Miscellaneous

Many health care professionals use transparent dressings on a frequent basis, but may not be aware of the purpose of these dressings. In fact, these dressings are not meant for all wounds. Read on to discover everything you ever needed to know about transparent film dressings.

Product Overview

Transparent film dressings are thin dressings which have no ability to absorb fluids. They act as a “second skin”. Imitating your outermost skin layer, they keep a moist wound environment, similar to a blister. They are semi-permeable to gases and have the ability to transmit moisture vapour. These types of dressings permit the migration of epithelial cells over the wound surface. Fluid often accumulates under these dressings.

Indications

• can be used on stage 1 and 2 pressure ulcers
• superficial wounds
• lacerations, or to cover sutured wounds
• minor burns
• to protect catheter sites and donor sites
• superficial dermal ulcers
• can be used to protect against friction

Contraindications

• must be applied to healthy skin, not to aging or fragile skin
• not recommended for infants or small children
• do not use on exudating wounds
• do not use for infected wounds

Advantages

• a cleaner wound surface is created as the accumulation of fluid under the dressing creates an autoloytic environment
• an excellent protective barrier against surface contaminants, bacteria and fluid
• provides protection from friction
• aids in pain control
• aids in autolytic debridement
• can be used as a secondary dressing
• can be left on for up to 7 days
• numerous shapes and sizes are available to fit a wide variety of wounds

Disadvantages

• fluid which accumulates under the dressing is sometimes mistakenly identified as pus
• the dressing needs to be changed when fluid accumulates excessively or leaks out the side of the dressing
• maceration of the skin around the wound (periwound) may occur if the dressing is not changed when it should be

When removing the dressing, care must be taken to ensure that you don’t tear or damage the skin. To remove, lift the corner of the dressing and pull the film outwards to the edges of the wound to break the barrier. It is important to support the surrounding skin during dressing removal.
In addition, some prefer to use skin protective sprays or wipes on the periwound area before application of the dressing. These help to keep the dressing edges from rolling.

Perhaps reading the last few articles regarding wound dressings has made you realize that there are many things you aren’t aware of when it comes to managing wounds in your client population. If so, we will be continuing our series on types of dressings over the next couple of months. If you would like to become truly expert in caring for your clients’ wounds, you may consider becoming certified in wound care management. For more information, visit www.woundeducators.com to find out how you can start today.

Source:
Baronoski, S & Ayello, E. Wound care essentials: Practice principles (2003). Edition: illustrated, Lippincott Williams & Wilkins.

Product Overview

Indications

• Should be used on clean wounds that do not contain necrotic tissue
• May be used as the only (primary) dressing for partial and full-thickness wounds
• Can be used on donor sites, split thickness skin grafts

Contraindications

• Should not be used on third-degree burns
• Not recommended for shallow or small wounds
• Should not be used for tunneling wounds
• Should not be used with wounds draining very thick exudate (will not pass through to the secondary dressing)

Advantages

• Protects new, fragile tissue from trauma
• Allows passage of exudate away from the wound bed, can be used on wounds with light, moderate, and heavy exudate
• May be left on the wound for up to a week, so that only the secondary dressing is changed
• Can be used with topical medications
• Can be used with gauze dressings
• Conform to the wound shape

Disadvantages

Require a secondary dressing that may need frequent changing due to exudate, which may not be cost effective or efficient in terms of materials and labour (i.e. gauze dressings)

“You can’t teach an old dog new tricks”. How often have we heard this saying and never thought of it as applying to ourselves? All of us can be guilty of clinging to the old and familiar at times, and wound care is no exception. Are you still attached (pardon the pun) to old ways of dressing wounds, simply because that’s the way you’ve always done things? If this applies to you, our new series of articles will provide you with an overview of all of the “new” dressings available, and when and why they should be used. It’s time to bid a fond farewell to our old friend, the traditional dressing.

Older is Not Always Better

Traditional dressings, which usually refer to gauze dressings and sometimes the application of an ointment, are quickly becoming a thing of the past, as today’s emphasis on evidence-based practice has shown these dressings to be inefficient and costly in terms of labour. Gauze dressings require frequent changing, or at least frequent remoistening, and are not cost-effective in today’s climate of cost efficiency.

