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Gerken ALH, Hattemer MA, Weiß C, Sigl M, Zach S, Keese M, Nowak K, Reißfelder C, Rahbari NN, Schwenke K. The impact of class I compression stockings on the peripheral microperfusion of the lower limb: A prospective pilot study. JOURNAL OF VASCULAR NURSING 2023; 41:212-218. [PMID: 38072575 DOI: 10.1016/j.jvn.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/13/2023] [Accepted: 08/22/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The use of medical compression stockings (MCS) in patients with peripheral arterial disease (PAD) and diabetes is the subject of an ongoing critical debate. While reducing leg edema of various origins by improving venous back flow, there is a concern about additional arterial flow obstruction when compression therapy is applied in pre-existing PAD. The aim of this study is to obtain further information on the use of class I MCS in patients with advanced PAD and to evaluate the framework conditions for a safe application. METHODS The total collective (n = 55) of this prospective, clinical cohort study consisted of 24 patients with PAD Fontaine stage IIb and higher studied before revascularization, of whom 16 patients were examined again after revascularization, and 15 healthy participants included for reference. The microperfusion of the lower extremity of all participants was examined in a supine, elevated, and sitting position using the oxygen to see (O2C) method. RESULTS The results indicate that leg positioning had the strongest influence on microcirculation (SO2 and flow: p = 0.0001), whereas MCS had no significant effect on the perfusion parameters (SO2: p = 0.9936; flow: p = 0.4967) and did not lead to a deterioration of values into critical ranges. CONCLUSION Mild medical compression therapy appears to be feasible even in patients with advanced PAD. Larger studies are warranted to observe any long-term effects, in particular for the treatment of reperfusion edema after revascularization.
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Affiliation(s)
- Andreas Lutz Heinrich Gerken
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany.
| | - Michelle Ann Hattemer
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Christel Weiß
- Department of Biometry and Statistics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Martin Sigl
- First Department of Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Sebastian Zach
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Michael Keese
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany; European Center for Angioscience, Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Straße 13-17, D-68167 Mannheim, Germany
| | - Kai Nowak
- Department of Surgery, RoMed Hospital Rosenheim, Pettenkoferstraße 10, D-83022 Rosenheim, Germany
| | - Christoph Reißfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
| | - Kay Schwenke
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany
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Rerkasem A, Nantakool S, Kulprachakarn K, Rojawat C, Ounjaijean S, Pongtam S, Prasannarong M, Saengyo S, Jakkaew T, Rerkasem K. The Effect of Standard Compression Adjuvant with a Tailored Exercise Training Program on Health-Related Quality of Life Outcomes in Treating Adults with Venous Leg Ulcer: A Randomized Controlled Trial. INT J LOW EXTR WOUND 2023:15347346231172566. [PMID: 37157222 DOI: 10.1177/15347346231172566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Exercise training adjuvant to standard compression is considered to improve calf muscle pump dysfunction in venous leg ulcer (VLU) and subsequent healing. The objectives of this trial were to assess the effectiveness of a tailored exercise training intervention in addition to standard compression therapy on health-related quality of life and anticipating wound healing. Twenty-four VLU participants were recruited and randomly divided into 2 groups. The control group was prescribed conventional compression, and the intervention group received compression plus progressive tailored exercise training. The 14-item chronic venous disease quality of life questionnaire (CIVIQ-14) was used to assess improvement after treatment over time (0, 6, and 12 weeks). Intervention and control groups achieved wound closure for 11 (92%) and 7 (58%) patients. After adjusting for age, sex, and wound size at baseline, the exercise intervention group had 2 times the probability of complete wound healing in 12 weeks than those in the control group (risk ratio = 1.98, 95% CI= 1.01-3.72, P = .047). The primary outcome was the difference in CIVIQ-14 score in 3 dimensions and global index score per visit. The outcomes were evaluated by independent assessors. Demographic, comorbidities, and wound assessments were collected on enrollment. The overall adherence to exercise protocol was 71%. After adjusting age, sex, size of VLU, and CIVIQ score at baseline, the participants in the intervention group had the average global index scores and psychological scores increase at week 12 than those in the control group (21.2; 95% CI= 7.1-35.2, P = .005, and 13.5; 95% CI = 2.9-24.2, P = .044, respectively). Both groups showed similar improvement in the mean change in physical and pain scores within-group over time. Patients with combined conventional compression therapy with exercise training appeared to have a higher quality of life score in psychological and global scores than those with compression therapy alone.
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Affiliation(s)
- Amaraporn Rerkasem
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sothida Nantakool
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kanokwan Kulprachakarn
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- School of Health Sciences Research, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Christine Rojawat
- Department of Surgery, Samut Sakhon Hospital, Samut Sakhon, Thailand
| | - Sakaewan Ounjaijean
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- School of Health Sciences Research, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sasinat Pongtam
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Mujalin Prasannarong
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Suwinai Saengyo
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Thanadul Jakkaew
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipan Rerkasem
- Environmental-Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Perry C, Atkinson RA, Griffiths J, Wilson PM, Lavallée JF, Cullum N, Dumville JC. Barriers and facilitators to use of compression therapy by people with venous leg ulcers: A qualitative exploration. J Adv Nurs 2023. [PMID: 36811300 DOI: 10.1111/jan.15608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/10/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Abstract
AIMS To explore barriers to, and facilitators of, adherence to compression therapy, from the perspective of people with venous leg ulcers. DESIGN An interpretive, qualitative, descriptive study involving interviews with patients. METHODS Participants were purposively sampled from respondents to a survey exploring attitudes to compression therapy in people with venous leg ulcers. Sampling continued until data saturation: 25 interviews between December 2019 and July 2020. Inductive thematic analysis of interview transcripts was undertaken to create a framework for the data, followed by deductive analysis informed by the Common-Sense Model of Self-Regulation. RESULTS A range of knowledge and understanding about the cause of venous leg ulcers and the mechanisms of compression therapy was demonstrated, which was not particularly related to adherence. Participants talked about their experience with different compression methods and their concerns about the length of time healing could take. They also spoke about aspects of the organization of services which affected their care. CONCLUSION Identifying specific, individual barriers/facilitators to compression therapy is not simple, rather factors combine to make adherence more or less likely or possible. There was no clear relationship between an understanding of the cause of VLUs or the mechanism of compression therapy and adherence; different compression therapies presented different challenges for patients; unintentional non-adherence was frequently mentioned; and the organization of services could impact on adherence. Ways in which people could be supported to adhere to compression therapy are indicated. Implications for practice include issues relating to communication with patients; taking into account patients' lifestyles and ensuring that they know about useful 'aids'; providing services that are accessible and provide continuity of appropriately trained staff; minimizing unintentional non-adherence; and acknowledging that healthcare professionals will always need to support/advise those who cannot tolerate compression. IMPACT Compression therapy is a cost-effective, evidence-based treatment for venous leg ulcers. However, there is evidence that patients do not always adhere to this therapy and there is limited research investigating reasons why patients do not wear compression. The study found no clear relationship between an understanding of the cause of VLUs or the mechanism of compression therapy and adherence; that different compression therapies presented different challenges for patients; that unintentional non-adherence was frequently mentioned and that the organization of services could impact on adherence. Attending to these findings offers the opportunity to increase the proportion of people undergoing appropriate compression therapy and achieving complete wound healing, the main outcome desired by this group. PATIENT/PUBLIC CONTRIBUTION A patient representative sits on the Study Steering Group, contributing to the work from developing the study protocol and interview schedule to interpretation and discussion of findings. Members of a Wounds Research Patient and Public Involvement Forum were consulted about interview questions.
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Affiliation(s)
- Catherine Perry
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Ross A Atkinson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jane Griffiths
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Paul M Wilson
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jacqueline F Lavallée
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, and MAHSC, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
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Abstract
BACKGROUND Venous leg ulcers are a chronic health problem that cause considerable economic impact and affect quality of life for those who have them. Primary wound contact dressings are usually applied to ulcers beneath compression therapy to aid healing, promote comfort and control exudate. There are numerous dressing products available for venous leg ulcers and hydrogel is often prescribed for this condition; however, the evidence base to guide dressing choice is sparse. OBJECTIVES To assess the effects of hydrogel wound dressings on the healing of venous leg ulcers in any care setting. SEARCH METHODS In May 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE, 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, 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 included randomised controlled trials (RCTs), either published or unpublished, that compared the effects of hydrogel dressing with other dressings on the healing of venous leg ulcers. We excluded trials evaluating hydrogel dressings impregnated with antimicrobial, antiseptic or analgesic agents as these interventions are evaluated in other Cochrane Reviews. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included four RCTs (10 articles) in a qualitative analysis. Overall, 272 participants were randomised, in sample sizes ranging from 20 to 156 participants. The mean age of the included population in the trials ranged from 55 to 68 years, 37% were women based on studies that reported the sex of participants. The studies compared hydrogel dressings with the following: gauze and saline, alginate dressing, manuka honey and hydrocolloid. Two studies were multicentre and the others were single-centre trials. Length of treatment using hydrogel dressing was four weeks in three studies and two weeks in one study. The follow-up period was the same as the duration of treatment in three studies and in one study the follow-up for wound healing was at 12 weeks after four weeks of treatment. Overall risk of bias was high for all trials because at least one of the three key criteria (selection bias, detection bias and attrition bias) was at high risk. Hydrogel compared with gauze and saline It is uncertain whether there is a difference in complete wound healing (risk ratio (RR) 5.33, 95% confidence interval (CI) 1.73 to 16.42; 1 trial, 60 participants) or change in ulcer size (mean difference (MD) -1.50, 95% CI -1.86 to -1.14; 1 trial, 60 participants) between interventions because the certainty of the evidence is very low. Data reported from one trial were incomplete for time-to-ulcer healing. Hydrogel compared with alginate dressing It is uncertain whether there is a difference in change in ulcer size between hydrogel and alginate gel because the certainty of the evidence is very low (MD -41.80, 95% CI -63.95 to -19.65; 1 trial, 20 participants). Hydrogel compared with manuka honey It is uncertain whether there is a difference in complete wound healing (RR 0.75, 95% CI 0.46 to 1.21; 1 trial, 108 participants) or incidence of wound infection (RR 2.00, 95% CI 0.81 to 4.94; 1 trial, 108 participants) between interventions because the certainty of the evidence is very low. Hydrogel compared with hydrocolloid One study (84 participants) reported on change in ulcer size between hydrogel and hydrocolloid; however, further analysis was not possible because authors did not report standard errors or any other measurement of variance of a set of data from the means. Therefore, it is also uncertain whether there is a difference in change in ulcer size between hydrogel and hydrocolloid because the certainty of the evidence is very low. No studies provided evidence for the outcomes: recurrence of ulcer, health-related quality of life, pain and costs. Overall, independent of the comparison, the certainty of evidence is very low and downgraded twice due to risk of bias and once or twice due to imprecision for all comparisons and outcomes. AUTHORS' CONCLUSIONS There is inconclusive evidence to determine the effectiveness of hydrogel dressings compared with gauze and saline, alginate dressing, manuka honey or hydrocolloid on venous leg ulcer healing. Practitioners may, therefore, consider other characteristics such as costs and symptom management when choosing between dressings. Any future studies assessing the effects of hydrogel on venous wound healing should consider using all the steps from CONSORT, and consider key points such as appropriate sample size with the power to detect expected differences, appropriate outcomes (such as time-to-event analysis) and adverse effects. If time-to-event analysis is not used, at least a longer follow-up (e.g. 12 weeks and above) should be adopted. Future studies should also address important outcomes that the studies we included did not investigate, such as health-related quality of life, pain and wound recurrence.
