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Table of Contents Kuala Lumpur Wound Conference 2017

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Message fromProf. Datuk Dr. Jeyaindran Tan Sri Sinnadurai Deputy Director General of Health, Ministry of Health Malaysia

Salutations to all the wound care professionals who have gathered here at the Wounds Malaysia conference. It is very refreshing that many consultants from different countries have gathered here for another successful earth shattering Wound Conference in the picturesque capital of Malaysia. Wound management is very close to my heart. There is a huge need for the advancement of this speciality and the patients will greatly benefit from the evidence based wound management.

Wounds are increasing in numbers and complexity as the world undergoes modernization. Diabetes Mellitus is also increasing at alarming rates and the subsequent complications which arise such as diabetic foot complications also pose a huge burden to the healthcare system. Every 20 seconds a foot is being amputated and these patients are from the working class. Therefore, the nation will be losing its productive workers. We have to embark on various programmes and develop strategies to prevent the complications and manage the problem in a proactive manner. Pathways, algorithms and education is crucial to manage chronic complex wounds. These initiatives have to be spearheaded by the champions in wound care lead by Dr. Harikrishna and his team who have invested their time and live to advance wound management in Malaysia and Asia. He is also launching two books namely the 4th edition of the Compendium of Wound Care Dressings and Other Modalities and the Diabetic Foot: Asian Perspective which is a great achievement.

I would like to congratulate Dr. Harikrishna and his team for organising an immensely successful conference and bringing the whole fraternity together. The attendance of people from 35 countries is proof enough of the support garnered by the Malaysian Society of Wound Care Professionals in wound management. I hope all of the delegates will take this opportunity to further advance your knowledge and expertise in the field of wound management during this conference.

Thank you.

With best regards,

Prof. Datuk Dr. Jeyaindran Tan Sri SinnaduraiAdvisor MSWCP

Table of Contents Kuala Lumpur Wound Conference 2017Message

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Message

Message fromThe Organizing ChairmanProf. Dr. Harikrishna K. R. Nair, S.I.S KMN

Welcome dear friends to the Wounds Malaysia: Kuala Lumpur International Wound Conference 2017. It gives me great pleasure and honour to have all my dear friends from the wound family consisting of vari-ous consultants from different specialities from many countries grace this conference and exchange expe-rience, knowledge and expertise in the field of wound management. Many of you have taken the time off your very busy schedule to be here to share your vast experience with us. This gesture is truly appreciated. We will be having many plenaries, symposiums and the training village as well as the masterclass. The stu-dents who passed the Certificate of Clinical Wound Care (CCWC) will also get their certificates during this conference. Meanwhile, the College of Wound Care Specialists has also been formed and various experts will be awarded the fellowship of the college.

Please allow me to take this opportunity to also thank the Ministry of Health especially The Honourable Minister of Health, Datuk Seri Dr. S. Subramaniam and the Director General of Health Datuk Dr. Norhisham Bin Abdullah for their support in wound management. In addition, I would also like to thank Prof. Datuk Dr. Jeyaindran Tan Sri Sinnadurai and Datuk Dr. Lokman Hakim Bin Sulaiman, our esteemed advisors for their continuous support. Dato’ Dr. Zaininah, Director of Kuala Lumpur Hospital and Dr.Lee Fatt Soon, Head of the Department of Internal Medicine, Kuala Lumpur Hospital are also very supportive.

I would also like to show my appreciation to the committee and the members of the Malaysian Society of Wound Care Professionals (MSWCP), the Organising Committee, The Asian Wound Care Association and the industry without whom we will be unable to advance wound care in Malaysia and Asia. My sincere hope is that we can work together and get as much knowledge and experience from this conference which will enhance our skills and competence in management our patients comprehensively and in a multidisci-plinary approach.

Thanking you. God bless.

Yours truly,

Dr. Harikrishna K.R.Nair S.I.S KMN Chairman Wounds Malaysia, President, Malaysian Society of Wound Care Professional (MSWCP)

List of Speakers Kuala Lumpur Wound Conference 2017

• Prof. Dr. Sadanori Akita, Japan

• Prof. Dr. Fu Xiao Bing, China

• Prof. Dr. V K Shukla, India

• Prof. Dr. Raj Mani, UK

• Dr. Thomas E. Serena, USA

• Prof. Dr. Kittipan Rerkasem, Thailand

• Prof. JP Hong, Korea

• Ms. Kathleen Leak, UK

• Prof. Dr. Yur-Ren Kuo, Taiwan

• Dr. Sriram Narayanan, Singapore

• Prof. Dr. Apirag Chuangsuwanich, Thailand

• Prof. Dr. Cao Yemin, China

• Dr. Poengki Dwi Poerwantoro, Indonesia

• Assoc. Prof. Dr. William McGuiness, Australia

• Widasari Sri Gitarja, Indonesia

• Dr. Luinio S.Tongson, Philippines

• Dr. Moustafa Elshal, Egypt

• Dr. Mohamed Waheed, Maldives

• Assoc. Prof. Dr. Aziz Nather, Singapore

• Assoc. Prof. Dr. Josephine Ip, Hong Kong

• Dr. Kenji Hayashida, Japan

• Dr. Takuto Oyama, Japan

• Dr. Soheila Kordestani, Iran

• Dr. Dmytro Klokol, Germany

• Prof. Nguyen Anh Tuan, Vietnam

• Ms. Diane Eng, Singapore

• Dr. Adisaputra, Indonesia

International Faculty

• Dr. S.Rukmanikanthan

• Dr. Naresh G

• Prof. Dr. Harikrishna K. R. Nair

• Prof. Dr. Liew Ngoh Chin

• Madam Mariam Mohd Nasir

• Madam Dr. Normala Basiron

• Dr. Leong Chee Loo

• Dr. Andre Dass

• Ms. Farrah Hani Imran

• Dr. Anantha

• Dr. Zamri Zuhdi

• Dr. K. Vilvkumaran

• Dr. Nizam Bin Ali Husien

• Dr. Rajalingam A/L Ramalingam

• Dr. Haris Ali Chemok Ali

• Dr. Phua Chui Har

• Dr. Nazni W. Ahmad

• En. Hamizal Bin Hamid

• Dr. Nur Ashikin Bte Ahmad

• Dr. Hanihaselah Mohd Saleh

• Ms. Chye PC

• Dr. Intan Sabrina binti Mohamad

• Dato Dr. Syed Alsagoff

• Datin Dr. Zil Falillah

• Pn. Mageswary

Malaysia

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Exhibition Floor Plan List of Exhibitors Kuala Lumpur Wound Conference 2017

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Schedules Kuala Lumpur Wound Conference 2017

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Kuala Lumpur Wound Conference 2017Schedules Plenary

Logical Treatment to Lymphoedema Related WoundsProf. Dr. Sadanori Akita, Japan MD, PhDProfessor-in-Chief, Department of Plastic Surgery, Wound Repair and Regeneration, Fukuoka University, Fukuoka, Japan.

Although primary lymphedema is considered one of vascular anomalies according to International Society for the Study of Vascular Anomalies, ISSVA, in Melbourne in 2014, more frequent and therapeutic modalities are effective in secondary lymphedemas observed in postmalignancy treatment of the breast and the gynecologic organs. For some cases, early phase lymphaticovenous anastomosis (LVA) are reported effective and others are used with vascularized lymph node transfer (VLNT) from distant from the lesion. Unfortunately, thorough approach to lymphedemas are not attempted so far in various location of the limbs and timing. Therefore, new reconstructive surgery with novel approaches has been attempted.

The hindlimbs of 10-week-old male C57BL/6J mice, after 30-Gy x-irradiation, surgical lymph node dissection, and 5-mm gap creation, were divided into four groups, with vascularized lymph node transfer abdominal flap and 1.0 × 10 adipose-derived stem cells. Lymphatic flow assessment, a water-displacement plethysmometer paw volumetry test, tissue quantification of lymphatic vessels, and functional analysis of lymphatic vessels and nodes were performed.

Photodynamic Eye images, using indocyanine green fluorescence, demonstrated immediate staining in subiliac lymph nodes, and linear pattern imaging of the proximal region was observed with the combined treatment of adipose-derived stem cells and vascularized lymph node transfer. Both percentage improvement and percentage deterioration with the combined treatment of adipose-derived stem cells and vascularized lymph node transfer were significantly better than with other treatments (p < 0.05). The numbers of lymphatic vessels with LYVE-1 immunoreactivity significantly increased in mice treated with adipose-derived stem cells (p < 0.05), and B16 melanoma cells were metastasized in groups treated with vascularized lymph node transfers by day 28.

Adipose-derived stem cells increase the number of lymphatic vessels and vascularized lymph node transfers induce the lymphatic flow drainage to the circulatory system. Combined adipose-derived stem cell and vascularized lymph node transfer treatment in secondary lymphedema may effectively decrease edema volume and restore lymphatic function by lymphangiogenesis and the lymphatic-to-venous circulation route.

CTRS Community ProgrammeProf. Dr. Fu Xiao Bing, China MD, PhDProfessor of Traumatology Academician, Chinese Academy of Engineering (Division of Medicine and Health) President, College of Life Sciences, PLA General Hospital, PLA Medical College, Beijing, China.

Wound Healing and Tissue Repair has great demand in China and great achievements have been achieved in recent years. In this presentation, we would like to give a briefly introduction about the main progress in this field, including epidemiological studies, new technologies research and their translational application in clinic, wound healing center establishment and international cooperation with other international wound healing societies, etc.

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Plenary

Traditional Medicines & Wound HealingProf. Dr. Vijay Kumar Shukla, India M.B.B.S, M.S.(Surgery), M.Ch.(Wales)Director, Institute of Medical Sciences. Professor, Department of General Surgery, Banaras Hindu University, Varanasi, India

Healing of wound is a challenging task to surgeon in ancient time and even in today’s era. Healing is protective mechanism of our body. In modern science many antibacterial formulations are available with their own limitations. Ayurveda is a science of medicine where there are so many pieces of pearl available to treat wound without any complication. Our Acharyas broadly described about treatment principles of wound management and classified the drugs related to Vrana Shodhana and Vrana ropana.

Vrana is one of the problems which have been managed by human being from beginning of civilization. The science of “Vrana Ropana” seems to be a serious matter of concern to the ancient healers. This fact can be very well understood while going through the surgical text - Sushruta Samhita where a good number of chapters deal with the science of Vrana alone. Vrana literally means a discontinuation of tissues. It is seen as debilitating and scaring disorder usually seen affecting the human being at any age. There are so many factors responsible to make healing process delayed. Though a variety of chemical substances have been evaluated and patented as wound healing agents, their inability to become successful drugs is due to the fact that these are able to act only at a particular step of the healing cascade. It is likely that more effective wound healing agent would be developed from natural products. The same thing is also being tried by Ayurvedic experts.

Measuring to Make the DifferenceProf. Dr. Raj Mani, UK PhD, FACA, FIPEM • Consultant, Academic Division of Human Development & Health, Faculty of Medicine, University of Southampton, UK.

The era of evidence based medicine (EBM) is regarded variably, individual views range from illuminating to obfuscating. EBM is built on the pillars of measurements quantitative and qualitative, to diagnose as well as to manage. EBM is an offspring of the technology revolution that we witnessed in the closing third of the last millennium. Today, gripped in vice of digital technology, EBM has evolved into Personalised Medicine that promises ‘the rainbow’. What does this offer wound care?

Even when nurtured with standardised care, chronic wounds heal variably. The use of measurements permits better, confident diagnosis as well as management. Illuminating examples are the use of Doppler ultrasound to differentiate between venous and arterial disease, the use of transcutaneous measurements of skin surface oxygen to identify levels of amputation in a limb of patients with diabetic foot disease, the use of simple or complex technology to follow the wound edge to calculate its size (from measurements of circumference, area, perimeter) all permit better, confident wound care.

Measurements of matrix metalloprotineases (MMP-9) have the potential to identify wounds with chronic disruptions of the connective tissue possibly one of the more difficult complications to manage clinically. The use of digital technology permits patients with chronic wounds to seek and receive medical advice from a distance – using mobile phones wound images can be transmitted with relative ease to an urban clinic for advice from specialists.

There continue to be confounding circumstances for example, the extent to which biofilms obstruct healing.

Much of the evidence gathered from measurement based studies over the past 40 years have enriched the literature in wounds.

Measurements simple as well as sophisticated bring relief to patients with wounds: going forward clinicians in the future must be adept in using and interpreting measurements to relieve the burden of wound care that confronts society.

Kuala Lumpur Wound Conference 2017

The Future: Clinical Research & Advances in Hyperbaric MedicineDr. Thomas E. Serena, USAMD FACS FACHM MAPWCACEO / Medical Director SerenaGroup®

A Randomized Controlled Trial on the Outcome in Comparing an Alginate Silver Dressing with a Conventional Treatment of a Necrotizing Fasciitis WoundDr. Kittipan Rerkasem, Thailand MD, PhDVascular Surgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Background: Necrotizing fasciitis (NF) is a high morbidity and mortality disease and also demands high economic resources. The standard treatment of NF is surgical debridement and proper dressing for wound bed preparation. The efficacy of silver alginate dressing can inhibit the growth of microorganisms and keep the environment clean for wound bed preparation. However an optimal dressing to manage such wounds has yet to emerge.

Methods: NF patients who were admitted between April 2013 and May 2016 were randomized to have wound dressing using either silverdressing (Ag group) or normal saline solution gauze (NSS group). The 4 main outcomes for comparison between the 2 groups were the duration of wound bed preparation, total cost during hospital stay, the duration of hospital stay, and the pain score.

Result: Thirty-nine patients were included in the study: 19 patients in the NSS group and 20 patients in the Ag group. The mean duration of wound bed preparation in the NSS group was 31.87 days, and in Ag group it was 21.39 days, but this trend was not statistically significant (P = .057). The mean cost of treatment in the NSS and Ag groups was not significantly different (P = .434; US$3308.83 and US$2647.82, respectively). The duration of hospital days in the 2 groups was not significantly different either (29.19 days [NSS group] and 20.99 days [Ag group]; P = .222). The pain score was significantly lower in the Ag group than those in the NSS group.

Conclusion: Although silver dressing seems to be expensive, the cost of total treatment during hospital stay and the duration of hospital stay were not significantly different between groups. However, the mean duration of wound bed preparation seems to trend favoring toward the silver dressing group.

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Plenary Kuala Lumpur Wound Conference 2017

Alternative Use of NPWT in Reconstructive SurgeryDr. JP (Joon Pio) Hong, KoreaM.D., Ph.D., M.B.A. Department of Plastic Surgery, Asan Medical Center University of Ulsan, Korea

Any wound can be simplified into the vertical and horizontal aspects of defect. The vertical wound depicts the defect from the skin and down (dead space), whereas the horizontal wound depicts the actual skin loss. It is our goal to address these two issues in order to achieve wound healing. Negative pressure wound therapy (NPWT) was introduced in 1997 and its use has been extended to managing many types of wounds, including diabetic foot ulcers, pressure ulcers, the open abdomen, chest wounds, skin grafts and traumatic lower extremity wounds. It is now considered to be one of the major advanced treatments for difficult wounds. NPWT provides an efficient way to enhance healing by increasing granulation, thus improving the vertical aspect of the wound. Once granulation is reached at the skin level, the horizontal aspect (epithelialisation) must be addressed.

The use of negative pressure therapy in wounds has been well documented. The effect of creating new vessels, forming granulation and excavating transudates has allowed difficult wounds to heal better. These same capabilities are also useful in providing better outcome for reconstructive surgeries.

The granulation over the wounds indicates the bed is ready for flap surgery allowing maximal chance for take. It also helps the wound to reduce edema leading to better outcome as well as indicate that the active infection is minimal. Thus the NPWT can be considered as an indicator for reconstructive preparation. Simultaneous irrigation in conjuction with NPWT has also shown to be an effective way to prepare wounds.

In order to achieve such granulation, NPWT can take a long period of time in cases with wide surface or large dead space. To reduce the time till achieving reasonable granulation, scaffolds such as collagen matrix, dermal allografts and other scaffold products have shown to increase the rate of granulation. Once reasonable granulation is achieved, one can choose the next ladder for reconstruction.

But there are multiple clinical situations where NPWT plays a valuable clinical role. Among them would be using in infants where reconstruction can be difficult, in ischemic wounds, conjuction with skin grafts, to prepare the wound for reconstruction, in early wound complications and in high tension incisional wounds.

In this session, we will discuss about the supporting role of negative pressure therapy for reconstructive surgery.

Oncological WoundsMadam Mariam Mohd Nasir, A.M.N., MalaysiaCert GLNI (Geneva) MBA (Mal/UK) BSc (Hons) Mal, WOCNEP(Hong Kong) SCM SRNNursing Consultant/Director, M&T Network Consultancy (Nursing Training)(Specialized in Enterostomal Therapy Nursing & Nursing Management)

Oncological wounds are malignant wounds as a result of cancerous cells infiltrating the skin and its supporting blood and lymph vessels causing loss in vascularity leading to tissue death. The lesion may be a result of a primary cancer or a metastasis to the skin from a local tumour or from a tumour in a distant site. (Christopher O’Brien, Medical Director of the Palliative Care Program at Saint John Regional Hospital)

The goals of care can shift from healing to a palliative approach, focusing on 3 core principles. The most important principle is symptom management, followed by wound management and treatment of the underlying tumour if possible and appropriate.

