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Davies HOB, Bradbury AW. The EVRA Trial: New Hope for People with Venous Leg Ulcers? Eur J Vasc Endovasc Surg 2018; 57:163-164. [PMID: 30150076 DOI: 10.1016/j.ejvs.2018.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/24/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Huw O B Davies
- University Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, B91 2JL, UK
| | - Andrew W Bradbury
- University Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, B91 2JL, UK.
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Norman G, Westby MJ, Rithalia AD, Stubbs N, Soares MO, Dumville JC. Dressings and topical agents for treating venous leg ulcers. Cochrane Database Syst Rev 2018; 6:CD012583. [PMID: 29906322 PMCID: PMC6513558 DOI: 10.1002/14651858.cd012583.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decision-making challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents. OBJECTIVES To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality. SEARCH METHODS In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification. SELECTION CRITERIA We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We conducted this NMA using frequentist meta-regression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole. MAIN RESULTS We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts.The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty.The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency. AUTHORS' CONCLUSIONS More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.The results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost.
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Affiliation(s)
- Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Nikki Stubbs
- St Mary's HospitalLeeds Community Healthcare NHS Trust3 Greenhill RoadLeedsUKLS12 3QE
| | - Marta O Soares
- University of YorkCentre for Health EconomicsAlcuin 'A' BlockHeslingtonYorkUKYO10 5DD
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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Körber A, Jockenhöfer F, Sondermann W, Stoffels-Weindorf M, Dissemond J. [First manifestation of leg ulcers : Analysis of data from 1000 patients]. DER HAUTARZT 2018; 68:483-491. [PMID: 28280910 DOI: 10.1007/s00105-017-3950-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND More than 1 million people in Germany suffer from leg ulcers. The diagnosis leg ulcer summarizes many different etiologies. The therapy of leg ulcers is an interdisciplinary and interprofessional challenge. Early identification of the cause of the leg ulcer and initiation of a causal therapy are essential for healing. OBJECTIVES The aim of this study was to investigate the initial manifestation age of patients with causally associated leg ulcers. Afterwards we calculated the most common etiologies according to decade. PATIENTS AND METHODS A prospective database at the University Hospital Essen, dermatological wound care center, was used to identify patients with chronic leg ulcers between 2002 and 2014. Clinical data of 1000 patients with chronic leg ulcers were analyzed in this monocentric study. RESULTS A total of 29 different etiologies were differentiated. Approximately 70% of etiologies were of vascular origin, while 30% were rare causes. The count of different etiologies showed significant differences related to the onset and the occurrence in individual decades of life. In particular, nonvascular etiologies such as pyoderma gangrenosum or necrobiosis lipoidica are relatively more common in younger patients than in the aged. CONCLUSION Based on the findings of our study, it is possible to limit the underlying etiology on the basis of the age of first manifestation of the leg ulcer in order to make targeted diagnostics more effective. Thus, this information can help to optimize scarce time resources in daily practice and improve the prediction probability of leg ulcers.
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Affiliation(s)
- A Körber
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland
| | - F Jockenhöfer
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland
| | - W Sondermann
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland
| | - M Stoffels-Weindorf
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland
| | - J Dissemond
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland.
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Protz K, Heyer K, Dissemond J, Temme B, Münter KC, Verheyen-Cronau I, Klose K, Hampel-Kalthoff C, Augustin M. Compression therapy - current practice of care: level of knowledge in patients with venous leg ulcers. J Dtsch Dermatol Ges 2018; 14:1273-1282. [PMID: 27992134 DOI: 10.1111/ddg.12938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/03/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Compression therapy is a mainstay in the causal treatment of patients with venous leg ulcers. It facilitates healing, reduces pain and recurrences, and increases quality of life. Up until now, there is a scarcity of scientific data with respect to the level of care and the specific knowledge of patients with venous leg ulcers. PATIENTS AND METHODS At first presentation, patients with venous leg ulcers anonymously answered a standardized questionnaire. Participating facilities nationwide included 55 outpatient care services, 32 medical practices, four wound centers, and one specialized care center. RESULTS Overall, 177 patients (mean age of 69.4; 75.1 % women) participated in the study. The average duration of florid venous leg ulcers was 17 months. With regard to compression therapy, 31.1 % of patients received none; 40.1 % used bandages; 28.8 % used stockings. Of the latter, 13.7 % were treated with compression class III; 67.4 %, with compression class II; and 19.6 %; with compression class I. While 70.6 % put on their stockings after getting out of bed in the morning, 21.1 % wore them day and night. In 39.2 % of individuals, the stockings caused them discomfort. Merely 11.7 % owned a donning device. On average, bandages were worn for 40.7 weeks, and 69 % were used without underpadding. In 2.8 % of patients, ankle and calf circumference was measured to monitor therapeutic success. 45.9 % reported doing leg exercises. CONCLUSIONS Although it is considered a basic therapeutic measure in venous leg ulcers, one-third of all patients received no compression treatment. Moreover, given the long duration of ulcers, adequate product selection and correct use have to be questioned, too. Our findings indicate that improvements in the level of knowledge among users and prescribers as well as patient training are required.
