Effect of Prophylactic Negative Pressure Wound Therapy vs Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery: A Randomized Clinical Trial

Negative Pressure Wound Therapy versus Conventional Dressing in Lower Limb Fractures: Systematic Review and Meta-analysis

Gustilo 3 lower limb fractures represent a significant challenge because of high complication risk. Two management strategies are commonly used for wound coverage until final closure: negative pressure wound therapy (NPWT) and conventional wound dressing (CWD), also described as standard wound coverage without subatmospheric pressure. Understanding their relative effectiveness is essential to improve patient outcomes. The aim of this systematic review and meta-analysis was to compare the efficacy of NPWT and CWD in Gustilo 3 lower limb fracture management, with a focus on overall rates, superficial infection, and deep infection rates. A systematic review of medical research databases was conducted in accordance with PRISMA guidelines. Studies comparing NPWT with CWD for Gustilo 3 fractures were included. Data extraction and quality assessment were performed. Treatment with CWD was associated with significantly higher rates of overall infection [pooled risk ratio (RR): 0.33; 95% confidence interval (CI): 0.14-0.51] and pooled risk difference (RD: 0.27; 95% CI: 0.15-0.38), superficial infection (pooled RR: 0.35; 95% CI: 0.04-0.66), and deep infection (pooled RR: 0.20; 95% CI: 0.02-0.38) compared with NPWT treatment. Overall infection rate remained significantly higher in the CWD group after analyzing only open tibia fractures (pooled RR: 0.35; 95% CI: 0.21-0.48). Nonunion rate was significant higher in the CWD group (pooled RR: 0.30; 95% CI: 0.00-0.59). Flap failure rate was similar in both groups (pooled RR: 0.09; 95% CI: -0.05 to 0.23). NPWT appears to be a reasonable option for wound management in Gustilo 3 lower limb fractures in terms of infection rates.

Peripartum interventions for people with class III obesity: a systematic review and meta-analysis

OBJECTIVE

This study aimed to identify evidence-based peripartum interventions for people with a body mass index ≥40 kg/m2.

DATA SOURCES

PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions.

STUDY ELIGIBILITY CRITERIA

Cohort and randomized controlled trials that implemented an intervention and evaluated peripartum outcomes of people with a body mass index ≥40 kg/m2 were included. The primary outcome depended on the intervention but was commonly related to wound morbidity after cesarean delivery (ie, infection, separation, hematoma).

METHODS

Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios with 95% confidence intervals and heterogeneity (I2 statistics) were reported.

RESULTS

Of 20,301 studies screened, 30 studies (17 cohort and 13 randomized controlled trials) encompassing 10 types of interventions were included. The interventions included delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, 6 types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared with planned vaginal delivery did not improve outcomes according to 3 cohort studies. One cohort study compared 3 g with 2 g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 randomized controlled trials, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort and 6 randomized controlled trials) met the inclusion criteria for the meta-analysis. Two randomized controlled trials compared subcuticular closure with suture vs staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; risk ratio, 1.09; 95% confidence interval, 0.75-1.59; I2=9%). Prophylactic negative-pressure wound therapy was compared with standard dressing in 4 cohort and 4 randomized controlled trials, which found no differences in wound morbidity (cohort n=2200; risk ratio, 1.19; 95% confidence interval, 0.88-1.63; I2=66.1%) or surgical site infections (randomized controlled trial n=1262; risk ratio, 0.90; 95% confidence interval, 0.63-1.29; I2=0).

CONCLUSION

Few studies address interventions in people with a body mass index ≥40 kg/m2, and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic negative-pressure wound therapy after cesarean delivery for people with a body mass index ≥40 kg/m2.

A Systematic Review and Meta-analysis of Two Negative Pressure Wound Therapy Devices to Manage Cesarean Section Incisions

This paper aims to evaluate whether there is a device-dependent effect on the reduction of surgical site complications in obese patients (body mass index [BMI] ≥ 30 kg/m2) undergoing cesarean section (C-section). PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for the period, January 2011 to September 2021. English language articles describing a randomized controlled trial (RCT) that compared either a -80 or -125 mm Hg single-use negative pressure wound therapy (sNPWT) device to standard dressings in obese (BMI ≥ 30 kg/m2) patients undergoing C-section were included. Conference abstracts and "terminated" RCTs with published results were deemed eligible for inclusion. The primary outcome of interest was surgical site infection (SSI), classified as composite, superficial, or deep. Secondary outcomes assessed included seroma, dehiscence, hematoma, bleeding, reoperation, readmission, blistering, and (composite) wound complications. A total of 223 titles were identified, of which 129 were screened by full-text review. Eleven RCTs encompassing 5,847 patients met the inclusion criteria and were considered eligible for further analysis (-80 mm Hg: six studies; -125 mm Hg: five studies). A statistically significant improvement in the composite SSI (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.54-0.89) and superficial SSI (OR: 0.66; 95% CI: 0.50-0.86) outcomes was observed with the -80 mm Hg device, compared with standard dressings. The same effect on SSI outcomes was not observed with the -125 mm Hg device (composite SSI-OR: 0.91; 95% CI: 0.64-1.28; superficial SSI-OR: 1.12; 95% CI: 0.70-1.78). There were no statistically significant differences in any of the other assessed outcomes. sNPWT devices may differ in their ability to reduce composite or superficial SSI after C-section. KEY POINTS: · Negative pressure benefits obese patients undergoing C-section.. · Negative pressure devices may differ in performance.. · A head-to-head clinical trial is needed..

Exploring the Limits of Artificial Intelligence for Referencing Scientific Articles

OBJECTIVE

 To evaluate the reliability of three artificial intelligence (AI) chatbots (ChatGPT, Google Bard, and Chatsonic) in generating accurate references from existing obstetric literature.

