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REVIEW • Rev. esc. enferm. USP 59 • 2025 • https://doi.org/10.1590/1980-220X-REEUSP-2024-0392en linkcopy

Open-access Infection assessment tools for acute and chronic wounds: a scoping review

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

    ABSTRACT

    Objective:  To map the tools available in the literature for assessing wound infection.

    Method:  This is a scoping review conducted from the Joana Briggs Institute Manual for Evidence Synthesis, in the databases of the Virtual Health Library, PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature and the academic literature repository, Google Scholar. The research question was developed based on the acronym PCC (Population/Concept/Context), resulting in the following formulation: “Which tools available in the literature assess wound infections?”

    Results:  The analysis included 32 wound infection assessment tools. Of these, 26 using clinical signs and symptoms of infection distributed across scales, checklists, classification systems, and completion forms were identified. In addition to these, 5 electronic devices and 01 software were identified.

    Conclusion:  The diversity of instruments highlights the complexity of wound infection management, emphasizing the need to discuss their applicability, benefits, and limitations to select the best evidence-based instrument.

    DESCRIPTORS
    Wound Healing; Risk Assessment; Wound Infection; Diagnostic Techniques and Procedures; Nursing

    RESUMO

    Objetivo:  Mapear as ferramentas disponíveis na literatura para avaliação de infecção em feridas.

    Método:  Trata-se de uma revisão de escopo conduzida a partir do Joana Briggs Institute Manual for Evidence Synthesis, nas bases de dados da Biblioteca Virtual em Saúde, PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature e do repositório de literatura acadêmica, Google Acadêmico. A pergunta de pesquisa foi elaborada com base no acrônimo PCC (População/Conceito/Contexto), resultando na seguinte formulação: “Quais ferramentas disponíveis na literatura avaliam infecção em feridas?”.

    Resultados:  A análise incluiu 32 ferramentas de avaliação de infecção em feridas. Dessas, foram identificadas 26 que utilizam sinais e sintomas clínicos de infecção distribuídas entre escalas, listas de verificação, sistemas de classificação e formulários de preenchimento. Além dessas, foram identificados 5 dispositivos eletrônicos, e 01 software.

    Conclusão:  A diversidade de instrumentos destaca a complexidade do manejo de infecção em feridas, enfatizando a necessidade de discutir sua aplicabilidade, benefícios e limitações para selecionar o melhor instrumento baseado em evidências.

    DESCRITORES
    Cicatrização; Avaliação de risco; Infecção dos ferimentos; Técnicas e procedimentos diagnósticos; Enfermagem

    RESUMEN

    Objetivo:  Mapear las herramientas disponibles en la literatura para evaluar la infección de heridas.

    Método:  Se trata de una revisión de alcance realizada desde el Joana Briggs Institute Manual for Evidence Synthesis, en las bases de datos de la Biblioteca Virtual en Salud, PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature y el repositorio de literatura académica, Google Scholar. La pregunta de investigación se desarrolló con base en el acrónimo PCC (Población/Concepto/Contexto), dando como resultado la siguiente formulación: “¿Qué herramientas disponibles en la literatura evalúan la infección de la herida?”

    Resultados:  El análisis incluyó 32 herramientas de evaluación de infecciones de heridas. De estos, se identificaron 26 que utilizan signos y síntomas clínicos de infección distribuidos en escalas, listas de verificación, sistemas de clasificación y formularios de llenado. Además de estos, se identificaron 5 dispositivos electrónicos y 01 software.

    Conclusión:  La diversidad de instrumentos resalta la complejidad del manejo de las infecciones de heridas, enfatizando la necesidad de discutir su aplicabilidad, beneficios y limitaciones para seleccionar el mejor instrumento basado en evidencia.

    DESCRIPTORES
    Cicatrización de Heridas; Medición de Riesgo; Infección de Heridas; Técnicas y Procedimientos Diagnósticos; Enfermería

    INTRODUCTION

    The treatment of infected wounds represents a challenge for health professionals due to the complexity involved in their management. This process includes understanding the biopsychosocial and environmental factors that interfere in the care of individuals with acute and chronic wounds. In addition, broad knowledge of the various factors influencing the healing process is required, as well as of the treatment options available, which vary according to accessibility and availability of resources and periodic monitoring of these patients(1, 2, 3).