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Affiliation(s)
- Kerstin Protz
- University Medical Center Hamburg Eppendorf, Institute for Health Services Research in Dermatology and Nursing (IVDP), CWC - Comprehensive Wound Center, Hamburg, Germany
| | - Kristina Heyer
- University Medical Center Hamburg Eppendorf, Institute for Health Services Research in Dermatology and Nursing (IVDP), CWC - Comprehensive Wound Center, Hamburg, Germany
| | - Joachim Dissemond
- Department of Dermatology, Venereology, und Allergology, University Hospital Essen, Essen, Germany
| | - Barbara Temme
- Wound Practice Berlin, Surgery, Hospital Neukölln, Berlin, Germany
| | - Karl-Christian Münter
- Group Practice Bramfeld, General Medicine, Internal Medicine and Phlebology, Hamburg, Germany
| | - Ida Verheyen-Cronau
- District Hospital Frankenberg gGmbH, Training Center for Nursing Professions, Frankenberg, Germany
| | - Katharina Klose
- University Medical Center Hamburg Eppendorf, Institute for Health Services Research in Dermatology and Nursing (IVDP), CWC - Comprehensive Wound Center, Hamburg, Germany
| | | | - Matthias Augustin
- University Medical Center Hamburg Eppendorf, Institute for Health Services Research in Dermatology and Nursing (IVDP), CWC - Comprehensive Wound Center, Hamburg, Germany
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Protz K, Heyer K, Dissemond J, Temme B, Münter KC, Verheyen-Cronau I, Klose K, Hampel-Kalthoff C, Augustin M. Kompressionstherapie - Versorgungspraxis: Informationsstand von Patienten mit Ulcus cruris venosum. J Dtsch Dermatol Ges 2018; 14:1273-1283. [PMID: 27992143 DOI: 10.1111/ddg.12938_g] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/03/2015] [Indexed: 11/30/2022]
Abstract
HINTERGRUND UND ZIELE Eine Säule der kausalen Therapie bei Patienten mit Ulcus cruris venosum ist die Kompressionstherapie. Sie unterstützt die Abheilung, reduziert Schmerzen und Rezidive und steigert die Lebensqualität. Bislang existieren kaum wissenschaftliche Daten zu dem Versorgungsstand und fachspezifischem Wissen von Patienten mit Ulcus cruris venosum. PATIENTEN UND METHODIK Standardisierte Fragebögen wurden bundesweit in 55 Pflegediensten, 32 Arztpraxen, vier Wundzentren und -sprechstunden sowie einem Pflegetherapiestützpunkt von Patienten mit Ulcus cruris venosum bei Erstvorstellung anonym ausgefüllt. ERGEBNISSE Insgesamt nahmen 177 Patienten (Durchschnittsalter 69,4 Jahre; 75,1 % Frauen) teil. Ein florides Ulcus cruris venosum bestand im Mittel 17 Monate. 31,1 % hatten keine Kompressionstherapie, 40,1 % Binden und 28,8 % Strümpfe. Bei der Bestrumpfung hatten 13,7 % Kompressionsklasse III, 64,7 % Kompressionsklasse II und 19,6 % Kompressionsklasse I. 70,6 % legten die Strümpfe nach dem Aufstehen an, 21,1 % trugen sie Tag und Nacht. 39,2 % bereiteten die Strümpfe Beschwerden. Lediglich 11,7 % hatten eine An- und Ausziehhilfe. Die Binden wurden im Mittel 40,7 Wochen getragen und bei 69 % nicht unterpolstert. Bei 2,8 % wurde der Knöchel- und Waden-Umfang zur Erfolgskontrolle gemessen. Venensport machten 45,9 %. SCHLUSSFOLGERUNGEN Ein Drittel hatte keine Kompressionsversorgung, obwohl diese eine Basismaßnahme der Therapie des Ulcus cruris venosum ist. Zudem ist deren korrekte Auswahl und Anwendung angesichts der langen Bestandsdauer der Ulzerationen zu hinterfragen. Weiterführende Fachkenntnisse bei Anwendern und Verordnern sowie Patientenschulungen sind erforderlich.
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Affiliation(s)
- Kerstin Protz
- Universitätsklinikum Hamburg Eppendorf, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), CWC - Comprehensive Wound Center, Hamburg
| | - Kristina Heyer
- Universitätsklinikum Hamburg Eppendorf, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), CWC - Comprehensive Wound Center, Hamburg
| | - Joachim Dissemond
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie am Universitätsklinikum Essen
| | - Barbara Temme
- Wundpraxis Berlin, Chirurgie, Krankenhaus Neukölln, Berlin
| | - Karl-Christian Münter
- Gemeinschaftspraxis Bramfeld, Allgemeinmedizin, innere Medizin und Phlebologie, Hamburg
| | - Ida Verheyen-Cronau
- Kreiskrankenhaus Frankenberg gGmbH, Schulzentrum für Pflegeberufe, Frankenberg
| | - Katharina Klose
- Universitätsklinikum Hamburg Eppendorf, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), CWC - Comprehensive Wound Center, Hamburg
| | | | - Matthias Augustin
- Universitätsklinikum Hamburg Eppendorf, Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), CWC - Comprehensive Wound Center, Hamburg
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Abstract
SummaryChronic ulcers (CUs) are a major cause of morbidity and mortality with increasing prevalence, in part due to the ageing population, and an increase of risk factors such as diabetes and obesity. CUs are caused by numerous diseases including venous dysfunction, diabetes mellitus, infections, peripheral neuropathy, pressure, and atherosclerosis. The current standard therapy for CUs includes compression, surgical débridement, infection control, and adequate wound dressings. As a high percentage of CUs do not adequately heal or quickly relapse with standard treatments, additional therapeutic approaches are pursued, termed “advanced wound care therapies”. Here, an overview on commonly applied therapies lacking significant evidence for wound healing is reviewed, followed by therapies with significant evidence supporting the routine use in the treatment of CUs, and a short outlook in a possible future wound treatment landscape.To give a résumé, the presented literature reveals that most of the commonly applied topical and advanced ulcer treatments largely lack solid scientific evidence for the induction or acceleration of wound healing. Surprisingly only “classical” treatments such as wound cleansing, débridement and compression have significant evidence. Novel approaches such as bilayered skin reconstructs, cell suspensions or extracorporal shock waves seem promising. Considering the increasing number of ulcer patients, there is a strong need for further basic research to fully understand all factors involved in wound development and healing of the various ulcer pathophysiologies, and the urgent need for prospective clinical trials comparing the various treatment options.
