MODERN WOUNDCARE

DR.HARIKRISHNA .R
MD(UKM) OSH(NIOSH) OHD(DOSH) CMIA(MAL) POST GRAD IN WOUND HEALING & TISSUE REPAIR (CARDIFF,UK) CHM (USA) ESWT(AUSTRIA,GERMANY) FMSWCP DIABETIC FOOTCARE CLINIC ,
NADI 2010 LUCILIA THE SAGA

The goal of treating any type of wound is to create an optimal wound healing environment by producing a well vascularised, stable wound bed that is conducive to normal and timely healing.

1. Falanga V. Wound Repair Regen 2000;8(5):347-52

Different etiology of wounds

Pressure Ulcer Diabetic Foot Ulcer

Minor burn Burn

Trauma

Venous Leg Ulcer Dehiscence

Chronic Wound Healing

Phases
Haemostasis
Minutes

Inflammation
Days Weeks Year +

Proliferation Remodeling

Wound Appearance - THE COLOUR MODEL

It is necessary to have a method to appraise the types of wound

without having to resort to specialised histologists for each and every wound.
The colour method is used to identify and prioritise the treatment

objectives in wounds and is also used in research.

In the early 80s, Lars Hellgrens, a Sweden dermatologist, was the

first to claim that wounds could be categorised according to the colour of the wound surface.

Wound Appearance - THE COLOUR MODEL

Pink - Epitheliazation

Red - Granulation

Black - Necrotic

Yellow - Slough

Wound Bed Preparation

Debridement Bacterial Balance

Exudate Management
Dr. Gary Sibbald, et al

Preparing the wound bed for healing debridement, bacterial balance & moisture balance
Ostomy/ wound management 2000, 46(1)

WOUND BED PREPARATION

IDENTIFY & REMOVE BARRIERS TO WOUND HEALING

PROMOTE WOUND HEALING

Wound bed preparation is the management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures
Paris International Advisory board in June 2002

*+ TIME

- Principles of Wound Bed Preparation

Surrounding Skin
Assess for: color, moisture, suppleness Size
Measure and/or trace wound area. Measure depth

Wound bed

WOUND ASSESSMENT
Wound edges
Assess for undermining & condition of margin

Assess for:
necrotic and granulation tissue, fibrin slough, epithelium, exudate,odor

11

TIME

(T = Reflects Tissue Viability )

Viable (granulation, epithelialising) Non viable (necrotic, sloughy, eschar) How does non viable tissue impede healing? Prolongs inflammation Impedes epithelialisation Medium for bacteria growth Goals in treating tissue in chronic wounds Clear away dead or necrotic tissue debridement Always ensure adequate tissue oxygenation for angiogenesis and granulation process

issue Non Viable: Necrosis, Eschar, Slough

Wound Cleansing
Purpose:
helps optimize wound healing decreases the potential for infection loosens and washes away cellular debris

(bacteria, exudate, purulent material and residual topical agents)

Routine Wound Cleansing

Solutions
Saline Distilled water

Non-toxic wound cleansers

Superoxidised

solution (Dermacyn) PHMB & Betaine solution (Prontosan)

Antiseptic Skin Cleansers

Antiseptics should not

be used to clean wounds

Topical antiseptics such

as:
Betadine Povidone-iodine Dakins solution(eusol) Acetic acid Hydrogen Peroxide

Delay healing by destroying viable cells

 Protect wound from trauma microbial contamination Reduce pain

DRESSING - PURPOSE

Maintain temperature & moisture of wound

Absorb drainage & debride wound Control &Prevent haemorrhage (pressure

dressing) Provide psychological comfort

DRESSING CATEGORIES
Traditional

Conventional
Advanced
Advanced/environmental dressings are more

expensive can leave in situ for several days

DRESSING CATEGORIES Traditional

spider web (1346 AD)

poultices leaves & herbs

honey

DRESSING CATEGORIES
CONVENTIONAL
Gauze Gamgee
Melolin

Primapore
Opsite post Op

Problems - Some Dressings

Adherence to wound Dehydration of wound Fiber shed

Strikethrough

Ideal/optimum dressing
Remove excess exudate
Maintain moist wound healing environment Allows gaseous exchange if appropriate Provide barrier to pathogens Provide thermal insulation Waterproof Trauma protection Non adherent Safe & easy to use
Theory of moist healing a moist environment created beneath a semi permeable membrane allows optimal conditions for the re-epithelization of wounds (Winter 1971)

