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Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
Thursday, December 04, 2014

A systematic review is more than an overview of the literature germane to a topic. A systematic review usually follows a rigorous process to include a broad range of relevant studies that have been undertaken and provide a detailed critical appraisal and synthesis of the individual studies. Here are the key steps:

 1. Identifying the research question: The purpose of the review is to address a clinical question using existing scientific evidence and knowledge. The question is the focus and will provide the direction for the review. For example: What is the body of knowledge relating to the management of venous leg ulcers?

 2. Identifying relevant studies and information: To ensure inclusion of a substantial breadth and comprehensiveness of evidence, a team is usually assembled to perform a comprehensive literature search with the help of a librarian scientist. Depending on the type of review, a number of electronic databases will be searched. The review may include published or unpublished primary studies with or without an explicit study design, theses, commentaries, editorials, and the grey literature (information in electronic and print formats not controlled by commercial publishing and other relevant references retrieved from web search). It is important that key non-peer-reviewed journals are hand searched to identify articles that would not be indexed in electronic databases.

3. Study selection: The strength of a review lies in the depth and breadth of the evidence covered. The team will independently review each title and abstract of the literature search results to determine whether the paper should be included for more in-depth review. Explicit inclusion and exclusion criteria will be helpful.

4. Charting the data: The research team members will extract data from selected papers using a standardized abstraction form to document systematically the context of relevant information in each paper. Given the range of study designs, reviews, reports, and commentaries, data will include names of the authors, the purpose of the study/paper, types of participants, research methods used, study setting, theoretical framework, outcome and assessment details, authors’ conclusion, and implication to practice.

5. Collating, summarizing and reporting the results: A consistent approach to reporting the findings will allow comparisons across intervention types, as well as identify contradictory evidence and delineate gaps in the evidence. Analyzing of the data will involve a narrative or descriptive numerical summary and a thematic analysis.

Now you can appreciate the scholarship that is required to conduct a systematic review. Next time when you read a review paper, see if you can identify the key steps. Remember, not all reviews are the same. Reviews that did not describe and follow a precise methodology are subjected to serious bias problem.

Wednesday, September 10, 2014

Management of diabetic foot ulcers requires comprehensive and lifelong behavioral modifications that include regular foot care, exercise, dietary changes, smoking cessation, and frequent blood glucose testing. People with foot ulcers do not always wear appropriate footwear to protect their feet, wash their feet daily, or follow diet recommendations. Poor adherence is one of the determining factors contributing to chronic nonhealing foot ulcers and associated home care costs. Although traditional educational interventions to improve knowledge are necessary, they are rarely sufficient to change behaviors. Emerging evidence highlights a need to shift the chronic disease management paradigm to focus on patient engagement and self-management.


My colleagues and I have recently received funding from Queen’s University in Kingston, Ontario, Canada, and the Ontario government to develop a support group using social media (the Online Foot Club) for people with diabetic foot ulcers. Social media encompasses a variety of platforms that provide opportunities for multiple users to exchange experiences/information and provide support through multisensory communication. The purpose of the Online Foot Club is to promote chronic disease self-management and treatment adherence. According to a 2012 survey,1 61% of adult internet users searched online and 39% used social media to obtain health information. Not all information available on the internet, however, is credible. With the shifting attitude toward social media, there is a need for healthcare professionals to actively engage and support patients using communication technology creatively. The innovative use of social media has the potential to widen the access of health information and make contact with difficult-to-reach or isolated population because of their geographical location, cultural dispositions, and socioeconomic status.


Tell us how your healthcare facility or university is using social media to help educate and communicate with patients.



1. Fox S, Jones S. The Social Life of Health Information. 2009.

Last accessed September 10, 2014.