STUDY DESIGN

 Between mid-March and late April 2023, ChatGPT, Google Bard, and Chatsonic were prompted to provide references for specific obstetrical randomized controlled trials (RCTs) published in 2020. RCTs were considered for inclusion if they were mentioned in a previous article that primarily evaluated RCTs published by the top medical and obstetrics and gynecology journals with the highest impact factors in 2020 as well as RCTs published in a new journal focused on publishing obstetric RCTs. The selection of the three AI models was based on their popularity, performance in natural language processing, and public availability. Data collection involved prompting the AI chatbots to provide references according to a standardized protocol. The primary evaluation metric was the accuracy of each AI model in correctly citing references, including authors, publication title, journal name, and digital object identifier (DOI). Statistical analysis was performed using a permutation test to compare the performance of the AI models.

RESULTS

 Among the 44 RCTs analyzed, Google Bard demonstrated the highest accuracy, correctly citing 13.6% of the requested RCTs, whereas ChatGPT and Chatsonic exhibited lower accuracy rates of 2.4 and 0%, respectively. Google Bard often substantially outperformed Chatsonic and ChatGPT in correctly citing the studied reference components. The majority of references from all AI models studied were noted to provide DOIs for unrelated studies or DOIs that do not exist.

CONCLUSION

 To ensure the reliability of scientific information being disseminated, authors must exercise caution when utilizing AI for scientific writing and literature search. However, despite their limitations, collaborative partnerships between AI systems and researchers have the potential to drive synergistic advancements, leading to improved patient care and outcomes.

KEY POINTS

· AI chatbots often cite scientific articles incorrectly.. · AI chatbots can create false references.. · Responsible AI use in research is vital..

Scalable and Versatile Metal Ion Solidificated Alginate Hydrogel for Skin Wound Infection Therapy

Bacterial infections in wounds continue to be a major challenge in clinical settings worldwide and represent a significant threat to human health. This work proposes novel expandable and versatile methods for solidifying sodium alginate (SA) with metal ions (such as Fe3+ , Co2+ , Ni2+ , Cu2+ , and Zn2+ ) to create Metal-Alginate (M-Alg) hydrogel with adjustable morphology, composition, and microstructure. It conforms to the wound site, protects against second infection, reduces inflammation, and promotes the healing of infected wounds. Among these hydrogels, Cu-Alginate (Cu-Alg) shows excellent sterilization effect and good efficacy against both gram-positive and gram-negative bacteria, including multidrug-resistant (MDR) strains such as Methicillin-resistant Staphylococcus aureus (MRSA) and Carbapenem-resistant Klebsiella pneumoniae (CRKP) due to its dual antibacterial mechanisms: contact-killing and reactive oxygen species (ROS) burst. Importantly, it exhibits low cytotoxicity and biodegradability. This simple and cost-effective gel-based system has the potential to introduce an innovative approach to the management of wound infection and offers promising new perspectives for the advancement of wound care practice.

The Impact of Body Mass Index on Postpartum Infectious Morbidities and Wound Complications: A Study of Extremes

OBJECTIVE

 As body mass index increases, the risk of postpartum infections has been shown to increase. However, most studies lump women with a body mass index (BMI) of above 40 kg/m2 together, making risk assessment for women in higher BMI categories challenging. The objective of this study was to evaluate the impact of extreme obesity on postpartum infectious morbidity and wound complications during the postpartum period.

STUDY DESIGN

 The present study is a secondary analysis of women who underwent cesarean delivery and had BMI ≥ 40 kg/m2 in the Maternal-Fetal Medicine Units Cesarean Registry. The primary outcome was a composite of postpartum infectious morbidity including endometritis, wound infection, inpatient wound complication prior to discharge, and readmission due to wound complications. Appropriate statistics used to compare baseline demographics, pregnancy complications, and primary outcomes among women by increasing BMI groups (40-49.9, 50-59.9, 60-69.9, and >70 kg/m2).

RESULTS

 Rates of postpartum infectious morbidity increased with BMI category (11.7% BMI: 50-59.9 kg/m2; 13.7% BMI: 60-69.9 kg/m2; and 21.9% BMI >70+ kg/m2; p = 0.001). Readmission for wound complications also increased with BMI (3.1% for BMI: 50-59.9 kg/m2; 6.2% for BMI: 60-69.9 kg/m2; and 9.4% for BMI >70+ kg/m2; p = 0.001). After adjusting for confounders, increased BMI of 70+ kg/m2 category remained the most significant predictor of postpartum infectious complications compared with women with BMI of 40 to 49.9 kg/m2 (adjusted odds ratio [aOR] = 6.38; 95% confidence interval [CI]: 1.37-29.7). The adjusted odds of readmission also increased with BMI (aOR = 2.33, 95% CI: 1.35-4.02 for BMI 50-59.9 kg/m2; aOR = 4.91, 95% CI: 2.07-11.7 for BMI of 60-69.9 kg/m2; and aOR = 36.2, 95% CI: 7.45-176 for BMI >70 kg/m2).

CONCLUSION

 Women with BMI 50 to 70+ kg/m2 are at an increased risk of postpartum wound infections and complications compared with women with BMI 40 to 49.9 kg/m2. These data provide increased guidance for counseling women with an extremely elevated BMI and highlight the importance of postpartum wound prevention bundles.

KEY POINTS

· Women with super obesity have higher rates of wound complications.. · Women at extremes of obesity experience worse postpartum infectious morbidity.. · More research is needed on effective strategies to minimize morbidity in this population..

Effect of hydrocolloid dressings on preventing air leakage when applying negative pressure wound therapy to the perineum, buttocks, and sacrococcygeal region

Maintaining a vacuum when applying negative pressure wound therapy (NPWT) is the key to its function, which is a challenge in the perineum, buttocks, and sacrococcygeal region. A retrospective cohort study was conducted to assess the effect of hydrocolloid dressings on preventing air leakage when applying NPWT in these regions. There were 61 patients in Group A (without the aid of hydrocolloid dressings) and 65 patients in Group B (with the aid of hydrocolloid dressings). The hydrocolloid dressing-assisted NPWT significantly reduced the incidence of air leakage compared with conventional NPWT placement (24.6% vs. 7.7%; risk ratio, 3.20; 95% confidence interval, 1.24-8.27; p = 0.009), while decreasing the number of open NPWT applications (2.2 vs. 1.7; difference, 0.43; 95% confidence interval, 0.19-0.66; p < 0.001), shortening hospital stays (20.1 vs. 16.1; difference, 4.07; 95% confidence interval, 1.68-6.46; p = 0.01), and reducing the incidence of adverse skin events (18.0% vs. 4.6%; risk ratio, 3.91; 95% confidence interval, 1.14-13.34; p = 0.017). These findings support the routine use of hydrocolloid dressing-assisted NPWT placement in the perineum, buttocks, and sacrococcygeal region.