As the cancer grows, it blocks and damages blood vessels, which can deprive the area of oxygen. This causes the skin and underlying tissue became necrotic. There may also be infection, and areas of the wound may become ulcerated.

Patients often find that they have several symptoms at the same time. The most common symptoms include leakage or discharge, an unpleasant smell, pain, bleeding and itching. The management will be mainly focusing on addressing those symptoms.

Cancer wounds also will cause many feelings, including anxiety, embarrassment and depression for the patients and their family members. Many people feel isolated and giving hope that nothing can be done. Psychological aspect is crucial.

Palliative care is the definitely the utmost importance including their relatives. Many ways are available to preserve their dignity and quality of life. We need to give some hope to them that the symptoms can be controlled or at least reduced.

The used of modern wound products can help them reduce the distressing symptoms but we shall not forgot basic care is as important as managing the wound and shall not be neglected.

Among all, we need to provide tender loving care, preserved their dignity and care for them with greatest empathy and understanding and to prepare them for bereavement too.

Paradigm in Wound HealingProf. Dr. Harikrishna K. R. Nair, S.I.S KMN., MalaysiaMD, OSH (NIOSH), OHD (DOH), CMIA (MAL), CHM (USA) ESWT (Austria, Germany), FMSWCP, PG in Wound Healing and Tissue Repair (Cardiff, UK), Head, Wound Care Unit, Dept. of Internal Medicine, KLH

Wound management is crucial as we are face many types of complex wounds. A proper wound assessment is important and the TIME concept was used since 2003. Currently, the Triangle of Wound Assessment was introduced by Keith Harding and Carolyn Dowsett whereby the triangle consists of the wound bed, the edge and the periwound skin. The wound bed is further divided to tissue, infection and exudate. This is a good way of assessing the wound and planning a treatment strategy.

In addition, we also need various modalities to manage wounds. Here we will discuss the usage of sodium polyacrylate and the modified collagen and glycerine in combination under the topic of Synergistic Gold Collagen Therapeutics (SGCT). The Modified Collagen Gel Enhances Healing Outcome and is shown by Haytham Elgharably et al (Wound Repair & Regeneration (2013) 21 473-481). There is significant increase in the length of rete ridges, improved quality of closure and re-establishing well-nourished epidermis. Therefore, there is more resistance to re-opening of the wound. Higher abundance of growth factor for angiogenesis was demonstrated whereby there was up-regulation of vascular endothelial growth factor (VEGF) and von Willebrand Factor (vWF) genes expression in excisional wounds treated with modified collagen gel (MCG). VEGF gene expression was measured using quantitative real-time PCR.

The sodium polyacrylate is effective in the management of exudate. Therefore, the usage of both in combination has been proven effective and they function synergistically for wound closure. Meanwhile, sodium polyacrylate has been used in some cases using the Dry Traction Method to remove excess exudate. Cases will be showcased with studies to show the various indications. The MCG lotion can be used for the periwound area and is effective in various conditions classified by the Harikrishna Periwound Skin Classification 2015.

Breast Tumour WoundsKathleen Leak, UK Director Clinical Education for Genadyne Bio Technique USA, Independent Specialist Wound Care.

Breast wounds within the United Kingdom following Breast cancer have become an everyday occurrence as all patients are offered reconstruction at the initial surgery. The chances of these wounds breaking down are higher than normal especially if the patient is diabetic or bariatric .It is important to remember breast Cancer can effect either gender.

It is essential to expedite healing these difficult wounds as for many patients this is just the start of their treatment plan. Radiotherapy and chemotherapy is often needed. Both of which are not generally given while the patient has a wound.

This presentation will show how with modern technology we can influence and change outcomes.

While acknowledging where ever you work in the world we all face the same problems that sharing ideas we can all improve our practise

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Recalcitrant WoundsProf. Dr. Yur Ren Kuo, TaiwanMD, PhD, FACSChairman, Department of Surgery; Chief Professor, Plastic Surgery, Kaohsiung Medical University Hospital, Taiwan

Chronic wounds are a challenge to wound care professionals and consume a great deal of healthcare resources around the globe. A chronic wound may be defined as one that is physiologically impaired due to a disruption of the wound healing cycle as a result of impaired angiogenesis, innervation, or cellular migration, among other reasons. Some common features shared by each of these recalcitrant wounds include prolonged or excessive inflammation, persistent infections, formation of drug-resistant microbial biofilms, and the inability of dermal and/or epidermal cells to respond to reparative stimuli. In aggregate, these pathophysiologic phenomena result in the failure of these wounds to heal. The underlying pathologies, however, differ among various types of chronic wounds.

Chronic wounds can be classified as diabetic foot ulcers (DFU), vascular ulcers (e.g., venous and arterial ulcers), and pressure ulcers (PUs). Chronic wounds related to malignancy require appropriate treatment of the malignancy, but in some cases, palliation may be all that can be offered. This presentation provides an overview of the chronic wound healing and discusses the established tenets and advanced treatment of recalcitrant chronic wounds.

Topical Oxygen TherapyDr. Sriram Narayanan, Singapore MBBS MS (Surgery) (Bombay), FRCS (Glasgow), FRCS (Gen. Surg), Dip Laparoscopic Surgery (France) A/Prof Sriram Narayanan, Senior Consultant Vascular and Endovascular Surgeon, The Harley street Heart and Vascular Centre, Gleneagles Hospital, Singapore.

Wound healing is a highly energy dependent process and oxygen requirements for a patient with a wound rise by over 50% of normal. However, in the local wound milieu, this need for oxygen can increased by up to 4 to 6 times over that of intact skin. This is even more so in the early inflammatory phase of wound healing where the respiratory burst demonstrated by neutrophils and macrophages for anti-microbial activity can raise oxygen demand 50-fold. Many of the key processes of wound healing too are highly influenced by the local oxygen content. Collagen synthesis is oxygen dependent and the collagen formed in hypoxic environments is only 30% as strong as normal collagen. Epithelial cell migration, another energy dependent process is also impaired in hypoxic environments. The generation of reactive oxygen species for anti-microbial activity requires adequate tissue oxygen levels. Oxygen also potentiates the local activity of antibiotics, promotes angiogenesis and is involved in key cell signalling pathways in wound healing. Little surprise then that a recent systematics review published in the Journal of Vascular Surgery (2016) of tests to predict wound healing in the diabetic foot showed that of the 8 tests assessed, trans-cutaneous oxygen pressures at the wound edge was by far the best predictor with a diagnostic odds ratio of 15.8. Techniques to enhance oxygenation of the wound include revascularisation of the foot by bypass surgery or angioplasty as a primary measure. Whilst this is essential, the impaired vasomotion seen in the micro-vasculature in the diabetic mean that revascularisation is only part of the process of wound oxygenation. Hyperbaric (HBOT) therapy has been an adjunct to help improve tissue oxygenation. However this too has its limitations. Whilst HBOT does increase the partial pressure of oxygen to 1800 mmHg (normal 100 mmHg), this returns to normal levels 204 hrs after therapy. HBOT also has the complications of barotrauma to the ear lung and eye. In addition the precipitous rise in systemic oxygen levels leads to an acute rise in basal metabolic rates with a rapid increase in glucose consumption. In a diabetic without the normal responses to fluctuating sugar levels, this can give rise to dangerous hypoglycaemia.

Topical oxygen therapy (or Continuous oxygen ambulatory therapy – COAT) provides high concentrations of humidified oxygen directly to the wound bed and raise the partial pressure of oxygen locally to 350 mmHg. This effect is continuous throughout the 24 hour cycle, unlike HBOT wherein the hyper-oxygenation effect is restricted to the 1.5-2 hrs of therapy and an hour or so beyond. The side effects of HBOT referred to above are avoided, although the levels of oxygen achieved are significantly less than HBOT.

Following an initial pilot study of 10 patients conducted at London and Cambridge, England, an NHS funded randomised single blind multi-centre RCT is currently ongoing at 18 hospitals in the UK to assess the effect of Topical Oxygen Therapy for Diabetic Foot Ulcers. Preliminary data from 40 patients in a 42 patient registry who are part of the treatment arm of this trial is now available. The median age of patients is 64 years with a mean ulcer duration of 17 months. Some 40% of these patients are current smokers. The mean ulcer size was 4.2 sq cm requiring a mean of 2.5 dressing changes a week.

Of the 32 patients who used topical oxygen therapy for 12 weeks, 41% had complete wound closure and 56% had >90% reduction in ulcer size. The mean reduction in ulcer size was 50% at weeks and 82% at 12 weeks. High patient satisfaction scores with the therapy of 8-9/10 were recorded across all weeks of therapy.

Preliminary data from this ongoing trial shows highly promising results for topical oxygen therapy for diabetic foot ulcers. In conjunction with vascular reconstruction procedures, this therapy offers an important tool in the armamentarium for amputation prevention in diabetic foot ulcers.

Pressure Ulcer ManagementProf. Dr. Apirag Chuangsuwanich, ThailandDivision of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in conjunction with shear and/or friction. Impaired mobility or unconscious patients are most vulnerable to pressure ulcers. Other predisposing factors for developing pressure ulcer are poor nutrition, poor sensation, urinary and fecal incontinence, and poor overall physical and mental health. The management of this common and burden problem must start from prevention of all the causes. But when the pressure ulcers occur, the management should include improve general condition, pressure reduction, adequate wound care and surgical intervention if necessary.

Reconstructive Surgery: Whats NewDr. Normala Basiron, MalaysiaHead & Senior Consultant Plastic Surgeon, Department of Plastic & Reconstructive Surgery,Kuala Lumpur Hospital, Malaysia.

Reconstructive surgery is all about repairing and restoring function of bodily structures and wounds affected by congenital defects, developmental abnormalities, trauma/injuries, infections, tumour and diseases. In Plastic & Reconstructive Surgery perspective, the ultimate aim of wound management is wound closure with optimal aesthetic outcome, preservation of function and patient satisfaction.

The traditional approach to wound treatment has undergone gradual but tremendous evolution over time resulting in various modifications in wound closure options being incorporated into the reconstructive ladder. With the advances in anatomical understanding and technological innovations the plastic and reconstructive surgeons are now have greater ability and freedom to achieve definitive wound closure with optimal aesthetic and functional outcome in variety of patients.

Although there is virtue in using the simplest solution to a given wound problem, at times more complex methods of reconstruction may be preferred, even when simpler methods can achieve wound closure. This presentation will describe and discuss the various wound closure options including negative pressure wound therapy, skin grafting, flaps surgery and tissue expansion.

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A Trial of Advance Wound Care Dressing Versus Topical Antibiotic Combination in Diabetic Foot UlcerProf. Dr. Cao Yemin, China Chief Physician, Professor, Shanghai Traditional Chineses Medicine - integrated Hospital

Aim: To compare and evaluate the efficacy of advance moist wound dressing against topically applied antibiotic combination on diabetic foot ulcers.

Method: 60 patients with ulcers were divided equally into observation group and comparison group. Both groups comprised of male and females, with an average age 69 and 66 respectively. There’s no obvious difference between the two groups in age, gender and ulcer level from statistics (p>0.05).

Treatment plan included oral hypoglycemic agents and /or subcutaneous insulin to control blood glucose, FPG ≤ 7.8mmol/L, PPG ‹11.1mmol/L. Swab culture, surgical debridement and nutrition support was done for all patients. All wounds were cleaned with Benzalkonium bromide tincture and rinsed with NaCl.

Observation group’s wound was applied with advanced moist dressing and changed daily or every other day. Comparison group’s wound was applied with 5% Metronidazole with Gentamicin and covered with gauze. It was changed daily.

The wound was assessed and evaluated by three components of no effect, improved and healed categories with healed and improved categories counted as an effective recovery rate.

Results: The observation group had 83.33% effective recovery rate compared to the comparison group of 60.00%. There was statistical significance p<0.05 between the two groups.

Conclusion: The recovery rate of the observation group is obviously greater than that of the comparison group. In observation group, the intervals between dressing change was longer, pain scale decreased, and the treatment sessions was shorter in comparison to direct application of topical antibiotic combination on the diabetic ulcers despite belief that it can help prevent infection and heal ulcers faster.

Surgical Wounds and SSIDr. Andre Dass, Malaysia MBBS (UM), FRCS (EDIN), M.MED (NUS) Head of Department of Surgery Hospital Kajang, Selangor, Malaysia

The presentation will look at the latest updates related to SSI in general.

It will then look at specific situations related to SSI namely:

• Topical Antibiotics for Surgical Wounds healing by primary intention• Antibiotics and Antiseptics for Surgical Wounds healing by secondary intention• Use of plastic drapes during surgery• Delayed Closure vs Primary Closure in perforated appendicitis• SSI in Biosynthetics vs Polypropylene mesh for open ventral hernia repair• SSI in developing countries

Burn Wound Healing Activity of Virgin Red Palm Oil: A Preliminary StudyDr. Poengki Dwi Poerwantoro, IndonesiaPlastic Reconstructive and Aesthetic Surgery Division, Burn Surgery Unit Pertamina Central Hospital, Jakarta, Indonesia

Management of burn injury has always been the domain of Burns Specialist. Since ancient time, local and systemic remedies have been advised for burn wound treatment and burn scar prevention. Healing of burn is still a challenge in modern medicine and there are few drugs capable of accelerating wound healing. As an alternative, plants are rich sources to survey.

New evidences from studies on wound, point to an involvement of oxidative stress in wound healing, and significantly improved by topical Vitamin E. Antioxidants in Vitamin E have been shown to accelerate wound healing in experimental animals.

Virgin Red Palm Oil (VRPO) is a special formulated product contains a large proportion of red palm oil. VRPO is widely used in Africa and has been reported in literature to promote wound healing. The antioxidant properties in VRPO (30% Tocopherols and 70% Tocotrienol) has been extensively researched for its nutritional and health properties, including antioxidant activities, that has benefits in promotion of burn and chronic wound healing.

However, the effectiveness of VRPO has not been proven clinically despite some positive testimonials from a limited number of patients. Thus, this study is carried out to determine the effectiveness and burn wound healing activity of VRPO.

Keywords: burn, wound healing, virgin red palm

Tumor WoundsMs. Chye PC, MalaysiaMD. ; MS ( Ortho ) UKM ; Fellowship Orthopaedic Oncology ( Chicago USA )Head Orthopaedic Oncology, Deputy Head, Department Of Orthopaedic Surgery, Hospital Kuala Lumpur, Malaysia

Approximately 5-10% of patients with metastatic diseases will develop a fungating wound. The incidence will be much higher taking into considerations of primary cutaneous malignancies like squamous cell carcinoma, basal cell carcinoma, malignant melanoma and even cutaneous T cell lymphoma. It is often associated with distressing symptoms like pain, discomfort, foul smelling discharge and bleeding. Its management is both challenging and exhausting to both patients, their caretakers and the clinicians. Contrary to common beliefs that fungating wounds are encountered only towards the end of life, many especially those caused by primary tumours can actually be successfully treated surgically and cured. For the metastatic fungating wounds, it is important to tailor the management according to the needs of the individual patient, focusing on symptoms control and improvement of quality of life.

Decreasing the Harmful Effects of MMPsAssoc. Prof. William McGuiness, Australia RN, Dip T, B Ed, MNS, PhD, FAWMADirector, Alfred La trobe Clinical School, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.

Antimicrobial Therapy in Wound ManagementDr. Leong Chee Loon, Malaysia

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Kuala Lumpur Wound Conference 2017Plenary

Management of Wounds in a Disaster SettingWidasari Sri Gitarja, Indonesia BSN, RN (Indonesia), WOC(ET)N (HongKong) • CEO Wocare Center Indonesia, Program Director of In ETNEP-WCET (Indonesian Enterostomal Therapy Nurse Education Program –registered by WorldCouncil of Enterostomal Theraphy)

Our concern about wound disaster situation management in Indonesia has been started from Banda Aceh in 2016 by Indonesian Wound Care Clinician association (InWCCA). We were successfully collaborated with the government and almost a hundred wound clinicians helped to treat the wounds. The earthquake, with a magnitude of 6.5 on the Richter scale, occurred at approximately 5:03 a.m. local time and was centered at a depth of 10 kilometers and about 106 km southeast of Banda Aceh. The National Disaster Mitigation Agency (BNPB) said as of 3 p.m. on Wednesday, at least 94 people had been reported dead, 128 severely wounded, 489 having suffered from minor injuries and the earthquake affected about 10,000 people homeless. Almost as quickly as the disaster struck, medical and relief teams began to mobilize to provide assistance. The first teams to arrive encountered total chaos, facing many wounded, few supplies, and nonexistent sanitary conditions. Triage is the process of prioritizing patient care based on need and available resources but wound clinicians must triage daily because of time and resources never seem to be sufficient. Wounds treat used with advanced wound dressings and wound bed preparation techniques that used in proper with this situation. Certainly, wound clinicians should gain experience in team building by joining multidisciplinary teams within their clinical sites. The experience of providing quality of wound management with situational limitations suggests that wound clinicians can make situation scenarios of care from the realm of disaster management. Other important think that we concern about conflict management and leadership would be an advantage in these situations.

