Larva therapy in wound management

The use of maggots for wound debridement has a long history and has lately gained ground in several countries. We collected prospective data to examine the current use of larva therapy (LT) in the UK. Quantitative information was collected on 70 patients treated in nine hospitals. LT is used primarily to treat leg ulcers and generally involves three applications of larvae at two to three day intervals. This method is judged effective in wound debridement and promotes the growth of granulation tissue. Wound exudate, odour, infection and pain are all reduced by the treatment. Adverse reactions are infrequent but include pain, bleeding, pyrexia and influenza-like symptoms. Prevention of hospital admission and surgery, reduced need for antibiotics and reduced hospital stay are all identified as outcomes of LT. The nurse practitioners who used LT believed it to have an important role in wound management. A randomized clinical trial, comparing LT with other debriding agents, is required for evaluation of cost effectiveness.

The use of a non-adherent silicone dressing in arterial leg ulceration

A case report demonstrating improvement in quality of life for a patient with a non-healing leg ulcer

An impressive therapeutic result of class III compression stockings in a patient with longstanding, extensive, combined leg ulcers

BACKGROUND

Only a few publications are available in the literature concerning the treatment of venous leg ulcers by means of medical compression stockings.

SUBJECT

A 59-year-old female patient with longstanding, extensive bilateral leg ulcers due to venous insufficiency, arteriolosclerosis and secondary lymphoedema, was treated successfully by flat-knitted medical compression stockings of compression-class III.

CONCLUSION

The great advantage of this treatment is the fact that it is comfortable and easy to carry out at home. Furthermore, the costs of compression therapy with medical compression stockings are only a fraction of those of conventional therapy by means of compressive non-elastic bandages. Once or twice weekly visits of the patient to the hospital are not necessary and less specialized dermatological nurses are needed.

Oral pentoxifylline for treatment of venous leg ulcers

BACKGROUND

Healing of venous leg ulcers is improved by the use of compression bandaging but some venous ulcers do not respond to compression therapy. Pentoxifylline, a drug which helps blood flow, has been used to treat venous leg ulcers but to date there has been no systematic review.

OBJECTIVES

To assess the effects of pentoxifylline ('Trental 400') for treating venous leg ulcers, when compared with placebo, or in comparison with other therapies, in the presence or absence of compression therapy.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases and Wounds Groups specialised registers (date of search August 1999), and reference lists of relevant articles. We hand searched relevant journals and conference proceedings, and contacted Hoechst (the manufacturer of the drug) and experts in the field.

SELECTION CRITERIA

Randomised trials comparing pentoxifylline with placebo or other therapy in the presence or absence of compression, in patients with venous leg ulcers.

DATA COLLECTION AND ANALYSIS

Details from eligible trials were extracted and summarised by one reviewer using a coding sheet. Data extraction was independently verified by one other reviewer.

MAIN RESULTS

Nine trials involving 572 adults were included. The quality of trials was variable. Eight trials compared pentoxifylline with placebo; in five of these trials patients received compression therapy. In one trial pentoxifylline was compared with defibrotide in patients who also received compression. By pooling eight trials that compared pentoxifylline with placebo (with or without compression) it was found pentoxifylline was more effective than placebo in terms of complete healing or significant improvement (relative risk for healing with pentoxifylline compared with placebo 1.41, 95% confidence interval 1.19 -1.66). Pentoxifylline and compression was more effective than placebo and compression (relative risk for healing with pentoxifylline 1.30, 95% confidence interval 1.10-1.54). Combination of similar trials using compression obtained a number needed to treat (NNT) of 7 (95%confidence interval 4-17). A comparison between pentoxifylline and defibrotide found no difference in healing rates. More adverse effects were reported in the pentoxifylline group, although this was not statistically significant (relative risk for adverse effects with pentoxifylline 1. 25, 95% confidence interval 0.87-1.80). Nearly half of the adverse effects were reported to be gastro-intestinal.

REVIEWER'S CONCLUSIONS

Pentoxifylline appears to be an effective adjunct to compression bandaging for treating venous ulcers. There was no cost effectiveness data available and healthcare commissioners may therefore conclude that it not be considered a routine adjunct. Pentoxifylline in the absence of compression may be effective for treating venous ulcers in the absence of compression, although the evidence should be cautiously interpreted. The majority of adverse effects are likely to be tolerated by patients, and gastrointestinal disturbances (indigestion, diarrhoea and nausea) are the most frequent adverse effect.

Compression bandages and stockings for venous leg ulcers

OBJECTIVES

To assess the effectiveness and cost-effectiveness of compression bandaging and stockings in the treatment of venous leg ulcers.

SEARCH STRATEGY

Searches of 19 databases, hand searching of journals, conference proceedings and bibliographies. Manufacturers of compression bandages and stockings and an Advisory Panel were contacted for unpublished studies.

SELECTION CRITERIA

Trials that evaluated compression bandaging or stockings, as a treatment for venous leg ulcers. There was no restriction on date or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Details of eligible studies were extracted and summarised using a data extraction sheet. Data extraction was verified by two reviewers independently.

