1
|
Wang Y, Liu B, Pi Y, Hu L, Yuan Y, Luo J, Tao Y, Li P, Lu S, Song W. Risk factors for diabetic foot ulcers mortality and novel negative pressure combined with platelet-rich plasma therapy in the treatment of diabetic foot ulcers. Front Pharmacol 2022; 13:1051299. [PMID: 36588684 PMCID: PMC9800930 DOI: 10.3389/fphar.2022.1051299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
The purpose of this study was to assess the risk factors for morbidity and mortality of diabetic foot ulcers (DFUs). For the treatment of diabetic foot ulcers, negative pressure wound therapy (NPWT) combined with platelet-rich plasma-fibrin glue (PRP) was also investigated. There were 653 patients in the diabetic foot ulcer group and 510 patients in the diabetic patients without foot ulceration (NFU) group, for a total of 1163 patients in the study samples after individuals without follow-up were excluded. The patients were randomized into two groups: the negative pressure wound therapy group and the negative pressure wound therapy combined with the PRP group. The findings of the univariate analysis revealed the blood indicators for predicting diabetic foot ulcer morbidity risk factors, such as C-reactive protein, albumin, creatinine, alkaline phosphatase, procalcitonin, platelets, 25-hydroxyvitamin D, β-2-microglobulin, monocyte ratio, low-density protein cholesterol (LDL), triglyceride, alanine aminotransferase (ALT), aminotransferase (AST), creatine kinase (CK) and total cholesterol. Using logistic regression analysis revealed only albumin and age to be independent predictors of diabetic foot ulcer mortality. Our study also revealed that, compared to negative pressure wound therapy alone, negative pressure wound therapy combined with PRP accelerated wound healing and reduced the mortality rate. According to the findings of this pilot study, new risk factors for diabetic foot ulcer morbidity and mortality have been found, and negative pressure wound therapy combined with PRP therapy may provide the first information that it is an effective adjunct treatment for diabetic foot ulcers.
Collapse
Affiliation(s)
- Yanling Wang
- Changsha Maternal and Child Health Hospital Affiliated to Hunan Normal University, Changsha, China
| | - Bang Liu
- Changsha Maternal and Child Health Hospital Affiliated to Hunan Normal University, Changsha, China
| | - Yinzhen Pi
- The First Hospital of Changsha, Changsha, China
| | - Li Hu
- The First Hospital of Changsha, Changsha, China
| | - Yeling Yuan
- Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Jiao Luo
- Changsha Maternal and Child Health Hospital Affiliated to Hunan Normal University, Changsha, China
| | - Yixiao Tao
- Changsha Maternal and Child Health Hospital Affiliated to Hunan Normal University, Changsha, China
| | - Ping Li
- Changsha Maternal and Child Health Hospital Affiliated to Hunan Normal University, Changsha, China
| | - Shan Lu
- Changsha Maternal and Child Health Hospital Affiliated to Hunan Normal University, Changsha, China
| | - Wei Song
- National & Local Joint Engineering Research Center of High-Throughput Drug Screening Technology, College of Health Science and Engineering, Hubei University, Wuhan, China,*Correspondence: Wei Song,
| |
Collapse
|
2
|
Campolina AC, Maricevich JPBR, Silva RO, Santa-Cruz F, Coutinho LR, Maricevich M, Raj S, Ferraz ÁAB. Evaluation of Chlorhexidine Concentration on the Skin After Preoperative Surgical Site Preparation in Breast Surgery-A Randomized Controlled Trial. Aesthetic Plast Surg 2022; 46:1517-1522. [PMID: 35614158 DOI: 10.1007/s00266-022-02908-5] [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: 02/02/2022] [Accepted: 04/19/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although there is a rationale supporting that preoperative showering with 2% or 4% chlorhexidine gluconate (CHG) would decrease skin bacterial colonization, there is no consensus that this practice reduces the risk of surgical site infection (SSI). OBJECTIVES Analyze the skin concentration of CHG after preoperative showering associated with the traditional skin preparation with CHG 4% for breast surgery. METHODS Randomized controlled trial that included 45 patients, all candidates for augmentation mammaplasty, allocated into three groups (A: no preoperative showering; B: one preoperative showering; C: two preoperative showering with CHG 4%) in a 1:1:1 ratio. Skin swabs collection was performed right before the surgical incision. The samples were, then, sent to spectrophotometry in order to determine the skin concentration of CHG at the beginning of surgery. RESULTS The age ranged from 18 to 61 years, with a mean of 37 years old. Group C had the lowest median concentration (0.057) followed by group B (0.060) and group A (0.072), however, with no statistical significance. The areola was the place with the lowest median concentration level (0.045), followed by the axilla (0.061) and the inframammary fold (IMF) (0.069). Still, when comparing the distribution of the sites, a statistically significant difference was found only between the axilla and the areola (p = 0.022). CONCLUSION Preoperative showering with CHG 4% did not increase the concentration of this agent on the skin surface right before the surgical incision. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
|
3
|
Jani VP, Jani VP, Munoz CJ, Govender K, Williams AT, Cabrales P. Application of negative tissue interstitial pressure improves functional capillary density after hemorrhagic shock in the absence of volume resuscitation. Physiol Rep 2021; 9:e14783. [PMID: 33661575 PMCID: PMC7931804 DOI: 10.14814/phy2.14783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/05/2021] [Indexed: 11/24/2022] Open
Abstract
Microvascular fluid exchange is primarily dependent on Starling forces and both the active and passive myogenic response of arterioles and post‐capillary venules. Arterioles are classically considered resistance vessels, while venules are considered capacitance vessels with high distensibility and low tonic sympathetic stimulation at rest. However, few studies have investigated the effects of modulating interstitial hydrostatic pressure, particularly in the context of hemorrhagic shock. The objective of this study was to investigate the mechanics of arterioles and functional capillary density (FCD) during application of negative tissue interstitial pressure after 40% total blood volume hemorrhagic shock. In this study, we characterized systemic and microcirculatory hemodynamic parameters, including FCD, in hamsters instrumented with a dorsal window chamber and a custom‐designed negative pressure application device via intravital microscopy. In large arterioles, application of negative pressure after hemorrhagic shock resulted in a 13 ± 11% decrease in flow compared with only a 7 ± 9% decrease in flow after hemorrhagic shock alone after 90 minutes. In post‐capillary venules, however, application of negative pressure after hemorrhagic shock resulted in a 31 ± 4% decrease in flow compared with only an 8 ± 5% decrease in flow after hemorrhagic shock alone after 90 minutes. Normalized FCD was observed to significantly improve after application of negative pressure after hemorrhagic shock (0.66 ± 0.02) compared to hemorrhagic shock without application of negative pressure (0.50 ± 0.04). Our study demonstrates that application of negative pressure acutely improves FCD during hemorrhagic shock, though it does not normalize FCD. These results suggest that by increasing the hydrostatic pressure gradient between the microvasculature and interstitium, microvascular perfusion can be transiently restored in the absence of volume resuscitation. This study has significant clinical implications, particularly in negative pressure wound therapy, and offers an alternative mechanism to improve microvascular perfusion during hypovolemic shock.
