Patients experiencing venous

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1 Cliical Cliical News Wouds iovatios Leg ulcer Wouds Iteratioal cliical s preset recet developmets i the field of leg ulcers, pressure ulcers, ski itegrity ad diabetic foot, icludig the latest from associatios, cliicias ad idustry. If you use a iovative techique i your practice that you would like us to feature i future issues, please the editor at: scale@woudsiteratioal.com The veous ulcer pipelie: a ovel approach to refractory veous ulcers Patiets experiecig veous leg ulcers are commo [1], but ufortuately, stadard treatmet icludig ifectio cotrol, primary dressigs, ad high-stregth Authors (left to right): Robert compressio achieves healig i Kirser ad Herbert Slade oly 30 75% of cases [2]. Guidelies suggest that wouds that are ot healig, as determied by isufficiet woud size reductio followig four weeks of stadard care, should receive adjuctive therapy [3]. The adjuctive therapy with the logest history of use is autologous ski graftig [4], which requires the creatio of a secod woud at the door site ad ca be problematic as ulcers ted to recur. Attempts to develop off-the-shelf products have produced moolayer costructs, such as cultured allogeeic adult keratiocytes [5], which suffer from costruct fragility [6], ad bilayered costructs. Systematic reviews of cell-based therapies for veous leg ulcers have foud limited high-quality evidece of beefit, with iheret challeges of blidig egieered tissue applicatio [7,8]. A recet Cochrae review foud 15 of 17 qualifyig radomised cotrolled trials to be uderpowered [9]. Most successful of these products is a tissue-egieered ski product, which is coceived as a bilayered 'huma ski equivalet' (Apligraf, Orgaogeesis). It cotais bovie collage ad allogeeic cells, which work to heal veous ulcers ad it bears histological similarity to ski [10,11], but as the allogeeic cells do ot egraft, the eed for a elaborate tissue costruct is ucertai. The authors recetly reported the efficacy ad safety of the HP trial (Healthpoit Biotherapeutics), which cosists of cryopreserved allogeeic, growth-arrested eoatal fibroblasts ad keratiocytes i a format that allowed the evaluatio of various doses [12,]. After rapid thawig, the cells are delivered to the woud surface i a modified fibri spray. I vitro studies have allowed optimisatio of the cellular formulatio to ehace the release of essetial growth factors, icludig vascular edothelial growth factor (VEGF), basic fibroblast growth factor (bfgf), keratiocyte growth factor (KGF), trasformig growth factor alpha (TGFα) ad, whe the cells are combied, graulocytemacrophage coloy-stimulatig factor (GM-CSF). The authors studied patiets with cofirmed ad refractory veous ulcers betwee 2 12cm 2 i area that had bee preset for weeks. Usig a double blid, parallel group desig, we compared weekly, or biweekly, applicatio of cells/ ml (N=45, 44) or cells/ml (N=46, 43) to the weekly applicatio of fibri vehicle without ay cells (N=50), with all five groups receivig four-layer compressio badages. Two hudred twety-eight patiets across 28 cetres were erolled ad 205 completed all visits. Usig Itet to Treat (ITT) aalysis, the authors foud that treatmet with spray cell therapy produced sigificatly greater reductio i woud area (p=0 0446), shorter time to healig (p=0.0058) ad a higher proportio of wouds closed (p=0.0267), tha stadard care aloe. The best results were see with /mL, give bi-weekly. This is the first report documetig beefit usig eoatal cell (as opposed to tissue) therapy for veous ulcers. Phase 3 studies are ow ogoig for this first-i-class, cell-based therapy that holds promise for better outcomes compared with curret stadard care. I cotrast to umerous publicatios of small trials ad case series suggestig the beefit of allogeeic cells, the preset trial was sufficietly large, properly radomised ad wellmasked, with complete reportig of prospectively determied outcomes ad usig ITT aalyses. To date, this experimetal therapy has geerated the best results see i the treatmet of refractory veous ulcers, ad iforms uderstadig of how to take ito accout the typical pharmaceutical parameters of dose, duratio ad frequecy whe testig cell-based therapeutics. Robert Kirser is Professor ad Vice Chairma at the Departmet of Dermatology ad Cutaeous Surgery Uiversity of Miami Leoard M. Miller School of Medicie; Herbert Slade is Chief Medical Officer at Healthpoit Biotherapeutics ad Adjuct Cliical Associate Professor at the Departmet of Pediatrics, Uiversity of North Texas Health Sciece Ceter 1. Valecia IC, Falabella A, Kirser RS, Eaglstei WH. Chroic veous 8 Wouds Iteratioal Vol 3 Issue 4 Wouds Iteratioal 2012