DRESSING CATEGORIES
Advanced
Films eg. Opsite, Tegederm, Suprasorb F
Hydrogels eg. Duoderm Gel, Intrasite Gel, Suprasorb

G, Purilon Gel Hydrocolloids eg. Duoderm CGF, Extra thin Comfeel, Suprasorb H, Cutinova Hydro Alginates eg. Kaltostat, Suprasorb A, Algisite, Seasorb Foams eg. Allevyn, Tielle, Suprasorb F, Mapilex, Biatain Charcoals eg. CarboFlex, Actisorb Plus Silver eg. Aquacel Ag, Acticoat, Polymem Silver

T Debridement
Debridement is not a single event - an initial phase and a maintenance phase. Debridement is an ongoing process.
V. Falanga, 2000

Method of Debridement (Removal)?

Surgical / scalpel? Mechanical? Hydro surgery debridement machine (eg. Versajet) Enzymatic? Autolytic? Biological? Combination?

Surgical debridement is gold standard of care, once ischemia is excluded.

(Wagner 1984, Knowles 1997, Laing 1994, Steed 1996,, Levin 1996).

T
Characteristic

Selecting a method of debridement Debridement method

Autolytic Surgical Enzymatic Mechanical

Speed

Tissue selectivity
Painful wound Exudate Infection Cost

3
1 3 4 1

2
4 1 1 4

1
2 4 3 2

4
3 2 2 3

Table 1 = most appropriate; 4 = least appropriatefrom Sibbald et al. 2000

Autolytic Debridement
Definition - The process by which the wound bed utilizes phagocytes and proteolytic enzymes to remove non-viable tissue This process can be promoted and enhanced by maintaining a moist wound environment.

Autolytic debridement
1

After 2 days

After 4 days

Autolytic Debridement Hydrogel

* As a selective type of debridement, autolysis removes only necrotic tissue

MODE OF ACTION HYDROGEL

Contains:

Cross-linked carboxymethylcellulose 2.3%

Gently rehydrates dry necrotic tissue Provides moist wound healing environment Softens necrotic tissue

Propylene Glycol USP 20.0%

Purified Water 77.7 %

Surgical Debridement
Scalpel/Scissors Curet Laser Hydrosurgery (Versajet)

Recommended for removal of thick, adherent eschar and devitalized tissue in large wounds
Not recommended in severely

compromised patients
Analgesia/anesthesia may required

The VERSAJET A new wave in surgical debridement

VERSAJET :
Saline Bag (3 L ~ 30 min) Console

Handpiece

Foot Pedal

Waste canister

Trademark of Smith & Nephew & Reg. U.S. Pat. & Tm. Off.

Enzymatic Debridement
The use of topically

applied enzymatic agents to stimulate the breakdown of nonviable tissue Faster debridement process compared to Autolytic

TIME

(I = Inflammation, Infection)

Persistent inflammation wounds become stuck The bacterial continuum

What is infection?
How does infection differ between the acute and

chronic wound? What factors need to be considered?

Assessing wound infection

Clinical Presentation of local wound infection

Secondary signs & symptoms

Delayed healing
Change in color of wound bed Absent/ abnormal granulation

tissue
or abnormal odor

Classic signs & Symptoms Advancing erythema Fever Warmth Edema / swelling Pain Purulence

serous drainage
pain at wound site

TIME

(M = Moisture Imbalance)

Desiccation / Maceration

Composition of chronic wound fluid

Matching exudate volume with product absorbency for

optimal moisture balance

Optimal Moisture Balance

Maceration

Desiccation

Exudate Management
Chronic Wound Fluid
Bacterial Burden Bioburden control Edema Breakdown of Necrotic tissue

Compression

Debridement

Exudate Management
None Low Moderate Heavy

Material

Conserve/ Donate

Fluid Control

Light

Moderate

High

Films
Sheet hydrogel

Amorphous hydrogel
Hydrocolloids

Sheet foams Cavity foams Alginates Hydrofiber

TIME

E = Edge of Wound

Non advancing wound

edge = non healing wound Undermining (critically colonised or infected) Persisting inflammation Non responsive cells
REVIEW T/I/M Factors

What if the epidermis fails to advance?