    The presence of a wound, especially chronic ones such as pressure ulcers, neuropathic, diabetic and vascular ulcers, negatively impacts patients’ quality of life. These injuries often cause pain, limitations and social isolation, interfering with daily life activities(3). They can develop into serious complications, such as osteomyelitis and sepsis, and can even lead to death. Furthermore, they entail high costs for the healthcare system due to prolonged treatments and hospitalizations in some cases(1, 2).

    Despite existing recommendations and guidelines for the treatment and management of wounds of different etiologies, there is no consensus in the literature on the best practice to be systematically and standardly applied in care. Many professionals still deal with variability in the application of best evidence and face difficulties in identifying and assessing the severity of infections consistently(4, 5). In clinical practice, the management of wound infections is largely based on health professinals’ experiences and knowledge, often without specialization in the area of wound care(4, 6).

    Infection identification traditionally occurs through clinical and visual observation of wounds, without systematization and standardization in the evaluation. Diagnosing infection is complex, as the characteristics of the wound vary according to the etiology and the patient’s morbidities, which hinders the identification of the infectious process in some cases, especially in chronic wounds, which may present subtly or even be asymptomatic(6, 7). The lack of structured tools to assist in this identification and decision-making results in an approach that is often subjective and dependent on the experience of the healthcare professional(8, 9).

    In the literature, there are few epidemiological studies on the prevalence and incidence of infected wounds, especially in Brazil. Most existing studies in the Brazilian context indicate specific results, generally restricted to institutional levels, without a specific monitoring system integrated into health networks, and present high variability, depending on the region of the country, the type of study, and the etiology of the wound analyzed(7).

    The use of tools can be a strategy adopted in units that treat wounds as a way of standardizing their management and treatment, allowing for a more objective and systematic evaluation. This helps and guides the professional in the assessment in a structured manner, using validated and reliable instruments, especially with regard to the identification and assessment of wound infections(7, 8). It is known that the inappropriate and indiscriminate use of antimicrobials can lead to microbial resistance. Therefore, the use of tools for these conditions allows early identification of infections and timely treatment(9).

    Therefore, accurate and effective assessment to identify wound infection is essential to ensure adequate treatment and prevention of additional complications. As explained, the use of tools for assessing wound infections serves as a subsidy to assist health professionals in the adequate identification of the infection, in decision-making for timely and safe treatment, in the effective and efficient management of the injury, as well as in a systematic and organized assessment(7, 10, 11).

    Between April and May 2024, a preliminary literature search was carried out, which did not identify scoping or systematic reviews aimed at mapping tools for assessing wound infection. No records of ongoing studies were found on the PROSPERO, Open Science Framework (OSF), or Figshare platforms either. The absence of studies providing a comprehensive and systematic view of the available tools highlights a significant gap in the literature and warrants this study.

    This gap in the literature, combined with the significant impact of wound infections on individuals and healthcare systems – such as longer hospital stays, increased treatment costs, risk of serious complications and mortality(1) –, highlights the clinical and healthcare relevance of the topic. This unprecedented and essential study aims to map the tools available in the literature for evaluating wound infections.

    METHOD

    Design of Study

    This is a scoping review conducted based on the Joana Briggs Institute Manual for Evidence Synthesis(12) and in the reporting recommendations of the checklist Prisma Extension for Scoping Reviews (PRISMA – ScR)(13), to ensure methodological rigor, clarity, and organization. The protocol for this review was registered with the OSF, under DOI 10.17605/OSF.IO/57C2E. The study was developed according to the following steps: elaboration of the research question, survey of relevant studies, selection, data extraction, and presentation of results.

    Research Question

    The formulation of the research question was based on the acronym PCC (Population/Concept/Context), with the population (P) being “individuals with wounds”, the concept (C) “wound infection assessment tools”, and the context (C) “infected wounds”. With this mnemonic combination, the following guiding question was defined: Which tools available in the literature assess wound infections?

