arterial ulcer in one noted healing after surgery (FP bypass), another patient had suggested surgery, a patient with rheu-matoid arthritis are still being treated in our institution, in three patients with polineuropathiom improvement is noted with infection control but are still on treatment.

Conclusion: From our past experience has proven that the launch of the Centre and the treatment of these patients by the principle of moist wound care was fully justified and appropriate. Moist wound care patients were well tolerated. Hidrobalansni system, without the addition of analge-sics was responsible for the high potential of reducing pain. Antimicrobial substances in addition to some of the bandages were effective in the treat-ment of wounds at risk of infection and infected rana.Upotreba products that contain collagen has led to faster healing of wounds due to improved mikroprokrvlejnosti tissue. The establishment of the modern center for the treatment of chronic wounds, except the use of the latest methods of treatment, we started with the formation of a unified database, create the specific information on the wounds, which will help in the statistical analy-sis and evaluation, and objective decision about the treatment strategy.

Reconstructive treatment of diabetic foot

Jelena Jeremic, Cedomir VuceticClinic for Orthopaedic Surgery and Traumatology,

Clinical Centre of Serbia, BelgradeFaculty of Medicine, University of Belgrade

Clinic for Plastic and Reconstructive Surgery, Belgrade

Introduction: Surgical treatment, which aims to save disturbed anatomical integrity and function, is reconstructive. If it is necessary to do the amputation of bigger or smaller anatomical part, if the way of doing it aims to save as much as possible, avoiding the radical procedures, using specific surgical procedures- it is, also, a reconstructive treatment.

Pouprose: We are showing surgical techniques and possibilities of reconstructive treatment in diabetic foot.

Method: Patients with diabetic foot were treated operatively when there was a deformity which had led to ulcers or to further local complications. The patients with ulcers and gangrene on toes and part of the foot were, also, treated operatively. The surgical reconstructive treatment is classified as preventive and reconstructive in cases of developed clinical picture. Pre-venting complications development, necrosis, gangrene, infection caused by surgical interventions is named as preventive reconstructive treatment. It included deformity correction, pressure distribution, improving the circulation of the operated part. Preventive reconstructive treatment aims to correct anatomical relations and function. Reconstructive treatment at developed clinical picture of diabetic foot included covering of skin deffects, resection of bones and joints, saving the foot integrity. With these operative procedures we are trying to save the anatomical integrity and function.

Results: Healing in earlier levels of changing was simplier and with greater chances for success (shorter time of operative wound healing, avoiding or delaying further unwanted changes on foot, better function and better esthetic result).

Conclusion: Reconstructive surgical treatment has two important parts, preventive and reconstructive treatment at developed clinical picture of diabetic foot. Surgical correction of deformities which lead to ulcers ap-pearance gives better results than non- operative treatment. Reconstructive procedures give less disability, provide functionality and better quality of life.

Vacuum Assisted Wound Closure in Vascular Surgery – Experience of Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre

Marko Dragas1,2, Igor Koncar1,2, Lazar Davidovic1,2

1 Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre

2 Medical Faculty, University of Belgrade

Vacuum assisted closure (VAC – KCI) has been increasingly used in the West-ern Europe and USA clinical practice since 15 years ago. Serbian National Agency for Drugs and Medical Devices registered this method in 2009. Ad-vantages of this method are faster wound healing, wound approximation and cost effects related to the wound and patient with wound care. There are not enough publications regarding usage of this method in vascular surgery. Of most importance are groin incisions due to the wound dehis-cence, lymphatic fistula or infections in 5% to 10% of patients following vascular procedures. These complications may be limb- or life-threatening, especially for early, deep wound infections. Also, cost effects in developed country are not automatically transmitted to developing countries due to the huge difference in procedure and hospital costs.

In order to explore potential of this method in vascular surgery and to test cost effects in a developing country Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre organized clinical trial supporting by Lavifarm ad. Representative of KCI for Serbia.

Aim of the trial was to compare treatment and cost effects of VAC and conventional wound treatment that was already used in the local clinical practice for decades.