Keyword: wound disaster, wound clinician and wound dressing

A Review of the Guidelines in the Management of Diabetic FootDr. Luinio S. Tongson, Philippines MD, FPCS, FPALES, CWS, DWCC, MSPH Head, Dr. Jame G. Dy Wound Healing & Diabetic Foot Center, Chinese General Hospital & Medical Center, Manila, Philippines.

Diabetes is the most common cause of non traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes. After a first amputation, people with diabetes are twice as likely to have a subsequent amputation as people without diabetes. Mortality rates after diabetic foot ulceration and amputation are high, with up to 70% of people dying within 5 years of having an amputation and around 50% dying within 5 years of developing a diabetic foot ulcer. Preventing the diabetic foot should be the first priority. This can be achieved by identifying the high-risk individuals, like those with peripheral neuropathy, peripheral vascular disease, foot deformities, and presence of callus.

The management of diabetic foot ulcers includes several facets of care. Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Clinical decisions, instructions of procedure, and health economics are being influenced by guidelines. Guidelines give general guidance to provide clinicians with recommendations based on the best available evidence. Guidelines help clinicians deliver the best health care possible. Clinical guidelines are only one option for improving the quality of care. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, or other details of clinical practice.

There are several guidelines for the evaluation and management of diabetic foot. The guidelines produced by the International Working Group address all of the key details for assessment and management of diabetic foot. The IWGDF Guidance on the management and prevention of foot problems in diabetes 2015 consists of 5 Guidance documents concerning: Prevention; Footwear and Offloading; Peripheral Artery Disease; Infection; Wound Healing.

The Effects of Growth Factors in Acceleration of Timing & Quality of Diabetic Foot Wound Healing & Limb SalvageDr. Moustafa Elshal, Egypt Senior Registrar in Vascular Surgery, Peripheral Endovascular Intervention and Diabetic Foot Management Department in National Institute of Diabetes and Endocrinology (NIDE) - Cairo, Egypt.

Introduction: 85 % of patients with Diabetic foot wounds underwent amputation at different levels due to inadequate ordinary wound management. The mechanism of action of Growth Factors induced therapy (AQ Recovery Serum) depends on the action 3 types of growth factors (PDGF, GMCSF, TGF beta 1, 2, 3).

Objective: To determine the differences in attempts at limb salvage using modern modalities as Growth Factors induced therapy (AQ Recovery Serum) in wound management, we studied the wound care for patients with diabetic foot wounds as an attempt for limb salvage.

Methods: Using outpatient medical database for years 2016-2017, we identified sample of patients who underwent Limb salvage care. we defined the wound care management procedure (AQ Recovery Serum Allura Company ) that occurred during the two years prospectively, after either diabetic foot wound surgical debridement or mechanical offloading .

We used descriptive analysis for wound follow up with adjustment of individual patient characteristics.

Finally, we examined the timing for wound healing & limb salvage in comparison with the ordinary modalities of wound management.

Results: Our sample included 15 patients (including 2 patients post heel debridement, 2 patients post dorsum debridement, 2 patients post toe/toes amputation, 3 patients neuropathic ulcer with Charcot’s joint, 6 patients neuropathic ulcer without Charcot’s joint). All patients had reasonable socioeconomic status. Timing of wound healing with differences in wound care modalities has shown a decrease in wound healing time with increase in wound healing quality. Where 12 patients acquired total healing, 2 patients showed progression in the healing process and one patient lost follow up.

Conclusion: wound care management using Growth Factors induced therapy (AQ Recovery Serum) has shown better time and quality of healing as well as limb salvage.

Rehab in Wound Management - Orthotics and ProstheticsDr Intan Sabrina binti Mohamad, MalaysiaRehabilitation Physician in Hospital Rehabilitasi Cheras, Kuala Lumpur, Malaysia.

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Kuala Lumpur Wound Conference 2017Plenary Symposium

Wound Care - The Maldivian ExperienceDr. Mohamed Waheed, Maldives

Maldives is a small country in Indian Ocean at south of India. It consists of many islands grouped in Atolls. The geographical distribution of islands is a challenge to provide health care facilities for whole population. The countries main hospitals are situated in the capital, and there are 6 regional hospitals.

The modern medicine was introduced in the country in early years of 1900. And alternative medicine was more popular during that time for every illness. Wound care was one of the least concerned services until recently. Due to the increased population and life span of Maldivians, chronic wound has become one of the concerns for the families and hospitals. Chronic wound affects physically, mentally, socially and financially. It is a burden to the health care services as it occupies many hospital beds for long duration, and many patients have to be referred to nearby countries for further management.

In 2015 Maldives Association of Surgeons in collaboration with Malaysian society for wound care professionals and ministry of Health of Maldives conducted the 1st advanced wound care workshop for doctors and nurses in the capital city of Male which awakened the policy makers and health professionals the demand and need for advance wound care services in the country. In the same year advanced wound care clinic was established in the main hospital under the department of surgery, with help and donations of MSWCP. Since then 2 more workshops has been conducted in other regions of the country.

The types of wounds are commonly, diabetic foot, pressure injuries, traumatic wounds, SSI, and vascular wounds. Since we are at the initial phase of advance wound care we do not have all the resources for advance wound care, and we use many modifications to different therapies.

From the experience we gain by initiating advance wound care we believe that it is one service to be established in each hospital. We are gradually expanding our service but we need more expertise and training in advance wound care and plastic and reconstructive surgery.

Wound Care in the Primary Care SettingDatin Dr. Zil Falillah, Malaysia Consultant Family Medicine, Al Muktafibillah Shah Health Centre, Dungun, Terengganu, Malaysia

Chronic wound care poses a significant burden to patients and society. The problem continues to grow rapidly due to increasing health care costs, an aging population, and a sharp rise in incidence of diabetes and obesity. Standards of care differ between hospital and primary care clinics. But once patient is discharge into the community, primary care practitioners and primary care teams are expected to play the role to consolidate the continuity of care by the multidisciplinary team required by the patients especially in managing the patient’s co-morbid conditions.

Ministry of Malaysia started a serious effort into improving wound care services with the formation of National Committee in June 2009, consisted of multidiscipline doctors and paramedics. It started with the development of wound care team in general hospitals and was later expanded into the health centres under Ministry of Health Malaysia.

The objectives were to provide higher quality wound care and achieving reliable and improved outcomes by incorporating scientifically based guidelines, algorithms and protocols.

This is also in line with the government’s policy of moving care closer to home meaning not only will primary care team continue to see patients with chronic wounds such as leg ulcers, pressure ulcers and diabetic foot ulcers, they are also seeing an increase in the number of patients who have been discharged from hospital with surgical wounds, who might previously have stayed in secondary or tertiary care for a longer period.

In expanding the services into primary care, there are three main challenges that need to be addressed: 1. Further effort is required to increase wound awareness among the medical profession, within the community, and government. 2. Education of the primary health care workers is required to improve the practice of evidence-based wound management and finally. 3. Financial support needs to be facilitated on all aspects of wound management at the national level.

Osteomyelitis and Diabetic Foot Infection - Whats NewDato Dr. Syed Alsagoff, Malaysia

1A: Step By Step Assessment of the Diabetic FootAssoc. Prof. Dr. Aziz Nather, Singapore MBBS (Sing), FRCS (Edin), FRCS (Glas), MD (Sing), FAMS (Sing)Senior Consultant, Division of Ankle and Foot, Dept. of Orthopaedic Surgery, National University Hospital, Singapore.

A step-by-step careful evaluation must be performed before one embarks to treat a diabetic foot.

General inspection of patient is first performed with vital signs, evaluation of heart, lungs, abdomen.

Local inspection of foot is then performed in a systematic fashion starting from toe-nails, toes, web space, dorsum of foot to sole (forefoot, arch, hindfoot) and heel. One must meticulously evaluate the 3 components of diabetic foot triad – neuropathy, vasculopathy and immunopathy. Sensory neuropathy is assessed by light pin-prick (touch), 128Hz tuning fork (vibration sense), position sense and 10-point SWMT. Vasculopathy is evaluated by color, temperature, pulp capillary refill, distal foot pulses (dp, pt) and Berger’s Test. Immunopathy is completed by deep ray by ray palpation to look for underlying OM (metatarsal heads) or septic arthritis (MTPJ, IPJ).

Following this detailed clinical examination, investigations include Markers of Infection – WBC, CRP, ESR, Tissue for c/s and Markers of Healing - HbA1C, Hb, Albumin, Creatinine. Plain radiographs of Foot / Ankle are performed.

When indicated, further investigations can include:

MRI, Bone Scan., Arterial Doppler.

Only then can a treatment plan be finalised and treatment instituted.

1A: A Review of Diabetic Hand ManagementAssoc. Prof. Dr. Josephine Wing-Yuk Ip, Hong Kong MBBS(HK), FRCS(Edinburgh), FHKCOS, FHKAM (ORTH), M.S (HK), European Diploma of Hand Surgery, Department of Orthopaedics & Traumatology, Queen Mary Hospital, the University of Hong Kong.

Diabetic hand problem is not a frequently mentioned complication of diabetes mellitus(DM) in the past. However with the ever increasing number of DM patients worldwide, it becomes more and more common. The pathology is similar to diabetic foot problem. Neuropathy, immunopathy are the main problems resulting is severe infection. The infection is more florid than non-diabetic infection and frequently requires multiple operations and amputation.

The upper limb nerve is shorter than lower limb nerve so peripheral neuropathy symptoms usually starts from lower limb. As the duration of DM increases and the blood sugar control is sub-optimal, peripheral neuropathy also occurs in upper limb. Sensory deficit starts from the fingertips and progresses proximally. The upper limb circulation usually well even with angiopathy. As the hand is the functional organ to perform activities of daily living and work tasks, it is prone to wear and tear. Minor abrasion or puncture may occur without patient’s notice. Immunopathy allows the infection to spread proximally rapidly. The infection types are similar to ordinary hand infections.

In our study of 37 DM hands, there is high No of deep infection and the duration of hospital stay is significantly longer. 66% requires multiple operations. 5% are necrotizing fasciitis.16% requires digital amputation. Early surgical decision of single digital amputation can effectively control the infection and hasten hand rehabilitation and maximize overall hand function and cosmesis

DM hand is a problem that needs attention nowadays as DM incidence is increasing worldwide.

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Symposium Kuala Lumpur Wound Conference 2017

1A: Recent Advances for Complicated Wounds in the Lower ExtremitiesDr. Kenji Hayashida, JapanM.D., Ph.DDivision of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, Shimane, Japan.The advent of free tissue transfer has offered several options that allow the restoration of defects caused by malignant tumors or sequelae after trauma. However, we should consider anastomosed site infection in complicated wound reconstruction with free flap. This report aims to present our experiences with microsurgical free tissue transfer for complicated wounds and analyze flap options in comparison of immediate reconstruction and secondary reconstruction. From July, 2011 to December, 2015, 22 free tissue transfers were used to reconstruct complicated wounds. There were 18 males and 4 females in this study. The overall flap success rate was 100%. No flap had recurrent infection that might cause subsequent flap loss. All patients healed well, but 3 cases received vein graft due to venous thrombosis. Our data showed prolonged hospital stay in secondary reconstruction group.

We used regimens recommended by the Japanese Association for Infectious Disease, and such regimens contributed the successful free flap transfer for complicated wounds. Patients with complicated wounds can receive benefits from one-step radical debridement and free flap transfer, as it results in a significant decrease in length of stay.

1A: Evolution in Reconstructive Surgery for Chronic OsteomyelitisJP (Joon Pio) Hong, KoreaMD, PhD, MMMDepartment of Plastic Surgery, Asan Medical Center University of Ulsan, Korea

2A: Regeneration or RepairAssoc. Prof. William McGuiness, Australia RN, Dip T, B Ed, MNS, PhD, FAWMADirector, Alfred La trobe Clinical School, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.

When the skin is wounded the resulting tissue loss can be replaced by similar epithelial tissue (regeneration) OR fibrous tissue, generally known as scarring (repair). The challenge for health professional is to provide management strategies that facilitate regeneration whilst limiting repair. This presentation will examine interventions that are aimed at encouraging regeneration over repair. The normal physiological responses of the skin when wounded will be discussed. The visual manifestations of this process will be presented and associations drawn to the observations health professional can make when assessing the progress of wound healing. Factors that facilitate or hinder healing will be discussed under the headings of; patient factors, contextual factors and health professional factors. Models for collaborative care will be presented including the utilisation of inter-disciplinary teams. The presentation is aimed at any health professional interested in improving the time-to-heal for their patients whilst minimising scarring.

2A: New Regime in Wound HealingProf. Dr. Harikrishna K. R. Nair, S.I.S KMN., MalaysiaMD, OSH (NIOSH), OHD (DOH), CMIA (MAL), CHM (USA) ESWT (Austria, Germany), FMSWCP, PG in Wound Healing and Tissue Repair (Cardiff, UK),Head, Wound Care Unit, Dept. of Internal Medicine, KLH

There is a dire need to have more modalities to manage the chronic complex wounds comprehensively with minimal or no complications. Currently, some of the wounds are defined as non healing wounds as they are stalled. A new dressing which is from plant stem cells has been developed which comes in a gel form and in a sheet form. This particular dressing is effective in increasing the rate of wound healing as well as kick starting the healing process in wounds that have stalled. Cases will be shown to demonstrate the effectiveness of this new dressing.

Subsequently, a new Negative Pressure Wound Therapy device will be highlighted. This device is portable and disposable. It comes with two variants which can last 15 or 30 days depending on which model. The efficacy of this new device will be discussed. The pressures are higher compared to other forms of Negative Pressure Wound Therapy systems available in the market. The device can be used to manage exudate effectively. Some cases will be highlighted in the presentation. These new regimes will help to bolster our armament in wound management and enable us to offer our patients better options.

2A: Topical Oxygen - Whats NewProf. Dr. Apirag Chuangsuwanich, ThailandDivision of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Oxygen is an essential component in the wound healing process and without it, wounds fail to heal. There is an increased demand of oxygen during the healing of damaged tissue. Many chronic wounds could not healed because of insufficiency of oxygen supply. Hyperbaric oxygen therapy (HBO) has been proved to be an effective method to provide oxygen to the hypoxic wounds and could improve wound healing to these wound. But HBO has many disadvantages and limitations, many topical oxygen therapies have been developed. In this presentation will review the various topical oxygen therapies.

2A: Biofilm Forming MRSA Survive in Kupffer Cells & Exhibit High VirulenceDr. Takuto Oyama, Japan

3A: Vascular & Biochemical Diagnostics in Wound CareDr. Thomas E. Serena, USAMD FACS FACHM MAPWCACEO / Medical Director SerenaGroup®

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3A: Holistic Approach to the Diabetic ischemia - Neuropathic Wounds Prof. Dr. Sadanori Akita, Japan MD, PhDProfessor-in-Chief, Department of Plastic Surgery, Wound Repair and Regeneration, Fukuoka University, Fukuoka, Japan.

Hemodialysis is the most causative factor to the peripheral artery disease in foot. The incidence of the amputation of limbs among hemodialysis patients is rapidly increasing in Japan. In the Japan Renal Data Registry, JRDR, 4238 of 4279 (99.0%) of Japan’s nationwide dialysis treatment facilities have patients enrolled and the number of new dialysis patients was 38055 in 2012.

The most common primary cause of renal failure among new dialysis patients is diabetic nephropathy. One of the common complications in hemodialysis is foot gangrene and ulcers. Peripheral arterial disease (PAD) in hemodialysis patients is common and the prevalence is 12% in Japan, according to 12 national surveys. However, the prognosis of lesions in hemodialysis often leads to major amputation and this results in high mortality, over 50% in 1 year.

Lesions of the lower extremities may rapidly exhibit clinical features. The PAD foot is prone to infection, especially among diabetic patients, the majority of whom are neuropathic and thus insensitive until severe deformity and trauma occurs. Moreover, critical limb ischemia (CLI), characterized by chronic ischemic rest pain or tissue deficiency, necessitates endovascular therapy (EVT) for revascularization for amputation-free survival or may demonstrate no intermittent claudication in CLI patients with non-ambulatory status.

First, care was taken in how to prevent and decrease worsening of these hemodialysis-related lower extremity lesions together with the nation’s leading affiliated medical societies and associations and some interpellations by a member of the House of Councilors, all of whom collaborated to start a new infrastructure to efficiently set the preventive measures against the disease worsening and complications.

In the basic policy on economic and fiscal management and reform in 2015, called the “Honebuto” principle decided by Japan’s cabinet on June 30, 2015, the government encourages preventive measures against cancer, other lifestyle-related diseases, and aggravation of diseases, including complications in order to reduce the likelihood of needing long-term care. Subsequently, in a study funded by a national grant from the Ministry of Health, Labor and Welfare (MHLW), we organized how to promote the basic policy for high risk amputation dialysis patients, and found a new incident of extremity amputation of 9.1 per 1000 patients according to the retrospective cohort survey of FY 2012 and FY 2013 by analyzing 179,453 consolidated possible anonymous patients’ data from over 310,000 patients, which is close to 99% of the nation’s number of patients. New amputations are related to the past illness of diabetes mellitus. The number and percentage of the extremity amputations are steadily increasing from FY 2009 to FY 2014 by recorded 240,000 patients’ data.