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Affiliation(s)
- Cibele Td Ribeiro
- Graduate Program in Physiology, Department of Physiology, Federal University of Paraná, Curitiba, Brazil
| | - Fernando Al Dias
- Department of Physiology, Federal University of Paraná, Curitiba, Brazil
| | - Guilherme Af Fregonezi
- PneumoCardioVascular Lab, Onofre Lopes University Hospital, Brazilian Company of Hospital Services (EBSERH) & Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
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Bellmunt-Montoya S, Escribano JM, Pantoja Bustillos PE, Tello-Díaz C, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev 2021; 9:CD009648. [PMID: 34590305 PMCID: PMC8481765 DOI: 10.1002/14651858.cd009648.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (in French 'cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire' (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system. This is the second update of the review first published in 2013. OBJECTIVES To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, AMED, and the World Health Organisation International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 19 October 2020. We also searched PUBMED to 19 October 2020 and checked the references of relevant articles to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared CHIVA to other therapeutic techniques to treat varicose veins. DATA COLLECTION AND ANALYSIS Two review authors independently assessed and selected studies, extracted data, and performed quantitative analysis from the selected papers. A third author solved any disagreements. We assessed the risk of bias in included trials with the Cochrane risk of bias tool. We calculated the risk ratio (RR), mean difference (MD), number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI). We evaluated the certainty of the evidence using GRADE. The main outcomes of interest were the recurrence of varicose veins and side effects. MAIN RESULTS For this update, we identified two new additional studies. In total, we included six RCTs with 1160 participants (62% women) and collected from them eight comparisons. Three RCTs compared CHIVA with vein stripping. One RCT compared CHIVA with compression dressings in people with venous ulcers. The new studies included three comparisons, one compared CHIVA with vein stripping and radiofrequency ablation (RFA), and one compared CHIVA with vein stripping and endovenous laser therapy. We judged the certainty of the evidence for our outcomes as low to very low due to inconsistency, imprecision caused by the low number of events and risk of bias. The overall risk of bias across studies was high because neither participants nor personnel were blinded to the interventions. Two studies attempted to blind outcome assessors, but the characteristics of the surgery limited concealment. Five studies reported the outcome clinical recurrence of varicose veins with a follow-up of 18 months to 10 years. CHIVA may make little or no difference to the recurrence of varicose veins in the lower limb compared to stripping (RR 0.74, 95% CI 0.46 to 1.20; 5 studies, 966 participants; low-certainty evidence). We are uncertain whether CHIVA reduced recurrence compared to compression dressing (RR 0.23, 95% CI 0.06 to 0.96; 1 study, 47 participants; very low-certainty evidence). CHIVA may make little or no difference to clinical recurrence compared to RFA (RR 2.02, 95% CI 0.74 to 5.53; 1 study, 146 participants; low-certainty evidence) and endovenous laser (RR 0.20, 95% CI 0.01 to 4.06; 1 study, 100 participants; low-certainty evidence). We found no clear difference between CHIVA and stripping for the side effects of limb infection (RR 0.83, 95% CI 0.33 to 2.10; 3 studies, 746 participants; low-certainty evidence), and superficial vein thrombosis (RR 1.05, 95% CI 0.51 to 2.17; 4 studies, 846 participants; low-certainty evidence). CHIVA may reduce slightly nerve injury (RR 0.14, 95% CI 0.02 to 0.98; NNTH 9, 95% CI 5 to 100; 4 studies, 846 participants; low-certainty evidence) and hematoma compared to stripping (RR 0.59, 95% CI 0.37 to 0.97; NNTH 11, 95% CI 5 to 100; 2 studies, 245 participants; low-certainty evidence). For bruising, one study found no differences between groups while another study found reduced rates of bruising in the CHIVA group compared to the stripping group. Compared to RFA, CHIVA may make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury or hematoma, but may cause more bruising (RR 1.15, 95% CI 1.04 to 1.28; NNTH 8, CI 95% 5 to 25; 1 study, 144 participants; low-certainty evidence). Compared to endovenous laser, CHIVA may make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury or hematoma. The study comparing CHIVA versus compression did not report side effects. AUTHORS' CONCLUSIONS There may be little or no difference in the recurrence of varicose veins when comparing CHIVA to stripping (low-certainty evidence), but CHIVA may slightly reduce nerve injury and hematoma in the lower limb (low-certainty evidence). Very limited evidence means we are uncertain of any differences in recurrence when comparing CHIVA with compression (very low-certainty evidence). CHIVA may make little or no difference to recurrence compared to RFA (low-certainty evidence), but may result in more bruising (low-certainty evidence). CHIVA may make little or no difference to recurrence and side effects compared to endovenous laser therapy (low-certainty evidence). However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed, and the results were imprecise due to the low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.
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Affiliation(s)
- Sergi Bellmunt-Montoya
- Angiology, Vascular and Endovascular Surgery, Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jose Maria Escribano
- Angiology, Vascular and Endovascular Surgery, Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | | | - Cristina Tello-Díaz
- Angiology, Vascular and Endovascular Surgery, Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Maria José Martinez-Zapata
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Monshipouri M, Aliahmad B, Ogrin R, Elder K, Anderson J, Polus B, Kumar D. Thermal imaging potential and limitations to predict healing of venous leg ulcers. Sci Rep 2021; 11:13239. [PMID: 34168251 PMCID: PMC8225806 DOI: 10.1038/s41598-021-92828-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022] Open
Abstract
Area analysis of thermal images can detect delayed healing in diabetes foot ulcers, but not venous leg ulcers (VLU) assessed in the home environment. This study proposes using textural analysis of thermal images to predict the healing trajectory of venous leg ulcers assessed in home settings. Participants with VLU were followed over twelve weeks. Digital images, thermal images and planimetry of wound tracings of the ulcers of 60 older participants was recorded in their homes by nurses. Participants were labelled as healed or unhealed based on status of the wound at the 12th week follow up. The weekly change in textural features was computed and the first two principal components were obtained. 60 participants (aged 80.53 ± 11.94 years) with 72 wounds (mean area 21.32 ± 51.28cm2) were included in the study. The first PCA of the change in textural features in week 2 with respect to week 0 were statistically significant for differentiating between healed and unhealed cases. Textural analysis of thermal images is an effective method to predict in week 2 which venous leg ulcers will not heal by week 12 among older people whose wounds are being managed in their homes.
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Affiliation(s)
- Mahta Monshipouri
- Biosignals for Affordable Healthcare, RMIT University, 124 Latrobe Street, Melbourne, VIC, 3000, Australia
| | - Behzad Aliahmad
- Biosignals for Affordable Healthcare, RMIT University, 124 Latrobe Street, Melbourne, VIC, 3000, Australia
| | - Rajna Ogrin
- Biosignals for Affordable Healthcare, RMIT University, 124 Latrobe Street, Melbourne, VIC, 3000, Australia
- Bolton Clarke Research Institute, Bentleigh, VIC, Australia
- Department of Business Strategy & Innovation, Griffith University, Brisbane, QLD, Australia
| | - Kylie Elder
- Bolton Clarke, 31 Janefield Drive, Bundoora, VIC, Australia
| | | | - Barbara Polus
- Biosignals for Affordable Healthcare, RMIT University, 124 Latrobe Street, Melbourne, VIC, 3000, Australia
| | - Dinesh Kumar
- Biosignals for Affordable Healthcare, RMIT University, 124 Latrobe Street, Melbourne, VIC, 3000, Australia.
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Stather P, Petty C, Langthorne H, Rayner E, Zhang J, Hayden K, Howard A. A randomised controlled clinical trial comparing the effectiveness of bandaging compared to the JuxtaCures™ device in the management of people with venous ulceration: Feasibility study. Phlebology 2021; 36:505-514. [PMID: 33435839 DOI: 10.1177/0268355520988226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The mainstay of treatment for venous ulceration remains compression therapy. Velcro Wrap devices are being increasingly used in these patients despite limited evidence. This feasibility study aimed to compare standard bandaging to the JuxtaCures™ Velcro wrap device. METHODS A single centre, unblinded RCT compared participants with venous ulceration randomised to either the JuxtaCures™ device or short stretch bandaging. Participants were followed up for 26 weeks. RESULTS 160 participants were screened with 40 randomised. 3 participants in bandaging and 1 in JuxtaCures™ didn't complete the study. 60% in JuxtaCures™ healed v 55% in bandaging despite larger ulcers in the JuxtaCures™ arm (9.33 cm2 v 6.97 cm2). There was no significant difference in time to healing (12.17 v 13.64 weeks). JuxtaCures™ showed improved ulcer reduction for those that didn't heal (14.91-5.00 cm2 v 14.20-8.62 cm2; P = 0.06). JuxtaCures™ had more consistent sub-bandage pressure dropping from 39-36 mmHg versus 41-25 mmHg in bandaging between application and removal (P < 0.001). Quality of life (EQ5D) was improved in JuxtaCures at 3 months (mean difference 0.14, p = 0.04), but not at 1 and 6 months, or in disease specific quality of life. Cost was lower in JuxtaCures™ £842.47 v £1064.68. Duration of appointment was significantly shorter in JuxtaCures™ (41 minutes v 53 minutes; P = 0.003). CONCLUSION This study has shown the feasibility and necessity of running a multicentre trial to evaluate the use of Velcro wrap devices for venous ulceration. It highlights the potential benefits of more consistent pressure, increased self-care, and potential with regards to ulcer healing, cost, nursing resource and quality of life.
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Affiliation(s)
- Philip Stather
- East Suffolk North Essex Foundation Trust, Colchester Hospital, Colchester, UK.,Norfolk and Norwich University Hospital, Norwich, UK
| | - Carroll Petty
- East Suffolk North Essex Foundation Trust, Colchester Hospital, Colchester, UK
| | - Helen Langthorne
- East Suffolk North Essex Foundation Trust, Colchester Hospital, Colchester, UK
| | - Emma Rayner
- East Suffolk North Essex Foundation Trust, Colchester Hospital, Colchester, UK
| | - Jufen Zhang
- Clinical Trial Unit, School of Medicine, Anglia Ruskin University, Chelmsford, UK
| | - Karen Hayden
- Clinical Trial Unit, School of Medicine, Anglia Ruskin University, Chelmsford, UK
| | - Adam Howard
- East Suffolk North Essex Foundation Trust, Colchester Hospital, Colchester, UK
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Martí-Carvajal AJ, Knight-Madden JM, Martinez-Zapata MJ. Interventions for treating leg ulcers in people with sickle cell disease. Cochrane Database Syst Rev 2021; 1:CD008394. [PMID: 34559425 PMCID: PMC8407242 DOI: 10.1002/14651858.cd008394.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The frequency of skin ulceration makes an important contributor to the morbidity burden in people with sickle cell disease. Many treatment options are available to the healthcare professional, although it is uncertain which treatments have been assessed for effectiveness in people with sickle cell disease. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the clinical effectiveness and harms of interventions for treating leg ulcers in people with sickle cell disease. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We searched LILACS (1982 to January 2020), ISI Web of Knowledge (1985 to January 2020), and the Clinical Trials Search Portal of the World Health Organization (January 2020). We checked the reference lists of all the trials identified. We also contacted those groups or individuals who may have completed relevant randomised trials in this area. Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 13 January 2020; date of the last search of the Cochrane Wounds Group Trials Register: 17 February 2017. SELECTION CRITERIA Randomised controlled trials of interventions for treating leg ulcers in people with sickle cell disease compared to placebo or an alternative treatment. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion. All three authors independently assessed the risk of bias of the included studies and extracted data. We used GRADE to assess the quality of the evidence. MAIN RESULTS Six studies met the inclusion criteria (198 participants with 250 ulcers). Each trial investigated a different intervention and within this review we have grouped these as systemic pharmaceutical interventions (L-cartinine, arginine butyrate, isoxsuprine) and topical pharmaceutical interventions (Solcoseryl® cream, arginine-glycine-aspartic acid (RGD) peptide dressing and topical antibiotics). No trials on non-pharmaceutical interventions were included in the review. All trials had an overall unclear or high risk of bias, and drug companies sponsored four of them. We were unable to pool findings due to the heterogeneity in outcome definitions, and inconsistency between the units of randomisation and analysis. Three interventions reported on the change in ulcer size (arginine butyrate, RGD peptide, L-cartinine). Of these, only arginine butyrate showed a reduction of ulcer size compared with a control group, mean reduction -5.10 cm² (95% CI -9.65 to -0.55), but we are uncertain whether this reduces ulcer size compared to standard care alone as the certainty of the evidence has been assessed as very low. Three trials reported on complete leg ulcer closure (isoxsuprine, arginine butyrate, RGD peptide matrix; very low quality of evidence). None reported a clinical benefit. No trial reported on: the time to complete ulcer healing; ulcer-free survival following treatment for sickle cell leg ulcers; quality of life measures; incidence of amputation or harms. AUTHORS' CONCLUSIONS Given the very low quality of the evidence identified in this updated Cochrane Review we are uncertain whether any of the assessed pharmaceutical interventions reduce ulcer size or result in leg ulcer closure in treated participants compared to controls. However, this intervention was assessed as having a high risk of bias due to inadequacies in the single trial report. Other included studies were also assessed as having an unclear or high risk of bias. The harm profile of the all interventions remains inconclusive.
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Affiliation(s)
- Arturo J Martí-Carvajal
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE (Cochrane Ecuador), Quito, Ecuador
- School of Medicine, Universidad Francisco de Vitoria (Cochrane Madrid), Madrid, Spain
| | | | - Maria José Martinez-Zapata
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Compression Therapy Is Not Contraindicated in Diabetic Patients with Venous or Mixed Leg Ulcer. J Clin Med 2020; 9:jcm9113709. [PMID: 33227909 PMCID: PMC7699243 DOI: 10.3390/jcm9113709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to investigate if compression therapy (CT) can be safely applied in diabetic patients with Venous Leg Ulcers (VLU), even when a moderate arterial impairment (defined by an Ankle-Brachial Pressure Index 0.5–0.8) occurs as in mixed leg ulcers (MLU). Materials and methods: in one of our previous publications we compared the outcomes of two groups of patients with recalcitrant leg ulcers. Seventy-one patients were affected by mixed venous and arterial impairment and 109 by isolated venous disease. Both groups were treated by tailored inelastic CT (with compression pressure <40 mm Hg in patients with MLU and >60 mm Hg in patients with VLU) and ultrasound guided foam sclerotherapy (UGFS) of the superficial incompetent veins with the reflux directed to the ulcer bed. In the present sub analysis of the same patients we compared the healing time of 107 non-diabetic patients (NDP), 69 with VLU and 38 with MLU) with the healing time of 73 diabetic patients (DP), 40 with VLU and 33 with MLU. Results: Twenty-five patients were lost at follow up. The results refer to 155 patients who completed the treatment protocol. In the VLU group median healing time was 25 weeks for NDP and 28 weeks in DP (p = 0.09). In the MLU group median healing time was 27 weeks for NDP and 29 weeks for DP (p = −0.19). Conclusions: when providing leg ulcer treatment by means of tailored compression regimen and foam sclerotherapy for superficial venous refluxes, diabetes has only a minor or no effect on the healing time of recalcitrant VLU or MLU.
