Patient With Sitosterolemia With Slow Healing Sternal Wound From Coronary Artery Bypass Surgery.

BACKGROUND: Sitosterolemia, also known as phytosterolemia, is a rare recessive genetic disorder characterized by accumulation of sitosterol from vegetable oils, nuts, and other plant-based foods in the body. In those with sitosterolemia, there is an increase of fatty deposits in the arteries (atherosclerosis), which may occur in early childhood, impeding blood flow and increasing the risk of a heart attack, stroke, or sudden death at a very early age. Visual signs of sitosterolemia may include small yellowish xanthomas beginning in early childhood. Xanthomas are accumulated lipids that develop in the heels, elbows, and buttocks. CASE: A clinical case study of a patient with sitosterolemia with slow healing surgical wound from coronary artery bypass surgery is described. Treatment of sitosterolemia is aimed at lowering plasma plant sterol levels with dietary restriction intake of both animal- and plant-based sterols. However, plant-based products (collagen, chitosan, etc) are also used for wound dressings, so alternative wound dressings were selected to decrease the possibility of systemic absorption. CONCLUSION: This case study describes a young adult male with sitosterolemia who presented with a slow healing surgical incision following coronary artery bypass surgery. Sitosterolemia is often characterized by atherosclerosis of the coronary arteries that occurs in children and early adulthood, especially affecting men. Treatment is aimed at lowering plasma sterol levels with the restriction of animal and plant sterols. There is considerable interest today in natural versus synthetic wound care products. Dressings containing chitosan, cellulose, collagen, etc, to be avoided to decrease the chance of systemic absorption.

Carotid body tumors: A retrospective case series of 11 patients.

BACKGROUND: Carotid body tumors (CBTs) are uncommon neuroendocrine tumors located near the carotid bifurcation within the carotid body. CBTs are slow-growing; affected individuals may remain asymptomatic for years and are often diagnosed incidentally following imaging studies. When present, symptoms are nonspecific. Because incidence is low, retrospective review of CBT case series is an ideal study design for investigating common symptomology, identifying successful diagnostic tools, and evaluating treatment outcomes. METHODS: This article describes a case series of 11 patients treated for CBTs at an academic medical center in the Southeastern US. A retrospective chart review of 11 patients who had been discharged from the hospital following treatment for CBTs between 2017 and 2021 was conducted. Descriptive statistics were used to delineate the case series. RESULTS: There were four males (36%) and seven females (64%) included in the retrospective case series. The age range was 34 to 79 with a mean of 56.73 (standard deviation 16.038). Three patients were found to have a neck mass on physical exam. Additional symptoms included vocal cord paralysis, facial paralysis, ischemic stroke, Bell palsy, dysphonia, and dizziness. Two patients had familial CBTs. Ten patients underwent surgical excision. CONCLUSION: This case series showed that patients with CBTs should be assessed with a combination of history and physical exams along with imaging studies to confirm the diagnosis. Because CBTs may become malignant and metastasize, it is important for NPs to be knowledgeable about presenting symptoms and appropriate diagnostic studies to be able to refer patients to vascular surgeons early to prevent complications.

Compression for Lower Extremity Venous Disease and Lymphedema (CLEVDAL): Update of the VLU Algorithm.

The Wound, Ostomy and Continence Nurses (WOCN) Society charged a task force with updating the venous leg ulcer (VLU) algorithm to include the addition of lymphedema with the new title of "Compression for Lower Extremity Venous Disease and Lymphedema (CLEVDAL)." As part of the process, the task force was charged to develop consensus-based statements to serve as clinical guidance related to CLEVDAL. The 3-member task force assisted by a moderator completed a scoping literature review to identify recommendations supported by research to qualify as evidence-based and to identify areas where guidance is needed to provide CLEVDAL. Based on the findings of the scoping review, the WOCN Society convened a panel of experts to develop consensus statements to direct care for those with lower extremity venous disease and lymphedema. These consensus statements underwent a second round of content validation with a different panel of clinicians with expertise in venous disease and lymphedema management. This article reports on the scoping review and subsequent evidence-based statements, along with the generation and validation of consensus-based statements to assist clinical decision-making in the CLEVDAL algorithm.