2 Cliical Update Iovatios i leg ulcers Expert Commetary Peter Vowde, MD FRCS, Visitig Professor of Woud Healig Research, Uiversity of Bradford, ad Cosultat Vascular Surgeo, Bradford Teachig Hospitals Foudatio Trust Lower limb veous ulceratio is oe of the cutaeous maifestatios of chroic veous disease ad, as such, its maagemet cosist of three basic strategies: The maagemet of the woud itself The maagemet of the abormal periwoud ski The maagemet of the uderlyig veous disease. Oly by addressig all of these three elemets of the disease process ca acceptable healig rates be achieved ad low ulcer recurrece rates obtaied. It is ow widely agreed that high-compressio badagig should form the maistay of treatmet for the majority of patiets with veous ulceratio, the level of compressio beig determied by patiet tolerace ad a measure of lower limb perfusio, such as the Doppler akle brachial pressure idex (ABPI). I selected patiets, early veous surgery or ablatio therapy may be appropriate to assist healig, but i geeral such treatmet is used, with the applicatio of compressio hosiery, to reduce the risk of ulcer recurrece rather tha assist with healig. Despite effective high-compressio therapy, whether by badagig or hosiery, some veous ulcers fail to heal ad these wouds, ofte referred to as 'hard to heal' have icreasigly bee the target of studies aimed at idetifyig adjuvat therapies that may assist i the healig. The challege with all such treatmets is: The early idetificatio of the sub-group of patiets whose wouds will fail to heal i a acceptable timeframe with 'stadard' care To offer such patiets a practical ad cost-effective alterative or adjuvat treatmet. I this paper o spray-applied cell therapy, Kirser ad Slade highlight both the advatages ad disadvatages of curretly available tissueegieered costructs ad autologous ski grafts as vectors to assist healig i this group of patiets i whom the challege is ofte ot just to achieve healig, but to produce a woud bed likely to support healig or the applicatio of a ski or a egieered ski substitute. Their phase 2 dosig study, origially reported i the Lacet [1], successfully demostrated the potetial for cryopreserved allogeeic, growth-arrested eoatal fibroblasts ad keratiocytes delivered i a modified fibri spray to assist healig. The challege ow is to demostrate the efficacy ad cost effectiveess of this treatmet whe applied as part of a larger cliical trial ad to cofirm effectiveess as the treatmet is exteded to geeral use. A cliically ad cost-effective bio-egieered solutio to address o-healig or delayed healig cotiues to elude us. May elegat potetial solutios have bee developed but most have failed to make a successful trasitio from early cocept or costruct to practical ad widely applicable device. Early results with this formulatio of spray-applied cell therapy have bee ecouragig ad storage, shelf-life, product hadlig ad woud bed status costraits seem to be less of a problem tha those ecoutered with some bio-egieered products. I await with iterest the ext report o this therapy, which I hope will cotai a health ecoomic model outliig the beefits of this form of treatmet as this will give a clear idicatio of the true potetial of this treatmet to impact o the care of the wider leg ulcer populatio. 1. Valecia IC, Falabella A, Kirser RS, Eaglstei WH. Chroic veous isufficiecy ad veous leg ulceratio. J Am Acad Dermatol, 2001; 44: isufficiecy ad veous leg ulceratio. J Am Acad Dermatol 2001; 44: O'Meara S, Cullum NA, Nelso EA. Compressio for veous leg ulcers. Cochrae Database Syst Rev. 2009; Issue 1:Art. No.: CD DOI: / CD pub2 3. Tag JC, Marsto WA, Kirser RS. Woud Healig Society (WHS) veous ulcer treatmet guidelies: What's ew i five years? Woud Repair Rege Jul 16. doi: /j X x. 4. Kirser RS, Eaglstei WH, Kerdel FA: Split-thickess ski graftig for lower extremity ulceratios. Dermatol Surg 1997; 23: Leigh IM, Purkis PE, Navsaria HA, Phillips TJ. Treatmet of chroic veous ulcers with sheets of cultured allogeic keratiocytes. Br J Dermatol 1987; 117: Bello YM, Falabella AF, Eaglstei WH. Tissue-egieered ski. Curret status i woud healig. Am J Cli Dermatol 2001; 2: Nelso EA, Cullum N, Joes J. Cliical evidece cocise: veous leg ulcers. Am Fam Physicia 2005; 71: Herschthal J, Kirser RS. Curret maagemet of veous ulcers: a evidece-based review. Surg Techol It 2008; 17: Joes JE, Nelso EA. Ski graftig for veous leg ulcers. Cochrae Database Syst Rev 2007;Issue 2:Art. No.: CD DOI: / CD pub3 10. Kirser RS, Fasteau J, Falabella A, Valecia I, Log R, Eaglstei WH. Cliical ad ecoomic outcomes with graftski for hard-to-heal veous leg ulcers: a sigle-ceter experiece. Dermatol Surg 2002; 28: Falaga V, Margolis D, Alvarez O et al. Rapid healig of veous ulcers ad lack of cliical rejectio with a allogeeic cultured huma ski equivalet. Huma Ski Equivalet Ivestigators Group. Arch Dermatol 1998; 134: Kirser RS, Marsto WA, Syder RJ, Lee TD, Cargill DI, Slade HB. Sprayapplied cell therapy with huma allogeeic fibroblasts ad keratiocytes for the treatmet of chroic veous leg ulcers: a phase 2, multicetre, double-blid, radomised, placebo-cotrolled trial. Lacet 2012 Aug 2. [Epub ahead of prit] Germa Leg Club iaugurated Barbara Kaiser Based o the Eglish 'Leg Club' model established by Ellie Lidsay, the first Leg Club i Germay was fouded i April 2012 by Barbara Kaiser. She works as a urse i Muich with 9

3 Cliical News Wouds iovatios a focus o woud care i Ambulatory Nursig ad has studied at the private medical uiversity, Paracelsus, i Salzburg for a Master's i scietific Woud Care Maagemet. The health system i Germay differs greatly from the Eglish health care system. The beefits of the Germa system are based o various pillars, such as health isurace, pesio isurace, uemploymet isurace ad accidet isurace. Due to the risig populatio i Germay, the umber of age-related diseases is growig, resultig i the healthcare system, despite the may reforms i recet years, beig put uder icreasig strai to improve the care of patiets. The risk of developig leg ulcers icreases with age ad aroud 1.5 millio people are said to be sufferig from ulcers i Germay [1]. After a patiet has bee discharged, problems with providig the correct care/treatmet have bee kow to arise. Patiets are cared for primarily by their GP ad, if requested, by a Outpatiet Nursig Service (Ambulatory Nursig). Further treatmet depeds o the expertise of the family physicia ad the outpatiet care service provider. Due to the low recogitio of the treatmet of ulcers by the health isurace compaies ad, as a cosequece, the low potetial fiacial gai, patiets with leg ulcers are ot prioritsed, either by physicias or the outpatiet care service providers. Therefore, patiets that are well cared for i hospitals, ted to receive a lower level of special diseaserelated care at home ad ca move from a optimal treatmet eviromet i the hospital to miimal ad mostly iefficiet treatmet at home. The Leg Club model ca provide a bridge betwee the stakeholders ad the various medical fields outside of the cliics. Through weekly meetigs, the Leg Club provides cotact with other sufferers, as well as access to expert ursig staff ad voluteers, all of whom are advised ad educated, followig the model established by Ellie Lidsay. Her model cosists of four major pillars: Professioally competet care i a o-medical istitutio that has the atmosphere of a club, with refreshmets provided Treatmet of all patiets together i oe room, i order to promote the exchage of kowledge Visits without appoitmets to eable patiets to access the Leg Club at their ow pace, so as to avoid artificial barriers Follow-up is available as log as the patiet wats it. This meas that, eve after the woud is healed, the idividual ca still visit the club ad get further advice ad/or traiig. The model ot oly icorporates traiig ad presetatios for patiets, but also ivolves a rage of cliicias, to raise awareess of the issue ad to promote the sharig of kowledge. The motivatio to start a Leg Club i Germay arose durig a lecture at the Uiversity of Salzburg by Dr Zemli, who became aware of the Leg Club i Eglad ad saw this model as a beefit i terms of the care of chroic wouds. Dr Zemli's presetatio ecouraged the author to become familiar with the model through site uits. Ms Kaiser was the ivited by Professor Hele Edwards to a four-week itership at the Queeslad Uiversity of Techology (QUT) i Brisbae, i Jauary I Brisbae, the model is itegrated ito the Health Care Service Ceter withi the QUT Uiversity. The uit i Brisbae is headed by Michelle Gibb, who fouded aother Leg Club i a local outpatiet care service, which is also itegrated ito the research with the Uiversity. The experieces of the author durig her itership raised the questio of whether it was possible to implemet a Leg Club i Germay. Begiig o 1 November 2011, a oe-year Leg Club project i Germay bega. I order to ru the