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Letters to the Editor
Disclosure concern
Dear Editor,
The article “Preparing the wound bed 2003 — focus on infection and inflammation” (Ostomy/Wound Management. 2003;49[11]:24–51) has raised some concerns. First, it should be noted that a good portion of the article was based on the work performed by several individuals who attended a workshop paid for by Smith & Nephew, including company representatives who also participated in the discussions. The “advisory board meeting” was not “supported” by a grant from this company; rather, participants were paid via honoraria. As a participant, I think it is a stretch of the imagination to refer to the little workshop group as the “Canadian Wound Care Advisory Board.” We were paid to share our opinions with the company on the topic “Inflammatory Ulcers”; this was made clear to participants up front. The article distorts this reality.
Several of the tables published in the article are almost exact copies of work done at this workshop. In addition, several individuals contributed a good deal of hard work that is not at all reflected in the small note of thanks at the end of the article. If authors are going to copy work done by others, they should be properly cited or included in the writing of the manuscript. We were not warned that our contributions might eventually be published in a peer-reviewed journal nor were we given the opportunity to contribute in order to be recognized. Our contributions have been completely misrepresented.
- Brian T. Kunimoto, MD
Timothy Kalla, DPM
Ed. Note: The above letter was forwarded to the corresponding author who declined to comment.
Reply
As described in our “Instructions for Authors,” Ostomy/Wound Management’s editorial process follows the guidelines of the International Committee of Medical Journal Editors.1,2 Because “The potential for conflict of interest can exist whether or not an individual believes the relationship affects his or her scientific judgment,”2 all authors of manuscripts submitted to OWM are required to disclose “commercial, proprietary, or financial interests,” including grants and honoraria to “conduct the study, write the manuscript, or otherwise assist in the development of the manuscript.” With respect to sponsorship of the above-mentioned article, the disclosure printed was the only one made by the authors.
Despite years of concerted efforts by those involved in the oral and written dissemination of scientific information (eg, via meetings, journals, text books), the disclosure of actual or potential conflicts of interest often remains a matter of interpretation and always relies on the honor system. While we are fortunate that this is the first time a potential conflict of interest concern has been brought to our attention, we cannot take it lightly because disclosure and integrity are the foundation of public trust in the peer-review process and credibility of published articles.
To further reduce potential disclosure ambiguity while acknowledging the importance of industry support to advance our collective knowledge, the scope of our conflict of interest disclosure has been broadened. It now includes a wider variety of sponsorship and consultancy agreements. As always, readers’ concerns and comments are welcome to help us maintain and improve the quality of the editorial and editorial process on which providers rely to make their decisions.
- Lia van Rijswijk, RN, MSN, CWCN
Clinical Editor
References
1. Ostomy/Wound Management. Instructions for authors. Available at: https://www.o-wm.com Accessed September 2, 2004.
2. International Committee of Medical Journal Editors. Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication. Available at: https://www.icmje.org/#conflicts. Accessed September 2, 2004.
Irrigation with saline
Dear Editor,
In the article, “A comparison of an antimicrobial wound cleanser to normal saline in reduction of bioburden and its effect on wound healing” (Ostomy/Wound Management. 2004;50[8]:28-41) the author compares cleansing properties of normal saline to an antimicrobial wound cleanser (0.057% sodium hypochlorite in an isotonic saline solution). The author determined that “...normal saline was not effective in reducing wound bioburden....” Yet, the author only used 5 cc to15 cc of normal saline to clean the wound.
Additionally, the study did not address whether normal saline was used under an appropriate pressure to adequately cleanse the wound. Wounds need to be irrigated with enough pressure to adequately clean the wound (ideally 4 to 15 psi) as cited by Baranoski and Ayello (Wound Care Essentials 2004). Additionally, the amount of solution used should be sufficient to adequately reduce the number of bacteria within the wound bed; 5 cc to 15 cc of normal saline is not enough saline to adequately clean the wounds described in this study.
Further study should be done to compare current best practice, such as irrigation under pressure with copious amounts of normal saline and the proposed amount and delivery of the antimicrobial wound cleanser.
- Carole Bauer, RN, BSN, OCN, CWOCN
Karmanos Cancer Institute
Detroit, Michigan
Reply
While I agree with the respondent that 4 to15 psi is the ideal amount of pressure to cleanse wounds with normal saline if that is all that you have, the amount of saline needed depends largely on the size of the wound. In the study, the volume of normal saline or antimicrobial wound cleanser applied to the wound was governed by the wound size and condition of the wound.
Normal saline will not affect the viability of micro-organisms. Actually, normal saline is recommended as a transfer and diluting medium for Microbiological Test Methods described in the US Pharmacopoeia and National Formulary (USP 23-NF 23 1995).
It is unclear what the respondent means by “copious amounts of normal saline” or what benefit or purpose this would serve. If the respondent presupposes that “copious amounts of normal saline” will dislodge or wash away bacteria, she hasn't considered a major aspect of chronic wounds — the formation of biofilm. According to estimates from the Centers for Disease Control and Prevention, biofilms account for two-thirds of the bacterial infections that physicians encounter.
According to the article “Sticky situations” (Science News. 2001;160), P. puta does not reproduce much during the first several hours. However, it begins synthesizing proteins to make pili — multipurpose appendages that “… can act like Velcro to anchor bacteria to the surface.” It is, therefore, doubtful that copious amounts of normal saline, even under recommended wound cleansing pressures, could affect an established wound biofilm.
Searching for a safe, effective antimicrobial wound cleanser capable of breeching the self-protecting aggregates of established bacterial biofilms or preventing their formation and ultimately reducing their numbers in chronic wounds would be a more meaningful study.
As noted in the article, more study is surely warranted. This study offers a tantalizing bit of evidence that hypochlorite solution may not be the villain we have been led to believe and that using an antimicrobial as a cleansing agent instead of a dressing may be a viable option for topical treatment.
- Julie Lindfors, RN, CWCCN