2021 Guideline for Management of Patients With Lower-Extremity Wounds Due to Diabetes Mellitus and/or Neuropathic Disease: An Executive Summary.

This article provides an executive summary of the Wound, Ostomy, and Continence Nurses Society's (WOCN) "2021 Guideline for Management of Patients With Lower-Extremity wounds Due to Diabetes Mellitus and/or Neuropathic Disease." This executive summary presents an overview of the systematic process used to update and develop the guideline and recommendations from the guideline for screening and diagnosis, assessment, and management and education of patients with lower-extremity wounds due to diabetes mellitus and/or neuropathic disease. In addition, the executive summary provides suggestions for implementing recommendations from the guideline. The guideline is a resource for WOC nurse specialists and other nurses and health care professionals who work with adults who have/or are at risk for lower-extremity wounds due to diabetes mellitus/neuropathic disease. The complete guideline includes the evidence and references supporting the recommendations, and it is available in print and electronically from the Wound, Ostomy, and Continence Nurses Society, 1120 Rt 73, Suite 200, Mount Laurel, New Jersey, 08054; Web site: www.wocn.org.

Impact of Complex Wounds on Health-Related Quality of Life: A Descriptive Study.

PURPOSE: To describe health-related quality of life (HRQoL) using the Wound-Quality of Life (Wound-QoL) questionnaire for those individuals referred to an academic medical center wound clinic. DESIGN: Prospective, descriptive study. SUBJECTS AND SETTING: One hundred eleven participants receiving care in an academic medical center wound clinic in the Southeastern United States. The sample comprised 67 males (60.4%) and 44 females (39.6%) with wounds of 6 major etiologies. METHODS: From June 2019 through May 2020, a convenience sample of 111 individuals completed the Wound-QoL questionnaire at the initial visit to the wound clinic. The Wound-QoL questionnaire is a valid and reliable tool consisting of 17 questions related to wound-QoL measured on a 5-point Likert scale, ranging from 0 (not at all affected) to 4 (very much affected). The questions are assigned to the 3 subscales: "body," "psyche," and "everyday life." The Wound-QoL individual items, subscales, and the total wound score (TWS) were calculated as mean values of the item scores, ranging from 0 to 4, where higher values correspond to decreased HRQoL. The TWS is defined as the sum of the 17 item responses, with values ranging from 0 to 68. Descriptive and parametric statistics were used to analyze the data from the Wound-QoL questionnaire. RESULTS: The mean TWS was approximately 3 points higher for Whites (n = 84) than for Blacks (n = 27) (32.42, SD = 17.96 vs 29.51, SD = 19.39), but this difference was not significant (P = .473). An independent-samples t test of TWS versus sex was not significant (P = .446). The TWS by age category was significant (P = .015), showing differences in mean scores based on age category. We found that the youngest (ages 17-39 years) and oldest (ages 70-98 years) participants were less bothered by their wounds in almost all respects than those in the middle age range (ages 40-69 years). The individual item means varied between 0.84 and 2.72, out of a possible range of 0 to 4. The highest means were for items on the emotional subscale with means from 1.93 to 2.72. Analysis of variance was used to examine the TWS and the 3 subscales over the 6 wound types; none were found to be significant (TWS: P = .454, body: P = .722, psyche: P = .452, everyday life: P = .087). CONCLUSION: Wound-QoL questionnaire scores indicated that the greatest impact of a wound on HRQoL was on the emotional subscale. These 4 items are related to the individual expressing worry, fear, unhappiness, or frustration with wound healing. The Wound-QoL questionnaire may be used to evaluate the impact the wound has on the individual's HRQoL.

Peristomal Skin Health: A WOCN Society Consensus Conference.

The Wound, Ostomy, and Continence Nurses (WOCN) Society identified the need to define and promote peristomal skin health. A task force was appointed to complete a scoping literature review, to develop evidence-based statements to guide peristomal skin health best practices. Based on the findings of the scoping review, the Society convened a panel of experts to develop evidence- and consensus-based statements to guide care in promoting peristomal skin health. These consensus statements also underwent content validation using a different panel of clinicians having expertise in peristomal skin health. This article reports on the scoping review and subsequent 6 evidenced-based statements, along with the generation and validation of 19 consensus-based statements, to assist clinical decision-making related to promoting peristomal skin health in adults.