Reconsider the principles of Wound Bed Preparation and the acronym TIME:
Has necrotic tissue been debrided? Is there a well vascularised wound bed? Has infection been put under control? What is the status with inflammation? To what level has moisture imbalance been corrected? What dressings have been applied?

CASE STUDIES-HBOT

CASE 1
Puan SS is a 32 year old diabetic on insulin injection.
She came to DFC upon discharge from the ward after having had wound debridement done to her left dorsum forefoot and plantar. 1st visit to DFC was on 21.9.2009

She consented to 3 sessions of MDT after which the wound was very much cleared of slough.
Following that the wound was dressed with advance modern dressings. During the wound granulation phase her wound was treated with HBO which is an adjunctive treatment for 30 sessions.

CASE 2
Cikgu K is a 64 year old female who went for right total

knee replacement Post op the knee wound was non healing and infected She was referred to the Diabetic Foot Clinic on the 23rd of December 2009 She was dressed with advanced wound dressings She underwent HBOT to hasten the healing of the wound

DISCUSSION

Chronic Wound Healing

Phases
Haemostasis
Minutes

Inflammation
Days Weeks Year +

Proliferation Remodeling

DEFINITION OF HYPERBARIC OXYGEN THERAPY

A mode of medical treatment in which a patient is

entirely enclosed in a pressure chamber and breathes 100% oxygen at a pressure greater than 1 atmosphere absolute (ATA) (The Committee on Hyperbaric Medicine)
ATA is the unit of pressure and 1 ATA is equal to

760 mmHg or pressure at sea level

HYPERBARIC CENTERS
CHINA

RUSSIA
JAPAN

UK
EUROPE US

MALAYSIA
MIDDLE EAST BANGLADESH SRI LANKA

2600 2000 400 200 400 800 5 10 1 1

Tarun Sahni et al Medicine Update ,Volume 14 , 2004

PHYSIOLOGICAL BASIS
(In 100 mls of blood )
Normal air (with 21%O2) Hb 95% saturated

-combined with Hb 19 mls - dissolved in plasma 0-32mls

100% O2

- combined with Hb 20 mls - dissolved in plasma 2.09 mls

TRANSCUTANEOUS OXYMETER - Tool to assess oxygen delivery to the patients skin(PERFUSION).

Hyperbaric Chambers
MONOPLACE

MULTIPLACE

MONOPLACE CHAMBER

MULTIPLACE CHAMBER IN LUMUT NAVAL BASE

Therapeutic effects of HBOT

IMMUNE STIMULATION NEOVASCULARIZATION VASOCONSTRICTION

BACTERICIDAL
REDUCES HALF LIFE OF CARBOXYHAEMOGLOBIN MECHANICAL EFFECTS REDUCES SIZE OF AIR EMBOLISM REACTIVATES SLEEPING CELLS IN THE

PENUMBRA REGION AROUND CENTRAL DEAD NEURONAL TISSUE

TOXIC EFFECTS / COMPLICATIONS (RARE)

Aural barotrauma due to blocked eustachian tube

Pneumothorax
Air Embolism Transient reversible myopia Claustrophobia Fire

with prolonged use rare

INDICATIONS OF HBOT
PRIMARY LINE OF TREATMENT
DECOMPRESSION SICKNESS AIR AND GAS EMBOLISM CARBON MONOXIDE POISONING / SMOKE

INHALATION

INDICATIONS cont
WOUNDS
PROBLEM WOUNDS DIABETIC FOOT INFECTED WOUNDS GAS GANGRENE ,

NECROTISING SOFT TISSUE INFECTIONS ACUTE TRAUMATIC ISCHAEMIAS , CRUSH INJURIES , COMPARTMENT SYNDROME COMPROMISED SKIN GRAFTS AND FLAPS THERMAL BURNS

INDICATIONS cont
ONCOLOGY

- OSTEORADIONECROSIS OF THE MANDIBLE OTHER INDICATIONS : - ACUTE SENSORINEURAL HEARING LOSS - INTRACRANIAL ABSCESSES - BELLS PALSY RESEARCH INDICATIONS : - CEREBRAL PALSY , STROKE , HEAD INJURY -AS A RADIOSENSITIZER IN GLIOBLASTOMA MULTIFORME