The revised medical health insurance fee system launched on March 28 2016 includes the management and instruction fee for the dialysis clinic or institution that is strongly encouraged to collaborate with the local registered PAD and foot care experts of revascularization and wound care specialists. This policy is the first in Japan to survey the effect of institute-to-institute or clinic-to-institute collaboration and the results are expected to be reviewed and recorded fully by registered to the local bureau of health and welfare. This innovative initiative will be welcomed in an aging society and the impact will be precisely followed by the Japan Renal Data Registry. The impact of this preventing the aggravation and complication of lifestyle-related diseases policy will contribute to the lowering severe foot gangrene, necrosis and amputation in dialysis patients. In 2017, for preparation of revisit of 2018 health reimbursement in Japan, the foot wound will be highlighted and this framework includes basic offloading of the foot and advanced wound therapy might be reimbursed as a whole.


3A: Pitfalls in Diabetic Ischaemic FootDr. Luinio S. Tongson, PhilippinesMD, FPCS, FPALES, CWS, DWCC, MSPHHead, Dr. Jame G. Dy Wound Healing & Diabetic Foot Center, Chinese General Hospital & Medical Center, Manila, Philippines.

Critical limb ischemia (CLI) is an independent cause of major amputation in diabetic population. The diagnosis of ischemic limb is important to the treatment algorithm of diabetic foot. There are some caveats in the evaluation of ischemic limb. The ischemic diabetic foot can be correctly treated when an early diagnosis is made. Infection of diabetic foot with associated peripheral artery disease, may rapidly evolves in severe local or systemic infection that may lead risk of major amputation or death. It is mandatory to apply a medical and surgical treatment procedure with the aim to control infection and improve blood perfusion to the foot following early diagnosis of ischemia and infection. In case of severe infection, surgical procedure should be applied first while revascularization procedure will follow soonest. Antibiotic therapy will be based on local bacteriological pattern and type of infection. In case of stable chronic limb ischemia, a vascular evaluation and management prior to surgical intervention is recommended. Reconstructive surgery, the last step in treatment of any diabetic foot lesion, must obtain a functional residual foot or a stump that will allow the patient to go back ambulatory with residual suitable walking capacity.

3A: Statins and PerfusionDr. Sriram Narayanan, SingaporeMBBS MS (Surgery) (Bombay), FRCS (Glasgow), FRCS (Gen. Surg), Dip Laparoscopic Surgery (France) A/Prof Sriram Narayanan, Senior Consultant Vascular and Endovascular Surgeon, The Harley street Heart and Vascular Centre, Gleneagles Hospital, Singapore

Statins are HMG-CoA reductase inhibitors that have been shown to reduce cardiovascular disease in patients with diabetes. The pathogenesis of diabetic foot ulcers is complex, involving mechanical, vascular, inflammatory, oxidative, endothelial and nutritive factors. The micro- and macro-vascular complications associated with diabetes mellitus have led many scientists to research the effects of statins in the treatment of impaired diabetic healing.

Statins reduce vasoconstriction by decreasing response to angiotensin-2 and by downregulating the pre-proendothelin-1 mRNA, thereby decreasing the synthesis of endothelin-1. They facilitate vascular relaxation by blocking Rho geranyl-geranylation, which enhances the expression of endothelial nitric oxide synthase. Statins also promote neovascularization in ischemic tissue by increasing endothelial progenitor cell activity. Increasing vascular perfusion may make statins potent inhibitors of diabetic wound pathogenesis and promoters of impaired diabetic healing.

Statins may stimulate angiogenesis by modulating the serine/threonine protein kinase Akt pathway, which stimulates the generation of nitric oxide. In a model of severe hindlimb ischemia in streptozotocin-induced diabetic mice, treatment with statins enhanced endothelial nitric oxide synthase expression, significantly preventing auto-amputation. Full-thickness wounds in streptozotocin-induced diabetic rats treated with topical atorvastatin have significantly faster wound-healing rates in comparison with control groups. The mean histopathologic and angiogenesis scores were significantly different at day 14 between statin and control groups. Rates of wound healing were found to be significantly higher in the streptozotocin-induced diabetic rats treated topically with atorvastatin compared with those treated with a mixture of lanolin–vaseline and the untreated group.

Impaired VEGF production in diabetic wounds is thought to be responsible for delayed healing, and statins may represent a potential remedy. Other exploratory therapies that restored impaired diabetic VEGF production ameliorated delayed diabetic healing. In vitro data show a biphasic dose-dependent effect of statins on angiogenesis associated with endothelial apoptosis and VEGF signaling. At low concentrations, HMG-CoA reductase inhibitors enhanced endothelial cell proliferation, migration and differentiation which were, by contrast, inhibited by high doses of statins. In animal diabetic models, simvastatin restored the impaired wound-healing process in diabetic mice (db/db) compared with their normo-glycemic littermates. Incisional wounds on diabetic db/db mice treated with intraperitoneal simvastatin (5 mg/kg) had increased VEGF expression, enhanced nitric oxide wound content, augmented breaking strength and improved wound healing in comparison with controls. Additionally, treatment with simvastatin led to enhanced quality of healed skin, with increased elasticity and decreased fibrosis. These results were verified to be the consequence of simvastatin acting through VEGF, as immunization with anti-VEGF antibody reversed the beneficial effects of simvastatin. Additionally, a slight increase in serum VEGF has been reported in hypercholesterolemic patients treated with simvastatin 20 mg/day for 4 weeks.

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1B: Surgical Options in Limb SalvageAssoc. Prof. Dr. Aziz Nather, Singapore MBBS (Sing), FRCS (Edin), FRCS (Glas), MD (Sing), FAMS (Sing)Senior Consultant, Division of Ankle and Foot, Dept. of Orthopaedic Surgery, National University Hospital, Singapore.

To achieve Limb Salvage, several strategies could be adopted in the Surgical Treatment of DM Foot.

Strategy 1: HOLISTIC TREATMENT must be administered including endocrine control, nutritional support, antibiotics, dressings and surgical option carefully selected.

Strategy 2: Careful Assessment must first be performed to evaluate foot problem – vasculopathy, neuropathy, immunopathy.

Strategy 3: Basic Investigations must be performed – Markers of Infection, Markers of Healing. Radiographs and Tissue Cultures must be performed.

Strategy 4: Surgical Option is then selected and surgical plan assembled.Options include:

• Debridement• Ray amputation / Excision MTPJ• Distal Amputation - Transmetatarsal - Pirogoff• Revascularisation first (non-life threatening situation) vs Revascularisation later (life-threatening situation)• Major Amputation if distal not possible - BKA - AKA

Distal Amputation is preferred but needs 1 palpable pulse (PT,DP). When not possible do not procrastinate. Perform decisive major amputation. Avoid “Creeping Amputation”.

1B: Correction of Foot Deformity Dr. S. Rukmanikanthan, Malaysia MS Ortho (UM), MD (Mal)Department Of Orthopaedic Surgery, Faculty Of Medicine, University of Malaya, Malaysia.

The foot is a very taxed part of the body, together the feet has got about 25% of the total number of bone in the whole body. As a body part, it provides load bearing, acts as a lever, a shock absorber, plays a role in balance and well as has protective roles against sharp or hot surfaces. As such deformities of the foot has a tendency to cause a lot of subsequent problems. Minor deformities has the potential to cause a lot of discomfort to the patient. Apart from discomfort, it can also potentially be limb or life threatening when ulcers develops and gets infected. Thus it is very important to deal with deformities early so they do not worsen and also so it causes the least amount of morbidity to the patient, Addressing deformities can either be accommodative as in modification of the shoewear or corrective where the deformity is corrected surgically or with splints. This talk will look into common deformities and how it can be managed.

1B: Revascularization of The Ischaemic FootDr Naresh Govindarajanthran, Malaysia MD (UKM), MS (UKM)• Consultant Vascular and General Surgeon, Kuala Lumpur Hospital, Malaysia

Revascularization of an ischaemic foot is imperative to achieve wound healing and limb salvage in diabetic wounds. Early recognition of the the ischaemic foot is essential and this is best done clinically and also via non invasive methods.

The goals of treatment include elimination of ischaemia, thus relieving symptoms of pain and also achieving early wound healing; and to regain function to pre-morbid levels. These patients who require treatment are usually compromised with multiple co-morbidities like diabetes mellitus, ischaemic heart disease and end stage renal failure. As such, the therapy instituted needs to be tailored individually to each patient to minimise complications while achieving optimum results.

The methods of revascularization include both open and endovascular method. Bypass surgery which is the gold standard has the best long term patency rates. However, the morbidity and mortality is higher compared to endovascular. Endovascular methods on the other hand have lower morbidity and mortality rates but is limited by the high cost of the devices required. In addition to that, the patency of the from this therapy is often lower. Despite that, it remains to be a useful method of therapy in patients who already have major cardiovascular issues.

Keywords: Ischaemic foot, Revascularization, Bypass, Endovascular

2B: Revisiting a Novel Therapy in Wound Management Prof. Dr. Harikrishna K. R. Nair, S.I.S KMN., MalaysiaMD, OSH (NIOSH), OHD (DOH), CMIA (MAL), CHM (USA) ESWT (Austria, Germany), FMSWCP, PG in Wound Healing and Tissue Repair (Cardiff, UK), Head, Wound Care Unit, Dept. of Internal Medicine, KLH

Currently in Asia there are many complex wounds which are infected compared to the west. There is a huge amount of antimicrobial dressings which are used to treat the infection and these include silver dressings, iodine based dressings and other antimicrobial dressings. It is important to assess the wound using the TIME concept. Subsequently, the presence of infection has to be ascertained. The Principles of Best Practice from the World Union of Wound Healing Societies on infection clearly defines it into 4 categories whereby there is contamination, colonization, critically colonized and infection. Therefore, utilisation of an antimicrobial dressing is according to our assessment.

In this presentation, a composite dressing will be showcased which has Gentian Violet, Methylene Blue and Ag with surfactant in a polyurethane foam. This dressing can be used as a cavity foam also. This retro tech dressing has 5 in 1 constituents which work synergistically to treat infection and help in wound healing. A review of journals will be highlighted and a case series which will show the usage of the retro tech dressing in chronic complex wounds will be discussed.

By contrast, another study reported a decrease of serum VEGF levels in hypercholesterolemic patients treated with 20 and 40 mg/day for 6 months. Other studies have also demonstrated the opposite effects on VEGF with statin treatment. Higher doses of statins have been shown to inhibit angiogenesis. In a study investigating wounded ob/ob mice treated with simvastatin (40 mg/kg injected intraperitoneally), researchers found a marked reduction in VEGF protein levels of wound keratinocytes. This is a very high dose, considering the average dose for LDL lowering in humans is 40 mg per day, with the maximum being 80 mg per day. It seems that the ability of simvastatin to enhance VEGF synthesis is dose- and time-dependent, as high doses and prolonged treatment with simvastatin did not result in an increase in VEGF.

Conversely, a small pilot study demonstrated that all diabetic foot ulcers in a group receiving 10-mg atorvastatin healed, whereas in a group receiving 80-mg atorvastatin, only 66% of ulcers healed. In patients suffering from diabetic foot ulcers, daily treatment with high-dose (80 mg) atorvastatin resulted in a reduction of recurrence and the development of new neuropathic diabetic foot ulcers compared with the treatment with low-dose (10 mg) atorvastatin. A possible explanation may suggest a preventive effect of high-dose statins in diabetic foot ulcer development.

In addition to ulcer development, preliminary observational data suggested that therapy with statins may protect against the development of diabetic peripheral sensory neuropathy. However, this data needs further confirmatory evidence and randomized clinical trials are lacking.

In summary, statins may play a role in the prevention and treatment of diabetic foot ulcers, and possibly other non-healing chronic wounds, by decreasing development of neuropathy, and increasing neovascularization, perfusion and, ultimately, oxygenation to ischemic diabetic wound tissue.

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2B: Utilising Molecular Biology in Wound ManagementDr. Soheila Kordestani, IranManaging Director, ChitoTech Inc., Tehran, Iran.

Wounding and their repair takes place in all tissues and organs of the body and many of repair processes are common to all tissues.

However, despite immense progress, wound healing remains a challenging clinical problem and it involves multiple cell populations, the extra cellular matrix and the action of soluble mediators such as growth factors and cytokines.

2B: Cell Extracts for Wound Healing Dr. Dmytro Klokol, GermanyStellar Biomolecular Innovations (Germany)European Wellness International Group (EU, Switzerland, Asia-Pacific)

Wound care and wound management are one of the core aspects of medicine, especially in surgical practice. According to the recent global analysis 1-2% of the population in developed countries experiences chronic wounds due to increased life expectancy and a rise in such co-morbidities as diabetes, obesity, venous hypertension, and peripheral vascular disease. In absolute figures if affects more than 6.5 million patients in USA only and involves more than $50 billion annually spent. The three most frequent types of chronic wound are diabetic foot ulcers, venous leg ulcers, and pressure ulcers. Even with the compliance with the Standards of Care, complete healing of chronic wounds is achieved in only 21-35% of cases. Addition of growth factors, placental therapy and cellular extracts improves the healing process in the chronic wounds, stimulates neoangiogenesis, keratinocytes proliferation and migration, and hence speeds up the wound closure and recovery. An overview of recommended products and potential indications for its application are proposed.

3B: Venous Ulcer HealingProf. Dr. Liew Ngoh Chin, MalaysiaMBBS, FRCS, MS (Surgery) • Professor of Surgery, Department of Surgery, University Putra Malaysia.

Venous hypertension secondary to venous reflux or obstruction is central to the causation of venous leg ulcer (VLU). A smaller subset of VLU is due to immobility, failure of the calf muscle or arthrodesis of the ankle joint that leads to inefficient drainage of the calf veins.

At the tissue level, venous hypertension results in extravasation of blood constituents into the perivascular space leading to tissue oedema and haemosiderin deposits. The extravasated white blood cells stimulates release of inflammatory mediators that results in pain and tissue damage.

Understanding the pathogenesis will lead to successful VLU healing. Abolition of venous reflux in the superficial vein is accomplished by either conventional surgery or endovenous ablation. Managing deep vein reflux is more challenging and technically demanding. In cases where deep venous reflux is not surgically correctable, compression therapy using multilayer bandage or graduated compressive stockings has proven effective. Obstruction in the deep veins can now be ameliorated by successful venous bypass procedure or percutaneous balloon angioplasty and stenting.

At the cellular level, better understanding of the interplay of cellular elements led to pharmacological manipulation that hastens VLU healing and improvement of symptoms. At present, there is evidence that Flavonoids, pentoxyphyllin and heparinoids have an adjuvant role in VLU healing and improvement of symptoms associated with venous hypertension.

Effective moisture control using foam and other high absorptive agents, in addition to compression has reduced the need for frequent dressing changes and decreased excoriation associated with moisture.

More importantly, it is recognized that upto 50% of patients with iliofemoral deep vein thrombosis is at risk of developing post thrombotic limb syndrome, some of which led to VLU. This sequelae of deep vein thrombosis is due to valve damage or residual venous obstruction. Aggressive recanalization of Iliofemoral DVT, reduction of oedema and prevention of recurrent DVT has been shown to reduce the risk of post thrombotic limb syndrome.

3B: RFA, Laser & VLU: Where Are We Now Dr. Sriram Narayanan, SingaporeA/Prof Sriram Narayanan, Senior Consultant Vascular and Endovascular Surgeon, The Harley street Heart and Vascular Centre, Gleneagles Hospital, Singapore

Venous leg ulcers (VLU) are common in the elderly population with an estimated prevalence of 1-2%. Traditional treatments with compression therapies have had variable success with healing rates of 45-90% reported. However, in tropical climates, compression is poorly tolerated and recurrence rates are high. The development of endovenous treatment strategies for superficial veins and new understanding of the pathogenesis of venous hypertension mean that this approach of ‘compression only’ for VLUs is changing.

VLUs occur due to a sustained rise in the ambulatory venous pressure at the ankle. This raised pressure may have its origins in incompetence of venous valves in the superficial or deep venous systems or a combination of the two. However recent research shows the presence of a non-thrombotic iliac vein lesion (NIVL) in the pelvis of 70-90% of people as the primary cause of this rise in venous pressure.The NIVL (or similar) was first described in by May and Thurner in 1957 as an iliac vein compression syndrome where the left common iliac vein was compressed by the right common iliac artery as the latter crossed over it in the pelvis. The eponymous May-Thurner syndrome was one of ilio-femoral thrombosis occurring secondary to this and was thought to be rare. Recent data from Sheshadri Raju and Peter Neglen however shows that this compression is anything but rare and although it may not lead to thrombosis in most people, it functions as a permissive lesion that can causes venous hypertension, deep vein thrombosis and many of the disorders of venous origin in the lower limb. Treatment of these NIVL lesions shows promising results for ulcer healing without the need for sustained compression therapy.