    Eligibility Criteria

    The inclusion criteria for this scoping review encompassed all available full-text manuscripts that answered the research question and were aligned with the study objective. To expand the search results, there were no restrictions regarding methodological design, publication period, or language. The context of this review was broad, with no restrictions on the care setting or any specific area of knowledge. Articles published in journals and gray literature publications, such as course completion papers, theses and dissertations, were considered.

    Any constructs, instruments, and technologies aiming at assessing wound infection were adopted as infection assessment tools for this study. Regarding etiology, both acute (such as burns, surgical and cut-contusion wounds) and chronic (such as pressure injuries, vascular, neuropathic and diabetic ulcers) injuries with healing by secondary intention were considered. Tumor wounds were excluded from the evaluation, as they have a specific pathogenesis that is different from other lesions.

    Search Strategy

    The search strategy was built based on the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH), using the Boolean operators AND and OR to optimize the retrieval of relevant information. The combinations were developed in conjunction with a librarian, considering the specifications of each database, to cover the maximum possible range of topics of interest, thus ensuring robust and comprehensive data collection, as seen in Chart 1.

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    Chart 1
    Search strategy in the databases - Rio de Janeiro, RJ, Brazil, 2024.

    The selected databases included the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, the Virtual Health Library (VHS,) and PubMed, due to their ability to bring works from different areas of health and nursing together, providing a wide variety of indexes. This choice ensured comprehensive and diverse coverage of the available literature. Additionally, gray literature was included, as recommended by JBI, through Google Scholar. The searches took place between May 1 and 17, 2024.

    Study Selection

    After searching the databases, the results found were transferred to the software Mendeley, where the identification and removal of duplicates were carried out. After removing duplicate works, articles were selected through reading of titles and abstracts, based on the criteria previously established in the study. The pre-selected papers were read in full to check for their permanence and relevance.

    The information from the documents selected for analysis was independently extracted by two reviewers, using spreadsheets from Microsoft Excel®. A third reviewer participated in the validation of the information and in the discussion to establish consensus among the authors, when required. The manuscript selection process flow is shown in diagram form, as per PRISMA-ScR recommendations.

    Data Extraction

    Data extraction was defined and adapted according to the JBI manual to select the following relevant information: year of publication, source of extraction of the tool or title of the manuscript, since some works were extracted from the same source, type of infection assessment tool, wound etiology, and the main characteristics of infection assessed by the tools.

    Data Presentation

    The extracted data were presented in table form, based on the categorized data. A narrative presentation of the information was carried out, considering the objective of this scoping review. To highlight the most common clinical characteristics identified in the data found, a word cloud was created using the Word Art website. This visual resource facilitates the understanding of findings that appear most frequently in studies.

    Ethical Aspects

    This scoping review was constructed exclusively based on publicly available secondary literature, without involving primary data or information identifying individuals. Therefore, in accordance with current ethical guidelines, there was no need to submit to the Research Ethics Committee, nor to request a Free and Informed Consent Form.

    RESULTS

    According to the previously established search strategies, the research was conducted in the selected databases and academic repositories, resulting in the following findings: 89 articles in VHL, 112 in CINAHL, 193 in PubMed, 40 in Scopus and 6,720 in Google Scholar, totaling 7,154 manuscripts. Then, duplicates were excluded using the software Mendeley, which resulted in the removal of 44 documents, leaving a total of 7,110 articles for the reading of titles and abstracts.

    After reading and analyzing the titles and abstracts, 116 manuscripts were selected for full reading, based on the eligibility criteria and the research question. Of these, 32 articles were finally included in the analysis and discussion, as described in the search and selection process flowchart presented in Figure 1.

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    Figure 1
    PRISMA-ScR flow diagram of the review publication selection process. Rio de Janeiro, RJ, Brazil, 2024.

    After analyzing the selected articles, Chart 2 was created, compiling the main information found in the selected manuscripts, to facilitate the clear and concise presentation of the data. The chart was organized and separated by year of publication, source or title of the manuscript, type of tool found, name of the tool, wound etiology, infection characteristics assessed by the tool and country(ies) of the studies.

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    Chart 2
    Characterization of the publications included in the review – Rio de Janeiro, RJ, Brazil, 2024.