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10
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Rother U, Grussler A, Griesbach C, Almasi-Sperling V, Lang W, Meyer A. Safety of medical compression stockings in patients with diabetes mellitus or peripheral arterial disease. BMJ Open Diabetes Res Care 2020; 8:8/1/e001316. [PMID: 32503811 PMCID: PMC7279622 DOI: 10.1136/bmjdrc-2020-001316] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/30/2020] [Accepted: 05/09/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Compression therapy is highly effective in the treatment of many venous diseases, including leg edema. However, its relevance in patients with peripheral arterial disease (PAD) or diabetes mellitus is critically discussed. The aim of the present study was to assess the influence of compression therapy on microperfusion and its safety in patients with PAD or diabetes mellitus. RESEARCH DESIGN AND METHODS A prospective analysis of 94 consecutive patients (44 patients with diabetes, 45 patients with PAD and 5 healthy controls) undergoing medical compression therapy was performed. Microperfusion was assessed by a combined method of white light tissue spectrometry and laser Doppler flowmetry under medical compression therapy (classes I and II), in different body positions (supine, sitting, standing and elevated position of the leg) and at different locations (great toe, lateral ankle and calf). RESULTS During the entire study, no compression-related adverse events occurred. Evaluation of microcirculation parameters (oxygen saturation of hemoglobin and flow) at the different locations and in sitting and standing positions (patients with diabetes and PAD) under compression therapy classes I and II revealed no tendency for reduced microperfusion in both groups. In contrast, in the elevated leg position, all mean perfusion values decreased in the PAD and diabetes groups. However, the same effect was seen in the healthy subgroup. CONCLUSIONS In consideration of the present inclusion criteria, use of medical compression stockings is safe and feasible in patients with diabetes or PAD. This study did not find relevant impairment of microperfusion parameters under compression therapy in these patient subgroups in physiologic body positions. TRIAL REGISTRATION NUMBER NCT03384758.
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Affiliation(s)
- Ulrich Rother
- Department of Vascular Surgery, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Anna Grussler
- Department of Vascular Surgery, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Colin Griesbach
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Veronika Almasi-Sperling
- Department of Vascular Surgery, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Werner Lang
- Department of Vascular Surgery, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, Friedrich-Alexander-Universitat Erlangen-Nurnberg, Erlangen, Bayern, Germany
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11
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Jonker L, Todhunter J, Schutter J, Halliday C, Fisher S. A multi-centre, prospective, randomised controlled feasibility study of plantar resistance exercise therapy for venous leg ulcers – Results of the PREVUE study. Phlebology 2020; 35:237-246. [DOI: 10.1177/0268355519858889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To evaluate the feasibility of an interventional study involving a seated plantar resistance exercise programme, using a StepIt pedal, aimed at promotion of venous leg ulcer healing. Methods Thirty-two venous leg ulcer patients, recruited from community, GP and hospital settings, were randomised to either a standard care or adjuvant StepIt exercise programme arm for up to 12 weeks. The exercise involved a twice daily routine of 10 times 1 min of exercise, i.e. 2 s push and 2 s lift repetitions (equating to 300 daily ‘steps’). Results Complete healing of the venous leg ulcers was observed in 10 out of 15 (67%; StepIt cohort) and 7 out of 17 (41%; control cohort), respectively (p-value 0.18, Fisher’s exact test). Baseline differences between the two cohorts were longer wound chronicity, less venous leg ulcer-related pain and better venous leg ulcer-related quality of life in the StepIt cohort. One adverse event, involving increased wound exudate and slough production, was observed in a participant using StepIt, and no study withdrawals were recorded in either arm. StepIt users whose wound had completely healed by week 12 were more likely to be compliant with the exercise programme (self-reported) and more positive about the trial experience; however, all would recommend the device to others. Conclusions Seated plantar resistance exercise shows promise and may accelerate venous leg ulcer wound healing. The StepIt pedal is well-received by patients, and its efficacy may depend on the degree of patient compliance with the exercise programme. Further larger scale studies are indicated to allow more concrete inferences to be made on the clinical and potential health economics impact that this device may have.
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Affiliation(s)
- Leon Jonker
- Cumbria Partnership NHS Foundation Trust, Carlisle, UK
| | - Jane Todhunter
- North Cumbria University Hospitals NHS Trust, Carlisle, UK
| | - Jose Schutter
- Cumbria Partnership NHS Foundation Trust, Carlisle, UK
| | | | - Stacey Fisher
- Cumbria Partnership NHS Foundation Trust, Carlisle, UK
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12
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Nandasiri GK, Ianakiev A, Dias T. Hyperelastic Properties of Platinum Cured Silicones and its Applications in Active Compression. Polymers (Basel) 2020; 12:polym12010148. [PMID: 31936039 PMCID: PMC7022899 DOI: 10.3390/polym12010148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 11/25/2022] Open
Abstract
This paper presents the fundamental research of design, development, and evaluation of an active compression system consisting of silicone based inflatable mini-bladders, which could be used in applying radial pressure for the treatment of venous disease. The use of mini-bladders will nullify the effect of radius of curvature and provide a higher resolution to the pressure distribution. They are designed with two elastomeric layers and inflation is limited only to one side. The mini-bladders apply a radial force onto the treated surface when inflated, and the pressure inside mini-bladders could be measured using the concept of back pressure, which provides the flexibility to inflate mini-bladders to a predefined pressure. The 3-D deformation profile of the mini-bladders was analysed using finite element method (FEM) and FEM simulations were validated with experimental data, which showed good agreement within pressure region required for the treatment of venous disease. Finally, the pressure transmission characteristics of mini-bladders were evaluated on a biofidellic lower leg surrogate and the results have shown that the mini-bladders could apply a uniform pressure irrespective of the location on the leg with a 60%–70% of inlet pressure successfully transmitted onto the leg surface, while 40%–50% was available after the fat layers.
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Affiliation(s)
- Gayani K. Nandasiri
- Advanced Textiles Research Group, School of Art and Design, Nottingham Trent University, Bonington Building, Dryden Street, Nottingham NG1 4 GG, UK
- Correspondence: (G.K.N.); (T.D.); Tel.: +44-94-77292-5855 (T.D.)
| | - Anton Ianakiev
- Department of Civil Engineering, School of Architecture Design and Built Environment, Nottingham Trent University, Nottingham NG1 4FQ, UK;
| | - Tilak Dias
- Advanced Textiles Research Group, School of Art and Design, Nottingham Trent University, Bonington Building, Dryden Street, Nottingham NG1 4 GG, UK
- Correspondence: (G.K.N.); (T.D.); Tel.: +44-94-77292-5855 (T.D.)
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13
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Stephens CJ, Spector JA, Butcher JT. Biofabrication of thick vascularized neo-pedicle flaps for reconstructive surgery. Transl Res 2019; 211:84-122. [PMID: 31170376 PMCID: PMC6702068 DOI: 10.1016/j.trsl.2019.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/06/2019] [Accepted: 05/14/2019] [Indexed: 01/01/2023]
Abstract
Wound chronicity due to intrinsic and extrinsic factors perturbs adequate lesion closure and reestablishment of the protective skin barrier. Immediate and proper care of chronic wounds is necessary for a swift recovery and a reduction of patient vulnerability to infection. Advanced therapies supplemented with standard wound care procedures have been clinically implemented to restore aberrant tissue; however, these treatments are ineffective if local vasculature is too compromised to support minimally-invasive strategies. Autologous "flaps", which are tissues equipped with their own hierarchical vascular supply, can be harvested from one region of the patient and transplanted to the wound where it is reperfused upon microsurgical anastomosis to appropriate recipient vessels. Despite the success of autologous flap transfer, these procedures are extremely invasive, incur obligatory donor-site morbidity, and require sufficient donor-tissue availability, microsurgical expertise, and specialized equipment. 3D-bioprinting modalities, such as extrusion-based bioprinting, can be used to address the clinical constraints of autologous flap transfer, primarily addressing donor-site morbidity and tissue availability. This advancement in regenerative medicine allows the biofabrication of heterogeneous tissue structures with high shape fidelity and spatial resolution to generate biomimetic constructs with the anatomically-precise geometries of native tissue to ensure tissue-specific function. Yet, meaningful progress toward this clinical application has been limited by the lack of vascularization required to meet the nutrient and oxygen demands of clinically relevant tissue volumes. Thus, various criteria for the fabrication of functional tissues with hierarchical, patent vasculature must be considered when implementing 3D-bioprinting technologies for deep, chronic wounds.
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Affiliation(s)
- Chelsea J Stephens
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Jason A Spector
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York; Division of Plastic Surgery, Weill Cornell Medical College, New York, New York
| | - Jonathan T Butcher
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York.
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14
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Siadat AH, Isseroff RR. Prolotherapy: Potential for the Treatment of Chronic Wounds? Adv Wound Care (New Rochelle) 2019; 8:160-167. [PMID: 31646060 DOI: 10.1089/wound.2018.0866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023] Open
Abstract
Significance: Chronic skin ulcers, including venous, diabetic, and pressure ulcers, constitute a major health care burden, affecting 2-6 million people in the United States alone, with projected increases in incidence owing to the aging population and rising epidemic of diabetes. The ulcers are often accompanied by pain. Standard of care fails to heal ∼50% of diabetic foot ulcers and 25% of venous leg ulcers. Even advanced therapies do not heal >60%. Thus there is an unmet need for novel therapies that promote healing and also address the concomitant pain issue. Recent Advances: Prolotherapy involves injection of small amounts of an irritant material to the site of degenerated or painful joints, ligaments, and tendons. Multiple irritants are reported to be efficacious, but the focus here is on dextrose prolotherapy. In vitro and in vivo studies support translation to clinical use. Concentrations as low as 5% dextrose have resulted in production of growth factors that have critical roles in repair. Numerous clinical trials report pro-reparative effects of dextrose prolotherapy in joint diseases, tendon, and ligament damage, and for painful musculoskeletal issues. However, most of the studies have limitations that result in low-quality evidence. Critical Issues: The preclinical data support a role for dextrose prolotherapy in promoting tissue repair that is required for healing chronic wounds and ameliorating the associated pain. Critical issues include provision of evidence of efficacy in human chronic wounds. Another potential obstacle is limitation of reimbursement by third-party payers for a therapy with as yet limited evidence. Future Directions: Preclinical studies in models of chronic wounds would support clinical translation. As dextrose prolotherapy has some mechanistic similarities to already approved honey therapies, it may have a shortened pathway for clinical translation. The gold standard for widespread adoption would be a well-designed clinical trial.
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Affiliation(s)
- Amir Hossein Siadat
- Department of Dermatology, Isfahan University of Medical Sciences, Isfahan, Iran
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15
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Aquil S, Sharma H, Alharbi B, Pacoli K, Luke PP, Sener A. The impact of a muscle pump activator on incisional wound healing compared to standard stockings and compression devices in kidney and kidney-pancreas transplant recipients: A randomized controlled trial. Can Urol Assoc J 2019; 13:E341-E349. [PMID: 30817287 DOI: 10.5489/cuaj.5822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to evaluate the impact of thrombo-embolic-deterrent + intermittent pneumatic compression (TED + IPC) vs. muscle pump activator (MPA) on incisional wound healing in kidney and simultaneous pancreas- kidney (SPK) transplant recipients. METHODS We conducted a single-centre, randomized controlled trial in which 104 patients (kidney n=94; SPK n=10) were randomly assigned to wear TED + IPC (n= 52) or MPA (n=52) for the first six days following surgery. Patient demographics, postoperative outcomes, and incisional wound images were taken using a HIPAA-compliant application on postoperative days (POD) 3, 5, and 30, and assessed using the validated Southampton Wound Care Score. RESULTS There were no demographic differences between the groups. The MPA group had a significant improvement in wound healing on POD 3 (p=0.04) that persisted until POD 5 (p=0.0003). At POD 30, both groups were similar in wound healing outcomes (p=0.51). Bayesian inferential analysis revealed that the use of TED + IPC following transplantation had inferior outcomes compared to the use of MPA with sequential moderate evidence. The rate of complex wound infections was significantly greater in the TED + IPC group compared to the MPA group (29% vs. 12%, respectively; p=0.03). Patients were more satisfied with the use of a MPA device than TED + IPC. No major complications were encountered in either group. CONCLUSIONS The use of a MPA device in the immediate postoperative period leads to a significant improvement in immediate and early wound healing, and decreased number of complex wound infections following kidney and SPK transplantation compared to standard TED + IPC therapy. Patients were more satisfied with the use of a MPA device than TED + IPC.