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Westby MJ, Dumville JC, Stubbs N, Norman G, Wong JKF, Cullum N, Riley R. Protease activity as a prognostic factor for wound healing in venous leg ulcers. Hippokratia 2017. [DOI: 10.1002/14651858.cd012841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Maggie J Westby
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's Hospital; Wound Prevention and Management Service; 3 Greenhill Road Leeds UK LS12 3QE
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Jason KF Wong
- University Hospital South Manchester; Plastic and Reconstructive Surgery; Southmoor Road, Wythenshawe Manchester UK M23 9LT
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Richard Riley
- Keele University; Research Institute for Primary Care and Health Sciences; David Weatherall Building, Keele University Campus Keele Staffordshire UK ST5 5BG
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Makrantonaki E, Wlaschek M, Scharffetter-Kochanek K. Pathogenesis of wound healing disorders in the elderly. J Dtsch Dermatol Ges 2017; 15:255-275. [PMID: 28252848 DOI: 10.1111/ddg.13199] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/21/2016] [Indexed: 12/25/2022]
Abstract
The elderly constitute the age group most susceptible to wound healing disorders and chronic wounds, the most prevalent being venous leg ulcers, pressure ulcers, and diabetic foot ulcers. However, other age-associated diseases should also be taken into consideration in the diagnostic workup of chronic wounds, and not be underestimated. A better understanding of the pathomechanisms involved in the wound healing process is of key importance in combatting the difficulties associated with the treatment of chronic wounds. In recent decades, considerable progress has been made in the development of pioneering therapeutic strategies for chronic wounds. In this context, the use of growth factors and cytokines, tissue engineering, and cell therapy - including stem cells - have proven very promising. Nevertheless, prior to their introduction into routine clinical practice, large controlled clinical trials are required to assess the safety of these techniques.
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Affiliation(s)
| | - Meinhard Wlaschek
- Department of Dermatology and Allergic Diseases, University Medical Center Ulm
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Catanzano O, Docking R, Schofield P, Boateng J. Advanced multi-targeted composite biomaterial dressing for pain and infection control in chronic leg ulcers. Carbohydr Polym 2017; 172:40-48. [DOI: 10.1016/j.carbpol.2017.05.040] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/27/2017] [Accepted: 05/13/2017] [Indexed: 01/10/2023]
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Pereira RF, Sousa A, Barrias CC, Bayat A, Granja PL, Bártolo PJ. Advances in bioprinted cell-laden hydrogels for skin tissue engineering. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s40898-017-0003-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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61
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Petri M, Stoffels I, Griewank K, Jose J, Engels P, Schulz A, Pötzschke H, Jansen P, Schadendorf D, Dissemond J, Klode J. Oxygenation Status in Chronic Leg Ulcer After Topical Hemoglobin Application May Act as a Surrogate Marker to Find the Best Treatment Strategy and to Avoid Ineffective Conservative Long-term Therapy. Mol Imaging Biol 2017; 20:124-130. [DOI: 10.1007/s11307-017-1103-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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62
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[German national consensus on wound documentation of leg ulcer : Part 1: Routine care - standard dataset and minimum dataset]. Hautarzt 2017; 68:740-745. [PMID: 28681135 DOI: 10.1007/s00105-017-4011-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Standards for basic documentation and the course of treatment increase quality assurance and efficiency in health care. To date, no standards for the treatment of patients with leg ulcers are available in Germany. OBJECTIVES The aim of the study was to develop standards under routine conditions in the documentation of patients with leg ulcers. This article shows the recommended variables of a "standard dataset" and a "minimum dataset". MATERIALS AND METHODS Consensus building among experts from 38 scientific societies, professional associations, insurance and supply networks (n = 68 experts) took place. After conducting a systematic international literature research, available standards were reviewed and supplemented with our own considerations of the expert group. From 2012-2015 standards for documentation were defined in multistage online visits and personal meetings. RESULTS A consensus was achieved for 18 variables for the minimum dataset and 48 variables for the standard dataset in a total of seven meetings and nine online Delphi visits. The datasets involve patient baseline data, data on the general health status, wound characteristics, diagnostic and therapeutic interventions, patient reported outcomes, nutrition, and education status. DISCUSSION Based on a multistage continuous decision-making process, a standard in the measurement of events in routine care in patients with a leg ulcer was developed.
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63
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Heyer K, Milde S, Schmitt J, May M, Helfrich J, Augustin M. [A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. Hautarzt 2017; 68:815-826. [PMID: 28567507 DOI: 10.1007/s00105-017-3990-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.
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Affiliation(s)
- K Heyer
- Competenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie (IVDP), Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - S Milde
- AOK-Bundesverband, Berlin, Deutschland
| | - J Schmitt
- Zentrum für Evidenzbasierte Gesundheitsversorgung (ZEGV), TU Dresden, Dresden, Deutschland
| | - M May
- AOK Rheinland/Hamburg, Hamburg, Deutschland
| | | | - M Augustin
- Competenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie (IVDP), Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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Fronzo C. Chronic venous disease and wound infection: approaches, prevention and outcome measures from EWMA. J Wound Care 2017; 26:350-351. [PMID: 28598763 DOI: 10.12968/jowc.2017.26.6.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In May, BSN medical hosted two clinical symposia at the 2017 EWMA conference. These described the challenges in reducing the costs of treatment for patients with chronic venous disease (CVD), the importance of compression therapy and physical activity in the management and prevention of leg ulcers, and the obstacles in treating wound infection, among other topics. Camila Fronzo, JWC chief sub editor, was there to summarise the main points of each session.
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Affiliation(s)
- Camila Fronzo
- JWC chief sub editor, was there to summarise the main points of each session
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65
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Heyer K, Protz K, Glaeske G, Augustin M. Epidemiology and use of compression treatment in venous leg ulcers: nationwide claims data analysis in Germany. Int Wound J 2017; 14:338-343. [PMID: 27199102 PMCID: PMC7949887 DOI: 10.1111/iwj.12605] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 11/26/2022] Open
Abstract
Chronic venous diseases are the most common causes of leg ulcers. Compression treatment (CT) is a central component of venous leg ulcer (VLU) therapy along with prevention based on guidelines and clinical evidence. However, large-scale data on the use of CT are rare. In particular, there have not yet been published nationwide data for Germany. We analysed data from a large German statutory health insurance (SHI) on incident VLU between 2010 and 2012. VLUs were identified by ICD-10 diagnoses. The status of active disease was defined by wound-specific treatments. Compression stockings and bandages were identified by SHI medical device codes. The overall estimated incident rate of active VLU of all insured persons was 0·34% from 2010 to 2012. Adapted to the overall German population, n = 229 369 persons nationwide had an incident VLU in 2010-2012. Among all VLU patients, only 40·6% received CT within 1 year, including 83·3% stockings, 31·8% bandages and 3·1% multi-component compression systems. Compression rates showed significant differences by gender and age. Large regional variations were observed. Validity of data is suggested by high concordance with a primary cohort study. Although recommended by guidelines, there is still a marked under-provision of care, with CT in incident VLUs in Germany requiring active measures.