Collapse
Affiliation(s)
- Vinay P Jani
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| | - Vivek P Jani
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, The Johns Hopkins School of Medicine Baltimore, MD, USA
| | - Carlos J Munoz
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| | - Krianthan Govender
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| | - Alexander T Williams
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| | - Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| |
Collapse
|
4
|
Zens Y, Barth M, Bucher HC, Dreck K, Felsch M, Groß W, Jaschinski T, Kölsch H, Kromp M, Overesch I, Sauerland S, Gregor S. Negative pressure wound therapy in patients with wounds healing by secondary intention: a systematic review and meta-analysis of randomised controlled trials. Syst Rev 2020; 9:238. [PMID: 33038929 PMCID: PMC7548038 DOI: 10.1186/s13643-020-01476-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/07/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) is a widely used method of wound treatment. We performed a systematic review of randomised controlled trials (RCTs) comparing the patient-relevant benefits and harms of NPWT with standard wound therapy (SWT) in patients with wounds healing by secondary intention. METHODS We searched for RCTs in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: July 2018) and screened reference lists of relevant systematic reviews and health technology assessments. Manufacturers and investigators were asked to provide unpublished data. Eligible studies investigated at least one patient-relevant outcome (e.g. wound closure). We assessed publication bias and, if feasible, performed meta-analyses, grading the results into different categories (hint, indication or proof of a greater benefit or harm). RESULTS We identified 48 eligible studies of generally low quality with evaluable data for 4315 patients and 30 eligible studies with missing data for at least 1386 patients. Due to potential publication bias (proportion of inaccessible data, 24%), we downgraded our conclusions. A meta-analysis of all wound healing data showed a significant effect in favour of NPWT (OR 1.56, 95% CI 1.15 to 2.13, p = 0.008). As further analyses of different definitions of wound closure did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. A meta-analysis of hospital stay (in days) showed a significant difference in favour of NPWT (MD - 4.78, 95% CI - 7.79 to - 1.76, p = 0.005). As further analyses of different definitions of hospital stay/readmission did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. There was neither proof (nor indication nor hint) of greater benefit or harm of NPWT for other patient-relevant outcomes such as mortality and adverse events. CONCLUSIONS In summary, low-quality data indicate a greater benefit of NPWT versus SWT for wound closure in patients with wounds healing by secondary intention. The length of hospital stay is also shortened. The data show no advantages or disadvantages of NPWT for other patient-relevant outcomes. Publication bias is an important problem in studies on NPWT, underlining that all clinical studies need to be fully reported.
Collapse
Affiliation(s)
- Yvonne Zens
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Michael Barth
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
- Basel Institute for Clinical Epidemiology & Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
- Düsseldorf, Germany
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology & Biostatistics, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Katrin Dreck
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Moritz Felsch
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Wolfram Groß
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Thomas Jaschinski
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Heike Kölsch
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Mandy Kromp
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Inga Overesch
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | - Stefan Sauerland
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670 Cologne, Germany
| | | |
Collapse
|
5
|
Chetter I, Arundel C, Bell K, Buckley H, Claxton K, Corbacho Martin B, Cullum N, Dumville J, Fairhurst C, Henderson E, Lamb K, Long J, McCaughan D, McGinnis E, Oswald A, Goncalves PS, Sheard L, Soares MO, Stubbs N, Torgerson D, Welton N. The epidemiology, management and impact of surgical wounds healing by secondary intention: a research programme including the SWHSI feasibility RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2020. [DOI: 10.3310/pgfar08070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Most surgical incisions heal by primary intention (i.e. wound edges are apposed with sutures, clips or glue); however, some heal by secondary intention (i.e. the wound is left open and heals by formation of granulation tissue). There is, however, a lack of evidence regarding the epidemiology, management and impact on patients’ quality of life of these surgical wounds healing by secondary intention, resulting in uncertainty regarding effective treatments and difficulty in planning care and research.
Objectives
To derive a better understanding of the nature, extent, costs, impact and outcomes of surgical wounds healing by secondary intention, effective treatments, and the value and nature of further research.
Design
Cross-sectional survey; inception cohort; cost-effectiveness and value of implementation analyses; qualitative interviews; and pilot, feasibility randomised controlled trial.
Setting
Acute and community care settings in Leeds and Hull, Yorkshire, UK.
Participants
Adults (or for qualitative interviews, patients or practitioners) with previous experience of a surgical wound healing by secondary intention. Inclusion criteria varied between the individual workstreams.
Interventions
The pilot, feasibility randomised controlled trial compared negative-pressure wound therapy – a device applying a controlled vacuum to a wound via a dressing – with usual care (no negative-pressure wound therapy).
Results
Survey data estimated that treated surgical wounds healing by secondary intention have a point prevalence of 4.1 per 10,000 population (95% confidence interval 3.5 to 4.7 per 10,000 population). Surgical wounds healing by secondary intention most frequently occurred following colorectal surgery (n = 80, 42.8% cross-sectional survey; n = 136, 39.7% inception cohort) and were often planned before surgery (n = 89, 47.6% cross-sectional survey; n = 236, 60.1% inception cohort). Wound care was frequently delivered in community settings (n = 109, 58.3%) and most patients (n = 184, 98.4%) received active wound treatment. Cohort data identified hydrofibre dressings (n = 259, 65.9%) as the most common treatment, although 29.3% (n = 115) of participants used negative-pressure wound therapy at some time during the study. Surgical wounds healing by secondary intention occurred in 81.4% (n = 320) of participants at a median of 86 days (95% confidence interval 75 to 103 days). Baseline wound area (p ≤ 0.01), surgical wound contamination (determined during surgery; p = 0.04) and wound infection at any time (p ≤ 0.01) (i.e. at baseline or postoperatively) were found to be predictors of prolonged healing. Econometric models, using observational, cohort study data, identified that, with little uncertainty, negative-pressure wound therapy treatment is more costly and less effective than standard dressing treatment for the healing of open surgical wounds. Model A (ordinary least squares with imputation) effectiveness: 73 days longer than those who did not receive negative-pressure wound therapy (95% credible interval 33.8 to 112.8 days longer). Model A cost-effectiveness (associated incremental quality-adjusted life-years): observables –0.012 (standard error 0.005) and unobservables –0.008 (standard error 0.011). Model B (two-stage model, logistic and linear regression) effectiveness: 46 days longer than those who did not receive negative-pressure wound therapy (95% credible interval 19.6 to 72.5 days longer). Model B cost-effectiveness (associated incremental quality-adjusted life-years): observables –0.007 (standard error 0.004) and unobservables –0.027 (standard error 0.017). Patient interviews (n = 20) identified initial reactions to surgical wounds healing by secondary intention of shock and disbelief. Impaired quality of life characterised the long healing process, with particular impact on daily living for patients with families or in paid employment. Patients were willing to try any treatment promising wound healing. Health professionals (n = 12) had variable knowledge of surgical wound healing by secondary intention treatments and, frequently, favoured negative-pressure wound therapy, despite the lack of robust evidence. The pilot feasibility randomised controlled trial screened 248 patients for eligibility and subsequently recruited and randomised 40 participants to receive negative-pressure wound therapy or usual care (no negative-pressure wound therapy). Data indicated that it was feasible to complete a full randomised controlled trial to provide definitive evidence for the clinical effectiveness and cost-effectiveness of negative-pressure wound therapy as a treatment for surgical wounds healing by secondary intention. Key elements and recommendations for a larger randomised controlled trial were identified.