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Affiliation(s)
- Shahid Aquil
- Department of Surgery, Division of Urology, Western University, London, ON, Canada.,Western University Schulich School of Medicine and Dentistry, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Hemant Sharma
- Department of Surgery, Division of Urology, Western University, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Bijad Alharbi
- Department of Surgery, Division of Urology, Western University, London, ON, Canada.,Western University Schulich School of Medicine and Dentistry, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Katharine Pacoli
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, Western University, London, ON, Canada
| | - Patrick P Luke
- Department of Surgery, Division of Urology, Western University, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada.,Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, Western University, London, ON, Canada
| | - Alp Sener
- Department of Surgery, Division of Urology, Western University, London, ON, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada.,Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, Western University, London, ON, Canada.,Department of Microbiology and Immunology, Western University, London, ON, Canada.,Centre for Human Immunology, Western University, London, ON, Canada
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Thistlethwaite KR, Finlayson KJ, Cooper PD, Brown B, Bennett MH, Kay G, O'Reilly MT, Edwards HE. The effectiveness of hyperbaric oxygen therapy for healing chronic venous leg ulcers: A randomized, double-blind, placebo-controlled trial. Wound Repair Regen 2018; 26:324-331. [PMID: 30129080 DOI: 10.1111/wrr.12657] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/16/2018] [Indexed: 11/28/2022]
Abstract
Over 30% of venous leg ulcers do not heal despite evidence-based treatment. This study aimed to determine the effectiveness of Hyperbaric Oxygen Therapy (HBOT) as an adjunct treatment for nonhealing venous leg ulcers. A randomized, double-blind, parallel group, placebo-controlled trial was undertaken in three hyperbaric medicine units. Adults with a venous leg ulcer, Transcutaneous Oxygen Measurement indicative of a hypoxic wound responsive to oxygen challenge, and without contraindications for HBOT; were eligible. Of 84 eligible patients, 10 refused and 74 enrolled. 43 participants achieved over 50% ulcer Percent Area Reduction (PAR) after four weeks of evidence-based care and were thus excluded from the intervention phase. Thirty-one participants were randomized to either 30 HBOT treatments (100% oxygen at 2.4 atmospheres absolute (ATA) for 80 minutes), or 30 "placebo" treatments, receiving a validated "sham" air protocol, initially pressurized to 1.2ATA, then cycled between 1.05-1.2ATA for eight minutes before settling at 1.05ATA. The primary outcome was numbers in each group completely healed. Secondary outcomes were ulcer PAR, pain and quality of life, 12 weeks after commencing interventions. The participants' mean age was 70 years (standard deviation (SD) 12.9) and median ulcer duration at enrolment was 62 weeks (range 4-3120). At 12 weeks, there was no significant difference between groups in the numbers completely healed. The HBOT intervention group had a mean of 95 (SD 6.53) ulcer PAR, compared to 54 (SD 67.8) mean PAR for the placebo group (t = -2.24, p = 0.042, mean difference -40.8, SE 18.2) at 12 weeks. HBOT may improve refractory healing in venous leg ulcers, however patient selection is important. In this study, HBOT as an adjunct treatment for nonhealing patients returned indolent ulcers to a healing trajectory.
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Affiliation(s)
| | - Kathleen J Finlayson
- School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - P David Cooper
- Department of Diving & Hyperbaric Medicine, Royal Hobart Hospital; School of Medicine, University of Tasmania, Hobart, Australia
| | - Bebe Brown
- Department of Diving & Hyperbaric Medicine, Royal Hobart Hospital, Hobart, Australia
| | - Michael H Bennett
- Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital, Sydney; Prince of Wales Medical School, University of NSW, Randwick, Australia
| | - Graeme Kay
- Wesley Centre for Hyperbaric Medicine, Auchenflower, Australia
| | | | - Helen E Edwards
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Weiß KT, Zeman F, Schreml S. A randomized trial of early endovenous ablation in venous ulceration: a critical appraisal: Original Article: Gohel MS, Heatly F, Liu X et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med 2018; 378:2105-114. Br J Dermatol 2018; 180:51-55. [PMID: 30238444 DOI: 10.1111/bjd.17237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Gohel et al. aimed to compare early endovenous ablation vs. deferred endovenous ablation of superficial venous reflux with regard to time to healing of venous leg ulcers, rate of healing at 24 weeks, recurrence rate, ulcer-free time and health-related quality of life. SETTING AND DESIGN This multicentre, parallel-group (ratio 1 : 1), randomized controlled trial was conducted in a vascular surgery department setting at 20 participating centres across the U.K. STUDY EXPOSURE A total of 450 patients with venous leg ulcers were randomly assigned to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group). OUTCOMES The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life. TRIAL INTERVENTIONS Endovenous laser or radiofrequency ablation, ultrasound-guided foam sclerotherapy, or nonthermal, nontumescent methods of treatment (such as cyanoacrylate glue or mechanochemical ablation) were performed either alone or in combination. The treating clinical team determined the method and strategy of endovenous treatment. RESULTS The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group. Furthermore, more patients had healed ulcers with early intervention [hazard ratio for ulcer healing 1·38, 95% confidence interval (CI) 1·13-1·68; P = 0·001]. The median time to ulcer healing was 56 days (95% CI 49-66) in the early-intervention group and 82 days (95% CI 69-92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85·6% in the early-intervention group and 76·3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrolment was 306 days (interquartile range 240-328) in the early-intervention group and 278 days (interquartile range 175-324) in the deferred-intervention group (P = 0·002). The most common complications were pain and deep vein thrombosis (DVT) (early-intervention group: pain, six of 28; DVT, nine of 28; deferred-intervention group: pain, six of 24; DVT, three of 24). CONCLUSIONS Gohel et al. conclude that early endovenous ablation of superficial venous reflux results in faster healing of venous leg ulcers than deferred endovenous ablation. Patients assigned to the early-intervention group also had longer ulcer-free time during the first year after randomization.
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Affiliation(s)
- K T Weiß
- Department of Dermatology and, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - F Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - S Schreml
- Department of Dermatology and, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Milam EC, Brinster NK. Superficial granulomatous pyoderma of the leg improved after conservative management with Unna boot and intralesional steroid injections. JAAD Case Rep 2018; 4:797-799. [PMID: 30246130 PMCID: PMC6141699 DOI: 10.1016/j.jdcr.2018.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Emily C. Milam
- Correspondence to: Emily C. Milam, MD, New York University School of Medicine, 240 E 38th St, Fl 11, New York, NY 10016.
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Sabolinski ML, Gibbons G. Comparative effectiveness of a bilayered living cellular construct and an acellular fetal bovine collagen dressing in the treatment of venous leg ulcers. J Comp Eff Res 2018; 7:797-805. [PMID: 29809059 DOI: 10.2217/cer-2018-0031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Aim: To compare the effectiveness of bilayered living cellular construct (BLCC) and an acellular fetal bovine collagen dressing (FBCD) for the treatment of venous leg ulcers. Methods: Data from WoundExpert® (Net Health, PA, USA) was used to analyze 1021 refractory venous leg ulcers treated at 177 facilities. Results: Kaplan-Meier analyses showed that BLCC (893 wounds) was superior to FBCD (128 wounds), p = 0.01 for: wound closure by weeks 12 (31 vs 25%), 24 (55 vs 43%) and 36 (68 vs 53%); reduction in time to wound closure of 37%, (19 vs 30 weeks); and improvement in the probability of healing by 45%. Conclusion: BLC versus FBCD showed significant differences in both time to and frequency of healing suggesting that BLCC may provide significant cost savings compared with FBCD.
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Affiliation(s)
- Michael L Sabolinski
- Managing Member Wound Care, Sabolinski LLC, 55 Jefferson Road, Franklin, MA 02038, USA
| | - Gary Gibbons
- Center for Wound Healing, South Shore Hospital, Suite 100, 90 Libbey Parkway, South Weymouth, MA 02189, USA
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20
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Abstract
SummaryCompression therapy is one of cornerstone in the treatment of venous and lymphatic disorders.It may be applied by means of different elastic or inelastic stockings, bandages, or other devices. Inelastic material is much more effective improving venous impaired haemodynamics than elastic material. Due to its physical properties inelastic material is able to exert a significantly higher pressure than elastic devices moving to the standing from the supine pressure; furthermore it is able to exert significantly higher pressure peaks during muscle exercise. This high pressure can overcome the intravenous pressure and cause intermittent occlusion of leg veins, restoring a kind of valve mechanism. Elastic material gives way to the muscle expansion during standing and walking and the pressure increase in these conditions is very low. Due to this low increase with muscle activity, elastic material does not exert an intermittent pressure but rather a sustained pressure not able to overcome the intravenous pressure. As a consequence, elastic material is hardly able to influence the venous diameter and its haemodynamic effects are minimal.Compared to elastic, inelastic material is significantly more effective in reducing venous reflux, increasing venous pumping function and reducing ambulatory venous hypertension.Compression therapy proved to be beneficial, over time, in every clinical condition from CEAP C1 to C6.Due to their characteristics and effects, in-elastic compression needs to be applied in the acute stages of venous disorders when a strong haemodynamic effect is necessary, while elastic stockings may be used in the chronic stages to maintain the results and prevent recurrences.A new concept in compression therapy is the inversely graduated compression pressure profile, higher over the calf than over the ankle, also named “progressive compression.” Both specially designed elastic stockings and appropriately applied bandages can exert a progressive compression which showed some interesting outcomes both in experimental and clinical settings in patients with chronic venous disorders and in athletes. Nevertheless its effectiveness in many pathological conditions (oedema treatment, venous leg ulcer, thromboprophylaxis, etc.) needs to be proved in future trials.
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21
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Poku E, Aber A, Phillips P, Essat M, Buckley Woods H, Palfreyman S, Kaltenthaler E, Jones G, Michaels J. Systematic review assessing the measurement properties of patient-reported outcomes for venous leg ulcers. BJS Open 2017; 1:138-147. [PMID: 29951616 PMCID: PMC5989950 DOI: 10.1002/bjs5.25] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 09/14/2017] [Indexed: 12/21/2022] Open
Abstract
Background A variety of instruments have been used to assess outcomes for patients with venous leg ulcers. This study sought to identify, evaluate and recommend the most appropriate patient‐reported outcome measures (PROMs) for English‐speaking patients with venous leg ulcers. Methods This systematic review used a two‐stage search approach. Electronic searches of major databases including MEDLINE were completed in October 2015, and then updated in July 2016. Additional studies were identified from citation checking. Study selection, data extraction and quality assessment were undertaken independently by at least two reviewers. Evaluation and summary of measurement properties of identified PROMs were done using standard and adapted study‐relevant criteria. Results Ten studies with data for four generic PROMS and six condition‐specific measures were identified. No generic PROM showed adequate content and criterion validity; however, the EuroQoL Five Dimensions (EQ‐5D™), Nottingham Health Profile (NHP) and 12‐item Short‐Form Health Survey (SF‐12®) had good acceptability. In general, the EQ‐5D™ showed poor responsiveness in patients with venous leg ulcers. Most condition‐specific PROMs demonstrated poor criterion and construct validity. Overall, there was some evidence of internal consistency for the Venous Leg Ulcer Quality of Life (VLU‐QoL) and the Sheffield Preference‐based Venous Ulcer questionnaire (SPVU‐5D). Test–retest reliability was satisfactory for the Venous Leg Ulcer Self‐Efficacy Tool (VeLUSET). Conclusion The NHP and VLU‐QoL questionnaire seemed the most suitable PROMs for use by clinicians. However, a valid condition‐specific PROM is still required.