Material and Methods. All patients with wound infection and dehiscence operated at the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre in the period from January 2011 – January 2012 were included in the trial. Primary endpoint of the study was wound closure, while secondary endpoints were duration of hospitalization, number of weekly wound dressings, costs of wound care, working time of medical nurse dedicated to the care of this patient related to the compli-cated wound. Patients were divided in several groups in order to be easier to compare and interpret results. 1. Wound with exposed synthetic vascular implant (25%), 2. Infected or dehisced laparotomy wound (13%) 3 Wound after foot amputation (29%) 4. Wound after major limb amputation (21%) 5. Fasciotomy wound (13%)

All data of patients treated with VAC therapy, except data related to dehisced laparotomy wound, were compared with the conventionally treated wound. There was successful wound suture during hospitalisation in 84% of patients. Among complication we recorded recurrence of infection (4%), bleeding (4%), limb ambutation (4%) and death (4%). There was

16 Wounds — Organization of a specialized multidisciplinary Wound Center for Chronic Wound Management in Copenhagen

significant difference between the conventional method in hospitalization length, costs of wound care, nursing necessary time and costs of wound care.

Vacuum assisted wound closure is effective method for care of complicated wounds in vascular surgery. Wound infection with exposed synthetic grafts might be solvable with this method, however greater number of patients is necessary to confirm that or to define subgroups of patients that are good responders to this therapy. Cost effectiveness ov VAC therapy is applicable in a developing countries scenario.

Organization of a specialized multidisciplinary Wound Center for Chronic Wound Management in Copenhagen

Finn GottrupProfessor of Surgery, MD, DMSci.

Copenhagen Wound Healing Center Department of Dermatology

Bispebjerg Hospital, Copenhagen, Denmark

Objective: To improve prophylaxis, diagnostics and treatment of wound patients. This is achieved during establishment of a multi-professional organization in the primary as well as in the secondary health care sector.

Methods: Such a multi-professional organization in the health care sector should consist of hospital centres and smaller units in the primary health care sector. Collaboration models between the hospital and commu-nity sector should be developed and standardized treatment protocols and patient guidelines should be carried out. Evidence for improved quality of treatment and care and a standardized educational program for all involved types of staff should be accomplished.

Results: Such a model has been established in Denmark. Clinically the organizational model consists of two hospitals units with own staff and in-beds: Copenhagen Wound Healing Center (since1996) and University Center of Wound Healing (since 2003).

The referral policy has been simplified and centralized. Treatment plans including diagnostics, treatment and prevention have bee optimized. Different types of educational services, basic and clinical research and prevention programs have been established. A national education program of 6 months for nurses has been achieved and a 2 year education for medical doctor and a national accepted wound expert area called “Clinical Wound Healing” have been worked out. For generation of evidences a PC database on patients with DFU primarily for research use has been worked out.

Conclusion: Development of organizational models including data-bases, systemic evaluation of quality of care and outcome measures may in the future give us the ideal and optimal method of organization of wound care delivering. Education and development evidence are vital parts of this development.

References:

1. Gottrup F et al. A new concept of a multidisciplinary wound healing center and a na-

tional expert function of wound healing. Arch Surg. 2001;136:765-72

2. Gottrup F. Organization of wound healing services: the Danish experience and the im-

portance of surgery. Wound Repair Regen. 2003; 11: 452-7.

3. Gottrup F. Optimizing wound treatment through health care structuring and profes-

sional education. Wound Rep Reg 2004; 12:129-133

4. Gottrup F. A specialised wound healing center concept: importance of a multidiscipli-

nary department structure and surgical treatment facilities in the treatment of chronic

wounds. Am J Surg 2004; 187:38-43S

5. Gottrup F. Management of the Diabetic Foot: Surgical and Organisational Aspects. Horm

Metab Res, 2005;37, Supplement 1:69-75

6. Gottrup F. Education and organization in wound healing and care. In: Shukla VK, Mani

R, Teot L, Pradhan S, eds. Management of wound healing. Jaypee, New Delhi. 2007, pp.

241-256.