    To help identify the main characteristics of infections in the studies analyzed, a word cloud was created, illustrated in Figure 2. This visual representation highlights the key clinical signs and symptoms of wound infections. The data presented reflect the most prevalent information found in the evaluated works.

    thumbnail of Figure 2
    Figure 2
    Word cloud of common signs and symptoms in publications. Rio de Janeiro, RJ, Brazil, 2024.

    The findings of this review identified 32 tools for assessing wound infection, with publications ranging from 1995 to 2023, with 13 works published in the last 5 years. Most of the tools found assess the infection qualitatively, through clinical signs and symptoms, corresponding to 26 instruments(9, 14, 15, 16, 17, 18, 20, 21, 22, 23, 26, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42). The others evaluate using more sophisticated technological resources, such as electronic equipment and devices, totaling 5 tools, and only 1 uses software for assessment of injury and infection(19, 24, 25, 27, 30, 39).

    The tools assessing infection through the signs and symptoms presented by the wound are traditional constructs, which come in different forms, ranging from forms, scales, classification systems, checklists, acronyms, explanatory booklets and algorithms, which can be printed on paper to be filled in with a pen or on digital platforms. Such tools assess infection through direct observation of the skin, lesion bed, and perilesional skin. The signs and symptoms of infection assessed vary according to the specificities of each construct and the etiology of the wound assessed(9, 14, 15, 16, 17, 18, 20, 21, 22, 23, 26, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42).

    Instruments that assess wound infections using technological resources include equipment that uses positron emission imaging combined with computed tomography, quantitative assessment of microbial load with the use of immunofluorescence images, software for recording, monitoring and analyzing wounds (including signs and symptoms of infection), sensors for evaluating odor as a predictive indicator of infection, and also the use of smartphones to help identify wound complications such as infections(19, 24, 25, 27, 30, 39).

    Among the traditional tools that assess infection based on clinical signs and symptoms, the following are distinctive: Clinical Signs and Symptoms Checklist (CSSC), Therapeutic Index for Local Infections (TILI), Infection Management Pathway, Wound Infection Continuum - International Wound Infection Institute (WIC-IWII), World Union of Wound Healing Societies (WUWHS) and the acronyms ASEPSIS, WIRE, NERDS and STONES, WIfI, IWGDF/IDSA System(9, 21, 26, 29, 36, 37, 41, 42). Other instruments were also identified in the studies analyzed, although they do not have specific names(14, 15, 16, 17, 18, 23, 28, 32, 34, 40). Classic signs and symptoms of infection mentioned in most of these tools include pain, heat, edema, erythema, purulent exudate, and odor(9, 14, 15, 16, 17, 18, 20, 21, 22, 23, 26, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42).

    Only the acronyms NERDS and STONES defined the number of signs and symptoms required to classify infection in a wound(9). No other tool has specified the number of clinical features that must be present in the lesion for the diagnosis of infection(9, 21, 26, 29, 36, 37, 41, 42). As traditional tools point out, no single sign or symptom reliably determines the presence or absence of infection in a wound. Therefore, the combination of multiple signs and symptoms indicative of infection should be used for a more accurate and safe clinical diagnosis(9, 29).

    The instruments also identified that some signs and symptoms are more specific and sensitive as predictors of infection than others. In addition, certain signs may manifest subtly or even not appear at all, depending on the type of wound and the patient’s clinical conditions(9, 34, 37, 41). The work also demonstrated that signs of inflammation - heat, erythema, edema and pain – can be present in infected wounds, and are considered classic signs of infection(9, 14, 15, 16, 19, 20, 23, 24, 27, 30, 31, 32, 33, 34, 31, 32, 33, 34, 36, 39, 40).

    Other tools analyzed have, in their composition, an item or domain that evaluates infection, among other characteristics, although they were not specifically designed for this purpose. These tools include RESVECH 2.0, DESIGN-R, Harikrishna Periwound Skin Classification (HPSC), Wound Trend Scale (WTS), Sessing Scale, the DMIST and SWAT mnemonics, as well as other unnamed tools. The most frequently identified clinical signs and symptoms of infection include: purulent exudate, foul odor, erythema, edema(16, 20, 22, 31, 33, 35, 38).