Limitations
This research programme was conducted in a single geographical area (i.e. Yorkshire and the Humber, UK) and local guidelines and practices may have affected treatment availability, and so may not represent UK-wide treatment choices. A wide range of wound types were included; however, some wound types may be under-represented, meaning that this research may not represent the overall surgical wound healing by secondary intention population. The lack of randomised controlled trial data on the relative effects of negative-pressure wound therapy in surgical wounds healing by secondary intention resulted in much of the economic modelling being based on observational data. Observational data, even with extensive adjustment, do not negate the potential for unresolved confounding to affect the results, which can reduce confidence in conclusions drawn from observational data. Definitive evidence from a randomised controlled trial may be the only way to overcome this lack of confidence.
Conclusions
This research has provided new information regarding the nature, extent, costs, impacts and outcomes of surgical wounds healing by secondary intention, treatment effectiveness, and the value and nature of future research, while addressing previous uncertainties regarding the problem of surgical wounds healing by secondary intention. Aspects of our research indicate that negative-pressure wound therapy is more costly and less effective than standard dressing for the healing of open surgical wounds. However, because this conclusion is based solely on observational data, it may be affected by unresolved confounding. Should a future randomised controlled trial be considered necessary, its design should reflect careful consideration of the findings of this programme of research.
Future work
This research signals the importance of further research on surgical wound healing by secondary intention. Key research questions raised by this programme of research include (1) which treatments are clinically effective and cost-effective for surgical wound healing by secondary intention for all patients or for particular patient subgroups? (2) Can particular prognostic factors predict time to healing of surgical wound healing by secondary intention? And (3) do psychosocial interventions have the potential to improve quality of life in people with hard-to-heal surgical wound healing by secondary intention? Given that negative-pressure wound therapy has been widely adopted, with relatively little evidence to support its use, the design and outcomes of a randomised controlled trial would need to be carefully considered. We focused in this research on wound healing, and maintain, based on the findings of patient interviews, that this is a key outcome for future research. Impacts of negative-pressure wound therapy on outcomes such as infection and reoperation should also be considered, as should patients’ views of the treatment. The type of patient group recruited and the outcomes of interest will all influence the duration of follow-up of any planned study. The comparator in any future study will also need careful consideration.
Trial registration
Current Controlled Trials ISRCTN12761776.
Funding
This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 7. See the National Institute for Health Research Journals Library website for further project information.
Collapse
Affiliation(s)
- Ian Chetter
- Hull York Medical School, University of York, York, UK
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Catherine Arundel
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Kerry Bell
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Hannah Buckley
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Karl Claxton
- Centre for Health Economics, University of York, York, UK
| | | | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jo Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Karen Lamb
- Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Judith Long
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | - Angela Oswald
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Laura Sheard
- Department of Health Sciences, University of York, York, UK
| | - Marta O Soares
- Centre for Health Economics, University of York, York, UK
| | | | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Nicky Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| |
Collapse
|
6
|
Loh ML, Goh BKL, Kong Y, Varughese G, Ng JL, Lo ZJ, Pek CH. Combination therapy of oxidised regenerated cellulose/collagen/silver dressings with negative pressure wound therapy for coverage of exposed critical structures in complex lower-extremity wounds. Int Wound J 2020; 17:1356-1365. [PMID: 32447838 DOI: 10.1111/iwj.13406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/05/2020] [Indexed: 01/17/2023] Open
Abstract
Complex wounds with exposed critical structures such as tendon and bone are a conundrum in wound management, especially in the setting where the patient is not a suitable candidate for flap surgery. While the individual use of negative pressure wound therapy (NPWT) and oxidised regenerated cellulose (ORC)/collagen/silver (PROMOGRAN PRISMA) dressing has been described in the literature, there are little data on the efficacy of their combined use. In this study, we describe a novel technique of combining the use of NPWT and ORC/collagen/silver dressings to manage complex wound beds as an alternative management option for patients not suitable for reconstructive flap surgery. This technique was performed in a series of 37 patients with complex lower-extremity wounds that were not healing with conventional NPWT alone. All patients had open wounds with exposed critical structures that were difficult to manage, such as exposed tendon, bone, deep crevices, and joint. Successful coverage of exposed critical structures was achieved in 89% of patients, and coverage was achieved within 28 days of combination therapy in 82% of these patients, without any complications. The novel technique of combining ORC/collagen/silver dressing and NPWT provides a useful option in the armamentarium of a reconstructive surgeon dealing with difficult complex lower-extremity wounds.
Collapse
Affiliation(s)
- Mei Ling Loh
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Benjamin K L Goh
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Yuan Kong
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - George Varughese
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Jia Lin Ng
- Department of Podiatry, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Zhiwen J Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chong Han Pek
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| |
Collapse
|
7
|
Brown S, Nixon J, Ransom M, Gilberts R, Dewhirst N, McGinnis E, Longo R, Game F, Bojke C, Chadwick P, Chandrasekar A, Chetter I, Collier H, Fernandez C, Homer-Vanniasinkam S, Jude E, Leigh R, Lomas R, Vowden P, Wason J, Sharples L, Russell D. Multiple Interventions for Diabetic Foot Ulcer Treatment Trial (MIDFUT): study protocol for a randomised controlled trial. BMJ Open 2020; 10:e035947. [PMID: 32312727 PMCID: PMC7245399 DOI: 10.1136/bmjopen-2019-035947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Diabetes affects more than 425 million people worldwide with a lifetime risk of diabetic foot ulcer (DFU) of up to 25%. Management includes wound debridement, wound dressings, offloading, treatment of infection and ischaemia, optimising glycaemic control; use of advanced adjuvant therapies is limited by high cost and lack of robust evidence. METHODS AND ANALYSIS A multicentre, seamless phase II/III, open, parallel group, multi-arm multi-stage randomised controlled trial in patients with a hard-to-heal DFU, with blinded outcome assessment. A maximum of 447 participants will be randomised (245 participants in phase II and 202 participants in phase III). The phase II primary objective will determine the efficacy of treatment strategies including hydrosurgical debridement ± decellularised dermal allograft, or the combination with negative pressure wound therapy, as an adjunct to treatment as usual (TAU), compared with TAU alone, with patients randomised in a 1:1:1:2 allocation. The outcome is achieving at least 50% reduction in index ulcer area at 4 weeks post randomisation.The phase III primary objective will determine whether one treatment strategy, continued from phase II, reduces time to healing of the index ulcer compared with TAU alone, with participants randomised in a 1:1 allocation. Secondary objectives will compare healing status of the index ulcer, infection rate, reulceration, quality of life, cost-effectiveness and incidence of adverse events over 52 weeks post randomisation. Phase II and phase III primary endpoint analysis will be conducted using a mixed-effects logistic regression model and Cox proportional hazards regression, respectively. A within-trial economic evaluation will be undertaken; the primary economic analysis will be a cost-utility analysis presenting ICERs for each treatment strategy in rank order of effectiveness, with effects expressed as quality-adjusted life years.The trial has predefined progression criteria for the selection of one treatment strategy into phase III based on efficacy, safety and costs at 4 weeks. ETHICS AND DISSEMINATION Ethics approval has been granted by the National Research Ethics Service (NRES) Committee Yorkshire and The Humber - Bradford Leeds Research Ethics Committee; approved 26 April 2017; (REC reference: 17/YH/0055). There is planned publication of a monograph in National Institute for Health Research journals and main trial results and associated papers in high-impact peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN64926597; registered on 6 June 2017.