Prevention of surgical site infection and sepsis in pregnant obese women

Obesity is a major determinant of health outcomes and is on the increase in women worldwide. It predisposes to surgical site infection (SSI). Risk factors for the SSI include extremes of age, smoking, comorbidities such as hypertension and diabetes, inappropriate vertical abdominal and or uterine wall incisions, increased operating time, subcutaneous layer of 3 cm or more, and unnecessary use of subcutaneous drain. Most bacteria that cause SSIs are human commensals. Common organisms responsible for SSI include Staphylococcus aureus and coliforms such as Proteus mirabilis, and Escherichia coli. A surgeon's gloves post caesarean section in the obese has a preponderance of Firmicutes and Bacteroidetes, which increases SSI risk. The interaction of skin commensals and vaginal microbiome at the surgical incision site increases the risk of SSI in the obese compared to non-obese. Minimizing the risk of SSI involves modification of risk factors, timely treatment of SSI to prevent sepsis and compliance with the recommended care bundles.

A Randomized Controlled Trial Comparing Two Wound Dressings Used in Obstetric and Gynecological Surgeries: Trushield NXT vs. Tegaderm

Background Surgical site infection (SSI) is considered as a healthcare-associated infection. Wound dressings play an imperative role in altering the risk of SSI. In this study, we compared the efficacy and safety of Trushield NXT Non-adherent dressing (Healthium Medtech Limited, Bangalore, India) to the traditional Tegaderm HP+ Pad Film Dressing with Non-Adherent Pad (3M, Bangalore, India) in post-operative wound management of obstetrics and gynecological surgeries. Methodology This was a single-centre, prospective, two-arm, parallel-group, randomized, single-blind study conducted between January 2022 and May 2022. One hundred two subjects were enrolled and randomized to receive Trushield or Tegaderm dressing (n=51 each). The incidence of SSI, adverse events (AEs), comfort and performance of the dressings, subject satisfaction, and pain score were assessed in both groups. Results The baseline demographics and clinical and physical data were comparable among the groups. During the follow-up study, no SSI or AEs were reported. On the product usage assessment scale, surgeons rated both dressings "good" to "excellent" and favored Trushield for comfortable usage and removal, while Tegaderm was favored for ease of application and flexibility. On the wound pain assessment scale, the proportion of patients reporting "no pain" after surgery was 5.9% in the Trushield group and 4.2% in the Tegaderm group, which increased to 87.8% and 88.6%, respectively, at the end of the follow-up. The subject satisfaction for the comfort and wound healing properties was similar for both products. Conclusion Both dressings were equally safe, efficient, and beneficial in the post-operative wound management of obstetric and gynecological surgeries.

Roles of negative pressure wound therapy for scar revision

The purpose of this study is to review the research progress of negative pressure wound therapy (NPWT) for scar revision and discuss the prospects of its further study and application. The domestic and foreign literatures on NPWT for scar revision were reviewed. The mechanism and application were summarized. NPWT improves microcirculation and lymphatic flow and stimulates the growth of granulation tissues in addition to draining secretions and necrotic tissue. As a significant clinical therapy in scar revision, NPWT reduces tension, fixes graft, and improves wound bed. In the field of scar revision, NPWT has been increasingly used as an innovative and constantly improving technology.

Optimizing Surgical Wound Care in Obstetrics and Gynecology

Importance

Obstetrics and gynecology (OB/GYN) accounts for at least half of all open abdominal surgeries performed. Rates of surgical wound complications after open procedures in OB/GYN range from 5% to 35%. Therefore, optimizing management of surgical wound complications has the potential to significantly reduce cost and morbidity. However, guidelines addressing best practices for wound care in OB/GYN are limited.

Objective

The objectives of this review are to describe the fundamentals of wound healing and to evaluate available evidence addressing surgical wound care. Based on these data, we provide recommendations for management of extrafascial surgical wound dehiscence after OB/GYN procedures.

Evidence Acquisition

Literature search was performed in PubMed, Medline, OVID, and the Cochrane database. Relevant guidelines, systematic reviews, and original research articles investigating mechanisms of wound healing, types of wound closure, and management of surgical wound complications were reviewed.

Results

Surgical wound complications in OB/GYN are associated with significant cost and morbidity. One of the most common complications is extrafascial dehiscence, which may occur in the setting of hematomas, seromas, or infection. Management includes early debridement and treatment of any underlying infection until healthy granulation tissue is present. For wounds healing by secondary intention, advanced moisture retentive dressings reduce time to healing and are cost-effective when compared with conventional wet-to-dry gauze dressings. Negative pressure wound therapy can be applied to deeper wounds healing by secondary intention. Review of published evidence also supports the use of delayed reclosure to expedite wound healing for select patients.

Conclusions

Optimizing surgical wound care has the potential to reduce the cost and morbidity associated with surgical wound complications in OB/GYN. Advanced moisture retentive dressings should be considered for wounds healing by secondary intention. Data support delayed reclosure for select patients, although further studies are needed.

Cost-effectiveness of closed incision negative pressure wound therapy in preventing surgical site infection among obese women giving birth by caesarean section: An economic evaluation (DRESSING trial)

BACKGROUND

There is growing evidence regarding the potential of closed incision negative pressure wound therapy (ci-NPWT) to prevent surgical site infections (SSIs) in healing wounds by primary closure following a caesarean section (CS).

AIM

To assess the cost-effectiveness of ci-NPWT compared to standard dressings for prevention of SSI in obese women giving birth by CS.

MATERIALS AND METHODS

Cost-effectiveness and cost-utility analyses from a health service perspective were undertaken alongside a multicentre pragmatic randomised controlled trial, which recruited women with a pre-pregnancy body mass index ≥30 kg/m2 giving birth by elective/semi-urgent CS who received ci-NPWT (n = 1017) or standard dressings (n = 1018). Resource use and health-related quality of life (SF-12v2) collected during admission and for four weeks post-discharge were used to derive costs and quality-adjusted life years (QALYs).