Autologous Fat Transfer for Scar Prevention and Remodeling: A Randomized, Blinded, Placebo-controlled Trial.

Autologous fat transfer-also referred to as fat grafting-has been reported to provide beneficial effects to overlying scar and skin. Despite procedural frequency, there is a paucity of high-level evidence guiding the surgeon in technique, patient selection, and efficacy. METHODS: A multicenter, double-blinded, randomized, internally placebo-controlled trial was performed with an aim to qualitatively and quantitatively evaluate the impact of autologous fat transfer on the quality of overlying scar tissue. Fat-grafted scars were evaluated and compared with paired, saline-injected "control" scars. Subjective and objective metrics were evaluated in treated sites for 12 months after treatment. RESULTS: Blinded qualitative results demonstrated a statistically significant improvement in scar quality over time in fat-grafted scars. However, these improvements were not found to be statistically different from changes noted in scars treated with saline. In addition, objective metrics did not statistically differ between saline-injected and autologous fat-grafted scars. CONCLUSIONS: Our results demonstrate that autologous fat grafting can improve the qualitative profile of a scar from both the patient and observer perspectives. However, there was no difference in improvement when compared with scars that were treated with saline in a randomized and blinded fashion. These results demonstrate that any improvements in scar quality related to fat grafting are also achieved using saline and suggest that mechanisms other than cell activity may be at play. Additional randomized, blinded, placebo-controlled trials are required to either corroborate or contest the putative beneficial effect(s) of adipose tissue on scar remodeling.

Telehealth for Wound Management During the COVID-19 Pandemic: Case Studies.

BACKGROUND: Prior to the COVID-19 pandemic, the Cardiovascular Surgery (CV) service of an academic medical center conducted a quality improvement project to decrease readmissions to the hospital from 2 rehabilitation facilities using telehealth via video calling. This initiative became of great importance with the COVID-19 pandemic because it helped the CV service better navigate and more efficiently meet the patient care needs associated with patient care restrictions. The CV service had to quickly evaluate and implement measures to reduce the rate of transmission of the coronavirus, which included adapting the clinic workflow to comply with state and federal recommendations. To minimize the interruption of clinical services and the associated revenue, a rapid transition from outpatient clinic visits to telehealth visits was implemented. CASES: Two cases reports of patients with wounds managed with 2 different telehealth platforms are described. Doxy.me platform allows the provider to e-mail or text a link to their personal waiting room for patients to join the video call. The second platform is Cisco Jabber platform to connect directly to the nursing unit at a skilled nursing or rehabilitation facility. CONCLUSION: Health care systems have had to adjust the manner in which they triage, evaluate, and care for patients using telehealth platforms that do not rely on in-person clinic visits during the COVID-19 pandemic. There are multiple telehealth platforms that require careful planning and treatment implementation. Each health care agency needs to choose the one or ones that function the best in their care setting.

What is the frequency of pressure injury in vascular patients undergoing major amputations?

Individuals with peripheral arterial disease who have undergone below or above knee amputations have limited mobility and may sit for long periods of time in a wheelchair, increasing their risk for pressure injury. The aim of this descriptive cross-sectional research study was to retrospectively review the charts of those patients with peripheral arterial disease undergoing lower limb amputations from 2016 to 2017 at a major academic medical center to determine the frequency of pressure injury. Hospital data were used to identify patients discharged from 2016 to 2017 with primary International Classification of Diseases (10th Revision) codes for below knee amputations/above knee amputations and pressure injury (ulcer). From 2016 to 2017, 46 patients were admitted to the inpatient vascular surgery service for a below or above knee amputation. Seventeen of those patients had documented pressure injuries at hospital discharge for a frequency of 37%. There were 11 males and 6 females with age range of 44 to 82 years with a mean age of 66 years. There was a total of 19 pressure injuries (2 patients had 2 pressure injuries). Ten of those 19 pressure injuries were present on admission to the hospital and 9 pressure injuries were hospital-acquired pressure injuries. Thirteen of the 19 pressure injuries (68%) were on the sacrum. Three of the pressure injuries (16%) were on the heel. Two (11%) were ischial pressure injuries with one knee (5%) pressure injury. Risk assessment is an essential part of vascular nursing practice that aims to identify individuals at risk for pressure injury with appropriate interventions to prevent their occurrence. Vascular nurses should be encouraged to educate patients/family members on the increased risk of pressure injuries in those undergoing amputation during hospitalization and after discharge to prevent them from occurring.