It also now understood that the occurrence of VLUs is secondary to transmission of high deep venous pressures to the superficial (great and short saphenous veins) via the perforating veins at the ankle. Indeed, the best results with perforator ablation are in patients with recalcitrant venous ulcers. Interventional therapy for VLUs therefore has concentrated on preventing the transmission of these high venous pressures to the ankle.

The development of endothermal techniques like Radiofrequency ablation (RFA) and Endovenous Laser therapy (EVLT) allowed a minimally invasive approach to be used for closure of the truncal superficial veins (great saphenous and short saphenous veins) as a means pf preventing transmission. This really followed on from the results of the ESCHAR trial (published in 2009) that compared open superficial venous surgery with compression versus compression alone. The trial suggested that whilst surgery did not improve rates of healing, it significantly reduced rates of ulcer recurrence. The ablation of incompetent superficial veins with either RFA or laser in patients with VLUs thus became common.

Further changes to practice took place after the understanding of the perforator veins in VLU pathogenesis came about. The new endovenous therapies were further improved for this and an RFA-stylet specifically designed for perforator vein ablation came about. In addition, techniques for targeted perforator vein ablation with laser also developed and management of VLUs evolved to include truncal vein ablation with perforator ablation with compression therapy.

However, both RFA and EVLT involve the use of heat to ablate the veins (hence the alternative term endothermal venous ablation) and that precludes their use in ablation of the great saphenous vein below the knee. This is because the saphenous nerve is closely related to the vein in the lower two-thirds of the leg and can be damaged by the high temperatures generated. The (even) newer non-thermal methods of Venaseal glue ablation and Clarivein therapy (the latter utilises a venous sclerosant) have thus been a further improvement on this. The author’s own pioneering experience with Venaseal glue ablation in venous ulcers shows rapid ulcer healing at under 6 weeks in all 14 cases with an ulcer recurrence of under 7% at 1 year without compression.

The modern approach to VLU management thus entails determining the primary source of the raised venous pressure at the ankle. If this is primarily deep venous hypertension from an NIVL, then venous stenting will be required. If there is superficial venous incompetence, then ablation of the incompetent truncal vein with perforator ablation using an endovenous technique is the procedure of choice. All interventions will require compression therapy to effect and maintain ulcer healing.

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3B: Compression Therapy: A Global Review Prof. Dr. Raj Mani, UKPhD, FACA, FIPEMConsultant, Academic Division of Human Development & Health, Faculty of Medicine, University of Southampton


4A: Evolution of Stoma ManagementMadam Mariam Mohd Nasir, A.M.N., MalaysiaCert GLNI (Geneva) MBA (Mal/UK) BSc (Hons) Mal, WOCNEP(Hong Kong) SCM SRNNursing Consultant/Director, M&T Network Consultancy (Nursing Training)(Specialized in Enterostomal Therapy Nursing & Nursing Management) Why do you think knowing about our past history is important?? It is mainly because it is the path that leads us to the present and the future. It is a story telling how people earlier than us have been challenged and facing all the difficulties. They continue without much facilities and products and how we can value that in our current practice.

It’s important because the past is what makes the present. We should learn to appreciate history because it lets us know about all the legendary figures that made a difference to the world in which we live today. The history of wound, ostomy and continence in Malaysia not much recorded and made known to others. It is because we are very poor in keeping records, especially maintaining and updating it. The specialty was not known as a three in one specialty. It grows separately until the speaker graduated from Wound, Ostomy & Continence Nursing Education Program in Hong Kong, 1995. That probably marked the day of Enterostomal Therapy Nursing really known to the industry as three disciplines in a specialty. But still, it is still undergoing awareness among all especially those in clinical area.

Stomacare nursing is the leading area that started in Malaysia as early as 1970s in General Hospital, Kuala Lumpur when a surgeon came back from overseas and stat operating and creating stoma. He notices that there is no stoma care nurse trained in the field and realizing this is crucial, he then initiated an effort to send a Nurse to Australia to be trained as Stoma Nurse and that person was Madam Tang Tai Peng, a Staff Nurse working in surgical ward at that time.

Once completed the course she came back and start a program train the trainer by organizing a workshops for other Nurses. Due to the need for expansion of service, the hospital managed to send another 5 Nurses, and they were sent for ET course in Australia. The same year the speaker was also undergone a WOCN in Princess Margaret Hospital, Hong Kong.

The story goes on and the speaker will share it with all in the conference.

4A: Pressure Injury Prevention and TreatmentProf. Nguyen Anh Tuan, VietnamMD, PhD • Director of Wound Care Center of University Medical Center of Ho Chi Minh City, Vietnam

The main cause of pressure sore at sacrum-coccyx area is a result of unrelieved pressure on a local tissue for a long time (pressure ulcer). This ulcer is a common disease and also is the result of bad care on patient. The patient normally has many concomitant diseases: diabetes, hypertension, unconscious, cerebral vascular accident, paralysis, marasmus…

Treatment has many difficulties and need to combine numerous specialties: endocrinology, vascular cardiology, plastic & reconstructive surgery, physiotherapy…

Author report his clinical experiences in treatment ulcer at sacrum-coccyx area and conclude: need to make well co-operation between specialties and combine treatment procedures (medicine and surgery) to get good result. Local care (TIME), repositioning, early mobilization, eliminate or reduce local pressure, flaps… are the most importance and are the keys of treatment.

Key words: sacrum-coccyx area, pressure ulcer.

4A: Case Discussion Dr. Anantha, Malaysia

5A: Case Series: Effective Treatment of Challenging Surgical Wounds Using Sodium Polyacrylate and MCGDr. Zamri Zuhdi, MalaysiaClinical Specialist in Hepatobiliary & Lecturer, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Malaysia.

Introduction: Wound bed preparation (WBP) is the process of removing local barriers to wound healing so as to maximize the potential for successful healing. It can be achieved through debriding non-viable tissue, pathogen, contaminants and foreign material and also drains areas of infection.

I presented a case series of variety of wound dehiscence and pressure ulcer which successful treatment combination dressing using sodium polyacrylate (Gold Dust) combined with modified collagen plus glycerine(Stimulen).

Case series and methods:Case 1: A 31 year old lady post operative laparotomy for multiple bowel perforation and complicated with wound dehiscence.Case 2: A 57 year old woman known case of periamullary carcinoma. Developed burst abdomen and wound dehiscence post whipple procedure.Case 3: A 35 year old known case of colon cancer which complicated with wound dehiscence post laparotomy.Case 4: A 39 year old lady postoperative laparotomy for intestinal obstruction which complicated with surgical wound infection.Case 5: A 47 year old female with morbid obesity and multiple co-morbid, developed large pressure ulcer.

Discussion: Difficult non healing wound contains exudate with high levels of inflammatory mediators like matrix metalloproteinases (MMPs), polymorphonuclear granulocyte-derived elastase (PMN elastase), increase activities of protease and high concentration of free radicals. Removal of the above have therapeutic effect on granulation tissue formation and WBP. Sodium polyacrylate(Gold Dust) have this effect. Collagen creates the most physiological interface between wound surface and its environment and it is impermeable to bacteria. Collagen also inhibits the actions of MMPs and facilitate migration of fibroblasts into the wound.

Conclusion: Combination of wound dressing using sodium polyacrylate(Gold Dust) combined with modified collagen plus glycerine(Stimulen) give a good result for managing difficult wound due to post operative as well as pressure ulcer..

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Kuala Lumpur Wound Conference 2017Symposium

5A: A Novel Therapy of Combining Ultrasound and Electrical Field Stimulation as an Adjuvant Treatment for Recalcitrant Venous Leg UlcersMs. Diane Eng, SingaporeNurse Clinician, Wound & Ostomy Management, Tan Tock Seng Hospital, Singapore

Chronic wounds are rapidly increasing in prevalence, due to rising healthcare costs, aging population, and expanding co morbidities (Vowden and Vowden 2016). To address those and other needs regarding chronic wounds, standard wound care is often employed alone or in combination with adjunctive wound therapies that administer several types of biophysical energy to further enhance healing (Kloth 2014).

The biophysical effects of ultrasound therapy relevant to wound healing include increased local blood flow and vascular permeability, angiogenesis, cellular protein synthesis, and improved collagen substance and alignment (Dolibog et al. 2008). Intact skin has transepithelial potential given that the skin surface containing a negative charge from chloride ions, whereas the dermis maintains a positive charge via sodium ions (Ennis et al 2011). Since chronic wounds lose the electrical current, they have decreased healing potential. In response, electrical stimulation therapy improves the electrochemical wound process by reintroducing the currents and assisting with the healing (Herberger et al 2012).

Although, both ultrasound and electric stimulation therapy have been in use for decades, their combination as a single therapy for chronic wound management remains novel.

Objective: The purpose of this paper was to describe a novel device that combines ultrasound and electric field stimulation therapy (CUSEFS) in terms of its clinical effectiveness as an adjunctive therapy in treating recalcitrant venous leg ulcers (VLU).

Methodology: Convenience sampling of five chronic (VLU) patients with average wound duration of 60 weeks and recalcitrance to compression therapy were recruited. Performed weekly for 20 minutes, CUSEFS provided ultrasound frequencies of 1.0-3.0 MHz with an intensity ranging from 0.0- 2.0 W/cm2, whereas the electrical field stimulation interferential beat frequency ranges from 0-250 Hz. Weekly ulcer area measurement, wound photography, and periwound skin assessment were performed to ascertain ulcer healing. Patients were followed up either until complete ulcer healing was achieved or for until 16 weeks elapsed.

Results: The median ulcer size at recruitment was at 26 cm2. All five VLU patients responded to CUSEF with a mean size reduction of 46.12% (12.5 cm2) in 4 weeks, for a total mean wound area reduction of 74.6 % (20.14 cm2) at 16 weeks. The wound beds also exhibited healthy granulation tissue, wound edges and periwound skin.

Conclusion: This case series provided preliminary results demonstrating the positive effects of CUSEFS in stimulating wound healing in recalcitrant VLU patients, both in chronicity and quality of healing.

5A: Shock Wave Therapy as An Adjuvant in Wound HealingDr. K. Vilvkumaran, MalaysiaHead, Dept. of Orthopedic and Traumatology, Tengku Ampuan Rahimah Hospital, Klang, Maalysia

5A: Case Discussion: Surgical Site Infection with its Associated ComplicationDr Nizam Bin Ali Husien, MalaysiaWound Care Unit, Sarawak General Hospital, Kuching, Sarawak, Malaysia.

Surgical site infection (SSI) are defined as infection occurring up to 30 days after surgery (or up to one year after surgery in patients receiving implants) and remain the most common complication following operative procedures.

It’s affecting either the incision or deep tissue at the operation site. Management of SSI can be very challenging per se and further aggravated by some other complications. Of those, intestinal or enterocutaneous fistulas are the most challenging because of their association with significant morbidity and mortality.

Optimal management with holistic and interdisciplinary approach is required to improve the patient’s prognosis. In addition to primary management of sepsis, conservative treatment remains the treatment mainstay, including the combination of wound management, nutritional support and psychosocial support.

Here, I would like to discuss few cases of SSI with/without fistula follow by its management and outcomes in Sarawak General Hospital, Kuching.

6A: Flaps and GraftsAssoc. Prof. Dr. Josephine Wing-Yuk Ip, Hong Kong MBBS(HK), FRCS(Edinburgh), FHKCOS, FHKAM(ORTH), M.S (HK), European Diploma of Hand Surgery, Department of Orthopaedics & Traumatology, Queen Mary Hospital, the University of Hong Kong.

6A: Dermatological Wounds Dr. Rajalingam Ramalingam, MalaysiaHead of Department, Department of Dermatology, Hospital Tengku Ampuan Afzan, Kuantan, Malaysia.

Many dermatoses cause a breach in the skin. These wounds can take the form of superficial desquamation, erosions or ulcers with deep tissue involvement. Some dermatological wounds are transient in nature, improving with treatment, while some are chronic and non-healing with adverse systemic sequelae. The pathogenesis underlying these dermatological wounds vary greatly, and involve infectious, inflammatory, autoimmune, malignant, metabolic, drug-induced, psychogenic and genetic processes. Awareness of these dermatoses as well as their fundamental pathomechanism, is imperative in initiating prompt and proper treatment to the patient, as well as to minimize unnecessary and erroneous procedures.

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6A: Management of Biofilm: Whats NewDr. Adisaputra Ramadhinara, Indonesia MD, CWSP, FACCWSWound Care Physician, The Specialist Wound Center, Jakarta, Indonesia

Bacterial biofilm can be defined as group of microorganisms that live together within self-produced extracellular polymeric substances and get attached to any surfaces. Recent metaanalysis showed that biofilm bacteria were presented in 78.2% of chronic wounds, and they are generally tolerant to antimicrobials due to their ability to shift from the rapidly proliferating planktonic state that is sensitive to antibiotics into the biofilm population that are mostly contain of metabolically dormant cells. Furthermore, the complex structure of biofilm matrices that contain polysaccharides, nucleic acids and lipids create a barrier that would impair the antimicrobial activities, making them hard to eradicate. Recent studies have demonstrated several updates in the strategy to manage biofilm. Nakagami et al (2016) demonstrated a novel approach to clinically identify the presence of biofilm bacteria in the wound bed, through the wound blotting technique using nitrocellulose membrane. This simple yet cost-effective method has been shown to be able to assess the presence of biofilms in 70 separate wound measurements in a study involving 16 patients with 23 pressure ulcers. Cowan et al (2013) showed the efficacy of larvae debridement therapy using Lucilia sericata to clinically eradicate mature biofilms of Pseudomonas aeruginosa and Staphylococcus aureus in the in vitro study using pig skin explants to undetectable levels after two days. Another in vitro study by Yang et al (2016) successfully demonstrated the effectiveness of wiping the wound bed using poloxamer-based surfactant polymers to reduce the level of biofilm bacteria. Fitzgerald et al (2016) through their in vitro and in vivo study using several biofilm models demonstrated the superior microbicidal activities of cadexomer iodine against Pseudomonas aeruginosa, Staphylococcus aureus, and MRSA biofilm, when compared to several other dressings such as hydrofiber with silver and povidone iodine. Despite of promising results from recent studies in biofilm, the fundamental concept of biofilm management in wound care still requires adequate debridement, followed by proper topical antimicrobial administration and preventing planktonic bacteria from regrouping and forming new biofilms through the application of antiseptics that have sustained release mechanisms.

6A: Case DiscussionDr. Haris Ali Chemok Ali, MalaysiaM.B.B.S. (UM), M.S. Ortho (UM), C.M.I.A. (NIOSH), C.M.I.E. (ABIME).Orthopaedic Surgeon / Head of Department, Serdang Hospital, Selangor, Malaysia.

4B: Surgical Intervention of Acute and Chronic Diabetic Foot InfectionProf. Dr. Yur Ren Kuo, TaiwanMD, PhD, FACS, Chairman, Department of Surgery; Chief Professor, Plastic Surgery, Kaohsiung Medical University Hospital, Taiwan

Current techniques in chronic wound bed preparation found to be effective in assisting the wound-healing process. The process begins with the identification of a correct diagnosis of the wound’s etiology and continues with optimizing the patient’s medical condition and assessment of the wound site. However, treatment of diabetic foot ulceration (DFU) remains challenging because of unsatisfactory results. The international consensus and practical guidelines on the management of chronic non-healing foot ulcers suggest multi-disciplinary approaches.

After arterial inflow and venous outflow are assessed, the wound itself should be thoroughly evaluated. The presence of infection and peripheral vascular disease complicate the treatment of these wounds including control of diabetes, orthotic shoe wear, offloading device, wound care and angioplasty surgery. Vascular surgeons with endovascular intervention or bypass surgery are most important in selected cases for peripheral artery occlusion disease (PAOD).

Debridement as the basis of most wound-healing strategies is then emphasized. Local flap and free flap reconstruction could be performed for diabetic foot ulceration with vital tissue exposure. Many adjunctive therapies are designed to improve the care of DFU including biological dressing, negative pressure wound therapy (NPWT), hyperbaric oxygen (HBO), recombinant growth factors, acellular matrix product, etc. In summary, the most important role in the treatment of recurrent DFU is prevention. The surgical intervention or conservative treatment should be depended on patient condition.

4B: Off-Loading In DFU And Charcot Osteoarthropathy Dr. Phua Chui Har, Malaysia Rehabilitation Physician, Department of Rehabilitation Medicine, Hospital Sultan Ismail, Johor Bahru.

Diabetic foot ulcers are caused by an imbalance between excessive pressure at the plantar aspect of foot and cycles of repetitive stress resulting from daily ambulation. Off-loading is an essential treatment modality which redistribute the plantar pressure thereby result in faster healing of uncomplicated neuropathic foot ulcers and minimizing the risk of amputation. Once a diagnosis of Charcot arthropathy is confirmed, off-loading is the immediate treatment goal. This is done to prevent further destruction to the bony structure of the foot.