Not only are they not cost-efficient, but they are not particularly effective in terms of healing, either. Ovington (2001) points out that gauze dressings, even wet-to-dry gauze dressings, cause tissue debridement, but often of healthy tissue as well. This can lead to increased pain, delayed healing, and risk of infection for the patient; thus, wet-to-dry dressings are no longer acceptable practice.

Several agents commonly used to treat wounds in the past have now become more and more obsolete, as evidence shows hem to be more harmful than helpful. Old standards, such as Betadine and peroxide, lead the pack. The Agency for Health Care Research and Policy (2008) states, “Do not use povidone iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide and acetic acid as they have been shown to be cytotoxic”. These agents may add to your patient’s discomfort and may delay healing.

The New Guard- Advanced Dressings

What can the new generation of dressings do that the old dressings can’t? You may think of the new dressings as “specialists”, each tackling specific areas of wound healing, such as:

Ÿ  Absorbing exudate

Ÿ  Maintaining hydration

Ÿ  Donating moisture

Ÿ  Addressing the biochemical wound environment

However, the most important precept of wound care has not changed: moist wound healing is still the gold standard. Research has been able to show that keeping wounds moist increases rates of healing, reduces patient discomfort, decreases rates of infection, improves cosmesis, and reduces associated costs.

Over the next several weeks, we will examine the “next generation” of advanced wound dressings, paying particular attention to indications and contraindications, as well as advantages and disadvantages of each dressing.

If you would like to know more about becoming a wound care management specialist, please visit www.woundeducators.com for more information.

References:

Ovington, L. (2007). Advances in wound dressings. Clinics in Dermatology, 25, pg. 33-38.

A healthy wound bed is the foundation upon which wound care products can do their job–promoting healing. There are five steps required to create a healthy wound bed, including the restoration of the bacterial balance, the elimination of nonviable tissue, providing a moist environment/maintaining moisture balance, and the correction of cellular dysfunction.

The final step is the restoration of biochemical balance.

Restoration of Biochemical Balance

First, wounds should not be judged based on looks alone, because red tissue does not always indicate a healthy wound. In fact, biopsies of red wounds have shown expression of excessive protein molecules derived from the circulation such as fibrin and fibrinogen, which can lead to the wound being stuck in a non-healing, red state.

The extracellular matrix (ECM), which defines the environment of cells, consists of macromolecules including proteins and polysaccharides, and provides mechanical strength and protection, functioning as a medium for cell communication such as growth factor signaling. The ECM also provides cell-matrix adhesion, which regulates cell functions in wound healing.

In normal wounds that heal properly, cells change as the wound is repaired. But in chronic wounds, those cells become lazy and stuck—they become unresponsive to any treatments and don’t function or divide as they should. This can cause a prolonged inflammatory response, as well as excessive fluid output, both of which also delay or halt the healing process.

Chronic wound fluid

This chronic wound fluid also contains chronic inflammatory cells, which cause the genetic code to normal cell death to be inhibited and delayed, which in turn causes defective extracellular matrix remodeling, reepithelialization failure, failure of wound edge migration, increase in senescent fibroblasts becoming unresponsive to growth factors, and a further increase in senescent cells. When the wound’s edges don’t migrate properly, it’s been linked to an inhibition of normal programmed cellular death (apoptosis) within fibroblasts and keratinocytes, which in turn delays healing, as well as makes using topical growth factors ineffective.

In the case of treating biochemical imbalances in wounds, one must also address the general nutritional status of the patient. Other influences that relate to biochemical imbalances, and thus can delay wound healing include conditions such as diabetes, vascular insufficiency, ischemia, and nutritional deficiencies. For any healing to be successful, treatment must also address these issues.  

Wound products can assist in the healing of chronic wounds

Products such as Xelma extracellular matrix protein, which consist of amelogenin proteins, a thickening agent propylene glycol alginate and water, can help in the healing of hard to heal ulcers, primarily venous leg ulcers. When applied to the wound bed, Xelma provides a temporary extracellular matrix protein for cell attachment, creating favorable conditions for wound healing by restoring vital cell functions, including proliferation, migration and production of growth factors and essential extracellular matrix proteins. Xelma also functions well under compression bandaging.

To learn more about advanced wound products that can assist in wound bed preperation, consider taking one of the courses offered by WoundEducators.com.