project successfully, a project maagemet system was put i place, which comprised the project start-up phase, the plaig ad executio phase, the coordiatio ad modificatio phase ad the cosolidatio of the project. Durig the Australia itership ad followig a visit to Worcester i Eglad, it became clear that the Leg Clubs were primarily set up i church istitutios. It was, therefore, suggested that this be the case i Germay as well.however, the Ambulater Pflegediest Diakoie Immauelkirche e.v. Müche-Ost a mobile ursig cetre uder the patroage of the Dea of Bavaria was i fact able to implemet the project. The aforemetioed outpatiet care service has existed for 15 years. It caters for approximately 90 patiets, icludig those with chroic wouds. As a result of a presetatio o the Leg Club model ad the already existig arragemets i the care of chroic wouds, it was foud that there was cosiderable iterest i ehacig the level of care relatig to chroic wouds. Thus, the head of ursig ad the maagemet of the outpatiet care service joied i the project to implemet a Leg Club. It was decided that a meetig place should be created to promote the sharig of kowledge i idividuals with leg ulcers. Through a etwork of various medical specialties, the aim of the club was to improve the quality of life of patiets with ulcers ad to promote healig of these wouds. The focus was put o educatio ad the promotio of self-care skills, accompaied by a professioally competet woud care specialist. This social project is i lie with the philosophy ad facilities of the outpatiet care service. Ivolved i the project are the the Board of the Ambulatory Care service, the admiistrative maagemet, the ursig team ad of course the patiets, while potetial visitors iclude GPs, cliics, podiatry, physiotherapy, utritioal therapy, ad woud experts, represetatives of the pharmaceutical idustry, pharmacies ad medical supply stores. It should be oted, that the implemetatio of the Leg Club model i Germay was oly possible with the approval ad support of Ellie Lidsay. Ellie persoally checked the implemetatio both before ad after opeig ad gave permissio for the use of the Leg Club's official logo. It became clear that shared experiece was beeficial to patiets, as they were ot left aloe with their coditio. The kowledge patiets gaied while frequetig the club, helped improve trust i the high-quality work of specialist urses ad helped promote cooperatio. Ufortuately, due to the differet health systems i the UK ad Germay, the Leg Club model caot be implemeted i its UK format i Germay. The akle-brachial pressure idex 10 Wouds Iteratioal Vol 3 Issue 4 Wouds Iteratioal 2012

4 Cliical Update Iovatios i leg ulcers (ABPI) value is, for example, ot usually measured by the urse i Germay. Also, i Germay, badages ad medical aid ca oly be prescribed by a doctor. To implemet Ellie Lidsay's model i Germay i its etirety will require more time. The issues that emerge from ulceratio ca be distressig for patiets. To prevet ogoig sufferig, the most importat issue is for the patiet to further their kowledge of the disease. Oly the ca log-term problems be solved. Barbara Kaiser is a Registered Nurse, Natural Health Professioal ad MSc i Woud Care Maagemet 1. Dissemod J. Ulcus cruris - Geese, Diagostik ud Therapie, 3.Auflage - Breme; UNI-MED, 2009, Seite 15 The Leg Club reaches Tasmaia Tasmaia is a islad state 240km south of the Australia cotiet. It has a populatio of aroud 508,000, of whom about half live i the south, i the greater Hobart area. Commuity Nursig Services withi the Souther Tasmaia Area Health Services (STAHS) provide both geeralist ad specialist services. Geeral commuity urses provide log ad short-term care, moitorig ad support to people who are post-acute, aged, disabled, udergoig palliative care, those with chroic diseases ad their carers. They are supported by specialist urses, who are employed i the areas of palliative care, breast care, cotiece, spial ijury ad metal health. A large part of the work udertake by commuity urses is woud care [1], but local practices, skills ad resources vary from area to area [2] ad specialist woud maagemet urses are ot yet employed i commuity health to support the teams. The STAHS-fuded service for assessmet of people with chroic wouds, such as leg ulcers, is the hospital out-patiet woud cliic. The cliic is held o two half-days each week, oe for ew ad returig patiets to be assessed by a cosultat, while a Registered Nurse reviews returig patiets o the other half-day. Access requires a Geeral