A wound practitioner’s best strategy for healing an ulcerated foot will invariably fail without proper off-loading principles. Wound healing that has stalled despite best-practice techniques may require re-evaluation of off-loading choices. Basic principle of off-loading include mandatory management of any hyperkeratosis in the ulcerated and non-ulcerated foot. Primarily, the goals of off-loading in wound patients are to reduce tissue motion, accommodate osseous deformities or protrusions, provide maximum shock absorption, and reduce the amount of time the foot is on the ground.

This discussion explores the basic biomechanical concepts that modify and influence ambulation and gait patterns. The majority of pathology occurs during the propulsive phase of gait. Repeated assaults at or in excess of this threshold result in wound formation. Choices of an off-loading devices will be widely discussed because of their usefulness and are vital to reduce the stress load and impact on the foot structures during gait. It is also important to judge age, gender, weight, presence of an open wound or infection, vascularity and neurologic status of the limb in our decision process of prescribing the proper off-loading devices.

In conclusion, successful outcomes for wound healing requires a multidisciplinary approach. Early implementation of proper off-loading strategies will definitely improve the outcome of DFU and Charcot Osteoarthropathy.

4B: Case Discussion: Ms. Diane Eng, SingaporeNurse Clinician, Wound & Ostomy Management, Tan Tock Seng Hospital, Singapore

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5B: Myths & Facts About Nutrition in Wound Healing Pn. Mageswary, MalaysiaHead of Dietetic and Food Services Department, Selayang Hospital, Selangor, Malaysia.

There are numerous evidences demonstrating the essential role of nutrition in wound healing process. Inadequate nutrition may impair and prolong wound healing. This is more prevalent among malnourished patients admitted with comorbidities like diabetes. Malnutrition becomes a barrier to proper wound healing in many patients.

Wound healing is a complex process and demands higher energy, protein, vitamins, minerals and certain immune-nutrient for replacing injured or loss tissues. A well planned balanced diet is essential to fulfil the nutrient demand and supplementation of protein and other nutrients are recommended in some complex non-healing wounds. When a patient is screened and found to be malnourished or at risk of malnutrition, nutritional support intervention by a multidisciplinary healthcare team is needed for better and speedy wound healing. However, when it comes to effective wound care management, there is no threat quite like misinformation or taboo believes among patients. To avoid the wrong information, we should continuously know wound healing facts well and always educate patients the evidenced based facts.

5B: Biotherapy UpdatesDr. Nazni W. Ahmad, MalaysiaMedical entomology Unit, Infectious Disease Research Centre, Institute for Medical Research, Kuala Lumpur.

The earliest report of leeches being used medicinally dates back to ancient Egypt, where tomb paintings (1567–1300 BC) depicted their use by a barber surgeon. In the ancient world, leeches were used as one of several methods of bloodletting, since it was thought that bloodletting would cure a number of ailments such as mental illness, nose bleeds, insomnia, obesity, tumours, strokes, and gout. The belief was that removal of the patient’s blood would correct the humoral imbalance and restore good health and this supports the meaning of “leech’ in Anglo-Saxon means ‘to heal’. The Roman physician, Nicander of Colophon (200-130 BC) was probably the first medical practitioner to use leeches for therapeutic purposes. Early Chinese writings from the first century AD also described the therapeutic use of leeches. The usage and practice of leeches has also been mentioned in ancient Sanskrit, Persian and Arabic literature.

The Malaysian leeches were identified using the classical morphology-based taxonomy and was identified as species of Hirudinaria javanica and Hirudinaria manillensis. The identification was further confirmed using molecular techniques based on the mitochondrial cytochrome-c oxidase sub-unit 1.The bacterial contents on the external body and in the mouth region of leeches were identified as Proteus mirabilis, Aeromonas salmonicida, Aeromonas sobria, Vibrio alginolyticus, Moraxella sp. and Stenotrophomonas maltophilia.

For therapeutic purposes, it is preferable to use disinfected leech. However, to date successful disinfection of leech is not known or reported. We attempted to disinfect Malaysian leech by testing eleven sterilizing and antibacterial agents in different combination and concentration. Tested leech has been observed to be extremely sensitive to many combinations. One combination was finally used to successfully disinfecting the leech. Body contents of disinfected leech were cultured in blood agar to verify the absence of microbial contamination. The disinfection was further confirmed by electronmicroscopy, whereby no microbes were observed. This is the first successful report of complete disinfection of leech and opens a new avenue for the effective and safe use of medicinal leech in the treatment of various conditions.

6B: Atypical WoundsDr Nur Ashikin Bte Ahmad, Malaysia Dermatology unit, Medical Sciences Cluster, Faculty of Medicine, Selayang Campus, Selangor.

Pressure ulcers, venous leg ulcers, diabetic foot ulcers, and arterial ulcers are among the most common types of chronic wounds encountered in our daily practise. Atypical wounds are those who do not fit into any of these categories .There is no exact definition for an atypical ulcer or wound, as it represents a complex of clinical judgment based on the physician’s experience and the combination of a variety of factors such as appearance of the wound, presence of underlying diseases, site of the wound and the different healing process of the wound. Some of the commonly encountered aetiologies for atypical wound include infections, cutaneous malignancy, inflammatory processes, metabolic and genetic factors.

The atypical presentation may lead to an inaccurate diagnosis thus delaying prompt institution of therapy. This lecture will discuss the varied causes of atypical wound, clinical presentations, investigations and treatments modalities. At the end of the presentation, it is hoped that the audience will be able to identify atypical wound to ensure a successful patient management.

5B: MDT in the Primary Care Setting En. Hamizal Bin Hamid, MalaysiaAssistant Medical Officer, Wound Care Unit, Hospital Melaka, Malaysia.

Maggot Debridement Theray (MDT) was first introduced sometime in 2003, whereby for the first time in Malaysia, Ministry of Defence Lumut, Hospital at Perak Darul Ridzuan utilized Sterile Larvae for purpose of treating wounds. With the increasing incidences of antibiotic resistance in hospitals, MDT started to gain popularity from 2007 whereby it is used for treating antibiotic resistant cases.

In the early years, MDT was only practiced in government hospitals with Hospital Kuala Lumpur under the leadership of Dr Harikrishna Nair being the pioneer thereon spreading the usage to Hospital Melaka and then introduced to Health Clinics surrounding the state of Melaka. MDT was used in these centers with outstanding results, achieving 90 to 100 percent wound closure.

Subsequently, MDT was introduced to Health Clinics in the states of Johore, Negeri Sembilan under the guidance of the respective Health Offices of Kota Tinggi, Kluang, Muar, Batu Pahat, Rembau, Tampin and Kuala Pilah.

To date more than 100 patients have been successfully treated with MDT in Health Clinics of the three respective states of Johore, Melaka and Negeri Sembilan giving rise to plans of expanding throughout Malaysia through the efforts of Wound Care Society Assistant Medical Officer Melaka Team.

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2. Case Series: Effective Treatment of Challenging Surgical Wounds Using Sodium Polyacrylate Combined with Modified Collagen Plus Glycerine

Authors : Mr Zamri ZUHDI, Hairol OthmanCentre : Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000 Kuala Lumpur, Malaysia.

Introduction • Wound bed preparation (WBP) is the process of removing local barriers to wound healing so as to maximize the potential for

successful healing. It can be achieved through debriding non-viable tissue, pathogen, contaminants and foreign material and also drains areas of infection.

• This is a case series of variety of wound dehiscence and pressure ulcer which successful treatment combination dressing using sodium polyacrylate (Gold Dust) combined with modified collagen plus glycerine (Stimulen).

Case Report• Case 1: A 31 year old lady post operative laparotomy for multiple bowel perforation and complicated with wound dehiscence.• Case 2: A 57 year old woman known case of periamullary carcinoma. Developed burst abdomen and wound dehiscence post

whipple procedure.• Case 3: A 35 year old known case of colon cancer which complicated with wound dehiscence post laparotomy.• Case 4: A 39 year old lady postoperative laparotomy for intestinal obstruction which complicated with surgical wound infection.• Case 5: A 47 year old female with morbid obesity and multiple co-morbid, developed large pressure ulcer. Methodology• For the wound dehiscence cases, depending on the size of the wound, half a pack to 1 pack of Gold Dust 3g sachet was mixed

with sterile water to turn it into a paste. Stimulen was added onto the paste and packed into the wound with gauze and Gamgee as secondary dressings. Dressing change is daily for highly exudating wounds and every other day for moderate exudating wounds.

• For the pressure ulcer, initially 4 packs of Gold Dust was used daily tapering down to just 1 pack every other day till patient was discharged to another hospital out of Kuala Lumpur.

Results• All the 4 cases of wound dehiscence showed remarkable improvement within 3 weeks with exudate and infection under control

and reduction in wound size. The pressure injury wound was recovering well until patient requested to be transferred back to a hospital near her hometown.

Discussion• Difficult non healing wound contains exudate with high levels of inflammatory mediators like matrix metalloproteinases (MMPs)

(1), polymorphonuclear granulocyte- derived elastase (PMN elastase), increase activities of protease and high concentration of free radicals(2). Removal of the above have therapeutic effect on granulation tissue formation and WBP(1). Sodium polyacrylate (Gold Dust) have this effect. Collagen creates the most physiological interface between wound surface and its environment and it is impermeable to bacteria(3). Collagen also inhibits the actions of MMPs and facilitate migration of fibroblasts into the wound (4).

Conclusion• Combination of wound dressing using sodium polyacrylate (Gold Dust) with modified collagen plus glycerine (Stimulen) gives

a good result for managing difficult wound due to post operative as well as pressure ulcer.

Symposium Poster Submissions

6B: New Innovations in Wound Healing Ms. Farrah Hani Imran, MalaysiaHead of Plastic & Reconstructive Surgery, Burns Unit & Wound Care Team, Consultant Plastic Surgeon & Lecturer, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (National University of Malaysia), Kuala Lumpur, Malaysia.

6B: Case Discussions (Primary Care): Experience of Managing Chronic Venous Leg Ulcers in Primary Care SettingDr Hanihaselah Mohd Saleh, Malaysia Consultant Family Medicine Specialist, Mengkibol Health Clinic, Kluang, Johor, Malaysia.

Chronic venous leg ulcers (CVLU) are common wound seen in primary health care¹. Managing CVLU is very challenging and time consuming as the concern is increasing burden in workload and resources. Managing this condition requires assessment of both the ulcer and also general condition of the patient. Wound assessment is an essential part of the management, as the ulcers is not an isolated disease but manifestation of underlying problem³. It has a point prevalence of 0.11% and a high level of chronicity. 24% of patients’ have ulcers that persist for more than 1 year and 35% for more than 5 years; 20% of patients have experienced 10 or more episodes of ulceration and 45% of patients are housebound because of related immobility4 .

Management of chronic venous ulcer is complex, and ranges from clinical treatment to surgical therapy of the underlying venous abnormality. The right method of wound care is essential to speed up healing process and to prevent further complication. The essential requirements of management are ulcer’s debridement with appropriate precautions, dressings’ option aiming to maintain adequate moisture balance, to treat the infection, application of graduated compression bandage after evaluation of the arterial circulation and to address patient’s concerns, such as pain and offensive wound discharge.

We did observational case series of 6 patients with chronic venous leg ulcers treated at primary health clinic in Kluang District from November 2016 till April 2017(5 months). In these 6 patients with chronic venous leg ulcers, there were significant reduction in ulcer area were observed over 12-weeks follow up period, implicating the need of persistence in treatment. 2 (33%) of the cases recovered within 3 months and 4 (67%) of the cases still undergo dressing showing various wound recovery rate ranging from 10% to 50% reduction of baseline wound surface area.

CVLU can be manage effectively in primary health care with the advance modern wound dressing materials and techniques, well-trained health care personel who are passionate, continueos health education and motivation to the patients and family members and with the systematic,holistic and comprehensive approach of wound management.

Kuala Lumpur Wound Conference 2017

1. Combined Super-oxidized Therapy: An Effective Treatment for Chronic Wounds

Authors : Harikrishna K.R.Nair, MD FMSWCP, Angeline SRNCentre : Wound Care Unit, Dept. of Internal Medicine, SCACC Hospital Kuala Lumpur, Malaysia.

Abstract: Managing chronic wounds is always a challenge in current health care, this study aims to assess the efficacy of combined super oxidized therapy in treating chronic wounds. Ten patients were enrolled, with 6 diabetic foot ulcer cases, 3 venous ulcer cases, and 1 lower extremity ulcer case.

The treatment efficacy was assessed by changes in wound size, pain score via Visual Analogue Scale and exudate level for period of 1 month. Statistical analysis was done using Wilcoxon Signed Ranks Test and paired T-Test. Patient satisfaction on treatment outcome was collected too. Overall there was significant reduction in wound size, pain and exudate level with good patient satisfaction on treatment outcome. No adverse events were reported.

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4. Case Report on Non Healing Venous Ulcer Utilizing RTD A Novel Broad Spectrum Antimicrobial Foam for Infection And Exudate Control

Authors : Noraishah M.R MD (UKM), Siti Norlaili Aiza MBCHB (LEEDS), Nazirah M.R MD (University of Brawijaya), Julizaayu RN, Mazliza Basharudin RN, Anita Roswati RN

Centre : Wound Care Clinic, Hospital Putrajaya, Malaysia.

Abstract: • Healthcare professionals are increasingly being challenged by the non healing venous ulcer. Friedberg et al. found out that the

people aged over 70 years old, the prevalence of venous ulceration is close to 13%¹.• ‘Hard to heal’ wounds may have a large surface area, with a duration of months or years, and the presence of fibrin on more

than 50% of the wound surface area².• Despite using limb compression, debridement, skin grafting and / or dressing therapies as interventions in the treatment of

venous leg ulcers, reports still indicate that around 20% of these wounds remain unhealed after 50 weeks or more of therapy³.• A study was conducted using Retro Tech Dressing (RTD) a novel broad spectrum antimicrobial foam dressing on 5 non healing

venous ulcer. These wound duration ranges from 1 month to 3 years and have been treated with multi modalities available in the country.

• The study is still on going and to date we have seen significantly marked improvement in all cases studied with varying degree of wound closure.

Introduction • Non healing venous ulcer has shown negative impact to patient’s quality of life.• Enoch & Price state that “it is important to appreciate and acknowledge that some chronic wounds are resistant to all efforts

and treatments aimed at healing”.• Biofilms are found in 60% of chronic wounds. • In this case series, a new broad spectrum antimicrobial foam (RTD) is used to get the infection under control so that the wound

can heal normally. This dressing is a propriety highly absorbent broad spectrum antimicrobial foam conatining Methylene Blue, Gentian Violet and Silver Ion integrated into the polymer matrix.

Methodology• 6 patients were selected for their non healing venous ulcer ranging from 1 months to 3 years.• All 6 cases were seen twice weekly at Wound Care Clinic, Hospital Putrajaya.• Their wounds were cleaned and RTD dressing applied covering the wound bed, secured with gauze. All of them were put on

2 layer compression bandage.

Result• All 6 cases showed sign of healing. The wound area started to reduce in terms of the length and width in all cases. • The percentage of wound reduction was 25 to 100%. • Case 1 - A 59 years old female patient developed venous ulcer at left lateral leg after scratching the skin due to itchiness. She

had daily dressing at general clinic however wound doesn’t show any sign of healing after more than 1 month. • She was started with RTD dressing and after 27 days the wound was totally healed.• Case 2 - A 76 years old female patient with recurrent venous ulcer left leg. After 5 weeks using RTD dressing, the wound totally

healed. • Case 3 - A 58 years old female patient with 1 month old venous ulcer at right calf. After applied RTD dressing, the wound edge

have shrunk more 60% in size plus healthy granulation and epithelialization seen throughout the wound.• Case 4 - A 69 years old male patient with long standing venous ulcer for the past 2 years plus. After 7 months the wound

healed.• Case 5 - A 57 years old male patient with venous ulcer enveloping left leg for 3 years prior to start RTD dressing. In 3 months

plus marked improvement was seen with twice weekly RTD dressing.• Case 6 - A 63 years old male patient suffering from right foot venous ulcer for the past 2 years. After 9 months plus, the wound

size was reduced significantly.

Conclusion• In all 6 cases, infection was well controlled leading to healthy tissue granulation and wound closure. • The combination of methylene blue, gentian violet and silver plus singlet oxygen exerts a synergistic and powerful microbial

killing for both fungi and bacterial. The presence of surfactant in RTD dressing helps in inflammation reduction and the foam with a good capillary suction helps in exudate management.

Kuala Lumpur Wound Conference 2017Poster Submissions

3. A Case Report on the Usage of Broad Spectrum Antimicrobial Foam (RTD) in A Dressing of A Diabetic Foot Ulcer Wound

Authors : MR Mohamad Helmi, L AzuraCentre : Wound Unit Hospital Ampang, Department of Orthopedic Hospital Ampang, Kuala Lumpur, Malaysia.

Introduction • Diabetic foot ulcer is a serious complication of diabetes mellitus and comprises about 1.2% among the Malaysian population.

In managing these cases, limb salvage is the ultimate goal. However, addressing the local and systemic infection is a huge challenge unless this issue can be overcome, then limb salvage is not possible.