Sources
Chuck Gokoo, MD, CMO CWS, FACCWSa (2009). A Primer on Wound Bed Preparation. Journal of the American College of Certified Wound Specialists. 1, 35–39
Kathryn Vowden RGN, DPSN(TV) & Peter Vowden MD, FRCS (2002). Wound Bed Preparation. Retrieved April 14 from www.worldwidewounds.com.
Mölnlycke Health Care (2009). Retrieved April 19 from www.molnlycke.com.

Without a healthy wound bed, most wound care products are ineffective. In order to create a healthy wound bed, there are five steps required. The first three steps in wound bed preparation are the restoration of the bacterial balance, the elimination of nonviable tissue, and providing a moist environment/maintaining moisture balance.

The fourth step is what we are going to focus on right now–the correction of cellular dysfunction. (The final step is the restoration of biochemical balance, which we will discuss in the final post in this series.)

Cells play a key role in wound healing

Cells play a key role in angiogenesis (new blood vessel formation), as well as adhesion, migration, proliferation, and capillary bed formation. Keratinocytes are key cells involved in restoring the epidermal skin layer. In chronic wounds, these keratinocytes don’t lose their nuclei, thus they are incapable of normal cellular migration over the wound bed. (On the flip side, sometimes hyperproliferation of keratinocytes occurs, which is when the cells reproduce rampantly, resulting in a thick layer of cells at the wound margin.)

What happens to the wound environment in chronic wounds?

In chronic wounds, the environment is typically proinflammatory and full of high levels of cytokines and matrix metalloproteinases. In addition, this proinflammatory environment is lacking the tissue inhibitors of metalloproteinases. This out-of-balance state impairs the normal progression of wound healing and closure.

Chronic wounds are slow to heal, thanks to cells that become senescent (think lazy, old, unresponsive, unable to divide). When cells are senescent, they are also unresponsive to cytokines (protein messengers) and growth factors. Because these cells are unresponsive, chronic wounds are often inflamed, slow to close, and secrete excessive wound fluid, all of which in turn results in cellular senescence. When wound edge migration is slow or nonexistent, it stops the normal programmed cellular death within fibroblasts and keratinocytes. In other words, it’s a vicious cycle.

Systemic factors often exacerbate chronic wounds

Often, chronic wounds are exacerbated by underlying patient physiological issues, including diabetes, vascular insufficiency, ischemia, and nutritional deficiencies. When cells are unresponsive, the use of topical growth factors is often unsuccessful, as the underlying cellular dysfunction is what needs to be addressed.

The extracellular matrix plays a role in wound healing

The extracellular matrix (ECM), a structure that surrounds and supports cells, contains specialized proteins and molecular signals that are used to control the cell’s shape, migration, proliferation, differentiation, and overall survival.

Collagen is a component of the ECM, because it’s an important connective protein and structural component within cells. Collagen helps with clotting factors, promoting granulation and epithelialization, and forming a stronger tissue base for remodeling. Collagen is also a key component in products used for wound healing, as it assists in cell differentiation, cell behavior, cell migration, proliferation, and synthesis of a number of proteins, including collagen itself.

Wound dressings can promote healing in chronic wounds

Recent research has indicated the use of collagen can stimulate proliferation, migration, and the synthesis of new proteins in a chronic wound, and that adding collagen (or specifically configured denatured collagen) to wound dressings can target the nonadvancing wound edge and help promote wound closure.

Such a dressing should absorb exudate, be non-adherent to the wound bed, act as a depot for cells and proteins that help in wound closure, and contain topical antibacterial agents to maintain bacterial balance. To learn more about advanced wound products that can assist in wound bed preperation, consider taking one of the courses offered by WoundEducators.com

Register today and begin an exciting career as a certified wound specialist.

Sources

Elizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, FAPWCA, FAAN (2009). The TIME Principles of Wound Bed Preparation. Retrieved April 15 from www.woundcarejournal.com.

Frank DiCosmo, PhD (2009). Edge Effect: The Role of Collagen in Wound Healing. Retrieved April 17 from www.woundcarejournal.com.

Chuck Gokoo, MD, CMO CWS, FACCWSa (2009). A Primer on Wound Bed Preparation. Journal of the American College of Certified Wound Specialists. 1, 35–39.