CONTRAINDICATION GANGRENE

CASE SERIES MEDICATED HONEY

6 diabetic patients with diabetic foot ulcers who

presented at the Diabetic Foot Care Clinic were recruited for this study History was taken Wound was assessed and the size , site recorded and scaled photographs were taken Malodour was documented At the start of treatment , wound culture swabs were taken for C& S Written consent was taken

End Points were

The removal of the infection ( bacterial burden and

wound bed preparation ) TIME CONCEPT

Prevention of amputation

Dressings
Wound cleansing Debridement

The medicated honey dressing was applied to the

wound surface A suitable secondary dressing was applied Wounds were reviewed every 48 hours Serial photographs were taken

Case Study C086 ( Diabetic Foot, Streptococcus B, E.Coli )

Case studies done by : Dr HariKrishna.R, MD; Shahanisah Ahmad, RN; Noor Hayati Arbi, RN; Diabetic Foot Clinic, Hospital Kuala Lumpur, Malaysia
45 yrs old woman, T2D, referred for amputation but she insisted NO

Prior to the treatment in Diabetic Foot Clinic, the wound was dressed with; hydrogel ( Intrasite gel ), alginate ( Kaltostat ), film dressing ( Melolin ), and paraffin gauze ( Jelonet ). Patient presented the wound at the DFC on 26/11/08 as we can see pic 1 and 2, prior treatment has had No Effect.

The Streptococcus B group and E.Coli infections were successfully managed without the use of antibiotics.

Due to the treatment with honey-based ointment, amputation of the 2nd toe of this Diabetic Type 2 patient was avoided.

The 2 wounds on the left foot of this 45 yrs woman, healed successfully in 43 days, no adverse effect was observed.

RESULTS
TABLE

DISCUSSION

Wound Healing with MEDICATED HONEY

2 Debriding 4 Reduces Malodour

1 Antimicrobial

3 Antiinflammatory

5 Stimulates healing

History of Honey 4,000 years ago

Edwin Smith Surgical Papyrus

(17th century B.C.) Case Two: Gaping headwound Treatment: After stitching treat it with grease, honey and lint every day until the patient recovers.

The history of honey

HIPPOCRATES (460375BC) GREEKS, CHINESE, ROMANS CHINESE VAN KEETAL (1892) US MEDICAL ARCHIVES

Wound Healing

Topical antiseptic for sores and wound and skin ulcers

Prevent scars: treat small-pox, diseases of the mouth and throat

Antibacterial activity reported

Prevention of infection in wounds

Laxative: coughs & sore throats, to agglutinate wounds: eye diseases

CELSIUS (C. 25AD)

Laxative: coughs & sore throats, to agglutinate wounds: eye diseases

ARISTOTLE (384-322AD)

Book on The virtues of honey in preventing many of the worst disorders and in the cure of several others
SIR JOHN HILL (1759)

For general coughs, treating Association sore throats and skin ulcers

AMERICAN PHARMACEUTICAL (1916-1935)

What is so special about

HONEY

Healing with Honey

recurrent theme that runs The the numerous publicationsthrough on clinical evidence for honey is the broad range of efficacy. No designed wound treatment can currently offer the five attributes as listed.
[ Dr. Rose Cooper , 2005 ]

Healing with Honey

5 properties of honey
Debriding Antimicrobial

Reduces Malodour Antiinflammatory

Stimulates healing

Not all supermarket honey can be used in wound healing.

Honey helps to heal wounds NATURALLY!

MONOCHROMATIC INFRARED PHOTO THERAPY (MIRE)

Infrared Therapy Systems

Professional System Model 480

Model 120 for Patients or Wound Professionals

How does
Infrared Therapy System (MIRE) works?

RBC MIRE Passes through skin

Nitric Oxide (NO)

Endothelial Cell

How Does Anodyne Therapy Work?