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Affiliation(s)
- Kristina Heyer
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP)University Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
| | - Kerstin Protz
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP)University Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
| | - Gerd Glaeske
- Centre for Social Policy ResearchUniversity of BremenBremenGermany
| | - Matthias Augustin
- German Center for Health Services Research in Dermatology (CVderm), Institute for Health Services Research in Dermatology and Nursing (IVDP)University Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
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Norman G, Dumville JC, Westby MJ, Stubbs N, Soares MO. Dressings and topical agents for treating venous leg ulcers. Hippokratia 2017. [DOI: 10.1002/14651858.cd012583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Gill Norman
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's Hospital; Wound Prevention and Management Service; 3 Greenhill Road Leeds UK LS12 3QE
| | - Marta O Soares
- University of York; Centre for Health Economics; Alcuin 'A' Block Heslington York UK YO10 5DD
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Makrantonaki E, Wlaschek M, Scharffetter-Kochanek K. Pathogenese von Wundheilungsstörungen bei älteren Patienten. J Dtsch Dermatol Ges 2017; 15:255-278. [DOI: 10.1111/ddg.13199_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/21/2016] [Indexed: 01/13/2023]
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Järbrink K, Ni G, Sönnergren H, Schmidtchen A, Pang C, Bajpai R, Car J. The humanistic and economic burden of chronic wounds: a protocol for a systematic review. Syst Rev 2017; 6:15. [PMID: 28118847 PMCID: PMC5259833 DOI: 10.1186/s13643-016-0400-8] [Citation(s) in RCA: 257] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 12/19/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic non-healing wounds present a substantial economic burden to healthcare system; significant reductions in quality of life for those affected, and precede often serious events such as limp amputations or even premature deaths. This burden is also likely to increase with a larger proportion of elderly and increasing prevalence of life-style diseases such as obesity and diabetes. Reviews of the evidence on the burden of illness associated with chronic wounds have not been comprehensive in scope and have not provided an assessment of the distribution of the health care costs across categories of resource use. METHODS/DESIGN This study is a systematic review of multiple databases for studies on adult patients with chronic wounds and with the primary objective to assess the impact on health-related quality of life by category of ulcers, and associated direct and indirect costs. Eligible studies will primary be empirical studies evaluating, describing or comparing measurement of quality of life and economic impact. Two reviewers will independently screen titles and abstracts and select studies involving adults with chronic wounds. These investigators will also independently extract data using a pre-designed data extraction form. Differences in applied methodologies and uncertainties will clearly be accounted for. Conservative valuations of costs and impact on health-related quality of life will be prioritised. Variations that may depend on age distribution, the categorisation of ulcer, healthcare system etc. will be described clearly. DISCUSSION The proposed systematic review will yield a comprehensive assessment of the humanistic and economic burden of chronic wounds in an adult population. A better understanding of the humanistic and economic burden of chronic wounds is essential for policy and planning purposes, to monitor trends in disease burden and not at least in order to estimate the real-world cost-effectiveness of new treatments and therapies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037496.
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Affiliation(s)
- Krister Järbrink
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Gao Ni
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Henrik Sönnergren
- Department of Dermatology, Skåne University Hospital, Lasarettsgatan 15, 221 85 Lund, Sweden
| | - Artur Schmidtchen
- Dermatology and Innate Immunity Laboratory, Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Caroline Pang
- Medical Library, Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232 Singapore
| | - Ram Bajpai
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, 3rd Floor Reynolds Building, St Dunstan’s Road, London, W6 8RP UK
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Westby MJ, Norman G, Dumville JC, Stubbs N, Cullum N. Protease-modulating matrix treatments for healing venous leg ulcers. Cochrane Database Syst Rev 2016; 12:CD011918. [PMID: 27977053 PMCID: PMC6463954 DOI: 10.1002/14651858.cd011918.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous leg ulcers (VLUs) are open skin wounds on the lower leg that occur because of poor blood flow in the veins of the leg; leg ulcers can last from weeks to years, and are both painful and costly. Prevalence in the UK is about 2.9 cases per 10,000 people. First-line treatment for VLUs is compression therapy, but around 60% of people have unhealed ulcers after 12 weeks' treatment and about 40% after 24 weeks; therefore, there is scope for further improvement. Limited evidence suggests non-healing leg ulcers may have persisting elevated levels of proteases, which is thought to deter the later stages of healing; thus, timely protease-modulating matrix (PMM) treatments may improve healing by physically removing proteases from the wound fluid. OBJECTIVES To determine the effects of protease-modulating matrix (PMM) treatments on the healing of venous leg ulcers, in people managed in any care setting. SEARCH METHODS In September 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We searched for published or unpublished randomised controlled trials (RCTs) that evaluated PMM treatments for VLUs. We defined PMM treatments as those with a purposeful intent of reducing proteases. Wound healing was the primary endpoint. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included 12 studies (784 participants) in this review; sample sizes ranged from 10 to 187 participants (median 56.5). One study had three arms that were all relevant to this review and all the other studies had two arms. One study was a within-participant comparison. All studies were industry funded. Two studies provided unpublished data for healing.Nine of the included studies compared PMM treatments with other treatments and reported results for the primary outcomes. All treatments were dressings. All studies also gave the participants compression bandaging. Seven of these studies were in participants described as having 'non-responsive' or 'hard-to-heal' ulcers. Results, reported at short, medium and long durations and as time-to-event data, are summarised for the comparison of any dressing regimen incorporating PMM versus any other dressing regimen. The majority of the evidence was of low or very low certainty, and was mainly downgraded for risk of bias and imprecision.It is uncertain whether PMM dressing regimens heal VLUs quicker than non-PMM dressing regimens (low-certainty evidence from 1 trial with 100 participants) (HR 1.21, 95% CI 0.74 to 1.97).In the short term (four to eight weeks) it is unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (very low-certainty evidence, 2 trials involving 207 participants).In the medium term (12 weeks), it is unclear whether PMM dressing regimens increase the probability of healing compared with non-PMM dressing regimens (low-certainty evidence from 4 trials with 192 participants) (RR 1.28, 95% CI 0.95 to 1.71). Over the longer term (6 months), it is also unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (low certainty evidence, 1 trial, 100 participants) (RR 1.06, 95% CI 0.80 to 1.41).It is uncertain whether there is a difference in adverse events between PMM dressing regimens and non-PMM dressing regimens (low-certainty evidence from 5 trials, 363 participants) (RR 1.03, 95% CI 0.75 to 1.42). It is also unclear whether resource use is lower for PMM dressing regimens (low-certainty evidence, 1 trial involving 73 participants), or whether mean total costs in a German healthcare setting are different (low-certainty evidence, 1 trial in 187 participants). One cost-effectiveness analysis was not included because effectiveness was not based on complete healing. AUTHORS' CONCLUSIONS The evidence is generally of low certainty, particularly because of risk of bias and imprecision of effects. Within these limitations, we are unclear whether PMM dressing regimens influence venous ulcer healing relative to dressing regimens without PMM activity. It is also unclear whether there is a difference in rates of adverse events between PMM and non-PMM treatments. It is uncertain whether either resource use (products and staff time) or total costs associated with PMM dressing regimens are different from those for non-PMM dressing regimens. More research is needed to clarify the impact of PMM treatments on venous ulcer healing.