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Affiliation(s)
- E Poku
- School of Health and Related Research University of Sheffield Sheffield UK
| | - A Aber
- School of Health and Related Research University of Sheffield Sheffield UK
| | - P Phillips
- School of Health and Related Research University of Sheffield Sheffield UK
| | - M Essat
- School of Health and Related Research University of Sheffield Sheffield UK
| | - H Buckley Woods
- School of Health and Related Research University of Sheffield Sheffield UK
| | - S Palfreyman
- Edmonton Clinic Health Academy, University of Alberta Edmonton, Alberta Canada
| | - E Kaltenthaler
- School of Health and Related Research University of Sheffield Sheffield UK
| | - G Jones
- School of Social Sciences Leeds Beckett University Leeds UK
| | - J Michaels
- School of Health and Related Research University of Sheffield Sheffield UK
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22
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Shannon R, Nelson A. A single-arm trial indirect comparison investigation: a proof-of-concept method to predict venous leg ulcer healing time for a new acellular synthetic matrix matched to standard care control. Int Wound J 2017; 14:729-741. [PMID: 27868341 PMCID: PMC7949811 DOI: 10.1111/iwj.12687] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/21/2016] [Accepted: 10/06/2016] [Indexed: 11/27/2022] Open
Abstract
To compare data on time to healing from two separate cohorts: one treated with a new acellular synthetic matrix plus standard care (SC) and one matched from four large UK pragmatic, randomised controlled trials [venous leg ulcer (VLU) evidence network]. We introduce a new proof-of-concept strategy to a VLU clinical evidence network, propensity score matching and sensitivity analysis to predict the feasibility of the new acellular synthetic matrix plus SC for success in future randomised, controlled clinical trials. Prospective data on chronic VLUs from a safety and effectiveness study on an acellular synthetic matrix conducted in one wound centre in the UK (17 patients) and three wound centres in Australia (36 patients) were compared retrospectively to propensity score-matched data from patients with comparable leg ulcer disease aetiology, age, baseline ulcer area, ulcer duration, multi-layer compression bandaging and majority of care completed in specialist wound centres (average of 1 visit per week), with the outcome measures at comparable follow-up periods from patients enrolled in four prospective, multicentre, pragmatic, randomised studies of venous ulcers in the UK (the comparison group; VLU evidence network). Analysis using Kaplan-Meier survival curves showed a mean healing time of 73·1 days for ASM plus SC (ASM) treated ulcers in comparison with 83·5 days for comparison group ulcers treated with SC alone (Log rank test, χ2 5·779, P = 0·016) within 12 weeks. Sensitivity analysis indicates that an unobserved covariate would have to change the odds of healing for SC by a factor of 1·1 to impact the baseline results. Results from this study predict a significant effect on healing time when using a new ASM as an adjunct to SC in the treatment of non-healing venous ulcers in the UK, but results are sensitive to unobserved covariates that may be important in healing time comparison.
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Affiliation(s)
| | - Andrea Nelson
- Head of School, School of HealthcareUniversity of LeedsLeedsUK
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23
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Andriessen A, Apelqvist J, Mosti G, Partsch H, Gonska C, Abel M. Compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines. J Eur Acad Dermatol Venereol 2017; 31:1562-1568. [DOI: 10.1111/jdv.14390] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- A. Andriessen
- Radboud UMC; Nijmegen & Andriessen Consultants; Malden The Netherlands
- International Compression Club (ICC); Berndorf Austria
| | - J. Apelqvist
- Department of Endocrinology; University Hospital of Malmö; Malmö Sweden
| | - G. Mosti
- Department of Angiology; Clinica MD Barbantini; Lucca Italy
- International Compression Club (ICC); Berndorf Austria
| | - H. Partsch
- Medical University Vienna; Vienna Austria
- International Compression Club (ICC); Berndorf Austria
| | - C. Gonska
- Medical & Regulatory Affairs; Lohmann & Rauscher GmbH & Co KG; Rengsdorf Germany
| | - M. Abel
- Medical & Regulatory Affairs; Lohmann & Rauscher GmbH & Co KG; Rengsdorf Germany
- Patient Outcome Group (POG); European Wound Management Association (EWMA); Frederiksberg Denmark
- International Compression Club (ICC); Berndorf Austria
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Abstract
The postthrombotic syndrome (PTS) is a frequent cause of long-term disability in patients with lower extremity deep vein thrombosis. A broad variety of interventions have been applied to patients with established PTS, including lifestyle, medical, compressive, endovascular, and open surgical therapies. However, the volume of evidence to support many individual elements of care is sparse, and important questions remain that must be answered to enable judicious individualization of PTS care. The purpose of this article is to describe what is known about PTS care elements and to identify important evidence gaps that merit future studies.
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Affiliation(s)
- Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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25
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Suehiro K, Morikage N, Harada T, Samura M, Takeuchi Y, Mizoguchi T, Hamano K. Self-Care-Based Treatment Using Ordinary Elastic Bandages for Venous Leg Ulcers. Ann Vasc Dis 2017; 10. [PMID: 29147163 PMCID: PMC5684162 DOI: 10.3400/avd.oa.17-00029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: We aimed to study venous leg ulcer (VLU) healing and recurrence rates of VLU using a self-care-based treatment strategy. Methods: The study included 36 patients (43 legs) who visited our clinic between April 2009 and June 2015 because of non-healing VLUs and who had been treated by us for more than a year (until June 2016). Patients or their caregivers were first provided instructions for performing the "no-intentional-stretch" bandaging technique using ordinary elastic bandages. Wounds were cleansed with tepid water daily, and bandages were re-applied by patients or their caregivers; this was continued until VLUs were healed. Compression was discontinued after healing, but was restarted if persistent swelling and/or dermatitis was noticed on their legs. Results: The median ulcer size was 6.5 cm2 (range, 1-105 cm2). The median number of clinic visits until healing was six (range, 3-35). The 6- and 12-month healing rates were 67% and 86%, respectively. Twenty (44%) legs required compression therapy after VLU healing. The cumulative recurrence-free rate at 60 months was 86%. Conclusion: Reasonable healing and recurrence rates were achieved by applying a self-care-based VLU treatment strategy.
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Affiliation(s)
- Kotaro Suehiro
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takasuke Harada
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Makoto Samura
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Yuriko Takeuchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takahiro Mizoguchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Kimikazu Hamano
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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Wong P, Tan T, Chan C, Laxton V, Chan YWF, Liu T, Wong WT, Tse G. The Role of Connexins in Wound Healing and Repair: Novel Therapeutic Approaches. Front Physiol 2016; 7:596. [PMID: 27999549 PMCID: PMC5138227 DOI: 10.3389/fphys.2016.00596] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/16/2016] [Indexed: 12/26/2022] Open
Abstract
Gap junctions are intercellular proteins responsible for mediating both electrical and biochemical coupling through the exchange of ions, second messengers and small metabolites. They consist of two connexons, with (one) connexon supplied by each cell. A connexon is a hexamer of connexins and currently more than 20 connexin isoforms have been described in the literature thus far. Connexins have a short half-life, and therefore gap junction remodeling constantly occurs with a high turnover rate. Post-translational modification, such as phosphorylation, can modify their channel activities. In this article, the roles of connexins in wound healing and repair are reviewed. Novel strategies for modulating the function or expression of connexins, such as the use of antisense technology, synthetic mimetic peptides and bioactive materials for the treatment of skin wounds, diabetic and pressure ulcers as well as cornea wounds, are considered.
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Affiliation(s)
- Pui Wong
- Li Ka Shing Faculty of Medicine, School of Biomedical Sciences, University of Hong Kong Hong Kong, Hong Kong
| | - Teresa Tan
- Department of Surgery, Faculty of Medicine, Chinese University of Hong Kong Hong Kong, Hong Kong
| | - Catherine Chan
- Department of Surgery, Faculty of Medicine, Chinese University of Hong Kong Hong Kong, Hong Kong
| | - Victoria Laxton
- Intensive Care Department, Royal Brompton and Harefield NHS Foundation Trust London, UK
| | - Yin Wah Fiona Chan
- Department of Psychology, School of Biological Sciences, University of Cambridge Cambridge, UK
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University Tianjin, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong KongHong Kong, Hong Kong; Faculty of Medicine, Li Ka Shing Institute of Health Sciences, Chinese University of Hong KongHong Kong, Hong Kong
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27
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Abstract
Venous leg ulcers are the most common cause of chronic leg wounds, accounting for up to 70 % of all chronic leg ulcers and carrying with them a significant morbidity, especially for elderly patients. Among people aged 65 years and older, the annual prevalence is 1.7 %. Billions of dollars per year are spent caring for patients with these often difficult-to-heal and sometimes recurrent chronic wounds. Chronic non-healing wounds of the lower extremities are susceptible to microbial invasion and can lead to serious complications, such as delayed healing, cellulitis, enlargement of wound size, debilitating pain, and deeper wound infections causing systemic illness. Recognition and treatment of the infected venous leg ulcer is an essential skill set for any physician caring for geriatric patients. Most physicians rely on subjective clinical signs and patient-reported symptoms in the evaluation of infected chronic wounds. The conventional bacterial culture is a widely available tool for the diagnosis of bacterial infection but can have limitations. Systemic antibiotics, as well as topical antiseptics and antibiotics, can be employed to treat and control infection and critical colonization. Better understanding of microbial biofilms in the wound environment have caused them to emerge as an important reason for non-healing and infection due to their increased resistance to antimicrobial, immunological, and chemical attack. A sound understanding of the microbial-host environment and its complexities, as well as the pathophysiology of venous hypertension, must be appreciated to understand the need for a multimodality approach to treating an infected venous leg ulcer. Other treatment measures are often required, in addition to systemic and topical antibiotics, such as the application of wound bandages, compression therapy, and wound debridement, which can hasten clearance of the infection and help to promote healing.
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28
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Martinez‐Zapata MJ, Martí‐Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, Garcia J, Zaror C. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev 2016; 2016:CD006899. [PMID: 27223580 PMCID: PMC9308064 DOI: 10.1002/14651858.cd006899.pub3] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Autologous platelet-rich plasma (PRP) is a treatment that contains fibrin and high concentrations of growth factors with the potential to improve the healing of chronic wounds. This is the first update of a review first published in 2012. OBJECTIVES To determine whether autologous PRP promotes the healing of chronic wounds. SEARCH METHODS In June 2015, for this first update, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library): Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched for ongoing and unpublished clinical trials in the WHO International Clinical Trials Registry Platform (ICTRP) (searched January 2015). We did not impose any restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared autologous PRP with placebo or alternative treatments for any type of chronic wound in adults. We did not apply any date or language restrictions. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology, including two reviewers independently selecting studies for inclusion, extracting data, and assessing risk of bias. MAIN RESULTS The search identified one new RCT, making a total of 10 included RCTs (442 participants, 42% women). The median number of participants per RCT was 29 (range 10 to 117). Four RCTs recruited people with a range of chronic wounds; three RCTs recruited people with venous leg ulcers, and three RCTs considered foot ulcers in people with diabetes. The median length of treatment was 12 weeks (range 8 to 40 weeks).It is unclear whether autologous PRP improves the healing of chronic wounds generally compared with standard treatment (with or without placebo) (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.95 to 1.50; I(2) = 27%, low quality evidence, 8 RCTs, 391 participants). Autologous PRP may increase the healing of foot ulcers in people with diabetes compared with standard care (with or without placebo) (RR 1.22, 95% CI 1.01 to 1.49; I(2) = 0%, low quality evidence, 2 RCTs, 189 participants). It is unclear if autologous PRP affects the healing of venous leg ulcers (RR 1.02, 95% CI 0.81 to 1.27; I(2) = 0% ). It is unclear if there is a difference in the risk of adverse events in people treated with PRP or standard care (RR 1.05, 95% CI 0.29 to 3.88; I(2) = 0%, low quality evidence from 3 trials, 102 participants). AUTHORS' CONCLUSIONS PRP may improve the healing of foot ulcers associated with diabetes, but this conclusion is based on low quality evidence from two small RCTs. It is unclear whether PRP influences the healing of other chronic wounds. The overall quality of evidence of autologous PRP for treating chronic wounds is low. There are very few RCTs evaluating PRP, they are underpowered to detect treatment effects, if they exist, and are generally at high or unclear risk of bias. Well designed and adequately powered clinical trials are needed.
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Affiliation(s)
- Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | | | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP) ‐ Universitat Autònoma de BarcelonaIberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - José Angel Expósito
- Agency for Health Quality and Assessment of Catalonia (AQuAS)Roc Boronat, 81‐95BarcelonaCataloniaSpain08805
| | - Ignasi Bolíbar
- Hospital de la Santa Creu i Sant PauEpidemiología Clínica y Salud PúblicaSant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
| | - Luciano Rodríguez
- Banc de Sang i TeixitsTissue BankPasseig Taulat 106‐116BarcelonaCatalunyaSpain080035
| | - Joan Garcia
- Departament de Salut. Generalitat de CatalunyaCentre de Teixits i Teràpia CellularAutovia de Castelldedels, Km 2.7L'Hospitalet de LLobregatBarcelonaCatalunyaSpain08907
| | - Carlos Zaror
- Faculty of Dentistry, Universidad de la FronteraDepartment of Pediatric Dentistry and OrthodonticTemucoChile
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29
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Romanelli M, Gilligan AM, Waycaster CR, Dini V. Difficult-to-heal wounds of mixed arterial/venous and venous etiology: a cost-effectiveness analysis of extracellular matrix. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:153-61. [PMID: 27217787 PMCID: PMC4862353 DOI: 10.2147/ceor.s104067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Importance Difficult-to-heal wounds pose clinical and economic challenges, and cost-effective treatment options are needed. Objective The aim of this study is to determine the cost-effectiveness of extracellular matrix (ECM) relative to standard of care (SC) on wound closure for the treatment of mixed arterial/venous (A/V) or venous leg ulcers (VLUs). Design, setting, and participants A two-stage Markov model was used to predict the expected costs and outcomes of wound closure for ECM and SC. Outcome data used in the analysis were taken from an 8-week randomized clinical trial that directly compared ECM and SC. Patients were followed up for an additional 6 months to assess wound closure. Forty-eight patients completed the study; 25 for ECM and 23 for SC. SC was defined as a standard moist wound dressing. Transition probabilities for the Markov states were estimated from the clinical trial. Main outcomes and measures The economic outcome of interest was direct cost per closed-wound week. Resource utilization was based on the treatment regimen used in the clinical trial. Costs were derived from standard cost references. The payer’s perspective was taken. Results ECM-treated wounds closed, on average, after 5.4 weeks of treatment, compared with 8.3 weeks for SC wounds (P=0.02). Furthermore, complete wound closure was significantly higher in patients treated with ECM (P<0.05), with 20 wounds closed in the ECM group (80%) and 15 wounds closed in the SC group (65%). After 8 months, patients treated with ECM had substantially higher closed-wound weeks compared with SC (26.0 weeks versus 22.0 weeks, respectively). Expected direct costs per patient were $2,527 for ECM and $2,540 for SC (a cost savings of $13). Conclusion and relevance ECM yielded better clinical outcomes at a slightly lower cost in patients with mixed A/V and VLUs. ECM is an effective treatment for wound healing and should be considered for use in the management of mixed A/V and VLUs.