Releases Nitric Oxide (NO) from Hemoglobin
Nitric Oxide increases blood flow (1998 Nobel Prize)
Powerful vasodilator (arteries, veins, lymphatics) Mediator of angiogenesis Controls blood pressure

Nitric Oxide improves neural function and pain

Direct Mediator of the analgesic effect of morphine Indirect Reduces inflammation, swelling, hypoxia, ischemia

Nitric Oxide is critical for wound healing

Signaling molecule for collagen synthesis Improves collagen fibril alignment thus reducing scar tissue Anti-inflammatory Anti-bacterial/Anti-viral

Nitric Oxide mediates osteoblastic proliferation

MIRE Improves Microcirculation

Shown by MOOR Scanning Laser Doppler Image

Baseline

Anodyne 400% Increase

Placebo 40% Increase

Vasodilation after 30 Minutes

Improvement in Sensation Quantitative SWM

Journal of the American Podiatric Medical Association Mar 2002

Subjects with Diabetic Peripheral Neuropathy

Quantitative SW Monofilament 7

300 gm 100 gm
6

Deep pressure sensation only

LOPS - Insensate to 10 gram filament before MIRE

10 gm
2 gm

5.07 Monofilament
Level sensed after treatment
Normal

3 Protocol: 30 minutes 3x per week 12 sessions

30

40

50

60

70

80

90

Age
P < 0.0001 vs. Before Treatment

Improvements in Sensation, Pain, Balance

Diabetes Care January 2004
106% Increase in Light Touch Sensation
3.5 3
# Points Sensate

45% Reduction in Neuropathic Pain

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

70% Improvement in Balance/Fear of Falling

90% 80% 70%
% of Subjects

3.1
Visual Analog Scale

4.2

85%

2.5 2 1.5 1 0.5 0 # Points Sensate Before MIRE # Points Sensate After 12 Treatments

1.5

2.3

60% 50% 40% 30% 20% 10%

26%

VAS Before MIRE

VAS After 12 Treatments

0% Before MIRE After MIRE

P<0.001

P<0.0001

P<0.0001

A Randomized, Double-Blind Placebo Controlled Study Joslin Diabetes Center Morton Plant Hospital

2239 Patient Chart Review

Sensation and Pain Improvements in Peripheral Neuropathy Diabetes and Its Complications In Press
Sensation Improvement to 10 Gram Monofilament
8
# Sites Sensate to 10 gm SWM

Pain Reduction 10 Point VAS Scale

8 7
10 Point VAS Scale

7.6

7.2

P < 0.0001 for all results

7 6 5 4 3 2 1 0 Before MIRE After MIRE 2.9

6 5 4 3 2 1 0 Before MIRE After MIRE 2.4

Neuropathy studies published or submitted for publication now total over 4000 patients

79 Year Old Male - PVD

40 Year Venous Ulcer
Resolved 5 Months No Recurrence 4 Years

August 27, 1997 13.01 sq cm

Sept. 24, 1997 4.4 sq cm

May 28, 1998 4 Month Follow-up

Amputation Avoided
Glass embedded in toe surgically removed. Subject scheduled for toe amputation but refused surgery.

Sept. 3, 1997 0.64 sq cm

Oct. 29, 1997 0.18 sq cm

Dec. 3, 1997 Resolved

Resolved 3 months

CASE STUDY -MCT

Pn SL is a 65 year old charismatic lady who is non diabetic with no other comorbidities . She had a history of necrotising fasciitis . She was admitted to the Orthopaedic Ward of a tertiary hospital and then discharged after debridement and wound management . She was then discharged to the wound clinic in the same hospital. The wound was managed with advanced wound dressings . However , the wound did not heal .

Diagnosis : Non healing ulcer secondary to necrotising fasciitis .

Then she was referred to Kuala Lumpur Hospital for further management .

MANAGEMENT AT THE DFC IN HKL

WOUND ASSESSMENT WOUND CLEANSING WOUND DRESSING MICROCURRENT THERAPY

BIWEEKLY FOR FOUR WEEKS

1st Visit 22.12.2010

Bioflim. Calcitrol Ag foam dressing used

3.1.2011
Ulcer at the RT lateral lower limb

Posterior RT thigh

Posterior RT thigh

10.1.2011

27.1.2011

21.2.2011 Wound Progress

RT Lateral Ulcer healed

RT Posterior thigh

3.3.2011 Wound Progress

DISCUSSION : Micro-Current Therapy

A new novelty treatment

History of Micro-Current Therapy

Application of charged gold leaf onto wound sites to

promote healing (of smallpox scars)

Needle Acupuncture generates measurable electrical charges when twirled

Research on use of MCT in various fields have been done since 1980s Approved by US Medicare & MediAid

What is Micro-Current Therapy

Introduction of micro-amperes into the body

1 micro-amp is a millionth of an amp

1 micro-amp is 1000 times smaller than mili-amps Micro-ampere is the smallest unit of electricity flow and is naturally produced by the cells