RESULTS

ci-NPWT was associated with AUD$162 (95%CI -$170 to $494) higher cost per person and an additional $12 849 (95%CI -$62 138 to $133 378) per SSI avoided. There was no detectable difference in QALYs between groups; however, there are high levels of uncertainty around both cost and QALY estimates. There is a 20% likelihood that ci-NPWT would be considered cost-effective at a willingness-to-pay threshold of $50 000 per QALY. Per protocol and complete case analyses gave similar results, suggesting that findings are robust to protocol deviators and adjustments for missing data.

CONCLUSIONS

ci-NPWT for the prevention of SSI in obese women undergoing CS is unlikely to be cost-effective in terms of health service resources and is currently unjustified for routine use for this purpose.

A systematic review with meta-analysis on prophylactic negative pressure wound therapy versus standard dressing for obese women after caesarean section

AIMS

The purpose of this study is to assess the efficacy of prophylactic negative pressure wound therapy (NPWT) in obese women undergoing caesarean section.

DESIGN

An updated review and meta-analysis of randomized controlled trials following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

PubMed, Embase, Medline, Web of Science, and Cochrane Library were searched from inception up to March 2022 without restriction in language. We chose surgical site infection as the primary outcome.

RESULTS

NPWT resulted in a lower surgical site infection rate compared with conventional dressing (risk ratio [RR] = 0.76). The infection rate after low transverse incision was lower comparing the NPWT group with the control group ([RR] = 0.76). No statistically significant difference was detected in blistering([RR] = 2.91). The trial sequential analysis did not support the 20% relative decrease in surgical site infection in the NPWT group. (type II error of 20%).

Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis

Background

The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA).

Methods

PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995.

Findings

We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis.

Interpretation

In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence.

Funding

Dutch Association for Quality Funds Medical Specialists.

Topical negative pressure wound therapy to prevent wound complications following caesarean delivery in high-risk obstetric patients: A randomised controlled trial

BACKGROUND AND AIMS

We investigated whether the use of a prophylactic negative pressure wound therapy (NPWT) system in women undergoing caesarean would decrease wound complications in a high-risk population.

MATERIALS AND METHODS

A randomised controlled trial was performed. Women with risk factors for wound complications undergoing caesarean delivery were randomised to a standard dressing or NPWT placed over their caesarean wound. We standardised the closure of the subcutaneous fat and skin layers, both with Vicryl. Patients were followed for wound complications for up to 6 weeks after their caesareans. The incidence of wound complications was the primary outcome. The single-use NPWT system, PICO, was provided by Smith and Nephew for use in this trial. The trial was registered on clinicaltrials.gov, # NCT03082664.

RESULTS

We report here on 154 women randomised to either a standard dressing or to the NPWT. Wound complication rates were equivalent between groups, with 19.4 and 19.7% (P = 0.43) of women with follow-up information available experiencing wound complications.

CONCLUSION

We found no difference in wound complications in women with risk factors treated with a prophylactic NPWT system or standard wound dressing at the time of caesarean birth.

Meta-analysis of prophylactic negative pressure wound therapy for surgical site infections (SSI) in caesarean section surgery

Introduction

Negative pressure wound therapy (NPWT) has been used in reducing the incidence of surgical site infections (SSIs) and wound complications across various surgical categories. SSIs are a common post-surgical complication following caesarean section (CS) births, making it necessary to use prophylactic interventions to reduce SSI and wound complication incidences.

Aim

To conduct an updated meta-analysis on randomized controlled trials (RCTs) comparing SSI incidence and wound complications in women undergoing C-sections receiving NPWT or standard dressings after wound closure.

Material and methods

A systematic literature review was conducted using MEDLINE and CENTRAL databases, and clinical trial registries for RCTs that involved NPWT versus standard dressings in participants undergoing C-section procedures. The primary outcome was surgical site infection (SSI) and other wound complications (haematoma, dehiscence, seroma.

Results

A total of 11 RCTs were included in the meta-analysis with information from 5,693 patients. A reduction in overall SSI incidence (RR = 0.79, 95% CI: 0.66-0.95, p = 0.01, I2 = 0%) and wound complication rate (RR = 0.86, 0.75 to 0.98, p = 0.02, I2 = 5%) was found with all studies pooled together. Subgroup analyses showed that NPWT did not significantly reduce SSI incidence when stratified by the type of C-section (emergency/elective) whereas the type of NPWT device had a differential effect on SSI reduction, with PICO NPWT systems showing a beneficial effect (RR = 0.72, 0.58 to 0.91, p = 0.006, I2 = 0%) in comparison to the PREVENA closed-incision device (RR = 0.94, 0.68 to 1.29, p = 0.73, I2 = 0%).

Conclusions

Prophylactic NPWT is useful in reducing the incidence of SSIs in women undergoing C-sections based on synthesis of results from RCTs in obese women (BMI > 30 kg/m2).

Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery

Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.

Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis

Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes.

Methods

A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments.

Results

The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use (P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT (P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay (P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use (P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT (P < 0.05).

Discussion

For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients.

Use of closed incision negative pressure wound therapy on C-section wounds in obese women

Rates of obesity in pregnant women are increasing. Obesity is linked to increased patient risk of developing postoperative wound complications such as surgical site infection, wound dehiscence and haematoma formation. Closed incision negative pressure wound therapy (ciNPWT) has been introduced as a prophylactic intervention to reduce caesarian section (C-section) wound complications. Evidence from randomised controlled trials and retrospective studies has shown variable rates of success in reducing risk of SSI. The studies reviewed in this article found that ciNPWT had no statistically significant impact in reducing rates of wound dehiscence and haematoma formation or increasing long-term satisfaction with the appearance of scar tissue following C-section. Further research into the use of cINPWT to prevent surgical site infection is needed to determine the effectiveness of this therapy in reducing this wound complication.

Participation in obstetrical studies is associated with improved pregnancy outcomes

BACKGROUND

The association between pregnant patients participating in obstetrical studies and pregnancy outcomes is understudied.