• In term of local control of infection, a few dressing material and solution has been recommended. These are mainly alginates, foams, hydro fiber, hydrocolloids, hydrogels, iodine based and honey based. However in certain cases, despite of adequate management of surgical debridement together with addition of appropriate intravenous antibiotics and topical antimicrobials, sometimes a wound will still shows no improvement.

• In this case, we are evaluating the usage of Antimicrobial Hydrophilic Polyurethane Foam Matrix (RTD foam) where other topical modalities of controlling infection have not showed any good outcome.

Case Report• A 48 year old lady primarily presented with blister for 1 day prior to admission. On admission to ward, she was diagnosed with

diabetes mellitus with unrecordable high dextrostix and necrotizing fasciitis of her left foot. Subsequently she went for extensive wound debridement on the same day.

• Post operative day 1, wound looks healthy and was cleansed with sodium hypochloride solution and irrigated with sterile water and primary dressing of silver hydrogel daily. However, the wound did not improved and she went for second debridement after about 10 days. Post debridement, silver alginate was used every 3 days. We also noted that wound was still sloughy every time of the 3rd day of change of dressing and ultrasonic debridement was done as well before the commencement of the next cycle of dressing. Tissue culture and sensitivity at day 5 post third debridement showed MRO and was only sensitive to Collistin, hence the correct type of antibiotic used. At this point, patient had been counseled multiple times regarding the possibility of limb amputation despite of all the remedial actions.

• However at day 14 post third debridements, patient was referred to wound unit and started on antimicrobial hydrophilic polyurethane foam matrix (RTD) dressing. After the first change of RTD foam, we noticed that the slough tissues significantly reduced and wound bed appeared more healthy. Hence RTD foam was continued for total of 6 cycles in ward. In view of good response to the dressing, decorticotomy was done and resume back with the same foam dressing for another 3 cycles and later on proceeded with skin grafting. Patient was on RTD foam dressing for total of 6 weeks until the exact skin grafting date.

Conclusion• RTD foam should be considered as an option for local control of infection in wounds that showed no response to other type of

treatment whether topical or systemic treatment as well.

Discussion• Antimicrobial hydrophilic Polyurethane foam matrix (RTD) foam serves as high function of absorbent with combination of

methylene blue, gentian violet and silver ion that are intergrated to a therapeutic blue foam. The foam has been structured and function in such a way as what it is made of. Methylene blue acts to attract all exudates whether bacteria or dead tissues into the dressing material. Gentian violet function as for antibacterial and antifungal as well as providing analgesic effect. Silver ion alginates function as to kills all the gram positive and negative bacteria as it binds to the cells in the presence of exudates. With all of these, it will promote a healthy wound bed as it clears the exudates, giving a good antimicrobial and antifungal effect, preventing formation of biofilm, non cytotoxic and reduced the burden on pain during dressing. In relation to this case where managing exudates and infection considered as a challenge, the foam does works well and helps in assisting the wound bed for skin closure. As in any cases of non healing diabetic wound ulcer with good diabetic control, the major issues in wound healing are usually involving the unstoppable wound infection with formation of slough, biofilm and unhealthy wound bed. When these issues not addressed first, epithelialization cannot take place as infection and moisture still has not settled and TIME concept cannot be achieved. This patient however showed benefit as after 6 weeks of trial with RTD foam, the wound bed can easily be prepared for next phase of wound healing and wound size reducing and manage to cover up the exposed bone and tendons. However, compliancy towards wound care and managing one’s glucose level also important and play a key role in successful wound healing.

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8. Disposable Negative Pressure Wound Therapy (UNO) in Wound Healing

Authors : Dr. Harikrishna K. R. Nair MD FMSWCPCentre : Wound Care Unit, Dept of Internal Medicine, Kuala Lumpur Hospital, Malaysia.

Abstract: Since the event of TIME 2003, 2016 have been revisted by Dr David Leeper and Dr Kerlyn Carville. A few advancements have been added into the TIME concept whereby negative pressure wound therapy (NPWT) is included as one of them. NPWT is effective in exudate management plus it cuts down the bio burden in recalcitrant exudative wounds.

3 cases were chosen for this trial; 2 pressure injuries and 1 necrotising fasciitis.In all cases infection was cleared and patients were put on UNO and in a short duration improvements in exudate management can be seen (7 days to 14 days). Wounds improved in vertical closure and patients can continue with simple dressing.

In these reported cases, we used a new NPWT (UNO) which is mobile and disposable whereby it can be kept on the wound for either 15 days or 30 days to manage the wound exudate. UNO has dual function; variable and continuous and dual therapy mode; 80 & 125 pressure settings. Patients can bring this device back home and it helps in cutting down bed stays / bed occupancy in hospitals plus provide convenience for patients who need to be mobile.


6. Revisiting a Novel Therapy in Wound Management


Abstract: Antibiotic resistance has been increasing tremendously in the past decade. Various multi drug resistant organisms are being isolated and this has posed a huge problem in the management of chronic complex wounds. Biofilm also plays a big role in preventing wound closure. New types of advanced dressings are required to manage the bioburden. Therefore, dressings with compounds which have no resistance is the best to deal with this phenomenon of drug resistance organisms. In addition, synergistic compounds with different methods of action work better. In this case series, a new novel therapy with compounds such as gentian violet, methylene blue, silver and surfactant which was impregnated into a foam was utilized.

A total of 7 patients with 10 wounds were chosen by convenience sampling constituting a case series. There were 3 venous ulcers and 3 diabetic foot ulcers and 1 case of wound dehiscence.

All the wounds showed remarkable wound closure in terms of size. Infection was arrested and the most convincing was the healing of a 25 year old venous ulcer which was referred to us from another specialist clinic as it has stagnated and worsened during the cause.

5. Case Series of The Clinical Application of Highly Absorbent Antimicrobial Polyurethane Foam In Malaysia

Authors : Dr. Lee Chin Yen1,2, Dr. V.A. Jacob1,2, Dato’ Sri Dr. N. Premchandran2

Centre : 1. Wound Care Unit, Hospital Tengku Ampuan Afzan, Kuantan, Malaysia. 2. Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Kuantan, Malaysia.

Chronic non-healing wounds are a burden to patients, family and the healthcare system. The prevalence is increasing due to the aging population and compounding chronic medical illnesses. Wound healing is a cascade of physiological response in which the body reacts immediately after sustaining an injury (Beldon 2010). This dynamic yet well-coordinated process are divided into four phases (homeostasis, inflammatory, proliferative and remodelling) (Beldon 2010). However, alteration in any of the phases will lead to chronic non-healing wounds (Young and McNaught 2011).

This case series demonstrated the effectiveness of a new highly absorbent antimicrobial polyurethane foam (RTD©) in dealing with difficult-to-heal wounds. this dressing is versatile and can be used in throughout the continuum of healing process with silver as one of the core ingredients for antimicrobial actions (Lo et al. 2008).

Case 1 – A 76 year old patient with a mixed diabetic and vascular wound, had a stalled wound over his ankle for 3 months and subsequently treated with RTD. The wound healed within 2 months.

Case 2 – A subject with a venous ulcer. A 55 years-old lady with multiple venous ulcers over bilateral legs for 10 years. Despite the usage of daily conventional dressing, the wounds continued to grow in size. After applying compression bandages and RTD, there was significant improvement after 8 months.

Case 3 – A patient with diabetic foot ulcer complicated with peripheral vascular disease. A patient presented with right foot abscess over the first web space. Post-operatively, this was complicated by gangrene over the second and third toes. After using RTD, the wound over the first web-space gradually healed.

In conclusion, this new highly absorbent polyurethane foam dressing was effective in managing difficult-to-heal wounds. however, the underlying aetiology of the wound must be established prior to the application of this new dressing.

7. Hemicellulose Protein and Plant Stem Cells (Nanogen Aktiv & AktiGel) in Wound Healing


Abstract: • These days lots of wounds take prolonged periods to start healing due to multitude of reasons; heavy exudates, inflammation,

increased MMPs, elevated protease factors, deficient growth factors, fibroblast etc. Its important to get advanced or newer technological advancements in terms of wound dressing which can be used to kick start these stalled / non healing wounds. Hemicellulose protein and plant stem cells in membrane and gel formulation were used to look at how it affects the healing of 3 different non healing / delayed wounds.

• 3 different cases were chosen; Case 1. 34 years old male with non-healing primary immunosuppresive wound with above the knee amputation (left leg), Case 2. 73 years old female with squamous cell carcinoma, Case 3.71 years old female with non healing leg ulcer for the past 8 years.

• All 3 wounds showed good epithelialization in terms of moist wound healing and healing rates were good especially taking in consideration the difficulties in closing these wounds that have stalled for many years.

9. The Effects of Increasing Local Circulation through Neuromuscular Electric Stimulation for the Treatment of Diabetic Peripheral Neuropathy

Authors : Harikrishna K.R Nair (MD, FMSWCP), Andrew Chiew C.H (MBBS), Steven Lebow (Pedorthist)

Abstract: To ascertain the effectiveness of high voltage & low amperage electrical neuromuscular stimulation in the lower limbs of diabetic patients diagnosed with diabetic peripheral neuropathy, a pilot study was conducted in General Hospital of Kuala Lumpur (HKL) from 20th June 2016 to 19th August 2016 using Teslamax Neuromuscular Electric Stimulator. 10 Type II Diabetic patients from Wound Care Unit of HKL were selected by simple randomization. Every patient suffered from peripheral neuropathy & Diabetic Foot Ulcers. 41 treatment sessions (45 minutes in duration) was administered to each patient over a period of 9 weeks. An average reduction of 73% in terms of pain score is achieved in this study. By increasing the local circulation, Teslamax Neuromuscular Electric Stimulation is effective in the treatment of Diabetic Peripheral Neuropathy.

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12. Growth Factors Serum and Negative Pressure Wound Therapy in the Management of Necrotizing Fasciitis Wound: A Case Series

Authors : Syahidah Lokman, Rashidah Khalid Centre : Surgical Department, Hospital Port Dickson, Negeri Sembilan, Malaysia.

IntroductionWound healing constitute an important medical and socioeconomic problem worldwide. The last few decades witnessed the development of numerous innovative regimens for the management of patients with complex wounds.

Case SeriesWe described two case series of necrotizing fasciitis post wound debridement using two different modalities of wound care. First case series using negative pressure wound therapy (NPWT) while second case using growth factors serum (GF). We compared and assessed the use and efficacy of NPWT and GF in patients with necrotizing fasciitis after wound debridement

ConclusionIn term of the application, it was way easier to apply GF serum compared to NPWT. A single staff could performed the dressing alone using GF serum. The patient also was able to mobilize around compared to NPWT. After first cycle and 1 week of GF serum application, the wound granulates more and faster compared to NPWT. However, the results in 2 weeks’ time, was comparable for both GF serum and NPWT patient.

11. The Uses of Growth Factors in Chronic Wound Management

Authors : Dr. Harikrishna K. R. Nair MD FMSWCPCentre : Wound Care Unit, Dept of Internal Medicine, SCACC Hospital Kuala Lumpurl, Malaysia.

Abstract: Chronic wounds are the wounds that fail to heal in orderly and timely manner, featured prolonged inflammation, persistent infections and formation of microbial biofilms. Common chronic wounds include pressure ulcer, diabetic foot ulcer and venous leg ulcer. Chronic wound is always a challenge to healthcare system and patient, which has impact on patients’ quality life and burden the healthcare system with significant cost. Chronic wounds require effective treatments, to improve the healing. Growth factors have emerged to be new treatment for chronic wounds. Growth factors are substances produced in body naturally, to regulate variety of cellular processes. They are signalling molecules between cells that capable of stimulating growth, proliferation, healing and differentiation of cells. The presence of these signalling molecules promote healing by accelerating the formation of granulation tissue and epithelialisation. This study is aimed to study the effect of topical application of growth factors on chronic wounds in accelerating the formation of granulation tissue and reduce the size of wound. Patients were chosen using simple randomization within 2 months, fulfilled the criteria of clean wound, free from infection, and not involved in other wound dressing study. Total of six wounds from five patients were selected for the study, included one venous leg ulcer, two diabetic foot ulcers and two post-operation wounds. Patients come to Hospital Kuala Lumpur wound care unit for wound dressing once a week, wounds are assessed using TIME concept, wound photos with scaled ruler are taken to monitor the progress of wound healing. Growth factors of 0.1 ml / cm2 were applied and the wound are covered with second dressing. Wounds showed improvement within one month, with 4 wound size reduced more than 50% and 3 wounds closed within 3 weeks. Growth factors demonstrated effect of accelerating healing process of chronic wounds by promoting formation of granulation tissue.

10. Managing Perianal Diabetic Ulcer Using Zinc Cream (Metcovazin) for Wound Healing Process

Authors : Ns.Asrizal, S.Kep.,M.Kep.,RN.,WOC(ET)N.,CHt.N.,CH.,CHtCentre : “Asri Wound , Stoma, Continence & Hypnotherapy Care Centre Medan”

Faculty of Nursing North Sumatera University, Medical Surgical Departement

IntroductionPerianal diabetic ulcer is difficult to manage as it often contaminated by faeces. Consequently, a conventional wound care method is unable to heal this type of wound, or may heal the wound in an extended period.

MethodsThis is a case study of Mr. WD age of 28 years experienced perianal ulcer diabetic and has not been recovered after being treated for 6 months in a health care facility. Wound granulation was 0 % and the slough was 100 %. The wound was then treated in the wound care center with moist method (tissue management, inflammation and infection control, moisture balance, epitelial edge). The nursing interventions including: washing and cleaning the wound, debridement and choosing the wound dressing.

ResultsThe Epithelization was completed in 27th day, indicated that the wound healed in accordance with the wound healing physiology. Moist wound healing method has many benefits, namely : accelerating the fibrinolysis, angiogenesis, increase the formation of growth factors, so that the wound healed better.

DiscussionWound care with using zinc cream (metcovazin) is very good for wound healing process.

ConclusionsZinc cream (metcovazin) has a positive impact in healing the perianal diabetic wound.

13. Efficacies of PHMB and Betaine based Solution and Gel in Treating Necrotizing Fasciitis

Authors : Jazly Johari MD MMSWCP, Nyana Kalaiwani Krishnan MBBS MMSWCP, Lee Yuk Long Consultant SurgeonCentre : Wound Care Unit, Department of General Surgery, Hospital Shah Alam, Malaysia.

Abstract: Two patients with necrotizing fasciitis wounds were selected from the general surgery inpatient department to assess the efficacies of polyhexamethylene biguanide (PHMB) and betaine based solution and gel in the management of wound healing. The patients had the following conditions;

Patient 1: Fournier Gangrene (necrotizing fasciitis or gangrene affecting the perineum)

Patient 2: Necrotizing Fasciitis (multiple wounds at the back, upper and lower extremities)

ConclusionFrom the clinical point of view, both patient’s wound-bed have shown remarkable healing and positive progress towards wound closure. The unique combination of PHMB-betaine based solution and gel have proven to be effective in reducing bioburden as well as preventing the formation of biofilm. It reduces wound infection, pain and odor. In addition, PHMB-betaine solution as a wound cleansing agent with antimicrobial properties successfully treated the infected surgical wounds.

14. Abstract on Usage of Oxidized Regenerated Cellulose (Surgicel) in a Dressing of a Wound with Chyle Leakage

Authors : Helmi Rashidi, MDCentre : Wound Unit Hospital Ampang, Kuala Lumpur, Malaysia.

Abstract: Chyle leakage post surgery is a well known complication that might arise after a neck dissection. Even though it is a rare complication with statistic of 2-8% in a neck dissections, it is still considered to be a serious complication. Chyle leakage will lead to local maceration of surrounding skin and the accumulation of fluid will impair wound healing process. Although it is a rare complication, but it will bring sinister side effect to human body. This is because when chyle leaks, it will bring also the loss of proteins, fats and fats soluble vitamins, grace elements and lymphocytes to such a great extent and leads to hypovolemic shock, severe electrolyte imbalances, malnutrition and immunosuppression. In this study where leakage is less than 1.5L perday, the management should be via non surgical approach as per protocol. However, despite of doing daily packing dressing, negative pressure therapy and other modalities of local control, the leakage still persist until Surgicel comes into the picture and with combination of sodium polyacrylate (gold dust), the wound heals completely. Even though surgical previously only showed evidence in maintain hemostasis leakage.

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15. Accelerated Wound Contraction in Smoker Using Topical Treatment of Chitosan - Based Agent – A Case Study

Authors : Wan Zuraini M1, Nurul Amirah MK1

Centre : 1. Telok Datok Health Clinic, Ministry of Health Malaysia.

Introduction: Exposure to cigarette smoke has been shown to impair wound healing at all stages, particularly causing delay in wound contraction and re-epithelialization. Deacetylated derivative of chitin - chitosan, is a biological dressing that were found to have superior granulation and re- epithelialization effect than in control group in vivo. Nonetheless, previous clinical studies of chitosan have only focused on its effect on infected wound and to the date none was experimented on delay cicatrisation induced by smoking. Therefore, to address this research gap, the purpose of this paper is to examine the effect of commercially available topical chitosan (Dr WoundTM) to wound contraction in smoker.