Intracellular benefits of MCT include

70% increase in protein synthesis 30-40% increase in cell membrane transport

500% increase in ATP production and storage

Benefits of MCT
Wound Healing
200-350% increase in healing rate
Various types of wounds including arterial ulcers, decubitus

ulcers, pressure ulcers and venous ulcers Best for chronic, non/slow healing and recalcitrant wounds

Pain Management
95% success rate
Acute, sub-acute and chronic pain Highly recommended for migraines and headaches

Benefits of MCT
Muscular-skeletal complications
85-91% improvement in Range-of-Motion (ROM)
Stimulates osteogenesis, tissue repair, cartilage production

& tendon healing

Other medical conditions

Age-related Macular Degeneration (AMD)

Skin disorders, i.e. psoriasis

OTHER MODALITIES
SHOCK WAVE THERAPY FOR WOUNDS

Benefit of shock wave treatment in wound management

Extracorporeal shock waves can... increase the release of wound growth factors stimulate the expression of angiogenesis-related growth factors promote vessel ingrowth increase cell proliferation
a: the name of this author will be disclosed as soon as the corresponding study will be published

(Schaden et al., 2007; Wang et al., 2009; XXXa, 2009)

133

What type of wounds can be treated with shock waves?

Stage Grade
(according to Armstrong et al., 1998)

0 A
B C
Pre- or postulcerative lesion completely epithelialized
...with infection

1
Superficial wound, not involving tendon, capsule or bone
...with infection

2
Wound penetrating to tendon or capsule
...with infection

3
Wound penetrating to bone or joint
...with infection

...with ischemia

...with ischemia

...with ischemia

...with ischemia

...with ischemia and infection

...with ischemia and infection

...with ischemia and infection

...with ischemia and infection

NEVER treat an infected wound with shock waves (the shock waves might NEVER treat a Grade III wound with shock waves (direct exposure of bones or joints to Be careful with ischemic wounds, and NEVER treat a necrotic wound with shock waves (necrotic tissue cannot regenerate and must be removed)
134 disseminate bacteria from the wound into the body, possibly resulting in systemic infection and ultimately sepsis)

shock waves leads to incalculable risks)

EPIFLO-Transdermal Continuous Oxygen Therapy

Role of Oxygen and Wound Healing

Potentiation of antibiotics
(vancomycin, aminoglycosides e.g. gentamicin)

Fibroblast / ECM - collagen production

(proline / lysine hydroxylation with O2)

Suppression of toxin production / microbiocidal Polymorphonuclear cell function (PMNs) antimicrobial function Growth Factor Up regulation e.g. FGF, VEGF Nitric oxide increased

Central role in energy metabolism Neovascularization stimulation

NEGATIVE PRESSURE WOUND THERAPY

Negative Pressure Wound Therapy

Topical therapy that provides controlled sub-atmospheric pressure in a sealed system on the surface of a wound
Suction Pump

Sealed System Dressing Kit

Wound Interface

Recommended pressure 40-120 mmHg

*Wound fluid removal *Bacterial removal *Increased blood flow *Granulation tissue formation *Cell stimulation

GROWTH FACTORS
topical use of growth factors, artificial
skins, cultured epithelium with and without dermal components, and electrical stimulation , fibroblast growth factor (FGF), transforming growth factor beta (TGF-beta), platelet-derived growth factor (PDGF), and epidermal growth factor (EGF)

BIOTHERAPY
HIRUDOTHERAPY (LEECHES) ICTHYOTHERAPY (FISH)

APITHERAPY (BEE VENOM)

Assessment of patient
Comprehensive Assessment Multidisplinary approach
Psychosocial Health Age

Nutritional status - Protein - Vitamins Medications

Complicating condition - Vascular problem - Diabetic - Smoking - Immunosuppressive Wound Etiology - Pressure / trauma - Shearing / friction

Pain / Comfort Hygiene Stress

August 2008 HKL CME

MDT The Malaysian Scenario

145

INAUGURAL ASIA PACIFIC

WOUNDCARE CONGRESS 2012

21-24 June 2012

Sheraton Imperial
Kuala Lumpur www.mswcp.com.my

THANK YOU

NADI 2010

LUCILIA THE SAGA