7. Gottrup F, Apelqvist J. Present and new techniques and devices in the treatment of DFU:

a critical review of evidence. Diabetes Metab Res Rev. 2012; 28 Suppl 1:64-71

Organization of the Center of Chronic Wounds - Management in the Asklepios-Klinik-Hamburg-Harburg

Dr. Harald Daum et al.

History: The WundCentrum Harburg was founded in 1999. It is part of the Department of Vascular- and Endovascular Surgery. We started our work out of the interest to optimize the outcome of our patients with arte-rial caused gangrene and necrosis, but more and more we fixed our focus of all kind of chronic wounds. In 2011 we became certificated as the first woundcenter in Germany.

Organization: Our Woundcenter is integrated in an outpatient clinik within our hospital. There are three specialized wound-nurses working in the Woundcenter on a regular base. In addition to that at least one surgeon is attending. They are working close together with the angiologist in our team, so we get vascular duplex whenever it is necessary.

Advantages: In our Woundcenter we concentrate all patients with complex dressings and can prove new methods. This leads to more competence and helps to spare money. Furthermore we get a lot of new patients for the hospital for vascular reconstructions, which is a big deal for our hospital economists. Every nurse in education has to pass through this ward. Every patient is listed in a standardized wound-documentation with digital photo-documentation. This gives us the chance of a retrospective follow-up, if it is of interest.

So the centralization of patients with chronic wounds helps to improve the quality of treatment and has economic benefits.

Comprehensive treatment in the treatment of burns

Nenad StepićMilitary Medical Academy, Clinic for Plastic Surgery and Burns,

Belgrade, Serbia

Objectives: The burns are thermal damage to the body, characterized by local and systemic changes. The aim of this paper is to present the methods of modern treatment of burns.

Methods: Treatment of burned patients in specialized institutions consists of resuscitation of burned patient, monitoring, general treatment of burns, and local surgical treatment. Upon admission to the hospital, burn depth and surface and assessment of vital signs are evaluated, and pres-ence of associated trauma, urinary and central venous catheters are placed, and nasogastric tube, wound smear and blood for laboratory analysis are

Organisation of the Center for chronic wounds management- our experiences — Wounds 17

used, heart and lung X-ray and ECG are done, resuscitation and monitoring is going on, general therapy is administered and local treatment of burned surfaces is started. Depending on the patient general condition and on the burned surfaces localization, treatment is applied in a multidisciplinary approach. After burned surfaces demarcation, definitive evaluation of the depth and surface is done, based on which a decision is made on how to fur-ther local treatment, using the conservative and active surgical approach.

Results: This paper presents an algorithm of treatment from hospital admission until the final results, with the wording of replacement fluid, local and active surgical treatment is carried out at the Military Medical Academy. Clinical cases are presented with an analysis of the primary as-sessment, course of treatment and final results.

Conclusion: Treatment of burned patients is a complex process that often requires a multidisciplinary approach, and the success of the treat-ment depends on adequate assessment and implementation of optimal methods.

Keywords: burns, treatment, modern approach

Organisation of the Center for chronic wounds management- our experiences

Aleksandar Gajić, Center for hyperbaric oxygen chambre ant chronic wounds

management. Department for physical medicine and rehabilitation ” Dr Miroslav Zotovic”, Banjaluka, Republika Srpska,

Bosna and Hercegovina

Aim: the presentation of the organisation and results of the Center for chronic wounds management.

Materials and methods: Hyperbaric oxygen therapy we have since 2005 ,on department for vascular rehabilitation.Later, The Center was formed as special unit for hyperbaric oxygen(HBO) and other modality of the teratment. In Center worked 3 doctors and 12 nurses; the doctor and nurse is one team for wounds management. Also, we have many consult-ants –endocrinologyst ,psychiatryst,and others(multidiciplinary method. ) In Center we have Hospital department (21 beds) and 2 department for wound dressings and current diagnostic support (tpO2 and LDP). For now,we have terated aproximatelly 3000 patients. The most of them were treated (85%) about diabetic foot. All patients were terated by complex, therapy,paralel more kind of the therapy . 90% of all patients were treated by HBO. Results : The control parameters for wound s healing were: discrease of the surface of the wounds,the appearance of the granulation tissue, start of epithelasition ,discrease oedema and pain. At 86% of all patients we realised very good results ,at 8% of all cases treated by operative interventions and at 5% of all patients there arent any changes. Consclusion : The organisation of the Center for chronic wounds is very importante , because the chronic wounds are medical and also, socio-economic problem.