Kathryn Vowden RGN, DPSN(TV) & Peter Vowden MD, FRCS (2002). Wound Bed Preparation. Retrieved April 14 from www.worldwidewounds.com.

As previously discussed, a healthy wound bed lays the foundation for wound care product effectiveness. The first two steps in wound bed preparation are the restoration of the bacterial balance, and the elimination of nonviable tissue.

 The third step is providing a moist environment and maintaining moisture balance. (The fourth and fifth steps are the correction of cellular dysfunction, and the restoration of biochemical balance, respectively, which we will discuss in the next two posts.)

How does a moist wound bed facilitate healing?

A moist wound bed facilitates healing in many ways.  Studies show that a moist wound heals three to five times faster than a dry wound. There are many reasons for this: First, by preventing scab or crust formation over the wound bed, a moist wound environment eliminates the energy and time that would have been required for the body to breakdown these materials.  Keratinocyte travel time and distance across the wound surface are greatly reduced, as the cells are able to literally swim across the moist wound bed rather than burrow down beneath the dry tissue. A moist environment also traps enzymes within the wound bed, facilitating autolytic debridement. And lastly, a moist wound environment preserves growth factors within the wound fluid, and increases fibroblast proliferation and collagen synthesis.

Why is it important to maintain moisture balance?

It is important to maintain the proper moisture balance within a wound because, while a moist wound bed facilitates healing, a wound that is too wet can actually delay healing. For example, if a wound is too wet, the wound fluid will not only pool on the wound surface, but also flow onto the intact periwound causing maceration.  Excessive moisture may stop the healing process, slowing down or even blocking the proliferation of key cells in the wound healing process such as keratinocytes, fibroblasts and endothelial cells. If left unchecked, exudate can damage the surrounding healthy skin, as well as play host to bacteria.

How can wound moisture be managed?

Wound moisture can be managed directly with the use of absorbent dressings (the wound and surrounding skin should be kept moist but not saturated, and the use of absorptive dressings that have the ability to wick up and lock in moisture to prevent periwound maceration are best), compression and/or elevation, and Topical Negative Pressure (via devises such as the VAC - Vacuum Assisted Closure).

Indirectly, exudate can be managed via the control of infection or bacterial load, control of edema by systemic therapy, and use of immunosuppression or steroids to control inflammatory exudate from wounds (such as pyoderma gangrenousum, vasculitic or rheumatoid ulcers).

Why is dressing selection so important?

A moist wound environment enhances wound healing, so the dressing you select must assist with obtaining and maintaining this type of environment. This process begins with understanding the major dressing categories and indications and contraindications for each. 

To learn more about evidence based wound management and dressing selection register for our exiting and interactive wound management training program at www.woundeducators.com .

Sources
Elizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, FAPWCA, FAAN (2009). The TIME Principles of Wound Bed Preparation. Retrieved April 15 from www.woundcarejournal.com.

Mark Chariker, MD (2009). Moisture Balance: Exploring Options in Negative Pressure Wound Therapy. Retrieved April 16 from www.woundcarejournal.com.

Chuck Gokoo, MD, CMO CWS, FACCWSa (2009). A Primer on Wound Bed Preparation. Journal of the American College of Certified Wound Specialists. 1, 35–39.

Betsy Meyers (2007). Wound Management; Principles and Practice. Upper Saddle River, Prentice Hall, PA.

Kathryn Vowden RGN, DPSN(TV) & Peter Vowden MD, FRCS (2002). Wound Bed Preparation. Retrieved April 14 from www.worldwidewounds.com.

We’ve already discussed the importance of a healthy wound bed, which lays the foundation for wound care product effectiveness. And we’ve covered the first step in wound bed preparation, otherwise known as the restoration of the bacterial balance. 

The next step in wound bed preparation is the elimination of nonviable tissue, a process known as wound debridement.

Why is debridement necessary?

Nonviable tissue is often necrotic and includes both eschar (dried-out tissue, forming a thick, leathery texture) and slough (yellow and fibrinous necrotic tissue). Removal of necrotic tissue, also known as debridement, is necessary in order to address the bioburden levels in the wound bed, stimulate growth factor activity, and eliminate senescent cells and hyperproliferative nonmigratory tissue. When addressed correctly, the former two help in healing, while the latter, when not addressed, impairs healing. The goal of debridement is to remove necrotic tissue while preserving the healthy tissue. Necrotic tissue can accumulate continually, a process that in turn requires continuous debridement.