Collapse
Affiliation(s)
- Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jane Nixon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Myka Ransom
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rachael Gilberts
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Dewhirst
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Elizabeth McGinnis
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Roberta Longo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Frances Game
- Derby Teaching Hospitals NHS Fundation Trust, Derby, UK
| | - Chris Bojke
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | | | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Fernandez
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | | | | | - Peter Vowden
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Linda Sharples
- Department of Medical Statistics, London Schoool of Hygience and Tropical Medicine, London, UK
| | - David Russell
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
8
|
Seidel D, Storck M, Lawall H, Wozniak G, Mauckner P, Hochlenert D, Wetzel-Roth W, Sondern K, Hahn M, Rothenaicher G, Krönert T, Zink K, Neugebauer E. Negative pressure wound therapy compared with standard moist wound care on diabetic foot ulcers in real-life clinical practice: results of the German DiaFu-RCT. BMJ Open 2020; 10:e026345. [PMID: 32209619 PMCID: PMC7202734 DOI: 10.1136/bmjopen-2018-026345] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The aim of the DiaFu study was to evaluate effectiveness and safety of negative pressure wound therapy (NPWT) in patients with diabetic foot wounds in clinical practice. DESIGN In this controlled clinical superiority trial with blinded outcome assessment patients were randomised in a 1:1 ratio stratified by study site and ulcer severity grade using a web-based-tool. SETTING This German national study was conducted in 40 surgical and internal medicine inpatient and outpatient facilities specialised in diabetes foot care. PARTICIPANTS 368 patients were randomised and 345 participants were included in the modified intention-to-treat (ITT) population. Adult patients suffering from a diabetic foot ulcer at least for 4 weeks and without contraindication for NPWT were allowed to be included. INTERVENTIONS NPWT was compared with standard moist wound care (SMWC) according to local standards and guidelines. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was wound closure within 16 weeks. Secondary outcomes were wound-related and treatment-related adverse events (AEs), amputations, time until optimal wound bed preparation, wound size and wound tissue composition, pain and quality of life (QoL) within 16 weeks, and recurrences and wound closure within 6 months. RESULTS In the ITT population, neither the wound closure rate (difference: n=4 (2.5% (95% CI-4.7% - 9.7%); p=0.53)) nor the time to wound closure (p=0.244) was significantly different between the treatment arms. 191 participants (NPWT 127; SMWC 64) had missing endpoint documentations, premature therapy ends or unauthorised treatment changes. 96 participants in the NPWT arm and 72 participants in the SMWC arm had at least one AE (p=0.007), but only 16 AEs were related to NPWT. CONCLUSIONS NPWT was not superior to SMWC in diabetic foot wounds in German clinical practice. Overall, wound closure rate was low. Documentation deficits and deviations from treatment guidelines negatively impacted the outcome wound closure. TRIAL REGISTRATION NUMBERS NCT01480362 and DRKS00003347.
Collapse
Affiliation(s)
- Dörthe Seidel
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Köln, Germany
| | - Martin Storck
- Klinik für Gefäß- und Thoraxchirurgie, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Germany
| | - Holger Lawall
- Praxis für Herzkreislauferkrankungen, Ettlingen, Germany
- Innere Medizin, Max-Grundig Klinik, Bühlerhöhe, Germany
| | - Gernold Wozniak
- Gefäßchirurgische Klinik, Knappschaftskrankenhaus Bottrop GmbH, Bottrop, Germany
| | - Peter Mauckner
- Innere Medizin, St. Remigius Krankenhaus Opladen, Leverkusen, Germany
| | - Dirk Hochlenert
- Gemeinschaftspraxis Schlotmann-Hochlenert-Zavaleta-Haberstock, Köln, Germany
| | | | - Klemens Sondern
- Klinik für Innere Medizin/Diabetologie, Marien Hospital Dortmund-Hombruch, Dortmund, Germany
| | - Matthias Hahn
- Allgemein- und Viszeralchirurgie, Helfenstein Klinik, Geisslingen, Germany
| | | | - Thomas Krönert
- Klinik für Gefäßchirurgie, Thüringen-Kliniken "Georgius Agricola" GmbH, Saalfeld, Germany
| | - Karl Zink
- Diabetes Klinik, Diabetes Zentrum Mergentheim, Bad Mergentheim, Germany
| | - Edmund Neugebauer
- Department fur Humanmedizin, Universität Witten/Herdecke, Witten, Germany
- Medizinische Hochschule Brandenburg -Theodor Fontane, Neuruppin, Germany
| |
Collapse
|
9
|
Mohseni S, Aalaa M, Atlasi R, Mohajeri Tehrani MR, Sanjari M, Amini MR. The effectiveness of negative pressure wound therapy as a novel management of diabetic foot ulcers: an overview of systematic reviews. J Diabetes Metab Disord 2019; 18:625-641. [PMID: 31890688 DOI: 10.1007/s40200-019-00447-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 10/03/2019] [Indexed: 12/17/2022]
Abstract
Background Diabetic foot ulcer (DFU) is one the serious disabling conditions in patients with diabetes. Several approaches are available to manage DFU including Negative Pressure Wound Therapy (NPWT). The objective of this overview is systematically reviewing the related reviews about the effectiveness, safety, and cost benefits of NPWT interventions. Methods In October 2018, electronic databases including Medline, Embase, Scopous, Web of Science, the Cochrane Library and Google scholar were searched for systematic reviews about the NPWT's effectiveness and safety in DFUs. The Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist was used for the appraisal of the systematic reviews. According to this checklist the studies were categorized as high, moderate, low and critically low quality. Results The electronic searches yielded 6889 studies. After excluding duplicates and those not fellfield the inclusion criteria, 23 systematic reviews were considered. The sample size of the reviews ranged between 20 and 2800 patients published since 2004 to 2018. Twenty systematic reviews (86.95%) included only randomized clinical trials (RCT). Regarding the AMSTAR-2 checklist, 7 studies were assigned to high quality, 8 were categorized as low quality and 8 studies belonged to the critically low quality groups. Accordingly, three, two and one out of seven high quality studies approved the effectiveness, safety and cost benefit of the NPWT therapy, respectively. However, some of them declared that there is some flaws in RCTs designing. Conclusion This overview illustrated that either systematic reviews or the included RCTs had wide variety of quality and heterogeneity in order to provide high level of evidence. Hence, well-designed RCTs as well as meta-analysis are required to shade the light on different aspects of NPWT.
Collapse
Affiliation(s)
- Shahrzad Mohseni
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Aalaa
- 2Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Rasha Atlasi
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Reza Mohajeri Tehrani
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Sanjari
- 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,4Endocrinology and Metabolism Research Institute, next to Dr. Shariati Hospital, North Kargar Ave, Tehran, 1411713137 Iran
| | - Mohamad Reza Amini
- 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,4Endocrinology and Metabolism Research Institute, next to Dr. Shariati Hospital, North Kargar Ave, Tehran, 1411713137 Iran
| |
Collapse
|
10
|
Tchero H, Kangambega P, Fluieraru S, Bekara F, Teot L. Management of infected diabetic wound: a scoping review of guidelines. F1000Res 2019; 8:737. [PMID: 32528649 PMCID: PMC7265589 DOI: 10.12688/f1000research.18978.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 12/03/2022] Open
Abstract
Background: Various international guidelines and recommendations are available for management of diabetic foot infections. We present a review of the guidelines and recommendations for management of these infections. Methods: A systematic literature search was conducted through MEDLINE, CENTRAL, EMBASE, LILACS, DARE, and national health bodies. Based on the review of fifteen documents, we present details on the importance of suspecting and diagnosing skin, superficial infections, and bone infections in diabetics. Results: The guidelines recommend classifying the infections based on severity to guide the treatment. While antibiotics have shown the best results, other treatments like hyperbaric oxygen therapy and negative wound pressure have been debated. It is suggested that a team of specialists should be in-charge of managing the infected wounds. Infectious Diseases Society of America (IDSA) 2012 guidelines are widely followed world-over. All guidelines and reviews have consistent suggestions on the assessment of the severity of infection, diagnosis, start, selection, and duration of antibiotic therapy. Conclusions: It is reasonable to conclude that the IDSA 2012 guidelines are commonly followed across the world. There is a consensus among the Australian guidelines, Canadian guidelines, IDSA 2012, National Institute for Health and Care Excellence (NICE) 2015, and International Working Group on the Diabetic Foot (IWGDF) 2016 guidelines on the management of infected wounds for patients with diabetes mellitus.
