Wundmanagement 2/2012

How to equip an obesity centre

Obesity is a chronic disease which causes lifelong suffering in patients and which is extremely difficult to treat by using conservative forms of therapy. Obesity has been increasing significantly in Germany. All kinds of available therapy options should be equally taken into consideration when treating obesity – including operative methods reinforced by conservative measures. These are the first conclusions drawn by a team of experts for metabolic surgery according to a press release of 18th November 2010 in Frankfurt. [1] The team of experts is demanding an interdisciplinary strategy of treatment for both obesity and diabetes in Germany. Thus setting up an obesity centre should be an interdisciplinary task from the very beginning. This includes centre staff as well as external partners in the form of diabetologists, general practitioners, experts in nutritional medicine, nutritional advisors, psychologists, sports physicians, physiotherapists, rehab centres as well as obesity support groups, to name only a few. If you want to unite this multitude of therapists in order to achieve a sensible and effective form of therapy, interdisciplinarity has to be more than just a term, it has to be lived as well as organized. Our obesity centre carries out an interdisciplinary conference once a month, an offer which is well received by all participants and is steadily gaining popularity. Establishing an effective interdisciplinary cooperation in a so-called obesity team is the most important factor for quality obesity treatment. It should not present an insurmountable obstacle to supply an obesity centre with the necessary equipment in terms of material. In many areas, only few adjustments are required and many requirements may already be in existence. In any case, the costs should be manageable. Unfortunately the dramatic increase of morbid obesity in our population is in no way reflected in the treatment forms offered by the German health board [1] which is why every newly established obesity centre can be considered a step into the right direction.

Chronic wounds and nutrition

U. Bonacker

Antimicrobial therapy of intra-abdominal infections due to resistant bacteria in patients with morbide obesity

C. Eckmann, P. Kujath, H. Shekarriz

Morbide obesity is a well known risk factor for the development of postoperative infectious complications. Intra-abdominal infections (IAI) account for the majority of those infections. Treatment consists in most of the cases of a surgical source control and the application of antibiotics. IAI are mainly of polymicrobial origin. The group of patients with IAI suffering from resistant bacteria comprises the entire group of postoperative and tertiary peritonits. Bacteria of concern are Methicillin-resistant S. aureus (MRSA), Vancomycin-resistant enterococci (VRE), extended spectrum beta-lactamase (ESBL) –producing Enterobacteriaceae and Carbapenem-resistant organisms. Especially in the predominant of causing gram-negative bacteria, only a few options remain for the treatment. This article tries to add some information for the management of a very important group of diseases with a substantial morbidity and mortality, including considerations about antibiotic stewardship measures.

The role of a point-of-care protease test in wound diagnostics

R. Strohal, J. Dissemond, G. Hastermann, K. Herberger, S. Läuchli, G. Luch, D. Mayer, T. Neubert, M. Storck

Matrix metalloproteinases (MMPs) and serine proteases, such as elastase, are among the proteases that play a pivotal role in wound healing. To date the main focus of wound research has been on MMP-1, MMP-2, MMP-8 and MMP-9.
The current findings of the literature indicate that proteases are a promising biomarker for assessment of wound healing at a biochemical level. Apart from proteases there are also other markers associated with inflammation, such as tumour necrosis factor alpha
(TNF-a), which could serve as potential candidates for further diagnostic tests. These include the pH value of wound exudate which, inter alia, determines the activity of proteases contained in the wound exudate.
In daily clinical practice of wound management the therapy chosen after wound diagnosis is based on causal treatment. In future it might be possible to base wound therapy on the needs of the individual patient, for example by means of a protease point-of-care test (PoC-Test), expanding the diagnosis to include a specific local wound diagnosis. The participants of the expert meeting have devised a clinical algorithm describing the application of the protease rapid test.
Early detection of correctable factors in wound healing could offer wound therapists the chance to use a treatment that could expedite the healing process. The use of a protease rapid test to determine protease activity could give therapists important insights into which treatment possibilities are suitable and which are unsuitable and help them decide when treatment should be initiated or terminated.
Experts believe problem wounds, which despite a correct diagnosis and appropriate treatment fail to show any sign of healing within a period of two to four weeks, could be selective indications for the protease rapid test. Other selective indications could include problem wounds showing signs of inflammation. The protease rapid test could also be used before conducting skin graft transplants and using skin substitute products to assure timely and appropriate treatment, shorter healing time, avoidance of complications and reduction of costs.
Other possible indications for the protease rapid test could include wounds that fail to heal postoperatively, open abdominal wounds, as well as research into development of new products, such as absorbable MMP scavengers.
The experts recommend the protease rapid test to be introduced in several steps. At the present time, the test should be selectively used by wound specialists in specific centres following a medical prescription and after an introduction to the practical implementation of the test.
As soon as more experience is available on the use of the protease rapid test, the test could be made available to a greater number of users. A conceivable approach, which has been proposed by experts for acquisition of initial evidence for the protease point of care rapid test, entails the gathering of experience data after extensive use of the test by all first users who will have used the test in daily clinical practice of wound treatment, while taking account of the proposed indications. The experience gleaned could then be used to set up a register and find answers to questions such as e.g. the duration and suitable time point for using the test.
When training wound therapists on proteases and the protease rapid test it is important to impart an understanding of the concept of balance and imbalance, i.e. balance between synthesis and degradation of the extracellular matrix (ECM) in healing.