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Affiliation(s)
- Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's HospitalWound Prevention and Management Service3 Greenhill RoadLeedsUKLS12 3QE
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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Abstract
BACKGROUND One of the most significant, and growing, challenges in modern medicine, i.e. the treatment of chronic wounds, is marked by nonuniform data. This concerns both prevalence and incidence of chronic dermatosis, in particular venous ulcers (ulcus cruris), as well as the impact on the health-related quality of life, and practical and economic parameters of the success of different therapies. PURPOSE The aim of this work is to examine the epidemiology of chronic wounds, in particular age-associated venous ulcers, their impact on health-related quality of life, the treatment regimen, and practical and economic parameters of the success of different therapies. MATERIALS AND METHODS Performed were analysis of data on the care of venous ulcers in Germany, based on secondary data of Barmer GEK from 2009 and 2012, comparison with data of a NHS Kent Community Health Trust study, and analysis of studies concerning structures, processes and critical success factors for the treatment of chronic wounds, including economic effects. CONCLUSION Early causal therapy with treatment based on the stage of the wound, consequent goal-oriented interdisciplinary care, and relapse prophylaxis is critical for successful healing of venous ulcers. The costs of treatment significantly correlate with the duration of treatment which can be reduced by up to 60% using guideline-based concepts for the treatment of chronic wounds. Treatment success, in particular with regard to cost-benefit considerations, can be optimized by telemedicine networks of key players who treat chronic wounds.
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71
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Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, Morley R, O’Meara S, Goncalves PS, Soares M, Stubbs N. Wounds research for patient benefit: a 5-year programme of research. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04130] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BackgroundComplex wounds are those that heal by secondary intention and include lower-limb ulcers, pressure ulcers and some surgical wounds. The care of people with complex wounds is costly, with care mainly being delivered by community nurses. There is a lack of current, high-quality data regarding the numbers and types of people affected, care received and outcomes achieved.ObjectivesTo (1) assess how high-quality data about complex wounds can be captured effectively for use in both service planning and research while ensuring integration with current clinical data collection systems and minimal impact on staff time; (2) investigate whether or not a clinical register of people with complex wounds could give valid estimates of treatment effects, thus reducing dependence on large-scale randomised controlled trials (RCTs); (3) identify the most important research questions and outcomes for people with complex wounds from the perspectives of patients, carers and health-care professionals; (4) evaluate the potential contributions to decision-making of individual patient data meta-analysis and mixed treatment comparison meta-analysis; and (5) complete and update systematic reviews in topic areas of high priority.MethodsTo meet objectives 1 and 2 we conducted a prevalence survey and developed and piloted a longitudinal disease register. A consultative, deliberative method and in-depth interviews were undertaken to address objective 3. To address objectives 4 and 5 we conducted systematic reviews including mixed treatment comparison meta-analysis.ResultsFrom the prevalence survey we estimated the point prevalence of all complex wounds to be 1.47 per 1000 people (95% confidence interval 1.38 to 1.56 per 1000 people). Pressure ulcers and venous leg ulcers were the most common type of complex wound. A total of 195 people with a complex wound were recruited to a complex wounds register pilot. We established the feasibility of correctly identifying, extracting and transferring routine NHS data into the register; however, participant recruitment, data collection and tracking individual wounds in people with multiple wounds were challenging. Most patients and health professionals regarded healing of the wound as the primary treatment goal. Patients were greatly troubled by the social consequences of having a complex wound. Complex wounds are frequently a consequence of, and are themselves, a long-term condition but treatment is usually focused on healing the wound. Consultative, deliberative research agenda setting on pressure ulcer prevention and treatment with patients, carers and clinicians yielded 960 treatment uncertainties and a top 12 list of research priorities. Of 167 RCTs of complex wound treatments in a systematic review of study quality, 41% did not specify a primary outcome and the overall quality of the conduct and reporting of the research was poor. Mixed-treatment comparison meta-analysis in areas of high priority identified that matrix hydrocolloid dressings had the highest probability (70%) of being the most effective dressing for diabetic foot ulcers, whereas a hyaluronan fleece dressing had the highest probability (35%) of being the most effective dressing for venous ulcers; however, the quality of this evidence was low and uncertainty is high.ConclusionsComplex wounds are common and costly with a poor evidence base for many frequent clinical decisions. There is little routine clinical data collection in community nursing. A prospective complex wounds register has the potential to both assist clinical decision-making and provide important research evidence but would be challenging to implement without investment in information technology in NHS community services. Future work should focus on developing insights into typical wound healing trajectories, identifying factors that are prognostic for healing and assessing the cost-effectiveness of selected wound treatments.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Nicky Cullum
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Hannah Buckley
- Department of Health Sciences, University of York, York, UK
| | - Jo Dumville
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Jill Hall
- Department of Health Sciences, University of York, York, UK
| | - Karen Lamb
- Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Mary Madden
- Department of Health Sciences, University of York, York, UK
| | - Richard Morley
- Department of Health Sciences, University of York, York, UK
| | - Susan O’Meara
- Department of Health Sciences, University of York, York, UK
| | | | - Marta Soares
- Centre for Health Economics, University of York, York, UK
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Kröger K. [Leg ulcers - wound management instead of local wound care]. MMW Fortschr Med 2016; 158:51-54. [PMID: 27439834 DOI: 10.1007/s15006-016-8516-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Knut Kröger
- Klinik für Gefäßmedizin, HELIOS Klinik Krefeld, Lutherplatz 40, D-47805, Krefeld, Deutschland.