OBJECTIVE

This study aimed to evaluate the association between participation in obstetrical studies and maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of all patients delivering at a single center from 2013 to 2018. Patients with pregnancy loss at <13 weeks of gestation or major fetal anomalies were excluded. Patients who enrolled in one or more obstetrical studies were categorized as "study participants" and were compared with patients who did not enroll in an obstetrical study, that is, "study nonparticipants." The primary outcome was a composite of maternal morbidity diagnosed up to 6 weeks after delivery. The secondary outcomes included composite neonatal morbidity and other perinatal outcomes. Bivariate analyses compared baseline demographics and outcomes between groups. Multivariable logistic regression was used to estimate adjusted odds ratios with 95% confidence intervals. Subgroup analyses by study design (trial or observational) were planned.

RESULTS

Of 19,569 patients included in this analysis, 3848 (19.7%) were study participants, and 15,721 (80.3%) were study nonparticipants. Among study participants, 3023 (78.6%) enrolled in a trial, and 825 (21.4%) enrolled in an observational study. The study participants had higher body mass index and were more likely to be younger, non-Hispanic Black, publicly insured, nulliparous, and undergo cesarean delivery than study nonparticipants. Compared with study nonparticipants, the study participants had significantly lower odds of composite maternal morbidity (9.2% vs 8.7%; adjusted odds ratio, 0.83; 95% confidence interval, 0.73-0.95) and composite neonatal morbidity (27.5% vs 18.6%; adjusted odds ratio, 0.53; 95% confidence interval, 0.48-0.58). In addition, the odds of fetal death, 5-minute Apgar score of <5, neonatal death, maternal and neonatal intensive care unit admissions, and lengths of stay were lower for study participants than for study nonparticipants. In stratified analyses, maternal morbidity was only significantly decreased among trial participants; however, there was a significantly reduced odds of neonatal morbidity, regardless of study design (trial or observational vs no study).

CONCLUSION

Participation in obstetrical studies was associated with decreased maternal and neonatal morbidities after adjusting for potential confounders. This underscored the importance of pregnant patients enrolling in obstetrical clinical studies and potentially benefiting from the additional surveillance. Further study of how study participation exerts this effect on pregnancy outcomes is warranted.

Rational Design of Intelligent and Multifunctional Dressing to Promote Acute/Chronic Wound Healing

Currently, the clinic's treatment of acute/chronic wounds is still unsatisfactory due to the lack of functional and appropriate wound dressings. Intelligent and multifunctional dressings are considered the most advanced wound treatment modalities. It is essential to design and develop wound dressings with required functions according to the wound microenvironment in the clinical treatment. This work summarizes microenvironment characteristics of various common wounds, such as acute wound, diabetic wound, burns wound, scalded wound, mucosal wound, and ulcers wound. Furthermore, the factors of transformation from acute wounds to chronic wounds were analyzed. Then we focused on summarizing how researchers fully and thoroughly combined the complex microenvironment with modern advanced technology to ensure the usability and value of the dressing, such as photothermal-sensitive dressings, microenvironment dressing (pH-sensitive dressings, ROS-sensitive dressings, and osmotic pressure dressings), hemostatic dressing, guiding tissue regeneration dressing, microneedle dressings, and 3D/4D printing dressings. Finally, the revolutionary development of wound dressings and how to transform the existing advanced functional dressings into clinical needs as soon as possible have carried out a reasonable and meaningful outlook.

Incidence and risk factors for surgical wound complications in women with body mass index >30 kg/m2 following cesarean delivery: a secondary analysis

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Prophylactic negative pressure wound therapy on wound complications after cesarean delivery in women with obesity: a meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials aimed to assess whether negative pressure wound therapy affects the rate of wound complications when applied to women with obesity after cesarean delivery compared with standard postoperative dressings.

DATA SOURCES

This research used PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to January 2021, with randomized controlled trial as the publication type. There was no restriction applied for language or geographic location.

STUDY ELIGIBILITY CRITERIA

The selection criteria included only randomized controlled trials comparing the effect of negative pressure wound therapy with that of standard dressings on wound complications in women with obesity undergoing cesarean delivery.

METHODS

The primary outcome was a wound complication composite outcome (wound infection, separation or dehiscence, hematoma, seroma, or readmission secondary to a wound concern). The wound complication composite was analyzed by counting events once per patient. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random-effects model of DerSimonian and Laird. An I-squared (Higgins I²) value of >0% was used to identify heterogeneity.

RESULTS

Overall, 11 randomized controlled trials, which included 5746 participants with obesity undergoing cesarean delivery, were included. Of those participants, 2869 (49.9%) were randomized to the intervention group (negative pressure wound therapy), and 2877 (50.1%) were randomized to the control group (standard dressing). Prophylactic negative pressure wound therapy was not associated with a significant change in the rate of wound complications (relative risk, 1.00; 95% confidence interval, 0.81-1.23) compared with standard postoperative dressings. However, the use of negative pressure wound therapy decreased the rate of wound infections (relative risk, 0.79; 95% confidence interval, 0.66- 0.96) and increased the frequency of skin reactions (relative risk, 4.59; 95% confidence interval, 1.29-16.38). Negative pressure wound therapy did not result in a significant difference in the rate of dehiscence, hematoma, seroma, readmission, reoperation, and antibiotic use for wound infection.

CONCLUSION

Compared with standard postoperative incision dressings, negative pressure wound therapy did not affect the rate of wound complications but decreased the frequency of wound infections when applied to women with obesity after cesarean delivery. However, results should be interpreted with caution, as wound infection outcome includes different definitions per the individual trials.

CONDENSATION

Prophylactic negative pressure wound therapy has no effect on overall wound complications in women with obesity after cesarean delivery compared with standard dressings.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In January 2021, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane risk of bias tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Our primary outcomes were SSI, mortality, and wound dehiscence.