Collapse
Affiliation(s)
- Huidi Tchero
- Trauma & Orthopaedic Surgery, CH Saint Martin, Saint Martin, Guadeloupe
| | - Pauline Kangambega
- Endocrinology & Metabolism, CHRU de Pointe-A-Pitre, Pointe-A-Pitre, Guadeloupe
| | - Sergiu Fluieraru
- Reconstructive and Plastic Surgery, CHRU Montpellier, Montpellier, France
| | - Farid Bekara
- Reconstructive and Plastic Surgery, CHRU Montpellier, Montpellier, France
| | - Luc Teot
- Reconstructive and Plastic Surgery, CHRU Montpellier, Montpellier, France
| |
Collapse
|
11
|
Dutra LMA, Melo MC, Moura MC, Leme LAP, De Carvalho MR, Mascarenhas AN, Novaes MRCG. Prognosis of the outcome of severe diabetic foot ulcers with multidisciplinary care. J Multidiscip Healthc 2019; 12:349-359. [PMID: 31118658 PMCID: PMC6506632 DOI: 10.2147/jmdh.s194969] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/20/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Approximately 2-4% of individuals worldwide with diabetes mellitus have foot ulcers. This study aims to assess the factors affecting the outcomes of severe foot ulcers in diabetic individuals. Methods: An analytical prospective cohort study was conducted from March 1st, 2015, to March 1st, 2017. A total of 34 individuals was selected. The study included patients with foot ulcers below the ankle who were at risk of amputation. All tests used a <5% level of significance and confidence interval of 95%. A Pearson's chi-squared test and binary multiple regression were performed to assess the factors related to healing. Results: Only 11.7% of the individuals required amputation; ulcers classified as 2/B according to the University of Texas Diabetic Foot Ulcer Classification System healed before the 1/B ulcers. Neuropathic ulcers were the most prevalent (58.8%); 61.8% healed after 1 year. Most of the individuals were overweight, 47.1% had reduced glomerular filtration rates, and 78.8% had glycated hemoglobin >7%. Body mass index and osteomyelitis were the two significant variables in logistic regression. Conclusions: In this study, osteomyelitis was the main complication related to the risk of amputation, and elevated body mass index and osteomyelitis were the significant factors that induced a slower healing time.
Collapse
Affiliation(s)
| | - Manuela Costa Melo
- Departament of Nursing, Higher School of Health Sciences, Brasília, Federal District, Brazil
| | - Mirian Conceição Moura
- Department of Medicine, Higher School of Sciences and Hospital of the Secretary of Health of the Federal District, Clinical Neurophysiologist, Brasília, Federal District, Brazil
| | | | - Marta Rodrigues De Carvalho
- Department of Medicine, Higher School of Sciences and Hospital of the Secretary of Health of the Federal District, Clinical Neurophysiologist, Brasília, Federal District, Brazil
| | - Andre Neves Mascarenhas
- Department of Endocrinology, Regional Hospital of Asa Norte, Brasília, Federal District, Brazil
| | | |
Collapse
|
12
|
Zhang D, Li Z, Wang Z, Zeng F, Xiao W, Yu A. MicroRNA-126: a promising biomarker for angiogenesis of diabetic wounds treated with negative pressure wound therapy. Diabetes Metab Syndr Obes 2019; 12:1685-1696. [PMID: 31564936 PMCID: PMC6732575 DOI: 10.2147/dmso.s199705] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Negative pressure wound therapy represents an effective therapy to treat nonhealing diabetic wounds by promoting angiogenesis, of which the mechanism hasn't been investigated thoroughly. Growing evidence suggests that miRNAs hold great potential to be clinical biomarkers, and miR-126 is an essential angiogenesis regulator in diabetic wound repair. PURPOSE Our study aims to explore the effect of NPWT on the expression of miR-126 in the wound tissue and plasma of diabetic rat models and the association between circulating miR-126 and two quantitative indexes of angiogenesis. METHODS Full-thickness excisional wounds were created on the back of diabetic rats. Measure the wound closure and collect the wound tissue and blood for H&E, immunohistochemistry, Western blot and RT-PCR. Here we demonstrated that significantly increased capillary density and arteriolar density in the NPWT group at each specified time-point. RESULTS In the NPWT group, miR-126 expression was significantly increased on days 3, 5, 7, and 9 (P<0.05). Furthermore, statistically significant increases in VEGF mRNA and protein expression and p-ERK expression, as well as decreased SPRED1 expression, were noted upon treatment with NPWT on day 9. Our data revealed that miR-126 expression in the wound and plasma was significantly associated (P<0.05). Moreover, a positive correlation was also detected between increased levels of circulating miR-126 and arteriolar density, as well as capillary density (P<0.05). CONCLUSION The study suggested that miR-126 was upregulated by NPWT and could represent a promising monitoring tool for angiogenesis in diabetic wounds treated with NPWT.
Collapse
Affiliation(s)
- Dong Zhang
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei430071, People’s Republic of China
| | - Zonghuan Li
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei430071, People’s Republic of China
| | - Zheng Wang
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei430071, People’s Republic of China
| | - Fanwei Zeng
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei430071, People’s Republic of China
| | - Weidong Xiao
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei430071, People’s Republic of China
- Correspondence: Weidong Xiao; Aixi YuDepartment of Orthopedics, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang district, Wuhan, Hubei430071, People’s Republic of ChinaTel +86 1 870 718 2868; +86 1 350 718 7489Email ;
| | - Aixi Yu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei430071, People’s Republic of China
| |
Collapse
|
13
|
Lázaro Martínez JL, García Álvarez Y, Tardáguila-García A, García Morales E. Optimal management of diabetic foot osteomyelitis: challenges and solutions. Diabetes Metab Syndr Obes 2019; 12:947-959. [PMID: 31417295 PMCID: PMC6593692 DOI: 10.2147/dmso.s181198] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/03/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose: Diabetic foot osteomyelitis (DFO) is the most frequent infection associated with diabetic foot ulcers, occurs in >20% of moderate infections and 50%-60% of severe infections, and is associated with high rates of amputation. DFO represents a challenge in both diagnosis and therapy, and many consequences of its condition are related to late diagnosis, delayed referral, or ill-indicated treatment. This review aimed to analyze the current evidence on DFO management and to discuss advantages and disadvantages of different treatment options. Methods: A narrative review of the evidence was begun by searching Medline and PubMed databases for studies using the keywords "management", "diabetic foot", "osteomyelitis", and "diabetic foot osteomyelitis" from 2008 to 2018. Results: We found a great variety of studies focusing on both medical and surgical therapies showing a similar rate of effectiveness and outcomes; however, the main factors in choosing one over the other seem to be associated with the presence of soft-tissue infection or ischemia and the clinical presentation of DFO. Conclusion: Further randomized controlled trials with large samples and long-term follow-up are necessary to demonstrate secondary outcomes, such as recurrence, recurrent ulceration, and reinfection associated with both medical and surgical options.