MAIN RESULTS

Twenty two trials reporting 24 comparisons were identified. Compression was more effective than no compression (4/6 trials). When multi-layered systems were compared, elastic compression was more effective than non-elastic compression (5 trials). There was no difference in healing rates between 4-layer bandaging and other high compression multi-layered systems (3 trials). There was no difference in healing rates between elastomeric multi-layered systems (4 trials). Multi-layered high compression was more effective than single layer compression (4 trials). Compression stockings were evaluated in two trials. One found a high compression stocking plus a thrombo stocking to be more effective than a short stretch bandage. The second small trial reported no difference between the compression stockings and Unna's boot. There was insufficient data to draw conclusion about the relative cost-effectiveness of different regimens.

REVIEWER'S CONCLUSIONS

Compression increases ulcer healing rates compared with no compression. Multi-layered systems are more effective than single-layered systems. High compression is more effective than low compression but there are no clear differences in the effectiveness of different types of high compression.

Distal venous arterialisation for salvage of critically ischaemic inoperable limbs

BACKGROUND

Amputation remains the only option in patients with extensive arterial disease in whom conventional bypass operations are not feasible. Up to 10000 amputations for vascular disease are estimated to be done annually. We investigated the use of venous perfusion as an alternative method of limb salvage.

METHODS

Over 28 months, 18 patients with critical-limb ischaemia underwent bypass procedures to the venous bed of the foot with vein, synthetic graft, or a combination of these as the conduit. Various methods were used to destroy the valves of the venous system. We followed up patients for a mean of 17 months.

FINDINGS

Three grafts failed immediately after surgery and necessitated major amputation, with one death. One late failure did not necessitate amputation. 15 patients had relief of symptoms and retained a useful pain-free limb with healing of ulcers and gangrene. Two patients with functioning grafts died at 5 months and 13 months, respectively. Three patients had successful further radiological intervention. The overall limb-salvage rate was 83% and the 1-year limb-salvage rate was 75%.

INTERPRETATION

Distal venous arterialisation is a unique procedure that has exciting possibilities for limb salvage and merits further investigation. Increased use of this procedure may help to lower the number of limbs amputated for vascular disease.

In-patient management of leg ulcers

OBJECTIVE

To review in-patient management of leg ulcers and to compare our experiences with those from other similar centres.

DESIGN

A retrospective study.

SETTING

University of Benin Teaching Hospital, Nigeria.

PATIENTS

Forty five patients hospitalised with leg ulcers.

RESULTS

There were 27 males and 18 females (MF 3:2). The age range was 8-90 years (mean 32.5 years). The commonest sites were around the ankle(55.6%) and the distal third of the leg (40%). Trauma, diabetes mellitus and sickle-cell disease accounted for the commonest aetiological factors(35.6%, 22.2% and 17.8% respectively). Coliforms and Staphylococcus aureus were the commonest organisms isolated on culture. All the patients had routine wound dressing and antibiotics but only 25 patients (56%) responded fully to this line of preliminary management. The other 20 patients had wound debridement in addition. Nineteen patients(42%) needed skin grafting while four patients (9%) had below-knee amputation.

CONCLUSION

Our experience shows that leg ulcers whose nature portend an increase in morbidity and mortality are best managed as in-patients. The underlying causes should be addressed while local wound care is administered. Skin grafting and amputation should be employed when necessary.

Issues in wound management

BACKGROUND

Over the past 30 years there has been increased interest and research into wound management and the physiology of wound healing.

OBJECTIVE

To address some of the myths associated with wound healing, and consider common questions or comments made by patients, nurses and doctors.

DISCUSSION

The most effective approach to wound management involves a thorough history and examination to identify factors that are affecting healing and instituting a management plan to control or eliminate these factors. The type of wound dressing that is appropriate can be determined by the colour, depth and amount of exudate present.

Effect of electrical stimulation on chronic wound healing: a meta-analysis

The purpose of this meta-analysis was to quantify the effect of electrical stimulation on chronic wound healing. Fifteen studies, which included 24 electrical stimulation samples and 15 control samples, were analyzed. The average rate of healing per week was calculated for the electrical stimulation and control samples. Ninety-five percentage confidence intervals were also calculated. The samples were then grouped by type of electrical stimulation device and chronic wound and reanalyzed. Rate of healing per week was 22% for electrical stimulation samples and 9% for control samples. The net effect of electrical stimulation was 13% per week, an increase of 144% over the control rate. The 95% confidence intervals of the electrical stimulation (18-26%) and control samples (3.8-14%) did not overlap. Electrical stimulation was most effective on pressure ulcers (net effect = 13%). Findings regarding the relative effectiveness of different types of electrical stimulation device were inconclusive. Although electrical stimulation produces a substantial improvement in the healing of chronic wounds, further research is needed to identify which electrical stimulation devices are most effective and which wounds respond best to this treatment.