    Regarding the tools that quantitatively assess the microbial load present in the lesion bed and its concentration, the device MolecuLight and the Panasonic appliance Healthcare DU-AA01NP-H are highlighted. These devices allow for less invasive and rapid bedside infection assessment(24, 30). Additionally, the AromaScan equipment assists in monitoring wound progress and identifying possible infection based on the pattern of odors detected. Conductive polymer sensors, in turn, show changes in electrical resistance when exposed to a mixture of volatile chemicals(39).

    The use of smartphones, also found in the mapping of tools for this research, can be used to aid in the assessment of surgical wound complications such as SSI (Surgical Site Infection) or SSO (Surgical Site Occurrence), including seroma, cellulitis, hematoma, dehiscence and abscess(25). As for computed tomography, this technology has shown itself to be a possibility for identifying infection in deeper structures of the wound(27).

    Regarding the geographical distribution of the tools, 18 were identified on the American continent, 7 in Brazil, 4 in Canada, and 7 in the United States(9, 14, 15, 17, 18, 19, 23, 24, 25, 26, 31, 32, 34, 37, 38, 40). In Asia, 6 tools were found: 1 in Vietnam, 2 in Japan, 2 in China and 1 in Malaysia(16, 20, 22, 30, 35). In Europe, 8 tools were located, distributed within Germany (2), the Netherlands (2), the United Kingdom (3), and Portugal (1)(9, 21, 29, 33, 36). In other continents, no published works were found in this scoping review.

    Among the ten traditional clinical tools, specific for evaluating infection through signs and symptoms, 6 are from the European continent(9, 21, 29, 36) and 4 from the American continent(9, 26, 37). The others present some item or domain for infection assessment, but are not specific for this purpose(14, 15, 16, 17, 18, 19, 20, 22, 23, 28, 31, 32, 33, 34, 35, 38, 40). None of the Brazilian studies mapped in this review exclusively evaluate the infectious process in wounds(14, 17, 18, 19, 23, 28, 34).

    DISCUSSION

    Mapping the evidence available in the literature reveals that wound infection assessment tools have different applicability, with a predominance of instruments based on traditional approaches, which assess infection through clinical signs and symptoms observed in the lesions. This finding is in line with the main international guidelines, which recommend analyzing wound characteristics to diagnose infection. This approach stands out for being practical, accessible, fast and viable for application in different clinical scenarios, in addition to presenting good validity and reliability, allowing early diagnosis(9, 14, 15, 16, 17, 18, 20, 21, 22, 23, 26, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42).

    Clinical signs play a fundamental role in monitoring the progression of infected wounds, being key elements in guiding therapeutic decisions and assessing the response to treatment(8, 10, 29, 31, 33). Assessment tools allow these signals to be organized in a systematic way, promoting structured and more efficient monitoring(7, 9, 11). Careful analysis of clinical signs helps healthcare professionals identify early changes in the condition of the lesion, enabling timely adjustments in therapeutic interventions and contributing to improved clinical outcomes(8, 10).

    Most tools that assess infection based on clinical signs and symptoms include the cardinal signs of inflammation: pain, heat, edema, and erythema. This is justified by the fact that the inflammatory process is present in infected wounds, making these signs also relevant indicators of infection. It is known that they are not specific for infection if evaluated in isolation, but they should be considered as predictors of infection in wounds that present these characteristics without an identified cause. According to some tools, signs and symptoms of infection are still classified into classic, subtle, and systemic signs(8, 9, 14, 20, 21, 26, 29, 41, 42).

    Technological tools for assessing wound infection are less frequent in the literature, possibly due to high cost and limited availability(24, 27, 30, 39). However, these technologies can be particularly useful in contexts that require greater precision and agility. The reviewed studies suggest the need for further research to consolidate the use of these technologies in clinical practice. Despite this, they already demonstrate potential to offer a quick, safe, and less invasive diagnosis, favoring timely treatment and effective management of the infection(9, 19, 24, 25, 27, 30, 39).