Collapse
Affiliation(s)
- José Luis Lázaro Martínez
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid 28040, Spain
- Correspondence: José Luis Lázaro Martínez Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Universidad Complutense de Madrid, 3 Plaza de Ramón de y Cajal, Unidad de Pie Diabético, Madrid 28040, SpainTel +34 913 941 554Fax +3 491 394 2203Email
| | - Yolanda García Álvarez
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid 28040, Spain
| | - Aroa Tardáguila-García
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid 28040, Spain
| | - Esther García Morales
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid 28040, Spain
| |
Collapse
|
14
|
Liu Z, Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2018; 10:CD010318. [PMID: 30328611 PMCID: PMC6517143 DOI: 10.1002/14651858.cd010318.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. People with DM are prone to developing foot ulcers and, if these do not heal, they may also undergo foot amputation surgery resulting in postoperative wounds. Negative pressure wound therapy (NPWT) is a technology that is currently used widely in wound care. NPWT involves the application of a wound dressing attached to a vacuum suction machine. A carefully controlled negative pressure (or vacuum) sucks wound and tissue fluid away from the treated area into a canister. A clear and current overview of current evidence is required to facilitate decision-making regarding its use. OBJECTIVES To assess the effects of negative pressure wound therapy compared with standard care or other therapies in the treatment of foot wounds in people with DM in any care setting. SEARCH METHODS In January 2018, for this first update of this review, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries 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. We identified six additional studies for inclusion in the review. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any brand of NPWT in the treatment of foot wounds in people with DM, irrespective of date or language of publication. Particular effort was made to identify unpublished studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. We presented and analysed data separately for foot ulcers and postoperative wounds. MAIN RESULTS Eleven RCTs (972 participants) met the inclusion criteria. Study sample sizes ranged from 15 to 341 participants. One study had three arms, which were all included in the review. The remaining 10 studies had two arms. Two studies focused on postamputation wounds and all other studies included foot ulcers in people with DM. Ten studies compared NPWT with dressings; and one study compared NPWT delivered at 75 mmHg with NPWT delivered at 125 mmHg. Our primary outcome measures were the number of wounds healed and time to wound healing.NPWT compared with dressings for postoperative woundsTwo studies (292 participants) compared NPWT with moist wound dressings in postoperative wounds (postamputation wounds). Only one study specified a follow-up time, which was 16 weeks. This study (162 participants) reported an increased number of healed wounds in the NPWT group compared with the dressings group (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.03 to 2.01; low-certainty evidence, downgraded for risk of bias and imprecision). This study also reported that median time to healing was 21 days shorter with NPWT compared with moist dressings (hazard ratio (HR) calculated by review authors 1.91, 95% CI 1.21 to 2.99; low-certainty evidence, downgraded for risk of bias and imprecision). Data from the two studies suggest that it is uncertain whether there is a difference between groups in amputation risk (RR 0.38, 95% CI 0.14 to 1.02; 292 participants; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision).NPWT compared with dressings for foot ulcersThere were eight studies (640 participants) in this analysis and follow-up times varied between studies. Six studies (513 participants) reported the proportion of wounds healed and data could be pooled for five studies. Pooled data (486 participants) suggest that NPWT may increase the number of healed wounds compared with dressings (RR 1.40, 95% CI 1.14 to 1.72; I² = 0%; low-certainty evidence, downgraded once for risk of bias and once for imprecision). Three studies assessed time to healing, but only one study reported usable data. This study reported that NPWT reduced the time to healing compared with dressings (hazard ratio (HR) calculated by review authors 1.82, 95% CI 1.27 to 2.60; 341 participants; low-certainty evidence, downgraded once for risk of bias and once for imprecision).Data from three studies (441 participants) suggest that people allocated to NPWT may be at reduced risk of amputation compared with people allocated to dressings (RR 0.33, 95% CI 0.15 to 0.70; I² = 0%; low-certainty evidence; downgraded once for risk of bias and once for imprecision).Low-pressure compared with high-pressure NPWT for foot ulcersOne study (40 participants) compared NPWT 75 mmHg and NPWT 125 mmHg. Follow-up time was four weeks. There were no data on primary outcomes. There was no clear difference in the number of wounds closed or covered with surgery between groups (RR 0.83, 95% CI 0.47 to 1.47; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision) and adverse events (RR 1.50, 95% CI 0.28 to 8.04; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision). AUTHORS' CONCLUSIONS There is low-certainty evidence to suggest that NPWT, when compared with wound dressings, may increase the proportion of wounds healed and reduce the time to healing for postoperative foot wounds and ulcers of the foot in people with DM. For the comparisons of different pressures of NPWT for treating foot ulcers in people with DM, it is uncertain whether there is a difference in the number of wounds closed or covered with surgery, and adverse events. None of the included studies provided evidence on time to closure or coverage surgery, health-related quality of life or cost-effectiveness. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making regarding the use of NPWT to treat foot wounds in people with DM.
Collapse
Affiliation(s)
- Zhenmi Liu
- West China Hospital, Sichuan UniversityWest China School of Public HealthChengduSichuanChina610041
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Robert J Hinchliffe
- St George's Healthcare NHS TrustSt George's Vascular Institute4th Floor, St James WingBlackshaw RoadLondonUKSW17 0QT
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Fran Game
- Derby Hospitals NHS Foundation TrustDepartment of Diabetes and EndocrinologyUttoxeter RoadDerbyUKDE22 3NE
| | - Nikki Stubbs
- St Mary's HospitalLeeds Community Healthcare NHS Trust3 Greenhill RoadLeedsUKLS12 3QE
| | - Michael Sweeting
- University of LeicesterDepartment of Health Sciences, College of Life SciencesGeorge Davies CentreUniversity RoadLeicesterUKLE1 7RH
| | - Frank Peinemann
- Children's Hospital, University of ColognePediatric Oncology and HematologyKerpener Str. 62CologneGermany50937
| | | |
Collapse
|
15
|
Mavrogenis AF, Megaloikonomos PD, Antoniadou T, Igoumenou VG, Panagopoulos GN, Dimopoulos L, Moulakakis KG, Sfyroeras GS, Lazaris A. Current concepts for the evaluation and management of diabetic foot ulcers. EFORT Open Rev 2018; 3:513-525. [PMID: 30305936 PMCID: PMC6174858 DOI: 10.1302/2058-5241.3.180010] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.
Collapse
Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Thekla Antoniadou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Vasilios G Igoumenou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Georgios N Panagopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Leonidas Dimopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Konstantinos G Moulakakis
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - George S Sfyroeras
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Andreas Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| |
Collapse
|
16
|
Everett E, Mathioudakis N. Update on management of diabetic foot ulcers. Ann N Y Acad Sci 2018; 1411:153-165. [PMID: 29377202 PMCID: PMC5793889 DOI: 10.1111/nyas.13569] [Citation(s) in RCA: 383] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.