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Holt IGS, Green SM, Nelson EA. Oral nutritional supplements for treating venous leg ulcers. Hippokratia 2016. [DOI: 10.1002/14651858.cd012210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ian GS Holt
- Oxford Brookes University; Department of Nursing; Jack Straws Lane Marston Oxford Oxon UK OX3 0FL
| | - Sue M Green
- University of Southampton; Faculty of Healthcare Sciences; Highfield Southampton Hampshire UK SO17 1BJ
| | - E Andrea Nelson
- University of Leeds; School of Healthcare; Baines Wing Leeds UK LS2 9UT
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Heyer K, Herberger K, Protz K, Glaeske G, Augustin M. Epidemiology of chronic wounds in Germany: Analysis of statutory health insurance data. Wound Repair Regen 2016; 24:434-42. [DOI: 10.1111/wrr.12387] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/22/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Kristina Heyer
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE); Hamburg Germany
| | - Katharina Herberger
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE); Hamburg Germany
| | - Kerstin Protz
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE); Hamburg Germany
| | - Gerd Glaeske
- Center for Social Policy Research; University of Bremen; Bremen Germany
| | - Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE); Hamburg Germany
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Abstract
SummaryChronic wounds are of great socioeconomic importance. Usually they are associated with a long, complicated and burdensome course of disease and require high nursing and medical expenses. The quality of life of patients with chronic wounds is substantially impaired. This article provides a systematic overview of current studies on the morbidity and the health care situation of patients with chronic wounds, especially in patients with leg ulcers in Germany.Analyses based on routine data of statutory health insurances show higher incidence and prevalence rates, for example of patients with leg ulcers, compared with previously regional surveys. The quality of care is inadequate, particularly in diagnostics and therapy of patients with leg ulcers. To date, there is undersupply and a lack of execution and deficient knowledge about the compression treatment in patients with venous leg ulcers.Thus, there is need for further action in order to establish better implementation of guidelines in the management of patients with chronic wounds.
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Power through standards: The Federal Conference for Outcome Measurement and Benefit Assessment of Chronic Wounds. PHLEBOLOGIE 2016. [DOI: 10.12687/phleb2304-2-2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Summary
Background When concerning documentation and follow up measurement for chronic wounds, uniform standards are a vital precondition for further development of care in Germany. The Federal Consensus Conference “Outcome Measurement and Benefit Assessment for Chronic Wounds” has taken action and has approved systematic recommendations including small data records since 2013.
Aim In the following review rationales, objectives, methods and action outcomes of the Federal Consensus Conference are summarized.
Results Experts from more than 25 different scientific expert associations, professional associations, organizations specialized in care, representatives of statutory health insurance companies as well as the Federal Ministry of Health participated in the consensus formation. From 2013–2015 a total of eight consensus meetings as well as six online consensus enquiries were agreed upon. These entailed a) the relevant subject areas for consensus formation, b) the necessary standards for wound documentation, c) recommendations concerning the enquiries on quality of life for people with chronic wounds, d) recommendations for minimal clinically relevant differences, e) standards on utilization of secondary data and f) recommendations for health-economic analytics of ulcus cruris. The first four publications concerning this topic were finalized.
Conclusions The combination of personal attendance meetings and online enquiries with a broad panel of experts has proved to be an efficient tool for consensus formation regarding the documentation criteria and outcome criteria for chronic wounds using the example of ulcus cruris. The present results are subject of an active implementation in 2016/2017 and at the same time provide a chance for an improved process- and result quality concerning nationwide care.
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Borges EL, Ferraz AF, Carvalho DV, Matos SSD, Lima VLDAN. Prevenção de recidiva de úlcera varicosa: um estudo de coorte. ACTA PAUL ENFERM 2016. [DOI: 10.1590/1982-0194201600003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo Determinar a taxa de recidiva de úlcera varicosa, e verificar a associação entre recidiva e medidas de prevenção adotadas. Métodos Estudo de coorte com 50 pacientes maiores de 18 anos com úlcera varicosa pós-cicatrização acompanhados durante 10 anos. A recidiva foi avaliada por meio de inspeção direta durante a avaliação clínica, e as medidas de prevenção usadas foram informadas pelo paciente. Utilizou-se o teste qui quadrado de Pearson, sendo significante p-value ≤0,05. Resultados A recidiva de úlcera varicosa foi de 62,2%, a maioria em mulheres, seguida por idosos, analfabetos e aposentados. Mostrou-se medida eficaz na prevenção de recidivas o seguinte conjunto: uso da meia de compressão, repouso e aplicar creme hidratante. Conclusão A taxa de recidiva de úlcera varicosa foi elevada e as principais medidas de prevenção aplicadas em conjunto foram usar meia de compressão, repousar e aplicar creme hidratante.