    Regarding the types of wounds evaluated, it is observed that there is a diversity of etiologies, covering both acute and chronic wounds, which allows their application in different care contexts, such as primary, home, and hospital care(9, 21, 26, 29, 36, 37, 41, 42). This finding is similar to Cardinelli et al.’s (11) results, who also identified assessment instruments applicable to different etiologies and clinical scenarios.

    The literature presents a wide range of instruments for the evaluation of infected wounds, which vary from comprehensive tools capable of evaluating multiple lesions, to others more specific to certain etiologies(9, 14, 15, 16, 17, 18, 20, 21, 22, 23, 26, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42). Knowing these instruments and their particularities is essential so that health professionals can adapt care in a more precise, safe, and effective way(11).

    The use of wound assessment tools has proven to be a technology capable of improving the quality of patient care, since it guides clinical practice in the treatment and management of these injuries based on the best evidence. Its use also allows the standardization of wound analysis, reducing subjectivity in the assessment. Although the literature points to these instruments as a possibility for improving the quality of care, there are few published studies proving the effectiveness of their routine and systematic use in clinical practice(11, 43).

    The application of these technologies in the management of patients with wounds can present significant benefits; therefore, a thorough evaluation is required for an appropriate selection, depending on the context in which the injuries are managed and the objective of the evaluation. Furthermore, it is essential to understand how to use these tools correctly, to avoid their inappropriate use and, consequently, erroneous assessments(11, 43).

    With regard to the assessment of infection, the consensus of International Wound Infection Institute (IWII), formulated in 2022, presents specific tools for identifying wound infections of different etiologies. Some of these are in the psychometric validation phase, while others have already been validated for clinical use. Additionally, they include analysis of risk factors for infection(9).

    In the Brazilian context, a scoping review mapped 51 instruments available in the literature for wound assessment, of which only eight were adapted and validated for use in Brazil. However, none of these instruments are specific for wound infections. Most of the tools translated into Portuguese focus on assessing the healing process, classifying injuries and adequately preparing the wound bed to optimize treatment(11).

    Besides the variety of instruments available, it is crucial to consider the validity and reliability of assessment tools. There is no tool considered the “gold standard” for identifying wound infections, as this choice depends on the type of injury, the evaluation scenario and the available resources. Furthermore, the healthcare team must be properly trained and qualified to use infection assessment tools safely and effectively. Regardless of the instrument chosen, it is known that a reliable and validated tool helps in the care of patients with wound infections, preventing complications and promoting better decision-making(9, 11, 43).

    Despite advances in science and technology applied to wound care, there is still a significant gap in the systematization of evaluation and validation of specific tools to identify wound infections. This scoping review seeks to contribute to filling this gap by mapping existing tools, providing a comprehensive overview of their characteristics. Moreover, the research highlights the lack of validated instruments in the Brazilian context for assessing infection.

    This review results provide a basis for future clinical investigations and methodological studies aimed at creating and validating tools, strengthening evidence-based practice. By systematizing the data, this review seeks to assist health professionals in choosing appropriate methods to diagnose and manage wound infections, promoting the standardization of care and, consequently, better clinical outcomes for patients.

    CONCLUSION

    The diversity of tools for assessing wound infection available in the literature reflects the complexity and multidimensionality of managing infected wounds. These instruments range from simple forms for manual completion and global assessment of the lesion, covering different aspects such as the presence of clinical signs and symptoms of infection, to the use of more advanced and technological equipment for analysis of microbial load and imaging exams.

    The most commonly used assessment tools in clinical practice are based on clinical signs, and there are no validated instruments in Brazil to specifically identify wound infections. This study suggests the development of tools adapted to the Brazilian reality and the conduction of further research to validate the reliability, benefits, and limitations of these instruments in healthcare practice.

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    • Financial support “This study was financed in part by the Conselho Nacional de Desenvolvimento Científico e Tecnológico – Brasil (CNPq) process: 401923/2024-0 (spanish language version)”

    Edited by

    • ASSOCIATE EDITOR
      Marcia Regina Martins Alvarenga

    Publication Dates

    • Publication in this collection
      02 May 2025
    • Date of issue
      2025

    History

    • Received
      28 Nov 2024
    • Accepted
      06 Feb 2025
    Creative Common - by 4.0
    This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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