Collapse
Affiliation(s)
- Estelle Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
17
|
Ma Z, Li Z, Shou K, Jian C, Li P, Niu Y, Qi B, Yu A. Negative pressure wound therapy: Regulating blood flow perfusion and microvessel maturation through microvascular pericytes. Int J Mol Med 2017; 40:1415-1425. [PMID: 28901392 PMCID: PMC5627868 DOI: 10.3892/ijmm.2017.3131] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 07/11/2017] [Indexed: 01/18/2023] Open
Abstract
Negative pressure wound therapy (NPWT) has been demonstrated to accelerate wound healing by promoting angiogenesis. However, whether blood flow perfusion is regulated by microvessel maturation and pericytes following NPWT remains unclear, as well as the exact association between pericytes and collagen type IV. The aim of this study was to investigate the relevant association between blood flow perfusion and microvessel maturation and pericytes following NPWT, and to further explore the underlying molecular mechanisms. We also aimed to investigate the association between pericytes and collagen type IV. For this purpose, we created a rat model of diabetic wounds and microvascular blood flow perfusion was detected using a laser Doppler blood perfusion imager. The expression levels of angiogenin-1, tyrosine phosphorylation of tyrosine kinase receptor-2 (Tie-2), α-smooth muscle actin (α-SMA) and collagen type IV were detected and analyzed through immunohistochemistry, immunofluorescence, RT-qPCR and western blot analysis. The results revealed that NPWT promoted the overexpression of angiogenin-1, Tie-2, α-SMA and collagen type IV, and significantly increased blood flow perfusion coupled with microvessel maturation in the NPWT group at the later stages (7–10 days) of wound healing. Our results suggested that NPWT can preferentially enhance vessel maturation and increase the number of pericytes, thus regulating blood flow perfusion. On the other hand, pericytes and collagen type IV had a mutual interaction, promoting microvessel maturation.
Collapse
Affiliation(s)
- Zhanjun Ma
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Zonghuan Li
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Kangquan Shou
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Chao Jian
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Pengcheng Li
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yahui Niu
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Baiwen Qi
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Aixi Yu
- Zhongnan Hospital of Wuhan University, Department of Orthopedics, Wuhan University, Wuhan, Hubei 430071, P.R. China
| |
Collapse
|
18
|
Harries RL, Bosanquet DC, Harding KG. Wound bed preparation: TIME for an update. Int Wound J 2017; 13 Suppl 3:8-14. [PMID: 27547958 DOI: 10.1111/iwj.12662] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/16/2016] [Indexed: 12/11/2022] Open
Abstract
While the overwhelming majority of wounds heal rapidly, a significant proportion fail to progress through the wound-healing process. These resultant chronic wounds cause considerable morbidity and are costly to treat. Wound bed preparation, summarised by the TIME (Tissue, Inflammation/infection, Moisture imbalance, Epithelial edge advancement) concept, is a systematic approach for assessing chronic wounds. Each of these components needs to be addressed and optimised to improve the chances of successful wound closure. We present an up-to-date literature review of the most important recent aspects of wound bed preparation. While there are many novel therapies that are available to the treating clinician, often, there are limited data on which to assess their clinical value, and a lack of appreciation for adequate wound bed preparation needed before expensive therapy is used to heal a wound.
Collapse
Affiliation(s)
- Rhiannon L Harries
- Royal College of Surgeons/Welsh Wound Initiative Research Fellow, Wound Healing Research Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - David C Bosanquet
- South East Wales Vascular Network, University Hospital of Medicine, Cardiff, UK
| | - Keith G Harding
- Welsh Wound Innovation Initiative, Cardiff University, Cardiff, UK
| |
Collapse
|
19
|
Liu S, He CZ, Cai YT, Xing QP, Guo YZ, Chen ZL, Su JL, Yang LP. Evaluation of negative-pressure wound therapy for patients with diabetic foot ulcers: systematic review and meta-analysis. Ther Clin Risk Manag 2017; 13:533-544. [PMID: 28458556 PMCID: PMC5403129 DOI: 10.2147/tcrm.s131193] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives The aim of this study was to perform an updated systematic review and meta-analysis to assess the clinical efficacy, safety, and cost-effectiveness of negative-pressure wound therapy (NPWT) in the treatment of diabetic foot ulcers (DFUs). Methods We searched the Cochrane Library, MEDLINE, EMBASE, Ovid, and Chinese Biological Medicine databases up to June 30, 2016. We also manually searched the articles from reference lists of the retrieved articles, which used the NPWT system in studies of vacuum-assisted closure therapy. Studies were identified and selected, and two independent reviewers extracted data from the studies. Results A total of eleven randomized controlled trials, which included a total of 1,044 patients, were selected from 691 identified studies. Compared with standard dressing changes, NPWT had a higher rate of complete healing of ulcers (relative risk, 1.48; 95% confidence interval [CI]: 1.24–1.76; P<0.001), shorter healing time (mean difference, −8.07; 95% CI: −13.70– −2.45; P=0.005), greater reduction in ulcer area (mean difference, 12.18; 95% CI: 8.50–15.86; P<0.00001), greater reduction in ulcer depth (mean difference, 40.82; 95% CI: 35.97–45.67; P<0.00001), fewer amputations (relative risk, 0.31; 95% CI: 0.15–0.62; P=0.001), and no effect on the incidence of treatment-related adverse effects (relative risk, 1.12; 95% CI: 0.66–1.89; P=0.68). Meanwhile, many analyses showed that the NPWT was more cost-effective than standard dressing changes. Conclusion These results indicate that NPWT is efficacious, safe, and cost-effective in treating DFUs.
Collapse
Affiliation(s)
- Si Liu
- School of Nursing, Nanchang University
| | | | | | | | | | | | | | - Li-Ping Yang
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| |
Collapse
|
20
|
von Beckerath O, Zapenko A, Dissemond J, Kröger K. Ten-year analyses of the German DRG data about negative pressure wound therapy. Int Wound J 2016; 14:501-507. [PMID: 27374835 DOI: 10.1111/iwj.12635] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/13/2016] [Accepted: 06/17/2016] [Indexed: 12/17/2022] Open
Abstract
Exact data regarding the clinical role of negative pressure wound therapy (NPWT) for wound care in a specific country are not available. Thus, we analysed the use of NPWT in hospitalised patients in Germany. Detailed lists of all hospitalised cases treated with NPWT in Germany for each of the years from 2005 to 2014 were obtained from the Federal Statistical Office, as well as lists of the 15 most frequent principal and additional diagnoses documented with NPWT in 2014. Within the 10-year time period of the study, the number of cases treated with NPWT increased by 349%, from 37 053 in 2005 to 129 269 in 2014. The rate of all hospitalised cases treated with NPWT increased form 0·22% to 0·66% in Germany. In 2014, wounds affecting skin and subcutaneous tissue (5-916.a0) are the most frequent documented indication for NPWT followed by deep wounds involving bones and joints at the limbs (5-916.a1). Open abdomens (5-916.a3) count for higher numbers than deep wounds of the thorax, mediastinum and sternum (5-916.a2). Fifty percent of all cases hospitalised for stage IV pressure ulcers at sacrum or ischium and around one third (32.2%) of cases with pyothorax received NPWT. Every fourth to fifth case hospitalised for disruption of surgical wounds or infections following a procedure (24·1%), as well as for infections and inflammations because of internal joint prosthesis or because of an internal fixation device was treated with NPWT (22·9%). In cases with diabetic foot syndrome, it is still every tenth case (10·1%). This analysis shows a substantial increase in the use of NPWT in the last decade for hospitalised patients. NPWT has a fixed role in the treatment of stage IV pressure ulcers at sacrum or ischium, pyothorax, infection and inflammation because of internal joint prosthesis or an internal fixation device and diabetic foot syndrome.