Key words: Chronic wound, organisation

Presentation of the Swiss Wound Care Association (SAfW).

Dr. Sebastian Probst

The aim of this presentation is to demonstrate strategies how the Swiss Wound Care Association (SAfW) (Swiss German section and Swiss French section) promotes modern wound care within Switzerland to patients, their caregivers, nurses and medical doctors (MD’s). This is done through educa-tional coursesthat vary from a basic wound course to a Master in Advanced Studies (MAS) in wound care and the establishment of interdisciplinary education of specialised wound care nurses and MDs. Additionally the SAfW promotes scientific projects in this area with a grant. Thedevelopment and implementation of education of wound care specialist’s education as well as the wound care projects within Switzerland are a mainstay of the SAfW and will be presented.

Intravenous Iron Administration For Acute and Chronic Wound Healing in Anemic Patients

Branko CalijaDedinje Cardiovascular Institute, Belgrade, Serbia

Healing of an open wound, be it from a surgical procedure plays a crucial part in recovery and health. The most common complication is infection, which often affects compromised and elderly patients. An open, festering wound becomes a breeding ground for bacteria and other microbes. The in-fection can spread to the bloodstream and cause sepsis, a serious and often fatal condition. Without the proper amount of iron, wound would starve off oxygen and not complete the steps of healing as oxygen plays a vital role in the repair and making of new, healthy tissue. Iron deficiency anemia may be a result of chronic blood loss, acute blood loss, malabsorption of iron or a deficient diet. Laboratory tests to diagnose iron deficiency anemia include low hemoglobin and hematocrit, low mean corpuscular volume (MCV), low serum iron, low ferritin and elevated total iron binding capacity (TIBC). Iron’s primary job involves carrying oxygen-rich hemoglobin to the cells and tissues of the body. Wound-healing takes many steps and involves diverse components. It generally occurs in three stages, the inflammatory phase in which wound healing begins; the proliferative phase in which cells begin to cover the wound; and the maturation phase in which scar tissue is formed. A cascade of events occurs to allow for these processes. Because iron’s responsibility involves getting oxygen via the hemoglobin to the wound site, it plays an important role in healing. Healing could not take place without oxygen. Management of Anemia. Anemia, is not only is a major risk factor for transfusion, but it is also an independent predictor of morbidity and mortality, and patients should be monitored throughout their course of care. Management of anemia consists of treating the underlying cause and use of hematinic agents to rapidly restore hemoglobin levels to normal. Choice of agents should be guided by the etiology of the anemia as well as the patient’s condition and available time prior to surgery; commonly used agents include iron (oral or intravenous preparations), folic acid, vitamin B12, and erythropoiesis stimulating agents (ESAs). ESAs are highly effective in increasing hemoglobin levels and they can produce the equivalent of one unit of blood per week of treatment. Intravenous iron preparations are available with various formulations (i.e. iron sucrose, and iron gluconate) each with specific characteristics to treat iron deficiency anemia. Given the concerns associated with ESAs mentioned above, the role of intravenous iron has become even more important as the primary therapy for anemia.

18 Wounds — Endovenous laser ablation veins in treatment of vsm, and prevention of recurrent venous ulcer

Additionally, evidence indicates that intravenous iron with or without ESA therapy can reduce blood transfusions in surgical patients.

Endovenous laser ablation veins in treatment of vsm, and prevention of recurrent venous ulcer

Dario Jocić

Introduction: Ligature, crosektomy and vein stripping was a standard in treatment of venous insufficiency and varicose veins. Since the beginning of the twentieth century endovenous thermal ablation has become, in the Western world, the most common method of treating varicose veins disease.