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Norman G, Westby MJ, Stubbs N, Dumville JC, Cullum N. A 'test and treat' strategy for elevated wound protease activity for healing in venous leg ulcers. Cochrane Database Syst Rev 2016; 2016:CD011753. [PMID: 26771894 PMCID: PMC8627254 DOI: 10.1002/14651858.cd011753.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Venous leg ulcers are a common and recurring type of complex wound. They can be painful, malodorous, prone to infection and slow to heal. Standard treatment includes compression therapy and a dressing. The use of protease-modulating treatments for venous leg ulcers is increasing. These treatments are based on some evidence that a proportion of slow to heal ulcers have elevated protease activity in the wound. Point-of-care tests which aim to detect elevated protease activity are now available. A 'test and treat' strategy involves testing for elevated proteases and then using protease-modulating treatments in ulcers which show elevated protease levels. OBJECTIVES To determine the effects on venous leg ulcer healing of a 'test and treat' strategy involving detection of high levels of wound protease activity and treatment with protease-modulating therapies, compared with alternative treatment strategies such as using the same treatment for all participants or using a different method of treatment selection. SEARCH METHODS We searched the following electronic databases to identify reports of relevant randomised clinical trials: The Cochrane Wounds Group Specialised Register (January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) Issue 12, 2015); Ovid MEDLINE (1946 to January 2016); Ovid MEDLINE (In-Process & Other Non-Indexed Citations January 2016); Ovid EMBASE (1974 to January 2016); EBSCO CINAHL (1937 to January 2016). We also searched three clinical trials registers, reference lists and the websites of regulatory agencies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Published or unpublished RCTs which assessed a test and treat strategy for elevated protease activity in venous leg ulcers in adults compared with an alternative treatment strategy. The test and treat strategy needed to be the only systematic difference between the groups. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection; we planned that two authors would also assess risk of bias and extract data. MAIN RESULTS We did not identify any studies which met the inclusion criteria for this review. We identified one ongoing study; it was unclear whether this would be eligible for inclusion. AUTHORS' CONCLUSIONS Currently there is no randomised evidence on the impact of a test and treat policy for protease levels on outcomes in people with venous leg ulcers.
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Affiliation(s)
- Gill Norman
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's HospitalWound Prevention and Management Service3 Greenhill RoadLeedsUKLS12 3QE
| | - Jo C Dumville
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Nicky Cullum
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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Westby MJ, Dumville JC, Stubbs N, Norman G, Cullum N. Protease-modulating matrix treatments for healing venous leg ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011918] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
BACKGROUND Venous leg ulcers are a common and recurring type of chronic, complex wound associated with considerable cost to patients and healthcare providers. To aid healing, primary wound contact dressings are usually applied to ulcers beneath compression devices. Alginate dressings are used frequently and there is a variety of alginate products on the market, however, the evidence base to guide dressing choice is sparse. OBJECTIVES To determine the effects of alginate dressings compared with alternative dressings, non-dressing treatments or no dressing, with or without concurrent compression therapy, on the healing of venous leg ulcers. SEARCH METHODS For this first update, in March 2015, we searched the following databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of alginate dressing in the treatment of venous ulcers were included. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed feasible and appropriate. MAIN RESULTS Five RCTs (295 participants) were included in this review. All were identified during the original review. The overall risk of bias was high for two RCTs and unclear for three. One RCT compared different proprietary alginate dressings (20 participants), three compared alginate and hydrocolloid dressings (215 participants), and one compared alginate and plain non-adherent dressings (60 participants). Follow-up periods were six weeks in three RCTs and 12 weeks in two. No statistically significant between-group differences were detected for any comparison, for any healing outcome. Meta-analysis was feasible for one comparison (alginate and hydrocolloid dressings), with data from two RCTs (84 participants) pooled for complete healing at six weeks: risk ratio 0.42 (95% confidence interval 0.14 to 1.21). Adverse event profiles were generally similar between groups (not assessed for alginate versus plain non-adherent dressings). AUTHORS' CONCLUSIONS The current evidence base does not suggest that alginate dressings are more or less effective in the healing of venous leg ulcers than hydrocolloid or plain non-adherent dressings, and there is no evidence to indicate a difference between different proprietary alginate dressings. However, the RCTs in this area are considered to be of low or unclear methodological quality. Further, good quality evidence is required from well designed and rigorously conducted RCTs that employ - and clearly report on - methods to minimise bias, prior to any definitive conclusions being made regarding the efficacy of alginate dressings in the management of venous leg ulcers.
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Affiliation(s)
- Susan O'Meara
- University of LeedsSchool of HealthcareRoom LG.12, Baines WingLeedsUKLS2 9JT
| | - Marrissa Martyn‐St James
- University of SheffieldSchool of Health and Related Research (ScHARR)Regent Court, 30 Regent StreetSheffieldSouth YorkshireUKS1 4DA
| | - Una J Adderley
- University of LeedsSchool of HealthcareRoom LG.12, Baines WingLeedsUKLS2 9JT
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81
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Goepel L, Herberger K, Debus S, Diener H, Tigges W, Dissemond J, Gerber V, Augustin M. [Wound networks in Germany: structure, functions and objectives 2014]. Hautarzt 2015; 65:960-6. [PMID: 25339384 DOI: 10.1007/s00105-014-3527-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Wound networks are structured collaborations between various professions and medical disciplines in the field of treatment of patients with chronic wounds. In view of the complex chronic courses of such wounds with many relevant underlying diseases, comorbidities and a multitude of possible therapy options, the evidence-based structured treatment of patients with wound problems is of particular importance. However, this treatment is very heterogeneous and often uncoordinated. OBJECTIVE This article describes a stocktaking of the active regional wound networks in Germany with characterization of their structures, activities and objectives. METHODS A nationwide survey was carried out targeting wound specialists and wound societies as well as already established wound networks for which an updating was carried out. All identified networks were issued with a standardized questionnaire about the size of the network, extent of regional coverage, participating medical disciplines and professional groups and activities. In addition to the preformulated questions, free text information was also encouraged. RESULTS A total of 35 wound networks could be identified. The majority of networks consisted of representatives of hospitals as well as physicians in private practice and nursing personnel. The most frequently represented medical disciplines were vascular surgeons (74%), general physicians (63%), diabetologists (60%), general surgeons (60%) and dermatologists (57%). The most frequent activities were informal meetings on further education (77%), exchange of experiences and second opinions (both 71%) and consultation on patient treatment (69%). Selective contracts were only implemented in very few cases. CONCLUSION The wound networks established in Germany on self-initiatives represent strong interdisciplinary and interprofessional-oriented specialist platforms with a high potential for structured and efficient treatment. Incentives for systematic utilization of these structures in the course of improvements in quality and remuneration of treatment of patients with chronic wounds would be desirable.