Practitioer (GP) referral ad usually ivolves a four- to eight-week wait for a appoitmet [2]. At other times, urses may cotact the hospital Cliical Nurse Cosultat for Wouds for geeral advice. Patiets have ofte had a o-healig woud for may moths or years before beig referred to the cliic. Although there is o local data available, it has bee suggested that this is ofte the result of a geeral lack of woud maagemet educatio, traiig, ad atioalised treatmet ad referral plas [3]. Oce a patiet's woud has healed, they are discharged from the cliic, with compressio hosiery whe applicable, but there is o access to follow-up for those with healed wouds for advice regardig woud prevetio strategies or early itervetio ad the treatmet of ew wouds. Further cliic visits require aother referral from the GP ad presetatio of a ew woud. Why set up a Leg Club? A Australia radomised cotrolled trial [4] demostrated a sigificat improvemet after 24 weeks i people attedig a Leg Club, compared with the cotrol group, which received traditioal home care by the same group of urses, usig idetical protocols. Improvemets were see i healig rates, quality of life, morale, self-esteem, pai ad fuctioal ability. Ruig alogside the trial was a participatory actio research study from which the results were very positively i favour of the Leg Club model, ot oly i relatio to leg ulcer maagemet, but also i empowerig cliets to make positive chages through icreasig their kowledge [1]. The Clarece Itegrated Care Cetre has bee developed with a view to improvig access to a wider rage of well-coordiated health services for people o Hobart s Easter Shore, with extra emphasis o people with chroic ad complex coditios [5]. This makes it a ideal veue to hold a Leg Club for the local commuity. There are successful clubs based upo the Lidsay Leg Club model established i four other Australia states, but this is the first i Tasmaia [6]. Studies have reported that leg ulcer care is sometimes less tha optimal, due to lack of time, support ad appropriate educatio/ traiig [7]. Locally, woud maagemet educatio is available for a fee from various orgaisatios. Nurses ot attedig educatio sessios are still required to provide a woud maagemet service, however, this caot be as effective as the oe provided by a urse with specific traiig [8]. Educatio is essetial to urses beig able to provide effective ad appropriate care [9]. Oe of the aims of Easter Shore Leg Club is to provide a iformal eviromet for staff educatio. Leg Club protocols ad practices are based o evidece-based guidelies to provide researchbased woud maagemet i a friedly, o-threateig social eviromet ad give a stadardised approach to leg ulcer assessmet ad treatmet [10]. The Easter Shore Leg Club lead urse is edorsed as a Woud Maagemet Nurse Practitioer ad the other staff are icreasig their kowledge through completig the educatio programme provided by the Leg Club Foudatio [11] ad modules from a Australia olie woud educatio programme [12]. Graduate Figure 1. Left to right: Kris Peey, Lea Youg, Di Lyos, Jayare Kig. 11

5 Cliical News Wouds iovatios urses placed with the Commuity Nursig services will have the opportuity to sped time at the Leg Club to icrease their woud maagemet kowledge ad skills. May patiets discharged from the hospital woud cliic require ogoig review of akle brachial pressure idex (ABPI) ad measurig or advice for ew compressio hosiery. As they are usure about their eeds, they ofte use the same stockigs for may years util they develop aother leg ulcer. The the whole cycle begis agai. The Leg Club model of care helps reduce recurrece by providig post-healig moitorig ad 'well-leg' checks. It has bee widely documeted that chroic leg ulcers affect quality of life by restrictig mobility leadig to social isolatio ad icreasig axiety ad depressio [5] ad the Leg Club model aims to meet the social eeds of isolated cliets by facilitatig a iformal support etwork ad providig the settig for social iteractio ad for treatmet. The drop-i system with o GP referral required ecourages people to atted for iformatio ad advice, facilitatig early diagosis, treatmet ad educatio. Easter Shore Leg Club is held i a geeral activities room used at other times by allied health services ad other commuity groups. It is ideally placed close to a local shoppig cetre ad has free parkig at the door. Oe of the aims of the Australia Woud Maagemet Associatio is to raise public ad professioal awareess of the problems associated with chroic wouds [13]. Through promotio of the Leg