Methodology: The study included 45 patients operated between 1.10.2011. to 01.09.2012. 31person of that were female, average age 47.2 years. All patients were symptomatic, 14 patients were in stage C2, C3 in 18, 7 in C4, C5 in 4, and 2 patients had active venous ulcer. All patients were operated Nd-YAG 1064-nm laser, in terms of tumescent anesthesia. In the postoperative period, the patients were prescribed wearing elastic stockings 3-4 weeks after surgery. Patients were monitored, first, seventh postoperative day, month after surgery and after six months.

Results: In 11 patients was made endovenous laser ablation veins in both legs, in 5 patients was made ablation VSM, ITA small veins and in 3 patients was made endovenous and laser ablation of perforating veins. In the postoperative period, there was no deep vein thrombosis, infection or bleeding. Ultrasonographic screening examination one month after surgery in all patients was registered successful thermal ablation of the treated veins. The patients from the C5 and C6 groups during the study period, has no been recurrence of the ulcer.

Conclusion: Endovenous laser thermal ablation VSM, ITA vein shows excellent postoperative results. In period of the development of minimally invasive surgery, this method has taken its place. The method is successful in alleviating the symptoms, treatment and prevention of varicose syndrome recurrence of venous ulcers.

Key words: laser ablation endovenous veins, venous ulcers, varicose veins.

Debrisoft-or how to simply do the wound debriman

Borisav Mandić¹, Tijana Đurić¹,Marina Dišović¹¹Health centre “Dr Ristić” Novi Beograd, Srbija

Aim: Demonstration of fast and easy wound debridman by Debrisoft utilization. It is an active system which removes debris, necrotivc tissue, fybrin sediments, escudat and even hyperceratotic sediments on the edge of the wound. It is provided by milions of polyester microfybrin fibers in the Debrisoft.

It simultaneously allows the newformed granulated tissue and epithel to remain unharmed. Debrisoft is ised at vein ulcus, decubitus, diabet foot, acut wounds and postoperative wound that heal secondary.

Methods: We have analized efect of Debrisoft use at hard-to-heal vein ulcuses in which treatment of interactive compresses is also used. We have presented several cases in which Debrisoft was used for its efficeancy

in entirelly painless wound debridman after which speed of healing was accelerated.

Results: Single use of Debrisoft in 2-4 min. period provided very good result in removal of debris, necrotic tissue of fibrin sediments. For similar effect by classic methods it was needed 3-7 days!

In some cases, particulary with thick necrotic particle, parts of the dead tissue have to be removed by invasive methods (surgery) and after that treat with Debrisoft.

Conclusion: Debridman is neccessary treatment which enables heal-ing of chronic wounds. By Debrisoft use, it is accomplished fast, east and effectivly. Also, the whole procedure is very comfortable for the patient since it is completely painless.

Key words: Debrisoft, debridman, painless

Mesotherapy in dermatocosmetology and regulation of reparative processes of the skin

Nevenka Dokmanovic

Mesotherapy also known as intradermal therapy was created in 1952, thanks to Dr. Michel Pistor, and it was initially used in rheumatology and traumatology. It represent intradermal injection application method in a very small dosages, locoregional, with the goal of healing on the expance of effects of medications and effect of biostimulation active points and zones reflexogenic skin.

Indications in deramtocosmetology are numerous: Dermatological disorders (acne, seborrhea, scleroderma, eczema, trophic ulcers, hyperpig-mentation), rosacea, xanthelasma, cellulite, aging skin, hair diseases, scars, stretchs. Mesotherapy treatment gives a positive result at the expence of the effect of needle skin (intermittent effect), on specific pharmacological effects (pharmacological effect) and on reflex action and neurohumoralnog to distant organs and systems.