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Affiliation(s)
| | - Adrienne M Gilligan
- Department of Life Sciences, Truven Health Analytics, Fort Worth, TX, USA; Department of Pharmacotherapy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Curtis R Waycaster
- Department of Pharmacotherapy, University of North Texas Health Sciences Center, Fort Worth, TX, USA; Department of Market Access, Smith and Nephew Inc., Fort Worth, TX, USA
| | - Valentina Dini
- Department of Dermatology, University of Pisa, Pisa, Italy
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González de la Torre H, Quintana-Lorenzo ML, Perdomo-Pérez E, Verdú J. Correlation between health-related quality of life and venous leg ulcer's severity and characteristics: a cross-sectional study. Int Wound J 2016; 14:360-368. [PMID: 27112627 DOI: 10.1111/iwj.12610] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022] Open
Abstract
This study aims to determine health-related quality of life (HRQoL) in patients suffering with venous ulceration and to correlate wound's severity status with HRQoL loss as well as identify the aspects of HRQoL most negatively affected by the presence of venous ulcers. In this observational, cross-sectional, descriptive, analytical multi-centre study, data was compiled over a period of 3·5 months. Thrity-four patients with venous ulceration were recruited. The RESVECH 2·0 scale was used to monitor wounds. The MAID scale was used to measure wound's severity. The Charing Cross Venous Ulcer Questionnaire (CCVUQe) (Spanish version) was used to evaluate quality of life. The mean CCVUQe score was 60·58 ± 16·04. The HRQoL dimension most affected was 'Emotional state' (mean score = 77. 67 ± 17·34). The average RESVECH 2.0 score for the wounds was 13·15 ± 5·07. A statistically significant association between total CCVUQ-e score and total RESVECH 2.0 score was detected [Pearson correlation coefficient r = 0·546 (P ≤ 0·001)]. Venous ulcers affect patients' HRQoL, particularly their emotional status. There is a relationship between the severity of the wound and loss of HRQoL. The presence of non-viable tissue, poor exudate control and infection all determine loss of HRQoL. New studies are needed to confirm these findings.
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Affiliation(s)
- Héctor González de la Torre
- Complejo Hospitalario Materno-Infantil Insular de Gran Canaria, Servicio Canario de Salud, Las Palmas de Gran Canaria, Spain
| | - María L Quintana-Lorenzo
- Complejo Hospitalario Materno-Infantil Insular de Gran Canaria, Servicio Canario de Salud, Las Palmas de Gran Canaria, Spain
| | - Estrella Perdomo-Pérez
- Gerencia de Atención Primaria de Gran Canaria, Servicio Canario de Salud, Las Palmas de Gran Canaria, Spain
| | - José Verdú
- Department of Community Nursing, Preventive Medicine, Public Health and History of Science, Faculty of Health Sciences, University of Alicante, Alicante, Spain
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31
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Araújo RDO, Silva DCD, Souto RQ, Pergola-Marconato AM, Fernandes Costa IK, Torres GDV. Impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária. AQUICHAN 2016. [DOI: 10.5294/aqui.2016.16.1.7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objetivo: analisar o impacto das úlceras venosas (UV) na qualidade de vida (QV) das pessoas atendidas na atenção primária à saúde. Material e método: pesquisa quantitativa, descritiva e transversal, realizada com 101 usuários, atendidos em 42 serviços de saúde de Natal, Rio Grande do Norte, Brasil. Os dados foram coletados de fevereiro a setembro de 2014, por meio de um questionário sociodemográfico, clínico e de saúde, e do Charing Cross Venous Ulcer Questionnaire. Utilizou-se estatística descritiva e inferencial para a análise dos dados. Resultados: a QV esteve comprometida, principalmente, no estado emocional e estético, com pior média entre os indivíduos com mais de um ano de lesão. Identificou-se associação estatística significativa entre tempo de UV atual e estado emocional (p=0,008), com maior média (64,2) para aqueles com UV há mais de um ano. Conclusões: as pessoas com UV há mais de ano apresentam maior comprometimento da QV. Necessita-se de intervenções e ações de promoção à saúde dessa população.
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32
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Woo KY, Sears K. Knowledge, Attitude, and Practice in the Management of Mixed Arteriovenous Leg Ulcers. INT J LOW EXTR WOUND 2016; 15:52-7. [PMID: 26811376 DOI: 10.1177/1534734615626626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Leg ulceration is a chronic health condition that constitutes a significant disease burden. In this cross-sectional descriptive study, a sample of wound care clinicians were asked to respond to a web-based survey. Based on a review of literature and recommended best practices in the management of mixed arteriovenous (AV) ulcers, a questionnaire was developed to examine the knowledge, attitude, and practice pattern in the management of AV ulcers. A total of 436 clinicians participated in the survey. A number of assessment techniques were perceived to be relevant for the assessment of AV ulcers; medical history and the appearance of ulcers were the most commonly used methods in clinical practice. While over 80% of the participants conceded that compression should be used to promote wound healing, half of them would consider using compression for AV ulcers if ankle brachial index was less than 0.8. Half of the participants considered an ankle brachial index of 0.8 or higher as the optimal cutoff value for safe compression. The majority of respondents disagreed with the perception that caring for people with AV ulcers was unrewarding. However, challenges to promote treatment adherence, address psychosocial concerns, and optimize symptom management are common.
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Affiliation(s)
- Kevin Y Woo
- Queen's University, Kingston, Ontario, Canada
| | - Kim Sears
- Queen's University, Kingston, Ontario, Canada
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O'Brien J, Finlayson K, Kerr G, Edwards H. Evaluating the effectiveness of a self-management exercise intervention on wound healing, functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomised controlled trial. Int Wound J 2016; 14:130-137. [PMID: 26817648 DOI: 10.1111/iwj.12571] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/12/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022] Open
Abstract
Exercise that targets ankle joint mobility may lead to improvement in calf muscle pump function and subsequent healing. The objectives of this research were to assess the impact of an exercise intervention in addition to routine evidence-based care on the healing rates, functional ability and health-related quality of life for adults with venous leg ulcers (VLUs). This study included 63 patients with VLUs. Patients were randomised to receive either a 12-week exercise intervention with a telephone coaching component or usual care plus telephone calls at the same timepoints. The primary outcome evaluated the effectiveness of the intervention in relation to wound healing. The secondary outcomes evaluated physical activity, functional ability and health-related quality of life measures between groups at the end of the 12 weeks. A per protocol analysis complemented the effectiveness (intention-to-treat) analysis to highlight the importance of adherence to an exercise intervention. Intention-to-treat analyses for the primary outcome showed 77% of those in the intervention group healed by 12 weeks compared to 53% of those in the usual care group. Although this difference was not statistically significant due to a smaller than expected sample size, a 24% difference in healing rates could be considered clinically significant. The per protocol analysis for wound healing, however, showed that those in the intervention group who adhered to the exercise protocol 75% or more of the time were significantly more likely to heal and showed higher rates for wound healing than the control group (P = 0·01), that is, 95% of those who adhered in the intervention group healed in 12 weeks. The secondary outcomes of physical activity, functional ability and health-related quality of life were not significantly altered by the intervention. Among the secondary outcomes (physical activity, functional ability and health-related quality of life), intention-to-treat analyses did not support the effectiveness of the intervention. However, per protocol analyses revealed encouraging results with those participants who adhered more than 75% of the time (n = 19) showing significantly improved Range of Ankle Motion from the self-management exercise programme (P = 0·045). This study has shown that those participants who adhere to the exercise programme as an adjunctive treatment to standard care are more likely to heal and have better functional outcomes than those who do not adhere to the exercises in conjunction with usual care.
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Affiliation(s)
- Jane O'Brien
- School of Nursing Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Kathleen Finlayson
- School of Nursing Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Graham Kerr
- School of Exercise and Nutrition Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Helen Edwards
- Faculty of Health, Wound Management Innovation Cooperative Research Centre, Queensland University of Technology, Brisbane, Australia
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Jull A, Wadham A, Bullen C, Parag V, Kerse N, Waters J. Low-dose aspirin as an adjuvant treatment for venous leg ulceration: study protocol for a randomized controlled trial (Aspirin4VLU). J Adv Nurs 2015; 72:669-79. [PMID: 26708314 DOI: 10.1111/jan.12864] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2015] [Indexed: 01/22/2023]
Abstract
AIM The aim of this study was to determine the effect of low-dose aspirin on venous leg ulcer healing when used in addition to compression. BACKGROUND The mainstay of treatment for venous leg ulcers is compression therapy and there are few adjuvant treatments to accelerate healing. DESIGN Pragmatic, community-based, double-blind, randomized trial. METHODS Participants with venous leg ulcers will receive either 150 mg aspirin or placebo daily for up to 24 weeks. Participants will receive background treatment with compression therapy (system of choice guided by participant and/or clinical preference) delivered through district nursing services. The primary outcome will be time-to-healing. Secondary outcomes will include proportion healed at 24 weeks, change in ulcer area, change in health-related quality of life, adherence, efficacy of blinding and adverse events. The trial was funded in June 2014. DISCUSSION The trial commenced in March 2015 and is successfully recruiting. The trial is one of three trials that will contribute to an individual participant data meta-analysis to be undertaken at the York Trials Centre. TRIAL REGISTRATION Registered 5 June 2014 ClinicalTrials.gov NCT02158806. Protocol version 1·1, 14 April 2015.
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Affiliation(s)
- Andrew Jull
- School of Nursing, University of Auckland, New Zealand.,National Institute for Health Innovation, University of Auckland, New Zealand
| | - Angela Wadham
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Varsha Parag
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Ngaire Kerse
- School of Population Health, University of Auckland, New Zealand
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Tilbrook H, Forsythe RO, Rolfe D, Clark L, Bland M, Buckley H, Chetter I, Cook L, Dumville J, Gabe R, Harding K, Layton A, Lindsay E, McDaid C, Moffatt C, Phillips C, Stansby G, Vowden P, Williams L, Torgerson D, Hinchliffe RJ. Aspirin for Venous Ulcers: Randomised Trial (AVURT): study protocol for a randomised controlled trial. Trials 2015; 16:513. [PMID: 26554558 PMCID: PMC4641424 DOI: 10.1186/s13063-015-1039-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/29/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) are the commonest cause of leg ulceration, affecting 1 in 100 adults. There is a significant health burden associated with VLUs - it is estimated that the cost of treatment for 1 ulcer is up to £1300 per year in the NHS. The mainstay of treatment is with graduated compression bandaging; however, treatment is often prolonged and up to one quarter of venous leg ulcers do not heal despite standard care. Two previous trials have suggested that low-dose aspirin, as an adjunct to standard care, may hasten healing, but these trials were small and of poor quality. Aspirin is an inexpensive, widely used medication but its safety and efficacy in the treatment of VLUs remains to be established. METHODS/DESIGN AVURT is a phase II randomised double blind, parallel-group, placebo-controlled efficacy trial. The primary objective is to examine whether aspirin, in addition to standard care, is effective in patients with chronic VLUs (i.e. over 6 weeks in duration or a history of VLU). Secondary objectives include feasibility and safety of aspirin in this population. A target of 100 participants, identified from community leg ulcer clinics and hospital clinics, will be randomised to receive either 300 mg of aspirin once daily or placebo. All participants will receive standard care with compression therapy. The primary outcome will be time to healing of the reference ulcer. Follow-up will occur for a maximum of 27 weeks. The primary analysis will use a Cox proportional hazards model to compare time to healing using the principles of intention-to-treat. Secondary outcomes will include ulcer size, pain evaluation, compliance and adverse events. DISCUSSION The AVURT trial will investigate the efficacy and safety of aspirin as a treatment for VLU and will inform on the feasibility of proceeding to a larger phase III study. This study will address the paucity of information currently available regarding aspirin therapy to treat VLU. TRIAL REGISTRATION The study is registered on a public database with clinicaltrials.gov ( NCT02333123 ; registered on 5 November 2014).