Debridement methods

Debridement, which is technically the process of removing devitalized tissue and foreign material from a wound, can be achieved with a variety of techniques, including autolytic, biosurgery, enzymatic, mechanical, and surgical. Autolytic debridement gets rid of nonviable tissue by promoting the activities of phagocytic cells and endogenous enzymes. Biological/biosurgical debridement relies on the use of inoculating larvae that feed on the necrotic tissue in the wound. Enzymatic debridement uses exogenous agents such as proteolyic enzymes to digest necrotic tissue. Mechanical debridement utilizes gauze, which is allowed to dry on the wound and then removed (with the dead tissue adhered to the material). Hydrotherapy is also a type of mechanical debridement. Surgical debridement is just how it sounds, removing the necrotic tissue with a sharp instrument, or via ultrasound or hydrosurgery.

Determining the best debridement method

The type of debridement used depends on the patient’s overall condition and their individual treatment plan, as well as the size and position of the wound, wound etiology, the wound bed tissue involved, and moisture levels. Also taken into account are the patient’s pain tolerance, and the time available for the procedure. With chronic wounds, debridement is often conducted over a number of weeks and requires more than one method.

Wound care management is undergoing rapid changes in which new information becomes available constantly. At wound educators.com, we are committed to providing you with the latest, most up-to-date evidence-based knowledge available.

If you are interested in becoming a certified wound care specialist, visit www.woundeducators.com to learn how easy it is to take your career to the next level.

Elizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, FAPWCA, FAAN (2009). The TIME Principles of Wound Bed Preparation. Retrieved April 15 from www.woundcarejournal.com.

Chuck Gokoo, MD, CMO CWS, FACCWSa (2009). A Primer on Wound Bed Preparation. Journal of the American College of Certified Wound Specialists. 1, 35–39.

Cathy Thomas Hess, BSN, RN, CWOCN (2008). Meeting the Goal: Wound Bed Preparation. Advances in Skin & Wound Care (www.woundcarejournal.com). Vol 21, No. 7, Page 344.

Kathryn Vowden RGN, DPSN(TV) & Peter Vowden MD, FRCS (2002). Wound Bed Preparation. Retrieved April 14 from www.worldwidewounds.com.

Without a healthy wound bed, wound care products aren’t effective. But before such products can do their job, the wound bed must be prepared. The goal is a well vascularised, stable wound bed.

In order to achieve that, bacterial balance must be restored. Wounds already contain many organisms, but it is up to the clinician to recognize when a wound has become infected by assessing the wound bed and periwound tissue. (Wound bed preparation also requires the elimination of nonviable tissue, providing a moist environment and maintaining moisture balance, correction of cellular dysfunction, and restoration of biochemical balance, all of which we will discuss in the next four posts.) 

What variables affect the bacterial burden of a wound?

Four variables affect the bacterial burden of a wound: the amount of necrotic tissue, the number of microorganisms present, the bacterial virulence, and the host resistance. Host resistance is often the culprit, and can occur with conditions such as vascular disease, edema, and diabetes, as well as lifestyle issues including alcohol abuse, poor nutritional status, smoking, and immunosuppression/use of steroid medications. 

What are the local signs of infection?

Local signs of infection often include redness, warmth, edema, induration, and pain. These signs are also seen during the inflammatory and proliferative phase of wound healing, which can make it difficult to determine if the wound is infected. When any of these signs, in addition to purulent drainage, foul odor, discolored or friable granulation tissue, or tissue breakdown, are seen together, it is safe to say that bacterial infection at the wound site should be ruled out. 

How is infection determined?

 Clinical infection is determined by bacteria load; a load greater than 100,000 bacteria per gram of tissue or milliliter of fluid indicates the presence of infection. Infection is determined via tissue or punch biopsy, or with a swab culture using the Levine method. The Levine method involves rotating a swab culture over a 1-cm2 area of the wound with sufficient pressure to extract fluid from within the wound tissue. The swab must be taken after the wound is cleaned with normal saline and taken from viable tissue (bacteria growing in the tissue), not from dead or devitalized tissue.