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Affiliation(s)
- L Goepel
- Competenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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82
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Norman G, Westby MJ, Stubbs N, Dumville JC, Cullum N. A 'test and treat' strategy for elevated wound protease activity for healing in venous leg ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011753] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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83
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The German national consensus on wound documentation and outcomes: Rationale, working programme and current status. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.wndm.2015.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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84
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Romero-Collado A, Raurell-Torreda M, Zabaleta-del-Olmo E, Homs-Romero E, Bertran-Noguer C. Course Content Related to Chronic Wounds in Nursing Degree Programs in Spain. J Nurs Scholarsh 2014; 47:51-61. [DOI: 10.1111/jnu.12106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2014] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Edurne Zabaleta-del-Olmo
- University Institute for Primary Care Research Jordi Gol (Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol); Barcelona; Spain and Researcher associated with the Universitat Autònoma de Barcelona; Bellaterra Spain
| | - Erica Homs-Romero
- Figueres Basic Healthcare Area (Àrea Bàsica de Salut de Figueres) Catalan Health Institute (Institut Català de la Salut); Girona Spain
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85
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Augustin M, Herberger K, Kroeger K, Muenter KC, Goepel L, Rychlik R. Cost-effectiveness of treating vascular leg ulcers with UrgoStart(®) and UrgoCell(®) Contact. Int Wound J 2014; 13:82-7. [PMID: 24618370 DOI: 10.1111/iwj.12238] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/20/2013] [Accepted: 01/07/2014] [Indexed: 11/30/2022] Open
Abstract
Although chronic wounds have a high socio-economic impact, data on comparative effectiveness of treatments are rare. UrgoStart(®) is a hydroactive dressing containing a nano-oligosaccharide factor (NOSF). This study aimed at evaluating the cost-effectiveness of this NOSF-containing wound dressing in vascular leg ulcers compared with a similar neutral foam dressing (UrgoCell(®) Contact) without NOSF. Cost-effectiveness analysis from the perspective of the German statutory health care system was performed using a decision tree model for a period of 8 weeks. Cost and outcome data were derived from the clinical study 'Challenge' suggesting a response rate (≥40% wound size reduction) of UrgoStart(®) of 65·6% versus 39·4% for the comparator. In the treatment model, effect-adjusted costs of €849·86 were generated after 8 weeks for treatment with UrgoStart(®) versus €1335·51 for the comparator resulting in an effect-adjusted cost advantage of €485·64 for UrgoStart(®) . In linear sensitivity analyses, the outcomes were stable for varying assumptions on prices and response rates. In an 8-week period of treatment for vascular leg ulcers, UrgoStart(®) shows superior cost-effectiveness when compared with the similar neutral foam dressing without any active component (NOSF). As demonstrated within a randomised, double-blind clinical trial, UrgoStart(®) is also more effective in wound area reduction than the neutral foam dressing. Wound healing was not addressed in this clinical trial. Follow-up data of 12 months to allow for reulceration assessment were not generated.
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Affiliation(s)
- Matthias Augustin
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Herberger
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Lisa Goepel
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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86
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Klein S, Schreml S, Dolderer J, Gehmert S, Niederbichler A, Landthaler M, Prantl L. Evidence-based topical management of chronic wounds according to the T.I.M.E. principle. J Dtsch Dermatol Ges 2013; 11:819-29. [PMID: 23848976 DOI: 10.1111/ddg.12138] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 04/24/2013] [Indexed: 01/19/2023]
Abstract
The number of patients suffering from chronic wound healing disorders in Germany alone is estimated to be 2.5-4 million. Therapy related expenses reach 5-8 billion Euros annually. This number is partially caused by costly dressing changes due to non-standardized approaches and the application of non-evidence-based topical wound therapies. The purpose of this paper is to elucidate a straightforward principle for the management of chronic wounds, and to review the available evidence for the particular therapy options. The T.I.M.E.-principle (Tissue management, Inflammation and infection control, Moisture balance, Epithelial [edge] advancement) was chosen as a systematic strategy for wound bed preparation. Literature was retrieved from the PubMed and Cochrane Library databases and subjected to selective analysis. Topical wound management should be carried out according to a standardized principle and should further be synchronized to the phases of wound healing. Despite the broad implementation of these products in clinical practice, often no benefit exists in the rate of healing, when evaluated in meta-analyses or systematic reviews. This insufficient evidence is additionally limited by varying study designs. In case of non-superiority, the results suggest to prefer relatively inexpensive wound dressings over expensive alternatives. Arbitrary endpoints to prove the effectiveness of wound dressings, contribute to the random use of such therapies. Defining rational endpoints for future studies as well as the deployment of structured therapy strategies will be essential for the economical and evidence-based management of chronic wounds.
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Affiliation(s)
- Silvan Klein
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Germany
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Augustin M, Mayer A, Goepel LM, Baade K, Heyer K, Herberger K. Cumulative Life Course Impairment (CLCI): A new concept to characterize persistent patient burden in chronic wounds. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.wndm.2013.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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