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Affiliation(s)
- Helen Tilbrook
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Rachael O Forsythe
- St George's Vascular Institute, St George's Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK.
| | | | - Laura Clark
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Martin Bland
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Hannah Buckley
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Ian Chetter
- Hull York Medical School, University of Hull, Kingston upon Hull, UK.
| | - Liz Cook
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Jo Dumville
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
| | - Rhian Gabe
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Keith Harding
- Wound Healing Research Unit, Cardiff University, Cardiff, UK.
| | - Alison Layton
- Harrogate and District NHS Foundation Trust, London, UK.
| | | | - Catriona McDaid
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Christine Moffatt
- School of Health Sciences, University of Nottingham, Nottingham, UK.
| | - Ceri Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, UK.
| | - Gerard Stansby
- School of Surgical and Reproductive Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | | | - Laurie Williams
- St George's Vascular Institute, St George's Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK.
| | - David Torgerson
- Department of Health Sciences, York Trials Unit, University of York, York, UK.
| | - Robert J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK.
- St George's University of London, London, UK.
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Ingves MV, Power AH. Two Cases of Transcutaneous Electrical Nerve Stimulation of the Common Peroneal Nerve Successfully Treating Refractory, Multifactorial Leg Edema. J Investig Med High Impact Case Rep 2015; 2:2324709614559839. [PMID: 26425629 PMCID: PMC4528879 DOI: 10.1177/2324709614559839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The treatment of leg edema often involves promoting venous blood flow but can be difficult in patients with comorbidities that prevent traditional management strategies such as limb elevation or mechanical compression devices. The geko device is a self-contained neuromuscular stimulation device that adheres to skin over the common peroneal nerve and delivers a low-voltage stimulus that activates the lower-leg musculature resulting in enhanced superficial femoral vein blood flow and velocity. Here we report 2 cases of multifactorial and refractory leg edema successfully treated with the geko device over a period of 4 to 16 weeks. The device also improved pain and chronic wound healing. Although the geko device is costly, it was well tolerated and may provide another treatment strategy for resistant leg swelling.
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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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Rasmussen JC, Aldrich MB, Tan IC, Darne C, Zhu B, O'Donnell TF, Fife CE, Sevick-Muraca EM. Lymphatic transport in patients with chronic venous insufficiency and venous leg ulcers following sequential pneumatic compression. J Vasc Surg Venous Lymphat Disord 2015; 4:9-17. [PMID: 26946890 DOI: 10.1016/j.jvsv.2015.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/02/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Recent advancements in near-infrared fluorescence lymphatic imaging (NIRFLI) technology provide opportunities for non-invasive, real-time assessment of lymphatic contribution in the etiology and treatment of ulcers. The objective of this study was to assess lymphatics in subjects with venous leg ulcers using NIRFLI and to assess lymphatic impact of a single session of sequential pneumatic compression (SPC). METHODS Following intradermal microdoses of indocyanine green (ICG) as a lymphatic contrast agent, NIRFLI was used in a pilot study to image the lymphatics of 12 subjects with active venous leg ulcers (Clinical, Etiologic, Anatomic, and Pathophysiologic [CEAP] C6). The lymphatics were imaged before and after a single session of SPC to assess impact on lymphatic function. RESULTS Baseline imaging showed impaired lymphatic function and bilateral dermal backflow in all subjects with chronic venous insufficiency, even those without ulcer formation in the contralateral limb (C0 and C4 disease). SPC therapy caused proximal movement of ICG away from the active wound in 9 of 12 subjects, as indicated by newly recruited functional lymphatic vessels, emptying of distal lymphatic vessels, or proximal movement of extravascular fluid. Subjects with the longest duration of active ulcers had few visible lymphatic vessels, and proximal movement of ICG was not detected after SPC therapy. CONCLUSIONS This study provides visible confirmation of lymphatic dysfunction at an early stage in the etiology of venous ulcer formation and demonstrates the potential therapeutic mechanism of SPC therapy in removing excess fluid. The ability of SPC therapy to restore fluid balance through proximal movement of lymph and interstitial fluid may explain its value in hastening venous ulcer healing. Anatomical differences between the lymphatics of longstanding and more recent venous ulcers may have important therapeutic implications.
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Affiliation(s)
- John C Rasmussen
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Melissa B Aldrich
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | - I-Chih Tan
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Chinmay Darne
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Banghe Zhu
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | | | - Caroline E Fife
- Wound Care Clinic, CHI St. Luke's Health - The Woodlands Hospital, The Woodlands, Tex
| | - Eva M Sevick-Muraca
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, Tex.
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Kruse CR, Nuutila K, Lee CCY, Kiwanuka E, Singh M, Caterson EJ, Eriksson E, Sørensen JA. The external microenvironment of healing skin wounds. Wound Repair Regen 2015; 23:456-64. [PMID: 25857996 DOI: 10.1111/wrr.12303] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
The skin wound microenvironment can be divided into two main components that influence healing: the external wound microenvironment, which is outside the wound surface; and the internal wound microenvironment, underneath the surface, to which the cells within the wound are exposed. Treatment methods that directly alter the features of the external wound microenvironment indirectly affect the internal wound microenvironment due to the exchange between the two compartments. In this review, we focus on the effects of temperature, pressure (positive and negative), hydration, gases (oxygen and carbon dioxide), pH, and anti-microbial treatment on the wound. These factors are well described in the literature and can be modified with treatment methods available in the clinic. Understanding the roles of these factors in wound pathophysiology is of central importance in wound treatment.
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Affiliation(s)
- Carla R Kruse
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Plastic and Reconstructive Surgery, Odense University Hospital, Odense, Denmark
| | - Kristo Nuutila
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cameron C Y Lee
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Kiwanuka
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mansher Singh
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward J Caterson
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elof Eriksson
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jens A Sørensen
- Department of Plastic and Reconstructive Surgery, Odense University Hospital, Odense, Denmark
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Bellmunt‐Montoya S, Escribano JM, Dilme J, Martinez‐Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev 2015; 2015:CD009648. [PMID: 26121003 PMCID: PMC7097730 DOI: 10.1002/14651858.cd009648.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system. This is an update of the review first published in 2013. OBJECTIVES To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins. SEARCH METHODS The Trials Search Co-ordinator of the Cochrane Peripheral Vascular Diseases Group searched the Specialised Register (April 2015), the Cochrane Register of Studies (2015, Issue 3) and clinical trials databases. The review authors searched PubMed (April 2015). There was no language restriction. We contacted study authors to obtain more information when necessary. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared the CHIVA method versus any other treatments. Two review authors independently selected and evaluated the studies. One review author extracted data and performed the quantitative analysis. DATA COLLECTION AND ANALYSIS Two independent review authors extracted data from the selected papers. We calculated the risk ratio (RR), mean difference (MD), the number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI) using Review Manager 5. MAIN RESULTS No new studies were identified for this update. We included four RCTs with 796 participants (70.5% women). Three RCTs compared the CHIVA method with vein stripping, and one RCT compared the CHIVA method with compression dressings in people with venous ulcers. We judged the quality of the evidence of the included studies as low to moderate due to imprecision caused by the low number of events and because the studies were open. The overall risk of bias across studies was high because neither participants nor outcome assessors were blinded to the interventions. The primary endpoint, clinical recurrence, pooled between studies over a follow-up of 3 to 10 years, showed more favorable results for the CHIVA method than for vein stripping (721 people; RR 0.63; 95% CI 0.51 to 0.78; I(2) = 0%, NNTB 6; 95% CI 4 to 10) or compression dressings (47 people; RR 0.23; 95% CI 0.06 to 0.96; NNTB 3; 95% CI 2 to 17). Only one study reported data on quality of life (presented graphically) and these results significantly favored the CHIVA method.The vein stripping group had a higher risk of side effects than the CHIVA group; specifically, the RR for bruising was 0.63 (95% CI 0.53 to 0.76; NNTH 4; 95% CI 3 to 6) and the RR for nerve damage was 0.05 (95% CI 0.01 to 0.38; I(2) = 0%; NNTH 12; 95% CI 9 to 20). There were no statistically significant differences between groups regarding the incidence of limb infection and superficial vein thrombosis. AUTHORS' CONCLUSIONS The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping. However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed and the results were imprecise due to low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.
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Affiliation(s)
- Sergi Bellmunt‐Montoya
- Hospital de la Santa Creu i Sant Pau, IBB Sant PauAngiology, Vascular and Endovascular SurgerySant Quinti No. 89BarcelonaSpain08041
| | - Jose Maria Escribano
- Hospital Universitario Vall d'HebronAngiology, Vascular and Endovascular SurgeryPasseo Vall d'Hebron, 119‐129BarcelonaBarcelonaSpain08035
| | - Jaume Dilme
- Hospital de la Santa Creu i Sant Pau, IBB Sant PauAngiology, Vascular and Endovascular SurgerySant Quinti No. 89BarcelonaSpain08041
| | - Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni M. Claret 171Casa de ConvalescènciaBarcelonaCataloniaSpain08041
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Kranke P, Bennett MH, Martyn‐St James M, Schnabel A, Debus SE, Weibel S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev 2015; 2015:CD004123. [PMID: 26106870 PMCID: PMC7055586 DOI: 10.1002/14651858.cd004123.pub4] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic wounds are common and present a health problem with significant effect on quality of life. Various pathologies may cause tissue breakdown, including poor blood supply resulting in inadequate oxygenation of the wound bed. Hyperbaric oxygen therapy (HBOT) has been suggested to improve oxygen supply to wounds and therefore improve their healing. OBJECTIVES To assess the benefits and harms of adjunctive HBOT for treating chronic ulcers of the lower limb. SEARCH METHODS For this second update we searched the Cochrane Wounds Group Specialised Register (searched 18 February 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 1); Ovid MEDLINE (1946 to 17 February 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 17 February 2015); Ovid EMBASE (1974 to 17 February 2015); and EBSCO CINAHL (1982 to 17 February 2015). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the effect on chronic wound healing of therapeutic regimens which include HBOT with those that exclude HBOT (with or without sham therapy). DATA COLLECTION AND ANALYSIS Three review authors independently evaluated the risk of bias of the relevant trials using the Cochrane methodology and extracted the data from the included trials. We resolved any disagreement by discussion. MAIN RESULTS We included twelve trials (577 participants). Ten trials (531 participants) enrolled people with a diabetic foot ulcer: pooled data of five trials with 205 participants showed an increase in the rate of ulcer healing (risk ratio (RR) 2.35, 95% confidence interval (CI) 1.19 to 4.62; P = 0.01) with HBOT at six weeks but this benefit was not evident at longer-term follow-up at one year. There was no statistically significant difference in major amputation rate (pooled data of five trials with 312 participants, RR 0.36, 95% CI 0.11 to 1.18). One trial (16 participants) considered venous ulcers and reported data at six weeks (wound size reduction) and 18 weeks (wound size reduction and number of ulcers healed) and suggested a significant benefit of HBOT in terms of reduction in ulcer area only at six weeks (mean difference (MD) 33.00%, 95% CI 18.97 to 47.03, P < 0.00001). We identified one trial (30 participants) which enrolled patients with non-healing diabetic ulcers as well as venous ulcers ("mixed ulcers types") and patients were treated for 30 days. For this "mixed ulcers" there was a significant benefit of HBOT in terms of reduction in ulcer area at the end of treatment (30 days) (MD 61.88%, 95% CI 41.91 to 81.85, P < 0.00001). We did not identify any trials that considered arterial and pressure ulcers. AUTHORS' CONCLUSIONS In people with foot ulcers due to diabetes, HBOT significantly improved the ulcers healed in the short term but not the long term and the trials had various flaws in design and/or reporting that means we are not confident in the results. More trials are needed to properly evaluate HBOT in people with chronic wounds; these trials must be adequately powered and designed to minimise all kinds of bias.