Among dermatocosmetologist appeared a guestion appropriate to use intradermal injections surface to accelerate the reparative process in skin damage and reduced its pace of regeneration, which develops during aging. Consequently, it has been made a research of stimulation of skin reparation by glycosaminoglycans (GAG), through intradermal injection. The main positive effects of glycosaminoglycans are: normalization of col-lagen synthesis, stimulation of fibroblast proliferation, stimulation of the trophic tissues, active antioxidant protection, normalization of blood wall, antiplatelet activity. The research was conducted on rats, genous Wistar. The tested animals were divided into groups. In first group was studied the normal course of reparative processes without additional stimulation.In second group were rats whose reparative processes were stimulated by intrabdominal application GAG.In third group, stimulation of reparative processes are performed by intradermal injections of GAG about skin defect to a depth of 2 mm. The aim of this study was to evaluate the regeneration of skin and systemic reactions of the body in various ways applications products.

The results of exeperiment research shows that the drug glycosaminogly-can has a stimulatory effects on wound healing in all ways of application.Intradermal GAG applications has led to a more active process of reparation.

Keywords: Mesotherapy,glycosaminoglycan, reparations

Chronic wounds on postoperative cut – present cases — Wounds 19

Chronic wounds on postoperative cut – present cases

Dijana Lukic, Gordana Kanjevac, Javorka Delic

Most chronic wounds on department of the peripheral circulation The City Institute of Dermatology are venous and venous – diabetic,that are signifi cantly increasing.Postoperative wounds , is our patients are usually in place phlebectomy ( for coronary by – pass ) and after tumor surgery (higrom,lipoma), other less frequently after surgery.

Aim of presentation is to present patient with chronic wounds to cut operat-ing

First patient.72 years,males, on both sides phlebectomy.Operating on both sides of the cut ,in the region ankle, ulcers 4/6 cm on the inside, fi lled with witish solid content,theswelling and cellulitis surrounding tissue.Ulceration last month of operation.In the smear:Staphyl.aureus.Treatment of enzy-matic debridement,systemic antibiotic therapy for cellulitis.Transparent polyurethane coverings.Healing in the two months. Risk factors: diabetes.

photo 1 , photo 2 (wounds incurred after phlebectomy )

Second patient:35 years,females,wound on in the cut after surgery higrom, the right leg ankle,at the outside,3/4cm.Last two months.Wound was entirely fi lled, with adherent whitish masses,extremely painful.Smear: Citrobacter spp.Treatment:enzymatic debridement ,then silicone gel to stimulate healing.Four weeks after the treatment wound 1/ 0.5 cm com-pletely granular,without secretion.Risk factors: obesity, cutis laxa.

photo 1, photo 2 (wounds incurred after operations higrom)

Risk factors for wound postoperative cut on the immune and nutri-tional status of the patiente,surgical technique,local microbiological conditions the state of the periheral circulation , ways of dressing.Also,diabetes,anemia,obesity (F.Gottrup,Preventio of surgical site infec-tion,2008).Task of nurse to encourage patients , to establish a relationship of trust in health care professionals and provide support in the treatment.

Keywords: chronic wounds, postoperative cut

Injuries In Children

Sara RowanFlorence Italy

Despite the diversity of injuries occurring in various paediatric populations, treatment principles for wound healing and especially for infection are similar in both adult and paediatric cases.

Three distinct milestones may be noted in terms of wound healing in the last 30 years:

1.The introduction and use of moist wound healing (MWH). The research carried out on the benefi ts of MWH improved our understanding of the optimal wound microenvironment.

2. The creation of slow release antimicrobials such as silver dressings which allow us to prevent complications such as infection or treat them faster.

3. The third milestone is the use of NWPT in wound healing. NWPT can provide temporary wound cover following thorough debridement and before defi nitive closure in trauma injuries. It can reduce complexity of reconstruction, preparing the wound bed for fl aps or skin grafts following debridement and can reduce oedema and control exudate.

Dressing problems in children with injuries may involve size of dressings, conformability, durability, trauma upon removal and pain.

The aims of the latest technological advances in wound healing have been to achieve improvements with respect to:

• trauma upon dressing removal

• healing time

• bacterial barrier

• exudate control

• pain

• scarring

The treatment of wounds has advanced vastly over the years, aided along the way by improved understanding of the physiology of wound healing. Symptomatic of the advance is the fact that educational programs on these subjects are more readily available today.