MAIN RESULTS

In this fourth update, we added 18 new randomised controlled trials (RCTs) and one new economic study, resulting in a total of 62 RCTs (13,340 included participants) and six economic studies. Studies evaluated NPWT in a wide range of surgeries, including orthopaedic, obstetric, vascular and general procedures. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Eleven studies (6384 participants) which reported mortality were pooled. There is low-certainty evidence showing there may be a reduced risk of death after surgery for people treated with NPWT (0.84%) compared with standard dressings (1.17%) but there is uncertainty around this as confidence intervals include risk of benefits and harm; risk ratio (RR) 0.78 (95% CI 0.47 to 1.30; I² = 0%). Fifty-four studies reported SSI; 44 studies (11,403 participants) were pooled. There is moderate-certainty evidence that NPWT probably results in fewer SSIs (8.7% of participants) than treatment with standard dressings (11.75%) after surgery; RR 0.73 (95% CI 0.63 to 0.85; I² = 29%). Thirty studies reported wound dehiscence; 23 studies (8724 participants) were pooled. There is moderate-certainty evidence that there is probably little or no difference in dehiscence between people treated with NPWT (6.62%) and those treated with standard dressing (6.97%), although there is imprecision around the estimate that includes risk of benefit and harms; RR 0.97 (95% CI 0.82 to 1.16; I² = 4%). Evidence was downgraded for imprecision, risk of bias, or a combination of these. Secondary outcomes There is low-certainty evidence for the outcomes of reoperation and seroma; in each case, confidence intervals included both benefit and harm. There may be a reduced risk of reoperation favouring the standard dressing arm, but this was imprecise: RR 1.13 (95% CI 0.91 to 1.41; I² = 2%; 18 trials; 6272 participants). There may be a reduced risk of seroma for people treated with NPWT but this is imprecise: the RR was 0.82 (95% CI 0.65 to 1.05; I² = 0%; 15 trials; 5436 participants). For skin blisters, there is low-certainty evidence that people treated with NPWT may be more likely to develop skin blisters compared with those treated with standard dressing (RR 3.55; 95% CI 1.43 to 8.77; I² = 74%; 11 trials; 5015 participants). The effect of NPWT on haematoma is uncertain (RR 0.79; 95 % CI 0.48 to 1.30; I² = 0%; 17 trials; 5909 participants; very low-certainty evidence). There is low-certainty evidence of little to no difference in reported pain between groups. Pain was measured in different ways and most studies could not be pooled; this GRADE assessment is based on all fourteen trials reporting pain; the pooled RR for the proportion of participants who experienced pain was 1.52 (95% CI 0.20, 11.31; I² = 34%; two studies; 632 participants). Cost-effectiveness Six economic studies, based wholly or partially on trials in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in five indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty; coronary artery bypass grafts; and vascular surgery with inguinal incisions. They calculated quality-adjusted life-years or an equivalent, and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the evidence certainty varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs  than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). There may be a reduced risk of death after surgery for people treated with NPWT compared with standard dressings but there is uncertainty around this as confidence intervals include risk of benefit and harm (low-certainty evidence). People treated with NPWT may experience more instances of skin blistering compared with standard dressing treatment (low-certainty evidence). There are no clear differences in other secondary outcomes where most evidence is low or very low-certainty. Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery

BACKGROUND

Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS).

STUDY DESIGN

In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement.

RESULTS

In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds.

CONCLUSIONS

Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.

Pregnancy Care for Patients With Super Morbid Obesity

The patient with obesity represents unique challenges to the medical community and, in the setting of pregnancy, additional risks to both mother and fetus. This document will focus on the risks and considerations needed to care for the women with obesity and her fetus during the antepartum, intrapartum, and immediate postpartum stages of pregnancy. Specific attention will be given to pregnancy in the setting of class III and super morbid obesity.

:

Background

We aimed to determine the prevalence and risk factors of surgical site infection (SSI) after cesarean delivery (CD) in a rural area in China.

Methods

We identified 155 patients with incisional and organ/space SSIs by International Classification of Disease codes and matched them with 465 patients (controls) in a time-matched retrospective quality assurance analysis. Multiple logistic regression analyses were performed to examine the risk factors for SSI: the work-years of providers, the number of antenatal care (ANC) visits, CD after labor, positive discharge culture, postoperative C-reactive protein (CRP) levels and fever.

Results

and discussion: During the study, 155 women with SSI were identified among the 8640 patients who delivered by CD. The incidence of SSIs was 179 per 10 000patients (95%CI: 151–207 per 10 000 patients). The total duration of hospitalization in patients with SSI was 14.49 ± 8.68 days compared with 7.96 ± 2.35 days in patients with no SSI (P < 0.01). Multiple logistic regression analysis showed that the work-years of providers (odds ratio [OR] = 3.729, 95% confidence interval [CI]: 1.463–9.501, p = 0.006), irregular ANC visits (OR = 3.245, 95% CI: 1.264–8.329, p = 0.028), CD after labor (OR = 2.545, 95% CI: 0.935–6.926, p = 0.020), postoperative CRP level (OR = 2.545, 95% CI: 0.935–6.926, p = 0.016) and a positive discharge culture (OR = 2.954, 95% CI: 0.305–28.643, p = 0.019) were positively associated with SSI. However, the rates of maternal request (OR = 0.186, 95% CI: 0.065–0.535, p = 0.002) and postoperative fever (OR = 0.208, 95% CI: 0.087–0.494, p = 0.001) were negatively related to SSI.

Conclusions

Special attentions should be paid to CD patients who had irregular ANC visits, attempted labor, a positive discharge culture, higher CRP levels and fever after surgery, who had a greater risk of SSI.

•

The incidence of SSIs was 179 per 10 000 patients (95%CI: 151–207).

•

Risk factors of SSIs included: irregular ANC visits, a positive discharge culture.

•

Higher CRP levels and fever after surgery had a greater risk of SSI.