Club ad the provisio of iformal ad formal health promotio ad educatio, awareess may be icreased i both of these areas. This, i tur, de-stigmatises the coditio, icreasig self-esteem ad self-respect. Ope day Staff preset o the ope day icluded the lead urse ad three other commuity urses, while the voluteers provided the refreshmets. As this is a club, rather tha a cliic, people are called members rather tha patiets or cliets. Three members were expected to joi o the day ad other cliicias were ivited to look at how the system works. The first three members arrived, as well as iterested staff from podiatry, commuity trasport, commuity ursig, child health, social work, aged services ad a local GP. The three members icluded two wome with veous leg ulcers ad a ma with a above kee amputatio, but o curret wouds. They stayed varyig legths of time from oe-ad-a-half to three hours, happily chattig to voluteers ad ejoyig the compay, with all three eager to retur the followig week. Two extra people popped i followig their podiatry visits, ad also said that they would retur the followig week. Of the two people with wouds requirig dressig chages, oe woma was happy to be treated i the collective treatmet area, while the other opted for a private area. Both were accommodated, but after realisig that the treatmet area was ot easily viewed by everyoe, the woma see privately opted to be treated i the collective treatmet area the followig week. O week two, all members retured, ad two ew people joied, oe requestig woud treatmet ad the other requirig assessmet ad measurig for ew compressio hosiery after oticig a potetial ew woud developig. What lies ahead? There are two treatmet chairs ad two staff available most weeks, so to prevet log waitig periods for those ot wishig to stay loger it was decided to arrage appoitmet times for people requirig treatmet. It remais a drop-i club, so members are free to arrive ad leave wheever suits them. Oce there are more members, occasioal guest speakers will be orgaised. Iitial plas iclude a physiotherapist to discuss the importace of exercise, a podiatrist to demostrate footwear essetials ad other professioals to talk about compressio hosiery, self-care ad utritio. The Club is i the very early stage ad chages will be made as ad whe the eed arises. However, thigs are lookig positive at preset ad staff are very excited at the prospect of membership growig ad beig able to make a positive impact to the lives of those with chroic leg ulcers. Lea Youg is RN M Woud Care, MN(NP), MRCNA at Souther Tasmaia Area Health Service, DHHS, Tasmaia. 1. Shuter P, Filayso K, Edwards H, Courtey M, Herbert C, Lidsay E. Leg- Clubs beyod the ulcers: Case studies based o participatory actio research. Woud Practice Research 2001; 19(1): Departmet Health ad Huma Services (2011). Commuity Health Nursig Model of Care 3. Gottrup F. Optimizig woud treatmet through health care structurig ad professioal educatio. Woud Repair Rege 2004; 12(2): Edwards H, Courtey M, Filayso K, Shuter P, Lidsay E. A radomised cotrolled trial of a commuity ursig itervetio: improved quality of life ad healig for cliets with chroic leg ulcers. J Cli Nurs 2009; 18: Clarece Itegrated Care Cetre Operatios Group. (No date available). Terms of Referece. Available at: data/ assets/pdf_file/0005/52394/tor_-_cicc_operatios_group_-_ pdf (Accessed o 31 August, 2012) 6. The Lidsay Leg Club Foudatio (2005) Directory of Leg Clubs. Available at: (Accessed 22 September, 2012) 7. Stephe-Hayes J. The Leg Club Model: a survey of staff ad members perceptios of this model of care. J Woud Care 2010; 19(9): Asimus M. Woud maagemet model redesig jourey, Australia Resource Cetre for Healthcare Iovatios. Available at: archi.et.au/resources/safety/woud/woud-maagemet (Accessed o 24 August, 2011) 9. Cowma S, Gethi G, Clarke E, Moore Z, Craig G, Jorda-O Brie J, McLai N, Strapp H. A iteratioal edelphi study idetifyig the research ad educatio priorities i woud maagemet ad tissue repair. J Cli Nurs 2012; 21: The Lidsay Leg Club Foudatio. What is a Leg Club? 2005; Available at: (Accessed o 21 September, 2012) 11. (The Lidsay Leg Club Foudatio. Learig Zoe modules 2010; Available at: (Accessed o 21 September, 2012) 12. Govermet of Wester Australia. Departmet of Health. Wouds West Educatio 2012; Available at: educatio/idex.cfm (Accessed o 19 November, 2012) 13. Australia Woud Maagemet Associatio. Woud Awareess Campaig 2012; Available at: (Accessed o 19 November, 2012) 12 Wouds Iteratioal Vol 3 Issue 4 Wouds Iteratioal 2012