Monday, April 21, 2014

Wound infection and biofilm is one of the most exciting yet controversial topics in chronic wound management. Recent advances in the understanding of wound infection pathogenesis have generated tremendous interest in biofilm and how it is related to wound healing. Differentiation of critical colonization, deep wound infection, and biofilm is a challenging, but important, task. It is generally accepted that topical antimicrobial agents should be considered for localized wound infection and systemic agents are introduced for wound infection that involves soft tissue. Despite existing guidelines, only half of patients with diabetic foot ulcers received appropriate antibiotic therapy for the treatment of infection. Surgical site infection is a growing concern in the community. With the advent of a plethora of topical antimicrobial agents that have been developed in the last decades, clinicians are now challenged with decisions of when and what antimicrobial agents to use. According to results of the recent quick poll on this website, the majority of the readers agreed that general clinicians do not have adequate knowledge to manage wound infection. Researchers at Queen’s University School of Nursing in Kingston, Ontario, Canada recently surveyed 80 physicians and identified a significant knowledge gap in wound management, especially around wound infection and biofilm. There is a need to enhance the knowledge and build capacity for physicians to assess and treat wound infection and biofilms. It is very encouraging to observe that almost all respondents also acknowledged their roles in wound care and expressed a keen interest to further their knowledge. 

Wednesday, January 22, 2014
Blisters are common across all ages. In general, blisters are formed in areas where friction is a problem, such as tight footwear rubbing against the feet. A Stage II pressure ulcer can present itself as a blister. Blistering is also a predominant clinical sign for certain autoimmune skin diseases, such as pemphigoid and pemphigus. There is no consensus for the management of blisters. We conducted a recent quick poll on our website asking you whether blisters should be deroofed or removed. The majority of respondents voted in favor of leaving the blisters intact. I think the answer to whether to pop the blister or not will depend on a few factors: 1. Location: For areas such as the ankle, wrist, and elbow, where the blister may impair mobility or range of motion, it may be wise to drain the blister and use an atraumatic dressing to cover the area. 2. Stability of the blister: If the blister is large and protected by very fragile skin, it may be beneficial to manually drain the blister in a clean and controlled environment to minimize contamination of underlying tissue if the blister were deroofed accidentally. 3. Content of the blister: We usually recommend not to remove blisters that are clear and filled with serous fluid. However, pus and blood can be irritating to underlying tissue and may warrant prompt evacuation. 4. Pain: Blisters that are painful may also benefit from manual evacuation. To evacuate a blister, you can use a sterile needle or lancet to puncture the epidermis without damaging the dermal layer. Manual expression may be required to drain the fluid. Keep the skin flap to cover the dermis and consider an atraumatic dressing for protection.

Monday, October 21, 2013

It has been demonstrated that when bacterial growth reaches a critical threshold of 105 bacteria per gram of tissue, bacterial toxins can cause tissue damage in the superficial wound compartment, delaying healing. This phenomenon is referred in the literature as critical colonization, increased bacterial burden, covert infection, or localized infection. It is estimated that half of chronic wounds exhibit signs that are consistent with local infection, which is often caused by biofilm that is defined as a community of microorganisms living in an extra cellular polysaccharide matrix and attached to a substrate or surface. The prevailing opinion supports the notion that biofilm may be one of the primary causes for wounds that do not progress to complete healing. There are ways to remove biofilms. Sharp debridement is effective in physically removing and disrupting the biofilm structure rendering bacteria more susceptible to antimicrobial treatment. It has been demonstrated that biofilm and bacterial count can be significantly reduced after wound debridement. The recent Quick Poll questioned on this website asked readers’ opinion whether biofilm would reform in 24 hours. Indeed, there is evidence that if the wound is left without any treatment of topical antimicrobial agents after debridement, the biofilm can be reformed within 24-48 hours. The questions are:

• Does early use of antimicrobial agents could prevent biofilm from forming?

• If biofilm is ubiquitous in wounds, how often should antimicrobial dressings be used to promote healing?

• What kind of antimicrobial dressings should be used to treat biofilm infection?

Further research is needed to provide answers to the questions. Feel free to share your thoughts and practice with your colleagues. We’d love to hear your feedback!

About the Author

Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA, is Assistant Professor, School of Nursing, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada; Adjunct Research Professor, MClSc Program, School of Physical Therapy, and Faculty of Health Sciences, Western University, London, Ontario; Wound Care Consultant, West Park Healthcare Centre, Toronto, Ontario, and Clinical Web Editor, Advances in Skin & Wound Care.