Prophylactic negative pressure wound therapy on surgical site infection in obese women after cesarean section: A systematic review and meta-analysis

Prevention of surgical site infection (SSI) is a public health challenge. The objective of the study was to evaluate the efficacy of negative pressure wound therapy (NPWT) for preventing SSI and other wound complications in obese women undergoing cesarean section. The search terms included "negative pressure wound therapy", "obesity" and "cesarean section/delivery". Randomized controlled trials were used to compare the use of NPWT to standard dressings in preventing SSI in obese women after cesarean section. A comprehensive literature search of four databases was performed up to June 2021. The primary outcome was SSI. Secondary outcomes were seroma, hematoma, overall wound complications, and adverse skin reactions. Ten RCTs involving 5586 patients met the inclusion criteria. The use of NPWT reduced SSI (RR = 0.76, 95%CI: 0.63-0.92, P = 0.004). No statistically significant difference was detected in the incidence of overall wound complications (RR = 0.93, P = 0.48), seroma (RR = 1.10, P = 0.79), hematoma (RR = 0.63, P = 0.36) and hospital readmission (RR = 1.41, P = 0.15). NPWT significantly increased the occurrence of skin blistering with a RR of 4.60 (P = 0.04). Use of prophylactic NPWT after cesarean delivery among obese women is associated with a significant reduction of surgical site infection.

The Voodoo that We Do: Controversies in General Surgery

Incisional hernia remains a common complication following abdominal surgery, and its incidence can be reduced with standardized wound closure techniques. Robust evidence exists to support certain fascial closure methods, such as using a small bites, 4-to-1, continuous slow absorbable suture technique for elective midline laparotomies. On the other hand, there are other common surgical practices that lack quality data to support their routine use, such as abdominal binders, negative-pressure wound therapy, and reapproximation of subcutaneous tissue.

Surgical Site Infections

Surgical site infections (SSIs) are among the most common and most costly health care-associated infections, leading to adverse patient outcomes and death. Wound contamination occurs with each incision, but proven strategies exist to decrease the risk of SSI. In particular, improved adherence to evidence-based preventive measures related to appropriate antimicrobial prophylaxis can decrease the rate of SSI. Aggressive surgical debridement and effective antimicrobial therapy are needed to optimize the treatment of SSI.

Incisional negative pressure wound therapy for clean-contaminated wounds in abdominal surgery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The role of incisional negative-pressure wound therapy (iNPWT) in preventing surgical site infections (SSIs) in clean-contaminated abdominal wounds is still controversial. This meta-analysis was performed to evaluate whether the use of iNPWT could reduce SSIs and other complications in clean-contaminated abdominal surgery.

METHODS

The authors searched PubMed, EMBASE, Cochrane library, and Web of Science from database inception to 23 January 2021 for randomized controlled trials (RCTs). They assessed the risk of bias using the Cochrane Collaboration risk of bias tool and conducted a meta-analysis using RevMan 5.4.

RESULTS

Eleven RCTs, including 4112 patients, were analyzed, of which 2057 were treated with iNPWT and 2055 with standard dressings. The SSI rates (OR = 0.76, 95% CI = 0.61-0.94, P = 0.01), in patients undergoing an iNPWT intervention were significantly lower than those in patients receiving standard dressings. There was no statistically significant difference between the rates of incision dehiscence, seroma, and readmission between groups.

CONCLUSIONS

Application of iNPWT for clean-contaminated wounds in abdominal surgery reduced SSI rates but showed similar rates of wound dehiscence, seroma, and readmission compared with standard dressings.

Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals

BACKGROUND

There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes.

OBJECTIVE

This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals.

STUDY DESIGN

The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria.

RESULTS

Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals.

CONCLUSION

Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.

Effect of negative-pressure wound therapy on wound complications in obese women after caesarean birth: a systematic review and meta-analysis

BACKGROUND

Obesity is associated with increased surgical-site infection (SSI) following caesarean section (CS).

OBJECTIVE

To summarise the evidence on the effectiveness of negative-pressure wound therapy (NPWT) for preventing SSI and other wound complications in obese women after CS.

SEARCH STRATEGY

MEDLINE, Embase, CINAHL, Cochrane CENTRAL databases and ClinicalTrials.gov were systematically searched in March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of NPWT compared with standard dressings after CS birth.

DATA COLLECTION AND ANALYSIS

Pooled effect sizes were calculated using either fixed or random effects models based on heterogeneity. The Cochrane risk of bias and Grading of Recommendations Assessment, Development and Evaluation tools were used to assess the quality of studies and overall quality of evidence.

MAIN RESULTS

Ten RCTs with 5583 patients were included; studies were published between 2012 and 2021. Nine RCTs with 5529 patients were pooled for the outcome SSI. Meta-analysis results suggest a significant difference favouring the NPWT group (relative risk [RR] 0.79, 95% CI 0.65-0.95, P < 0.01), indicating an absolute risk reduction of 1.8% among those receiving NPWT compared with usual care. The risk of blistering in the NPWT group was significantly higher (RR 4.13, 95% CI 1.53-11.18, P = 0.005). All studies had high risk of bias relative to blinding of personnel/participants. Only 40% of studies reported blinding of outcome assessments and 50% had incomplete outcome data.

CONCLUSIONS

The decision to use NPWT should be considered both in terms of its potential benefits and its limitations.

TWEETABLE ABSTRACT

NPWT was associated with fewer SSI in women following CS birth but was not effective in reducing other wound complications.

Preparation and characterization of a novel polysialic acid/gelatin composite hydrogels cross-linked by tannic acid to improve wound healing after cesarean section dressing

The infections and delayed wound healing after cesarean delivery is one of the most complicated issues in surgical medicinal field. In the present investigation, designed novel polysialic acid loaded gelatin (PSA-Gel) composite hydrogels cross-linked by tannic acid (TA) has been developed and used as a facile wound dressing to improve cesarean wound healing ability with prevent bactericidal infections. The cross-linking effect was predominant when the TA content was lower, resulting in the formation of a cross-linked network. An effective TA cross-linking effect on the PSA-Gel hydrogel matrix was achieved when the amount of TA was around 15 wt %. The morphology of as-fabricated hydrogels was characterized using scanning electron microscopy (SEM) with an average pore sizes of PSA-Gel, PSA-Gel-TA-5%, PSA-Gel-TA-10%, and PSA-Gel-TA-15% hydrogels were 95.4 ± 12.6 μm, 120.4 ± 8.2 μm, 165.3 ± 21.6 μm, and 270.2 ± 32.5 μm, respectively. The effects of hydrogels on the swelling ratio, in vitro degradation, and mechanical properties were systemically evaluated. The TA cross-linked PSA-Gel hydrogels display strong antimicrobial behavior against gram-positive (Staphylococcus aureus) gram-negative (Escherichia coli) bacteria strains. Moreover, PSA-Gel-TA hydrogels also displayed favorable cytotoxicity toward L929 fibroblast cell lines. Finally, the therapeutic and wound healing potential of the PSA-Gel-TA hydrogels has been studied in vivo using the excision wound model in rats. The results indicate that the PSA-Gel-TA hydrogels have a greater and significant effect on wound closure and increased the wound healing rate compared with native PSA-Gel hydrogels and untreated control group at 94%, 73% and 65% on day 21. The findings suggest that PSA-Gel-TA hydrogels are promising dressing materials for the treatment of wound healing.