2019 Guideline for Management of Wounds in Patients With Lower-Extremity Venous Disease (LEVD): An Executive Summary.

This article provides an executive summary of the 2019 Guideline for Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD) published by the Wound, Ostomy and Continence Nurses Society (WOCN). The executive summary presents an overview of the systematic process used to update and develop the guideline. It also lists the specific recommendations from the guideline for assessment, prevention, and management of LEVD and venous leg ulcers (VLUs). In addition, the guideline includes a new section regarding implementation of clinical practice guidelines. The LEVD guideline is a resource for WOC nurse specialists and other nurses, physicians, therapists, and health care professionals who work with adults who have or who are at risk for VLU.

Case Study on Management of Postsurgical Pyoderma Gangrenosum After Spinal Surgery.

BACKGROUND: Postsurgical pyoderma gangrenosum (PSPG) is a rare autoimmune, neutrophilic dermatosis that results with the occurrence of pyoderma gangrenosum (PG) within surgical incisions. Presenting symptoms include erythema and pain at the surgical incision with wound dehiscence. The clinical appearance of the PSPG wound (similar to PG) shows raised with dusky red or violaceous (violet-colored) wound edges and undermining with little or no evidence of granulation tissue. "Pathergy" is the term used to describe worsening of the wound in response to trauma such as debridement. Postsurgical pyoderma gangrenosum should be suspected in postoperative wounds, which continue to become progressively worse despite broad-spectrum antibiotics, good wound care, and surgical debridement. CASE: A clinical case study of a patient with PSPG from spine surgery is described. CONCLUSION: Postsurgical pyoderma gangrenosum should be suspected in postoperative wounds, which continue to become progressively worse despite broad-spectrum antibiotics, good wound care, and surgical debridement.

Quality of Life in Individuals With Peripheral Arterial Disease Who Underwent Toe Amputations: A Descriptive, Cross-sectional Study.

Studies have shown above- or below-the-knee amputation has a profound impact on physical, mental, and emotional health; the impact of having a toe(s) amputated is unknown. PURPOSE: This descriptive research study measured health-related quality of life (HRQoL) using the Vascular Quality-of-Life Questionnaire-6 (VascuQol-6) among persons with peripheral arterial disease (PAD) who had undergone toe amputations. METHODS: A list of 127 patients discharged from the hospital in 2016 with a diagnosis of PAD and toe amputation was provided to the investigator. The independent variables of age (subsequently divided into groups of persons <65 and ≥65 years of age), gender, race, diabetes mellitus, and time of PAD diagnosis (within the year or 2 to 7 years before 2016) were abstracted from the patient charts. A letter was mailed to potential participants that explained the study and the VascuQol-6 tool, along with a prepaid envelope to return the completed tool. The VascuQol-6 tool is a valid and reliable instrument for assessing HRQoL that covered the different aspects of quality of life (QoL) affected by PAD. The tool contains six 4-point Likert scale questions about activity, symptoms, pain, emotional status, and social life, resulting in a total score between 6 and 24. Higher values indicate better perceived quality of life. Variables were analyzed using frequencies, percentages, means, and standard deviations, and a standard t test was used to compare interval scale items. Statistical significance was noted when P <.05. RESULTS: Thirty-eight (38) completed surveys were returned (30% completion rate). The mean total score was 15.5 ± 3.93 (range 7-24), and the mean overall score of the 6 items was 2.66 ± 0.90 (range 1-4). In addition to a low overall QoL score, the data showed QoL was negatively affected in every area assessed, but some participants were strongly affected whereas others were not affected at all. No significant differences in QoL scores were noted concerning age groups, gender, race, the presence of diabetes mellitus, or time since PAD diagnosis. CONCLUSION: In this study, patients with PAD and toe amputations had low QoL scores related to their disease. Additional research is needed to better understand HRQoL related to PAD to facilitate education of patients considering toe amputation.