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Affiliation(s)
- Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberdürrbacher Str. 6WürzburgGermany97080
| | - Michael H Bennett
- Prince of Wales Clinical School, University of NSWDepartment of AnaesthesiaSydneyNSWAustralia
| | - Marrissa Martyn‐St James
- University of SheffieldSchool of Health and Related Research (ScHARR)Regent Court, 30 Regent StreetSheffieldSouth YorkshireUKS1 4DA
| | - Alexander Schnabel
- University Hospital MünsterDepartment of Anesthesiology, Intensive Care and Pain MedicineAlbert‐Schweitzer‐Campus 1, Gebäude AMünsterGermany48149
| | - Sebastian E Debus
- University Heart Centre, University Clinics of Hamburg‐ EppendorfClinic for Vascular MedicineMartinistr 52HamburgGermany20246
| | - Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberdürrbacher Str. 6WürzburgGermany97080
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Finlayson K, Wu ML, Edwards HE. Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach: A longitudinal study. Int J Nurs Stud 2015; 52:1042-51. [DOI: 10.1016/j.ijnurstu.2015.02.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 01/22/2023]
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Tricco AC, Antony J, Vafaei A, Khan PA, Harrington A, Cogo E, Wilson C, Perrier L, Hui W, Straus SE. Seeking effective interventions to treat complex wounds: an overview of systematic reviews. BMC Med 2015; 13:89. [PMID: 25899006 PMCID: PMC4406332 DOI: 10.1186/s12916-015-0288-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 02/03/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Numerous, often multi-faceted regimens are available for treating complex wounds, yet the evidence of these interventions is recondite across the literature. We aimed to identify effective interventions to treat complex wounds through an overview of systematic reviews. METHODS MEDLINE (OVID interface, 1946 until October 26, 2012), EMBASE (OVID interface, 1947 until October 26, 2012), and the Cochrane Database of Systematic Reviews (Issue 10 of 12, 2012) were searched on October 26, 2012. Systematic reviews that examined adults receiving care for their complex wounds were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. RESULTS Overall, 99 systematic reviews were included after screening 6,200 titles and abstracts and 422 full-texts; 54 were systematic reviews with a meta-analysis (including data on over 54,000 patients) and 45 were systematic reviews without a meta-analysis. Overall, 44% of included reviews were rated as being of high quality (AMSTAR score ≥ 8). Based on data from systematic reviews including a meta-analysis with an AMSTAR score ≥ 8, promising interventions for complex wounds were identified. These included bandages or stockings (multi-layer, high compression) and wound cleansing for venous leg ulcers; four-layer bandages for mixed arterial/venous leg ulcers; biologics, ultrasound, and hydrogel dressings for diabetic leg/foot ulcers; hydrocolloid dressings, electrotherapy, air-fluidized beds, and alternate foam mattresses for pressure ulcers; and silver dressings and ultrasound for unspecified mixed complex wounds. For surgical wound infections, topical negative pressure and vacuum-assisted closure were promising interventions, but this was based on evidence from moderate to low quality systematic reviews. CONCLUSIONS Numerous interventions can be utilized for patients with varying types of complex wounds, yet few treatments were consistently effective across all outcomes throughout the literature. Clinicians and patients can use our results to tailor effective treatment according to type of complex wound. Network meta-analysis will be of benefit to decision-makers, as it will permit multiple treatment comparisons and ranking of the effectiveness of all interventions. Please see related article: http://dx.doi.org/10.1186/s12916-015-0326-3.
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3M7, Canada.
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Afshin Vafaei
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Paul A Khan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Alana Harrington
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Elise Cogo
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Charlotte Wilson
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Laure Perrier
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Wing Hui
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, Ontario, M5B 1W8, Canada.
- Department of Geriatric Medicine, University of Toronto, 27 Kings College Circle, Toronto, Ontario, M5S 1A1, Canada.
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Dickerson JE, Slade HB. Dehydrated amnion/chorion membrane and venous leg ulcers. Wound Repair Regen 2015; 23:141-2. [DOI: 10.1111/wrr.12257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jaime E. Dickerson
- Biotherapeutics, Smith & Nephew, Inc. Fort Worth Texas
- Department of Immunology and Cell Biology University of North Texas Health Science Center Fort Worth Texas
| | - Herbert B. Slade
- Biotherapeutics, Smith & Nephew, Inc. Fort Worth Texas
- Department of Pediatrics University of North Texas Health Science Center Fort Worth Texas
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Parker TJ, Broadbent JA, McGovern JA, Broszczak DA, Parker CN, Upton Z. Provisional Matrix Deposition in Hemostasis and Venous Insufficiency: Tissue Preconditioning for Nonhealing Venous Ulcers. Adv Wound Care (New Rochelle) 2015; 4:174-191. [PMID: 25785239 PMCID: PMC4352700 DOI: 10.1089/wound.2013.0462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Indexed: 01/07/2023] Open
Abstract
Significance: Chronic wounds represent a major burden on global healthcare systems and reduce the quality of life of those affected. Significant advances have been made in our understanding of the biochemistry of wound healing progression. However, knowledge regarding the specific molecular processes influencing chronic wound formation and persistence remains limited. Recent Advances: Generally, healing of acute wounds begins with hemostasis and the deposition of a plasma-derived provisional matrix into the wound. The deposition of plasma matrix proteins is known to occur around the microvasculature of the lower limb as a result of venous insufficiency. This appears to alter limb cutaneous tissue physiology and consequently drives the tissue into a 'preconditioned' state that negatively influences the response to wounding. Critical Issues: Processes, such as oxygen and nutrient suppression, edema, inflammatory cell trapping/extravasation, diffuse inflammation, and tissue necrosis are thought to contribute to the advent of a chronic wound. Healing of the wound then becomes difficult in the context of an internally injured limb. Thus, interventions and therapies for promoting healing of the limb is a growing area of interest. For venous ulcers, treatment using compression bandaging encourages venous return and improves healing processes within the limb, critically however, once treatment concludes ulcers often reoccur. Future Directions: Improved understanding of the composition and role of pericapillary matrix deposits in facilitating internal limb injury and subsequent development of chronic wounds will be critical for informing and enhancing current best practice therapies and preventative action in the wound care field.
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Affiliation(s)
- Tony J. Parker
- Tissue Repair and Regeneration Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - James A. Broadbent
- Tissue Repair and Regeneration Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jacqui A. McGovern
- Tissue Repair and Regeneration Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Daniel A. Broszczak
- Tissue Repair and Regeneration Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Christina N. Parker
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Zee Upton
- Tissue Repair and Regeneration Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Martí-Carvajal AJ, Knight-Madden JM, Martinez-Zapata MJ. Interventions for treating leg ulcers in people with sickle cell disease. Cochrane Database Syst Rev 2014; 2014:CD008394. [PMID: 25485858 PMCID: PMC7175837 DOI: 10.1002/14651858.cd008394.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The frequency of skin ulceration makes it an important contributor to the morbidity burden in people with sickle cell disease. Many treatment options are available to the healthcare professional, although it is uncertain which treatments have been assessed for effectiveness in people with sickle cell disease. OBJECTIVES To assess the clinical effectiveness and safety of interventions for treating leg ulcers in people with sickle cell disease. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register.We searched LILACS (1982 to August 2012), the African Index Medicus (up to August 2012), ISI Web of Knowledge (1985 to August 2012), and the Clinical Trials Search Portal of the World Health Organization (August 2012). We checked the reference lists of all the trials identified. We also contacted those groups or individuals who may have completed relevant randomised trials in this area.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 21 July 2014; date of the last search of the Cochrane Wounds Group Trials Register: 18 September 2014. SELECTION CRITERIA Randomised controlled trials of interventions for treating leg ulcers in people with sickle cell disease compared to placebo or an alternative treatment. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion. All three authors independently assessed the risk of bias of the included studies and extracted data. MAIN RESULTS Six studies met the inclusion criteria (198 participants with 250 ulcers). Each trial investigated a different intervention and within this review we have grouped these as systemic pharmaceutical interventions (L-cartinine, arginine butyrate, isoxsuprine) and topical pharmaceutical interventions (Solcoseryl(®) cream, RGD peptide dressing, topical antibiotics). Three interventions reported on the change in ulcer size (arginine butyrate, RGD peptide, L-cartinine). Of these, RGD peptide matrix significantly reduced ulcer size compared with a control group, mean reduction 6.60cm(2) (95% CI 5.51 to 7.69; very low quality of evidence). Three trials reported on the incidence of complete closure (isoxsuprine, arginine butyrate, RGD peptide matrix; ranging between low and very low quality of evidence). None reported a significant effect. No trial reported on: the time to complete ulcer healing; ulcer-free survival following treatment for sickle cell leg ulcers; quality of life measures; or incidence of amputation. There was no reported information on the safety of these interventions. AUTHORS' CONCLUSIONS There is evidence that a topical intervention (RGD peptide matrix) reduced ulcer size in treated participants compared to controls. This evidence of efficacy is limited by the generally high risk of bias associated with these reports.We planned to analyse results according to general groups: pharmaceutical interventions (systemic and topical); and non-pharmaceutical interventions (surgical and non-surgical). However, we were unable to pool findings due to the heterogeneity in outcome definitions, and inconsistency between the unit of randomisation and the unit of analysis. This heterogeneity, along with a paucity of identified trials, prevented us performing any meta-analyses.This Cochrane review provides some evidence for the effectiveness of one topical intervention - RGD peptide matrix. However, this intervention was assessed as having a high risk of bias due to inadequacies in the single trial report. Other included studies were also assessed as having a high risk of bias. We recommend that readers interpret the trial results with caution. The safety profile of the all interventions was inconclusive.
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Affiliation(s)
- Brijesh Nair
- Consultant Dermatologist, Department of Dermatology and Venereology, INHS Sanjivani, Kochi, India
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Rohner-Spengler M, Frotzler A, Honigmann P, Babst R. Effective Treatment of Posttraumatic and Postoperative Edema in Patients with Ankle and Hindfoot Fractures: A Randomized Controlled Trial Comparing Multilayer Compression Therapy and Intermittent Impulse Compression with the Standard Treatment with Ice. J Bone Joint Surg Am 2014; 96:1263-1271. [PMID: 25100773 DOI: 10.2106/jbjs.k.00939] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND After ankle and hindfoot fractures, edema has a major impact on the time for surgical intervention and may increase the risk of wound complications and infection postoperatively. The aim of this study was to evaluate the efficacy of multilayer compression and intermittent impulse compression therapy in reducing ankle and hindfoot edema compared with the standard treatment with elevation and ice. METHODS This was a randomized, controlled, single-blinded clinical trial using a repeated-measures design. Fifty-eight patients with unilateral fractures of the ankle or hindfoot were randomized into the cold pack (control) group, the bandage group, or the impulse compression group and were analyzed according to the intention-to-treat principle. The primary outcome was the reduction of edema as measured with the figure-of-eight-20 method. RESULTS Preoperatively and postoperatively, there were significant differences in edema reduction between the bandage group and the control group. After two days of intervention, the median preoperative edema reduction in the control group was -2.0 mm (-5%) compared with -11.0 mm (-23%) in the bandage group (p < 0.017), and -0.3 mm (0%) in the impulse compression group (p > 0.017). Postoperatively, after two days, the median edema changes were +3.5 mm (+7%) in the control group compared with -7.3 mm (-22%) in the bandage group (p < 0.017) and +5.0 mm (+46%) in the impulse compression group (p > 0.017). CONCLUSIONS Multilayer compression therapy results in a faster reduction of ankle and hindfoot edema, although with less ankle dorsiflexion on postoperative day three than the control group, and can be recommended as an alternative treatment. Intermittent impulse compression applied without any extra compression by stockinette or bandage and without elevation in off-session periods cannot be recommended as a superior alternative to the treatment with ice. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
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Affiliation(s)
- Manuela Rohner-Spengler
- Departments of Rheumatology and Physiotherapy (M.R.-S.) and Trauma Surgery (M.R.-S., P.H., and R.B.), Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland. E-mail address for M. Rohner-Spengler:
| | - Angela Frotzler
- Clinical Trial Unit, Swiss Paraplegic Centre, Guido A. Zäch Strasse 1, 6207 Nottwil, Switzerland
| | - Philipp Honigmann
- Departments of Rheumatology and Physiotherapy (M.R.-S.) and Trauma Surgery (M.R.-S., P.H., and R.B.), Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland. E-mail address for M. Rohner-Spengler:
| | - Reto Babst
- Departments of Rheumatology and Physiotherapy (M.R.-S.) and Trauma Surgery (M.R.-S., P.H., and R.B.), Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland. E-mail address for M. Rohner-Spengler:
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Messinger-Rapport BJ, Gammack JK, Thomas DR, Morley JE. Clinical update on nursing home medicine: 2013. J Am Med Dir Assoc 2014; 14:860-76. [PMID: 24286710 DOI: 10.1016/j.jamda.2013.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 09/18/2013] [Indexed: 12/18/2022]
Abstract
This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.
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The effect of a connexin43-based Peptide on the healing of chronic venous leg ulcers: a multicenter, randomized trial. J Invest Dermatol 2014; 135:289-298. [PMID: 25072595 PMCID: PMC4269806 DOI: 10.1038/jid.2014.318] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 06/30/2014] [Accepted: 07/14/2014] [Indexed: 12/29/2022]
Abstract
The gap junction protein, connexin43 (Cx43), has critical roles in the inflammatory, edematous, and fibrotic processes following dermal injury and during wound healing, and is abnormally upregulated at the epidermal wound margins of venous leg ulcers (VLUs). Targeting Cx43 with ACT1, a peptide mimetic of the carboxyl-terminus of Cx43, accelerates fibroblast migration and proliferation, and wound reepithelialization. In a prospective, multicenter clinical trial conducted in India, adults with chronic VLUs were randomized to treatment with an ACT1 gel formulation plus conventional standard-of-care (SOC) protocols, involving maintaining wound moisture and four-layer compression bandage therapy, or SOC protocols alone. The primary end point was mean percent ulcer reepithelialization from baseline to 12 weeks. A significantly greater reduction in mean percent ulcer area from baseline to 12 weeks was associated with the incorporation of ACT1 therapy (79% (SD 50.4)) as compared with compression bandage therapy alone (36% (SD 179.8); P=0.02). Evaluation of secondary efficacy end points indicated a reduced median time to 50 and 100% ulcer reepithelialization for ACT1-treated ulcers. Incorporation of ACT1 in SOC protocols may represent a well-tolerated, highly effective therapeutic strategy that expedites chronic venous ulcer healing by treating the underlying ulcer pathophysiology through Cx43-mediated pathways.
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