Randomized controlled trial of single-use negative-pressure wound therapy dressings in morbidly obese patients undergoing cesarean delivery

BACKGROUND

The single-use negative-pressure wound therapy dressings are designed to use over a closed surgical wound. Early prospective studies suggested that these dressings may be of potential benefit in reducing cesarean wound complications.

OBJECTIVE

This study aimed to test the hypothesis that incisional negative-pressure wound therapy decreases postoperative wound morbidity compared with standard surgical dressing in patients with class III obesity undergoing cesarean delivery.

STUDY DESIGN

In a single-site, parallel, randomized controlled trial, participants with class III obesity (body mass index ≥40 kg/m²) were recruited to participate in the study. Patients were consented in the ambulatory obstetrical units, on admission to the antepartum service, and on labor and delivery before active labor. Patients who had a cesarean delivery were randomized to either the standard surgical dressing or a prophylactic negative-pressure wound therapy device. The randomization was achieved using permuted blocks of 4, 6, and 8 in a 1:1 allocation ratio. The primary outcome was a composite outcome of wound complications. The planned enrollment of 242 subjects was based on the power to detect a 50% decrease in the composite wound outcome, assuming a 30% baseline wound morbidity rate for this population. The outcomes were assessed by study staff blinded to the patient's treatment arm.

RESULTS

An unplanned interim analysis was performed because of the slow enrollment and publication of larger trials showing no benefit of the negative-pressure wound therapy. Of 411 eligible patients during the study period, 212 participants with class III obesity were enrolled. Of these, 110 underwent cesarean delivery and were subsequently randomized (55 to standard dressing and 55 to prophylactic negative-pressure wound therapy device). The primary outcome occurred in 29.1% in the standard surgical dressing compared with 20% in the negative-pressure wound therapy group (risk difference, 9.1%; 95% confidence interval, -8.3 to 25.8%; P=.38). The study was stopped early because of a low enrollment rate and lower likelihood of seeing a clinically significant benefit.

CONCLUSION

The trial was stopped after an unplanned, interim analysis showed the use of a prophylactic negative-pressure wound therapy device used for cesarean delivery did not reduce wound complications compared with a standard surgical dressing.

Prophylactic Negative Pressure Wound Therapy After Laparotomy for Gynecologic Surgery: A Randomized Controlled Trial

OBJECTIVE

To estimate the effectiveness of prophylactic negative pressure wound therapy in patients undergoing laparotomy for gynecologic surgery.

METHODS

We conducted a randomized controlled trial. Eligible, consenting patients, regardless of body mass index (BMI), who were undergoing laparotomy for presumed gynecologic malignancy were randomly allocated to standard gauze or negative pressure wound therapy. Patients with BMIs of 40 or greater and benign disease also were eligible. Randomization, stratified by BMI, occurred after skin closure. The primary outcome was wound complication within 30 (±5) days of surgery. A sample size of 343 per group (N=686) was planned.

RESULTS

From March 1, 2016, to August 20, 2019, we identified 663 potential patients; 289 were randomized to negative pressure wound therapy (254 evaluable participants) and 294 to standard gauze (251 evaluable participants), for a total of 505 evaluable patients. The median age of the entire cohort was 61 years (range 20-87). Four hundred ninety-five patients (98%) underwent laparotomy for malignancy. The trial was eventually stopped for futility after an interim analysis of 444 patients. The rate of wound complications was 17.3% in the negative pressure wound therapy (NPWT) group and 16.3% in the gauze group, absolute risk difference 1% (90% CI -4.5 to 6.5%; P=.77). Adjusted odds ratio controlling for estimated blood loss and diabetes was 0.99 (90% CI 0.62-1.60). Skin blistering occurred in 33 patients (13%) in the NPWT group and in three patients (1.2%) in the gauze group (P<.001).

CONCLUSION

Negative pressure wound therapy after laparotomy for gynecologic surgery did not lower the wound complication rate but did increase skin blistering.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02682316.

FUNDING SOURCE

The protocol was supported in part by KCI/Acelity.

A Systematic Review and Meta-Analysis of Wound Complications after a Caesarean Section in Obese Women

(1) Background: Caesarean sections in obese patients are associated with an increased risk of surgical wound complications, including hematomas, seromas, abscesses, dehiscence, and surgical site infections. The aim of the present study is to perform a meta-analysis and systematic review of the current literature focusing on the strategies available to decrease wound complications in this population. (2) Methods: We reviewed the data available from the PubMed and the Science Direct databases concerning wound complications after caesarean sections in obese women. The following key words were used: “caesarean section”, “cesarean section”, “wound complication”, “wound morbidity”, and “wound infection”. A total of 540 papers were retrieved, 40 of which were selected for the final systematic review and whereas 21 articles provided data for meta-analysis. (3) Results: The conducted meta-analyses revealed that the use of prophylactic drainage does not increase the risk of wound complications in obese women after a caesarean sections (pooled OR = 1.32; 95% CI 0.64–2.70, p = 0.45) and that vertical skin incisions increase wound complications (pooled OR = 2.48; 95% CI 1.85–3.32, p < 0.01) in obese women, including extremely obese women. (4) Conclusions: Subcutaneous drainage does not reduce the risk of a wound complications, wound infections, and fever in obese women after caesarean sections. Negative prophylactic pressure wound therapy (NPWT) may reduce the risk of surgical site infections. The evidence of using a prophylactic dose of an antibiotic before the caesarean section is still lacking.