Management of a Groin Wound Using a Concentrated Surfactant-Based Gel Dressing.

BACKGROUND: A groin wound associated with a vascular graft infection is associated with significant morbidity. Management of groin wounds is often challenging due to their anatomical location that renders them difficult to visualize and keep clean. CASE: This case report describes the use of a concentrated surfactant-based gel dressing for an infected groin wound. CONCLUSIONS: Because of their location and complex topography, groin wounds are difficult to keep clean and maintain dressing integrity. This case study describes the use of a concentrated surfactant-based gel dressing that remained in place and promoted healing of an infected groin wound.

Case series of 18 patients with lower extremity wounds treated with a concentrated surfactant-based gel dressing.

The purpose of this case series was to assess the performance of a concentrated surfactant-based gel (CSG) dressing on 18 patients in the outpatient setting over 4 weeks. Wounds selected were full thickness, had been presented for greater than 4 weeks, and were located on the lower extremities. Patients were given the CSG dressing and instructed on its use. On follow-up clinic visits, the wound was assessed, measurements were obtained, Pressure Ulcer Scale for Healing (PUSH) Tool scores completed, and satisfaction with the dressing was solicited. Individual analysis of each subject's wound was conducted to determine if there was a healing trend over time with a decrease in total PUSH score. Descriptive statistics were used to analyze the results. Eighteen patients participated in this case series involving 9 women and 9 men with a mean age of 66 years (range from 52 to 91). All 18 of the patients had a primary diagnosis of peripheral vascular disease with 7 patients having venous leg ulcers and 11 patients with lower extremity arterial ulcers. The mean Total PUSH score before the CSG dressing was applied was 10.7 (range from 5 to 15) (standard deviation [SD] 3.09) and posttreatment was 8.3 (range from 0 to 14) (SD 4). All 18 patients had a decrease in their pretreatment score from the first clinic visit compared with the posttreatment PUSH Tool score, indicating that the CSG dressing may be an effective dressing in the management of lower extremity wounds.

Continuous betadine-bacitracin irrigation for vascular graft infections: A case series.

The aim of the study was to conduct a retrospective chart review of patients who underwent betadine/bacitracin continuous irrigation (BBCI) for vascular graft infections (VGIs) to review its use as a treatment option. A retrospective chart review from 2013 to 2017 was conducted of patients with VGIs that were treated with BBCI postremoval of the infected graft. The BBCI is a continuous infusion of 0.25% betadine in normal saline at 0.3 mL/kg/h for 48 hours then followed by bacitracin infusion with a concentration of 50,000 units bacitracin/per liter normal saline at 0.3 mL/kg/h for 72 hours. Descriptive statistics were used to describe the sample. The nine adult patients who received postoperative BBCI had an age range of 30-81 years, with average age of 58.8 years. Five of the subjects were females with four males. A total of nine patients with groin infections were identified, with two aortobifemoral bypasses, two axillofemoral bypasses, three femoral-femoral bypasses, one femoral artery pseudoaneurysm repair with Dacron patch, and one common femoral endarterectomy with Dacron patch. VGIs were identified from 10 days up to 72 months from the original vascular procedure. Six patients had negative wound cultures, while two had wound cultures positive for methicillin-resistant Staphylococcus aureus and one patient had positive culture for Escherichia coli. The length of time of BBCI ranged from 48 to 84 hours with average of 57.6 hours (standard deviation [SD] = 12.7 hours). The length of time of the bacitracin irrigation ranged from 30 to 72 hours with average of 48.4 hours (SD = 14.9 hours). All patients healed their groin wounds except for an 81-year-old patient with aortobifemoral bypass graft who developed ischemic bowel and expired. Patients received at least 6 weeks of intravenous antibiotics followed by oral antibiotic suppression therapy for life. VGIs are a devastating complication associated with a high morbidity. BBCI provides an option for antiseptic irrigation of the vascular graft site postgraft removal to promote wound closure.