Method: Selection of the sample subject (n=1) was based on following inclusion criteria (active smoker, open wound with delay contraction) and exclusion criteria (having chronic comorbidities such as diabetes, cancer and anemia, clinically infected wound, wound over joints, allergy to crab, prawn or mollusk). A 5 cm2 delay contraction of dehiscence wound from implant removal at right lateral thigh was chosen. Baseline assessment was taken and the patient was then subjected into Chitosan-based dressing protocol in which a thin layer of chitosan-based gel was applied as primary dressing. Apart from using distilled water for cleansing, no other dressing agent was used. The dressing changed at EOD frequency and visual assessment taken once a week.

Result: 36% reduction of wound size at day 7, 63% at day 14 and complete re-epithelialization was observed at day 22 of treatment.

Discussion: It is apparent that this unique biopolymer of chitosan probably reverses the detrimental effect of delay wound contraction in smoker. Mucoadhevisity and anti-inflammatory property of chitosan might be of responsible factors that aid the reinstatement of skin architecture. Combination of treatment wasn’t advocated in this study to minimize bias and to ensure the measurement of treatment effect are error-free. Further works with larger sample with control group experiment should be carried out to establish finding from this current evidence.

Conclusion: This finding provides important highlight on the potential usefulness of chitosan - based agent in treating delayed wound contraction.


16. Nicotine and Wound Healing – An Evidence Based Review

Authors : Wan Zuraini M Centre : Telok Datok Health Clinic, Ministry Of Health Malaysia.

Introduction:Smoking has been found to have multiple direct and indirect effect towards delay in wound healing through its toxic constituents such as carbon monoxide (CO), hydrogen cyanide and nicotine. Whilst CO and hydrogen cyanide acted at physiologic response phase, nicotine on the other hands has more extensive effect at different phases of cellular response. The objective of this EBR is to evaluate the effect of nicotine on different stage of wound healing.

Method: Systematic literature search protocol using pre-determined keywords that reflect the effect of nicotine to different stage of wound healing were gathered from electronic databases (OVID, PUBMED, OAIster, and TRIP). Grey literature was searched within www.opengrey.eu. Articles were also gathered using manual handsearch procedure. This protocol was then subjected to inclusion and exclusion criteria. E-cigarette was not included as it displays different cellular effect.

Result: From 263 articles, a final selection of sixteen articles of primary research were being appraised using relevant appraisal tools such as CONSORT and ARRIVE. Evidence was stratified using The Joanna Briggs Institute (JBI) level of evidence. Two studies were RCTs level of evidence 1c and fourteen studies were 2c level of evidence.

Discussion: Nicotine improved tissue oxygenation whilst there were reduced blood flow. This mechanism support ischemia process in cellular microenvironment. At certain non-lethal concentration, nicotine enhances angiogenesis but in contrast restrain fibroblast proliferation and keratinocyte migration.

Conclusion: This EBR provides useful insight on the effect of nicotine towards wound healing. Although this EBR couldn’t provide a concrete conclusion due to differences in study design; in general, specific range of nicotine dose accelerate early phase of wound healing but negatively support late phase of healing.

17. Biotherapy Updates

Authors : Nazni WA, Suhana A, Azahari AH, Khairul Asuad M, Harikrishna KRN1 and Lee HL Centre : Medical entomology Unit, Infectious Disease Research Centre, Institute for Medical Research, Jalan Pahang,

50588 Kuala Lumpur 1 Wound Specialist Centre, Specialist Complex (SCACC), Jalan Pahang, 50586 Kuala Lumpur,

Wilayah Persekutuan, Kuala Lumpur.

Abstract: The earliest report of leeches being used medicinally dates back to ancient Egypt, where tomb paintings (1567–1300 BC) depicted their use by a barber surgeon. In the ancient world, leeches were used as one of several methods of bloodletting, since it was thought that bloodletting would cure a number of ailments such as mental illness, nose bleeds, insomnia, obesity, tumours, strokes, and gout. The belief was that removal of the patient’s blood would correct the humoral imbalance and restore good health and this supports the meaning of “leech’ in Anglo-Saxon means ‘to heal’. The Roman physician, Nicander of Colophon (200-130 BC) was probably the first medical practitioner to use leeches for therapeutic purposes. Early Chinese writings from the first century AD also described the therapeutic use of leeches. The usage and practice of leeches has also been mentioned in ancient Sanskrit, Persian and Arabic literature.

The Malaysian leeches were identified using the classical morphology-based taxonomy and was identified as species of Hirudinaria javanica and Hirudinaria manillensis. The identification was further confirmed using molecular techniques based on the mitochondrial cytochrome-c oxidase sub-unit 1.The bacterial contents on the external body and in the mouth region of leeches were identified as Proteus mirabilis, Aeromonas salmonicida, Aeromonas sobria, Vibrio alginolyticus, Moraxella sp. and Stenotrophomonas maltophilia.

For therapeutic purposes, it is preferable to use disinfected leech. However, to date successful disinfection of leech is not known or reported. We attempted to disinfect Malaysian leech by testing eleven sterilizing and antibacterial agents in different combination and concentration. Tested leech has been observed to be extremely sensitive to many combinations. One combination was finally used to successfully disinfecting the leech. Body contents of disinfected leech were cultured in blood agar to verify the absence of microbial contamination. The disinfection was further confirmed by electronmicroscopy, whereby no microbes were observed. This is the first successful report of complete disinfection of leech and opens a new avenue for the effective and safe use of medicinal leech in the treatment of various conditions.

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20. Venous Leg Ulcers Managed Using Polyurethane Foam with Smartpore Technology: Case Report

Authors : Harikrishna K.R.Nair

Abstract:

Background:Cases of venous leg ulcers are expected to rise due to the rapidly aging population in Malaysia. Central to the management of these wounds is compression therapy together with appropriate wound dressing. Pain and discomfort during dressing changes are common in these patients. Polyurethane foam dressings with smartpore technology have dense uniform micropores which facilitates vertical absorption of exudates to reduce risks of wound and peri-wound area maceration. It also supports easy dressing removal with less pain and trauma to the wound bed by preventing the new epithelial cells from growing into the pore of the contact layer of dressing. Polyurethane foam dressings with smartpore technology can be a viable option in these cases.

Case presentation:A 49-year-old housewife with a solitary venous leg ulcer was treated with silver-impregnated polyurethane foam dressings with smartpore technology. She was satisfied with the results of her treatment.

Conclusion:This case of venous leg ulcer highlighted the advantages of polyurethane foam dressing with smartpore technology. The use of this type of dressing in this case report shows encouraging results and may provide a desirable option in venous leg ulcers in terms of practicality and improving the quality of life of patients.

21. The Efficacy, Practicality And Safety of Low-Frequency Ultrasound Wound Debridement for Chronic Wound Management: A Case Series

Authors : Akmal Hafizah Zamli, Chua Li Shun, Ahmad Baihaqi HassanCentre : Department of Rehabilitation Medicine, Sungai Buloh Hospital.

Abstract: Low frequency ultrasound wound debridement (UWD) is a considerably advanced technology introduced as one of the newer mechanical debridement methods. Comparable to that of surgical wound debridement, the reported additional benefits of low frequency UWD include less bleeding, minimally painful and its ability to produce cavitation effect that provide both bactericidal effects and biofilm elimination. We described our experience in application of UWD using a portable low frequency SonicOne® Ultrasonic Wound Care System as an outpatient procedure in 3 patients with complete motor paralysis following traumatic spinal cord injury (SCI). UWD was found to be effective, thus provides a minimally invasive option for mechanical wound debridement in patients with SCI. It is a well-tolerated and safe outpatient procedure; none of the patients developed any complications including autonomic dysreflexia. The average duration to perform the procedure was 11.55 minutes. This study provided initial evidence that application of UWD was efficacious, practical and safe for chronic wound management in patients with traumatic SCI.

Poster Submissions Kuala Lumpur Wound Conference 2017

18. Superior Anti-MRSA Potency of Lucilia Cuprina Larval Extract

19. Amputation vs Salvage : A Surgeon Dilemma

Authors : Teh CH1*, Nazni WA2, Lee HL2, Izzul, AA2, Norazah Ahmad3, Harikrishna KRN4

Centre : 1. Research Management Unit, Institute for Medical Research, Kuala Lumpur, Malaysia 2. Medical Entomology Unit, Infectious Disease Research Centre, WHO Collaborating Centre on Vectors,

Institute for Medical Research, Kuala Lumpur, Malaysia 3. Wound Care Unit, Hospital Kuala Lumpur, Malaysia

Abstract: The world is on the cusp of a post-antibiotic era in which common treatable infections and minor injuries can once again become dreadful as a result of increasing threat of antimicrobial resistance and shortage of effective drugs. As such, a plethora of studies had been undertaken to discover novel antibiotics from natural products. Fly maggots breed in decaying organic matters infested with diverse microbes and would have evolved effective anti-microbial system to protect themselves. Therefore the present study aimed to determine and compare the antibacterial activity of larval extracts of Sarcophaga peregrina, Musca domestica and L. cuprina against 4 pathogenic bacteria (Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa and Escherichia coli). The resazurin-based turbidometric assay demonstrated that the L. cuprina larval extract was inhibitory against all tested bacteria, whilst the larval extract of S. peregrina and M. domestica were only inhibitory against the MRSA, with a MIC of 100 mg ml-1. Subsequent sub-culture of aliquots revealed that the larval extract of L. cuprina was bactericidal against MRSA whilst the larval extracts of S. peregrina and M. domestica were bacteriostatic against MRSA. The superior potency of the larval extract of L. cuprina against MRSA was further substantiated by the formation of inhibition zone of 13.67 ± 1.15 mm in diameter in the agar well diffusion assay, which had been known to be less sensitive as compared to turbidometric assay; whilst no inhibition zones were observed for the larval extracts of S. peregrina and Musca domestica. It was also noteworthy that the diameter of the inhibition zone surrounding the well containing larval extract of L. cuprina was larger than that of the positive control, chloramphenicol. The apparent potency of L. cuprina larval extract against MRSA should be given due attention and study to identify and purify the active agent(s) as well as determination of the cytotoxicity of the larval extract on mammalian cells are greatly warranted for the development of a potential drug of natural origin against MRSA.

Authors : Shukur A.1, Tan KS1; Inderjeet Singh.1; Sharifudin S.1

Centre : 1Department of Orthopaedic, Hospital Teluk Intan, Perak, Malaysia.

Abstract: Trauma is one of the leading cause for amputation in young patient. It is rather difficult to make the call between salvage versus amputation in a young patient with MESS score less than 7. The decision of salvage was based on the patient as a whole, extent of the limb injury and discussion regarding pro and cons of salvage versus amputation. In view of decision for savaged limb, patient himself understand the whole process of multiple debridements, prolong hospital stay, multiple hospital admission, prolong course of antibiotic, metabolic burden, isolation from family members, and protraction from school or career due to treatment course. On the other hand, if patient keen for amputation, it requires shorter course of treatment with predictable outcome and prosthesis fitting. The primary goal of limb salvage is to restore and maintain stability in ambulation. We present a teenager with a huge degloving wound (35cm x15cm) over the right lower limb extending from mid thigh to middle third of the leg with open fracture of femoral condyle, patella, lateral tibial plateau and fibula, associated with severe soft tissue injury post motor-vehicle-accident. He endured multiple times of surgery in view of wound infections. Plastic surgery reluctant for flap procedure in view of wound involving knee joint, functionless limb post operative and risk of infections. His wound finally closed after weeks of VAC dressings.

Keywords: salvage limb; amputation; VAC dressing

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23. Case Review Of Management of Abdominal Wound Dehiscence in Sarawak General Hospital

Authors : PL Tang, AH NizamCentre : Wound Care Unit, Sarawak General Hospital,

Kuching.

Abstract: Abdominal wound dehiscence is a postoperative complication associated with significant morbidity and mortality. The management of this complication is a relatively unexplored area within the field of surgery. The paramount of the management is still proper wound bed preparation in order to optimise the area for subsequent stage of healing which enhance by modern wound dressing or any advance wound therapy, which can be used to prevent direct contact with intra-abdominal organs. Granulated exposed bowel can heal either by secondary intention or by covering with split-thickness skin grafts, for instance, as part of a two staged procedure or tissues flaps.

There are total of 65 cases of surgical site infection referred from Department of General Surgery to Wound Care team in Sarawak General Hospital, Kuching from January to August 2017 with 14 patients complicated with abdominal wound dehiscence. Here we described 2 cases of full thickness abdominal wound dehiscence (burst abdomen) with the management.

Poster Submissions

22. Case Series: Experience in Managing Hand Infection

26. Enzymatic Debridement: The Helping Hand

Authors : Kee Ai WongCentre : Orthopaedic Department, Sarawak General Hospital

Summary: We are reporting the experience in managing hand infection in our department. We highlighted the disastrous complications due to the delayed proper treatment of hand infection. Wound healing in severe hand infection can be achieved with proper wound management. However, the restoration of the function of the hand mainly depends on the adequate and timely prompt intervention and hand rehabilitation post operatively.

Case Presentation:Case 1: A 61-year-old lady, who was diagnosed with type 2 diabetes mellitus for more than ten years. She was presented with swelling, redness and discolouration of left hand for about a month. Her left thumb was pricked by chicken bone one month ago. The wound became worsened at day three after the prick. She sought treatment at private hospital however condition was not improved. She was then transferred to our Orthopaedic department. Extensive wound debridement was done and intra-operatively noted bone was exposed over the volar aspect of the thumb, necrotic patch over hand and wrist at radial aspect, pus over dorsal hand at base of index finger. Tissue and swab cultures yielded Candida albicans. During the hospitalisation, bedside serial wound debridement was performed and was put on gel dressing. We suggested for amputation of the thumb however patient refused. Patient discharged well after nine days of hospitalisation. She was advised for gel dressing at nearest primary healthcare clinic and instructed for hand physiotherapy. She was followed up as outpatient in our diabetic foot clinic. Unfortunately, patient defaulted outpatient follow up after eight months.

Case 2: A 34-year-old lady was presented with right hand pain and swelling for the past ten days. She went for massage and acupuncture at the beginning of illness and condition became worsen progressively. She was diagnosed with right mid-palmar abscess with impending compartment syndrome. She underwent incision and drainage and compartment and carpal tunnel release. However, intra-operatively noted only oedematous subcutaneous tissue with yellowish fluid, without pus collection, and compartment was not tense. During the hospital stay, the palmar hand skin became necrosis. Bedside serial wound debridement was done to remove the necrotic tissue of the hand. The wound was put on collagen gel and foam dressing as secondary dressing. A histopathological examination of tissue biopsy revealed leukocytoclastic vasculitis, while blood and tissue cultures showed negative results. She was discharged after one month of hospitalisation and follow up wound care and physiotherapy as outpatient. Wound closure achieved after four months of treatment.

Outcome and follow up:Case study 1: Patient defaulted follow up after eight months due to logistic issue. During the last review noted wound was epithelializing and the wound at thumb was closed. However, patient can only perform minimal flexion and extension of small joints of fingers and the thumb lost most of the function.

Case study 2: The wound healing achieved in four months. However, the function of the hand greatly reduced. Patient managed to perform flexion and extension of proximal and distal interphalangeal joints of all fingers, but the metacarpophalangeal joints were stiffed. There was minimal flexion of interphalangeal joint of the thumb.

Although we manage to achieve wound healing in the two patients, unfortunately we are unable to restore the full function of the hands.

Discussion:Hand infection often leads to marked functional disability and even fatal consequences (Gill et al. 1998). Trauma and diabetes were found to be the main predisposing factors in many reports (Abbas and Archibald 2005; Ahmed et al. 2009). Hand infections require prompt surgical intervention (Pemberton 1940). Its function mainly depends on the adequate surgical drainage and persistent physiotherapy post operatively (Pemberton 1940). In both of our cases, we are successfully salvaged the limbs, however, the function of the hand diminished due to the severity of the disease and noncompliant to physiotherapy.

Learning Points / Take Home Message:Prompt identification and immediate treatment of hand infection can prevent the disastrous complications.

The function of the hand after the infection mainly depends on the adequate and promptly drainage and persistent hand rehabilitation.

Consent:Informed consent for medical photography was obtained from patients.

Authors : PL Tang, AH NizamCentre : Wound Care Unit, Sarawak General Hospital,

Kuching.

Abstract: Wound debridement is crucial for successful wound management and remains a standard of care in the tissues management concept of wound bed preparation. Surgical debridement is the most rapid, direct and effective method of debridement but not all wounds and patients are suitable candidate for the treatment especially in condition of bleeding disorder or peripheral vascular disease. Enzymatic debriding agents appear as an effective alternative that accelerates slough or eschar degradation and debridement.

Case report of 84 years old, lady with underlying diabetes mellitus and peripheral vascular disease where right above knee amputation was done for wet gangrene of right foot had developed a left heel ulcer during hospital stay. In view of her underlying poor vascular perfusion, an enzymatic debriding agent with collagenase was used for debridement. Appropriate modern wound dressing was implemented later after wound bed optimized with enzymatic debridement and progress to subsequent stages of wound healing.

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