How is wound infection treated?

When infection is present, treatment can include topical and adjunctive therapies to reduce the bacterial load, contain the exudate, and improve the wound’s granulation tissue. Oral or intravenous antibiotics may also be used to decrease the bacterial load. Because topical antimicrobials can lead to resistance and treatments must be applied frequently, antimicrobial wound dressings such as those containing silver and cadexemor iodine are a good option to manage wound bioburden.

If you are interested in learning more about wound care, or wish to become certified as a wound care specialist, visit us online at woundeducators.com to explore your options. 

Sources:

Chuck Gokoo, MD, CMO CWS, FACCWSa (2009). A Primer on Wound Bed Preparation. Journal of the American College of Certified Wound Specialists. 1, 35–39.

Cathy Thomas Hess, BSN, RN, CWOCN (2008). Meeting the Goal: Wound Bed Preparation. Advances in Skin & Wound Care (www.woundcarejournal.com). Vol 21, No. 7, Page 344.

Harriett Loehne, PT, DPT, CWS, FACCWS (2009). Managing Bacterial Burden with Silver Dressings. Wound Care Journal (www.woundcarejournal.com).

Kathryn Vowden RGN, DPSN(TV) & Peter Vowden MD, FRCS (2002). Wound Bed Preparation. Retrieved April 14 from www.worldwidewounds.com.

Odor caused by wounds can be distressing for both the patient and the caregiver who must care for them. Odor can cause the patient to feel embarrassed or ashamed, and may lead them to withdraw from their daily civilities. Patients with foul-smelling wounds are often driven to cover up the odor using various methods which may actually impede wound healing, such as the application of scented creams or too-frequent bathing. In short, malodorous wounds can have a significant impact on the patient’s life, causing depression and poor self-esteem.

For the caregiver charged with caring for the wound, the task can be an unpleasant one. Wounds may be so foul-smelling that the caregiver becomes ill, making it difficult for the caregiver to perform the arduous task of caring for these wounds. Those who have cared for such wounds know how difficult this can be.

So what can be done to address the issue of foul-smelling wounds? As it turns out, the problem is not a hopeless one.

What causes wound odor?

The breakdown of tissue through tissue death and necrosis is a common cause of wound odor. Certain bacteria that colonize wounds and release compounds can also cause odor. For example, Pseudomonas has a characteristic odor, as does Klebsiella. Anaerobes are frequently the culprit of foul odors, and any wound that suddenly becomes foul smelling has likely become colonized with anaerobes.

Many people try to manage odor using deodorizers, ventilation and charcoal dressings, but generally find these methods ineffective.

How can wound odor be combated?

The most important first step in combating odor is to ascertain the cause, or source, of the odor. The pathogen should be identified where possible. Antimicrobial wound cleansers may be used, but should contain safe ingredients. The wound should be debrided if needed. The following products may be useful:

• products containing silver

• products containing polyhexamethylene biguanide

• for systemic infections, topical and systemic antibiotics may be used

• odor-control dressings, like those containing charcoal, may be used to absorb odor molecules, preventing odor from escaping the dressing

• Cyclodextrins are naturally occurring lipids which absorb odor, and work best in a humid environment, making them ideal for heavily exudating wounds

• Metronidazole has also been used to fight odor; when used topically it can eradicate the anaerobes that cause odor. It is easy and convenient, and using Metronidazole topically does not cause the same side effects as using the drug orally can. Several studies have found topical Metronidazole to be an effective odor destroyer.

The problem of wound odor can be life-altering for the patient who lives with constant foul odor, and can be unpleasant for the caregiver as well. Every effort should be made to identify the cause of the odor. There are several products that may be effective in combating odor.

If you are interested in learning more about wound care, or wish to obtain wound care certification, visit us online at woundeducators.com to explore your options.

Alvarez, O., Comfort, C., Hernandez, L., Kalinski, C., Laboy, D., McGrinder, B.,

                Nusbaum, J., & Schnepf, M. (2005) Effectiveness of a topical formulation

                containing metronidazole for wound odor and exudate control. Wounds,17(4),

                Pp. 84-90.

Fleck, C. Fighting odor in wounds. Advances in Skin and Wound Care, 19(5), pp. 242-

                245.