Vascular Graft Infection: Incidence and Potential Risk Factors.

PURPOSE: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. DESIGN: Retrospective, descriptive study. METHODS: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. RESULTS: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). CONCLUSION: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Descriptive study of the frequency of medical adhesive-related skin injuries in a vascular clinic.

A medical adhesive can be defined as a product used to secure a device (ie, tape, dressing, catheter, electrode, and ostomy pouch) to the skin. Skin injury related to medical adhesive usage occurs across all care settings with medical adhesive-related skin injuries (MARSIs) playing a significant role with patient safety. The purpose of this descriptive prospective study was to assess all adult patients with wounds seen in the vascular clinic for MARSI by the CWOCN NP over a 3-month time period. One hundred twenty patients comprising a total of 207 visits were seen by the CWOCN NP over the 3-month time frame. Seven patients presented to the clinic from home with MARSI for a frequency of 5.8%. There were four males and three females with ages ranging from 52 to 83 years with a mean age of 67.7 years. All patients had a diagnosis of peripheral vascular disease with MARSI present on the lower extremities. Six of the seven MARSI cases were related to having paper tape removed from the periwound skin at home resulting in epidermal stripping either by the home health care professional (N = 4) or by the patient themselves (N = 2). The other MARSI was related to tension blister from steri-strips applied with benzoin by health care professional on a lower leg incision. Patients were unclear as far as when these injuries had occurred and often remarked that they thought that tape injuries were unpreventable. There is a need for additional research studies examining MARSI frequency across care settings such as the vascular population to identify those at risk and then implement measures to prevent it.

Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus-Based Algorithm for Care Across the Continuum.

Chronic venous insufficiency is a prevalent disease that frequently leads to development of venous leg ulcers. While a number of evidence-based clinical practice guidelines have been developed that provide guidance for clinicians when caring for patients with chronic venous insufficiency, they lack adequate detail concerning selection and application of compression for prevention and management of venous leg ulcers. In order to address this need, the WOCN Society appointed a task force to develop an algorithm for compression for primary prevention, treatment, and prevention of recurrent venous leg ulcers in persons with chronic venous insufficiency. The task force used findings from a scoping literature review to identify current best evidence needed to support decision points and pathways within the algorithm. In addition, the task force convened a panel of 20 clinicians and researchers with expertise in lower extremity venous disorders in order to establish consensus around pathways and decision points within the algorithm lacking robust evidence. Following initial construction of the algorithm, a second interdisciplinary group of expert clinicians established content validity and provided additional qualitative feedback used to complete final revisions of the algorithm. This article reviews the process used to create this landmark algorithm, including generation of the evidence- and consensus-based statements used in its construction, the various pathways, and rich supplemental materials embedded within the algorithm, and the process used to establish content validity.

2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD): An Executive Summary.

The purpose of this article is to provide a summary of the recommendations from the 2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD), published by the Wound, Ostomy and Continence Nurses Society (WOCN). This article provides an overview of the process used to update and develop the guideline, and specific recommendations from the guideline for assessment, referral for further evaluation, interventions (ie, debridement, dressings, infection, antibiotics, nutrition, pain management, compression issues, medications, surgical options, and adjunctive therapies), and patient education and risk-reduction strategies. The LEAD guideline is a resource for physicians, nurses, therapists, and other healthcare professionals who work with adults who have/or are at risk for wounds due to LEAD. The full text of the published guideline, which includes the available evidence supporting the recommendations and a complete reference list, is available from the WOCN Society, 1120 Rt. 73, Suite 200, Mount Laurel, NJ, 08054; Web site: www.wocn.org. Refer to the Supplemental Digital Content (Supplement Digital Content 1, http://links.lww.com/JWOCN/A31) associated with this article for the complete reference list for the guideline. The guideline has been accepted for publication by the National Guideline Clearinghouse (www.guideline.gov/).