Examples of cases studies of children with trauma, burns and congenital malformation wounds treated in various countries will be presented.

The Role of Nurse in Treatment of Chronic Wounds

Anke BültemannWundcentrum Harburg, Asklepiosklinikum Hamburg-Harburg

Tissue viability nurses have divers tasks in a specialised wound care center. I am presenting my tasks in my institution.

Treatment: The diagnostic and treatment of the cause of a chronic wound is preliminary. Nurses percieve important information by use of their senses. These are fi ltered and passed on tothe physician. With the necessary perception of the human being at eyes’ heigth and enough confi dence the nurse becomes the patient’s representative and attains accesstohisor her experiences and needs concerning woundc are.

20 Wounds — Pressure ulcer-indicator for bad nursing care

Due to specialisation nurses may perform debridement techniques such as ultrasound assisted wound cleaning. sterile filter showering or electro-therapy. New products can be tested and rated, user observation studies accompanied.

Standards: Awound centeradjoinedto a hospital can help to unify the woundt herapy and adjust standards such asthe „Wundfibel“, the Wound-Watch (www.wunduhr.de), a uniform wound and photo documentation.

Structure: So called „multipliers“ optimise wound care within the hospital. These arenurses, instructed in wound care with a close contac to the wound center due to regular internal trainee ships and case discussions

External Network: In order to avoid the „revolving door effect“between hospitals and the outpatient sector, an interprofessional and interdisziplinary network needs to beset up. Regular conferences such as „ICW Arbeitsgruppen“ are comunication platforms be tweenthe sectors. Physicaltherapists, podologists, lymphatictherapeuts, nutrititional consult-ants should not beforgotten.

Pressure ulcer-indicator for bad nursing care

Kanjuh Ž.1Lazarević A.2 Dragin A.1

Clinic for rehabilitation “Dr Miroslav Zotović”Belgrade.1 College of nursing Belgrade2

Introduction and aim: Pressure ulcer has serious implications for patient, prolonged hospitalization and has major economic effect on a „health troth“ and patient. Traditionally, preassure sores ulcer is considered as a phenomenon that should be avoided and as a reflection of quality of nursing care. The aim of the paper is determined systematic review outlines the major risk factors and measures of prevention to the overall health of patient.

Methodology: Using key words „pressure ulcer”, „bedsore” „risk fac-tor”, „prevention”, „nursing” was carried out searching PubMed database. The research included papers which printed on English and Serbian language during the period of 1991-2011 year.

Results: Most pressure ulcers can be prevented by keeping in mind the fact that the ratio of the pressure-time most critical factor for its develop-ment. It has been shown that the lower the pressure acting for a long time may be crucial for the development of pressure ulcer than higher pressure for shorter duration. Also, prevention of pressure ulcer can not be seen in isolation to the overall treatment of patient. For example, a strict regime of change in patient position for 2 hours can reduce the occurrence of pressure ulcer, but also impairs the patient’s peace and healing to an unacceptable degree, especially in the ICU, if it lasts longer. Contrary, technical aids such as a bed or mattress antidecubital with variable pressures in some places, reducing the need for manual turning of patients, increase the potential im-pact of immobility, increased isolation and sensory limitations. In any case, both approaches to prevention should be gradually revised and adapted to prevent the patient’s overall condition.

Conclusion: A holistic approach that accepts the risk factors and managed, purposeful stance than that seeks to minimize risk, absolute end, which can reduce the quality of care.

Key words: pressure ulcer, risk factor, nursing care.

2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014, BELGRADE, SERBIA — Wounds 21

2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014, BELGRADE, SERBIA

Dear coleagues,

We inform you that the second Congress will be held in year 2014, in Belgrade. We are confident that the next Congress will be an excellent opportunity for the presentation of new findings and results of treatment, for exchanging experiences and socializing with colleagues from other countries.

Prim. dr Javorka Delić, president

Serbian Wound Healing Society

www.lecenjerana.com

22 Wounds — 2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014, BELGRADE, SERBIA

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