Collapse
Affiliation(s)
- Olga von Beckerath
- Department of Vascular Medicine, HELIOS Klinik Krefeld GmbH, Krefeld, Germany
| | - Alexander Zapenko
- Department of Vascular Medicine, HELIOS Klinik Krefeld GmbH, Krefeld, Germany
| | - Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Essen, Germany
| | - Knut Kröger
- Department of Vascular Medicine, HELIOS Klinik Krefeld GmbH, Krefeld, Germany
| | | |
Collapse
|
21
|
Dresing K. [Diabetic foot syndrome]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2016; 28:321-2. [PMID: 27339218 DOI: 10.1007/s00064-016-0456-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- K Dresing
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| |
Collapse
|
22
|
Arti H, Khorami M, Ebrahimi-Nejad V. Comparison of negative pressure wound therapy (NPWT) &conventional wound dressings in the open fracture wounds. Pak J Med Sci 2016; 32:65-9. [PMID: 27022347 PMCID: PMC4795891 DOI: 10.12669/pjms.321.8568] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective: Successful closure is a primary step of treatment in open fracture wounds. Delayed healing or complications can lead to increased treatment duration, costs and disability rates. The aim of this study was to compare Negative Pressure Wound Therapy (NPWT) and conventional wound dressings in patients with open fracture wounds. Methods: In a prospective randomized clinical trial study, 90 patients with open fractures that were referred for treatment were enrolled between February 2013 to March 2015. Patients were divided into two groups. Group I underwent NPWT and group II underwent conventional wound dressing. Then patients were followed up for one month. Within the one month, the number of dressing change varied based on the extent of the wound. Duration of wound healing, presence of infection and the number of hospitalization days in these patients were recorded and compared at the end of the study between the two groups. Questionnaires and check lists were used to collect data. Analysis was done with SPSS 20, paired sample T-test, and chi-square tests. P<0.05 was considered significant. Results: There was a significant difference between the rate of wound healing in the group one or NPWT group and group II (conventional wound dressings) P<0.05. There was no significant difference between two groups in incidence of infection (P=0.6). Conclusion: Using NPWT expedites the healing process of extremity wounds. It is more economical and can be considered as a substitute for the treatment of extremity wounds.
Collapse
Affiliation(s)
- Hamidreza Arti
- Prof. Hamidreza Arti, Department of Orthopedic Surgery & Trauma Research Center, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Khorami
- Mohsen Khorami, Assistant Professor, Department of Orthopedic Surgery & Trauma Research Center, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Vahid Ebrahimi-Nejad
- Vahid Ebrahimi-Nejad, Resident, Department of Orthopedic Surgery & Trauma Research Center, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| |
Collapse
|
23
|
Game FL, Attinger C, Hartemann A, Hinchliffe RJ, Löndahl M, Price PE, Jeffcoate WJ. IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:75-83. [PMID: 26340818 DOI: 10.1002/dmrr.2700] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- F L Game
- Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS FT, Derby, UK
| | - C Attinger
- Department of Plastic Surgery, Medstar Georgetown University. Hospital, Washington DC, USA
| | - A Hartemann
- Pitié-Salpêtrière Hospital, APHP, Paris 6 University, ICAN, Paris, France
| | - R J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - M Löndahl
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - P E Price
- Vice-Chancellors' Office, Cardiff University, Cardiff, UK
| | - W J Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
24
|
Game FL, Apelqvist J, Attinger C, Hartemann A, Hinchliffe RJ, Löndahl M, Price PE, Jeffcoate WJ. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:154-68. [PMID: 26344936 DOI: 10.1002/dmrr.2707] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The outcome of management of diabetic foot ulcers remains a challenge, and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012, the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas, which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies, which did not fit in the aforementioned categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews, and the conclusion is similar: that with the possible exception of negative pressure wound therapy in post-operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality.
Collapse
Affiliation(s)
- F L Game
- Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS FT, Derby, UK
| | - J Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - C Attinger
- Department of Plastic Surgery, Medstar Georgetown University, Hospital, Washington D.C., USA
| | - A Hartemann
- Pitié-Salpêtrière Hospital, APHP, Paris 6 University, ICAN, France
| | - R J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - M Löndahl
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - P E Price
- Vice-Chancellors' Office, Cardiff University, Cardiff, Wales, UK
| | - W J Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
25
|
Liu J, Zhang P, Tian J, Li L, Li J, Tian JH, Yang K. Ozone therapy for treating foot ulcers in people with diabetes. Cochrane Database Syst Rev 2015; 2015:CD008474. [PMID: 26505864 PMCID: PMC8246444 DOI: 10.1002/14651858.cd008474.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND It has been reported that ozone therapy might be helpful in treating foot ulcers in people with diabetes mellitus (DM). OBJECTIVES To assess the effects of ozone therapy on the healing of foot ulcers in people with DM. SEARCH METHODS In March 2015 we searched: The Cochrane Wounds Group 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, EBSCO CINAHL, Science Citation Index, Chinese Biomedical Literature Database and The Chinese Clinical Registry. There were no restrictions based on language, date or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ozone therapy with sham ozone therapy or any other interventions for foot ulcers in people with DM, irrespective of publication date or language. DATA COLLECTION AND ANALYSIS Two reviewers independently screened all retrieved citations, selected relevant citations and extracted data. Disagreements were resolved by discussion with a third reviewer. The methodological quality of included studies and the evidence level of outcomes were assessed using the Cochrane risk of bias tool and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach respectively. Data were expressed using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with their 95% confidence interval (95% CI). Review Manager (RevMan) software was used to analyse the data. MAIN RESULTS Three studies (212 participants) were included in this review. The overall risk of bias was high for two trials and unclear for one.One trial (101 participants) compared ozone treatment with antibiotics for foot ulcers in people with DM. The study had a follow-up period of 20 days. This study showed that ozone treatment was associated with a greater reduction in ulcer area from baseline to the end of the study than treatment with antibiotics (MD -20.54 cm(2), 95% CI -20.61 to -20.47), and a shorter duration of hospitalisation (MD -8.00 days, 95% CI -14.17 to -1.83), but did not appear to affect the number of ulcers healed over 20 days (RR 1.10, 95% CI 0.87 to 1.40). No side effects were observed in either group.The other two trials (111 participants) compared ozone treatment plus usual care with usual care for foot ulcers in people with DM. The meta-analysis results did not show evidence of a difference between groups for the outcomes of reduction of ulcer area (MD -2.11 cm(2), 95% CI -5.29 to 1.07), the number of ulcers healed (RR 1.69, 95% CI 0.90 to 3.17), adverse events (RR 2.27, 95% CI 0.48 to 10.79), or amputation rate (RR 2.73, 95%CI 0.12, 64.42). AUTHORS' CONCLUSIONS The available evidence was three small RCTs with unclear methodology, so we are unable to draw any firm conclusions regarding the effectiveness of ozone therapy for foot ulcers in people with DM.
Collapse
Affiliation(s)
- Jian Liu
- The First Hospital of Lanzhou UniversityCritical Care Medicine DepartmentNo 1 Donggang West RoadLanzhou CityGansuChina730000
| | - Peng Zhang
- Nanyang Central HospitalDepartment of Pediatric SurgeryNanyangHenanChina473000
| | - Jing Tian
- Nanyang Central HospitalNanyangHenanChina473000
| | - Lun Li
- The Second Xiangya Hospital of Central South UniversityDepartment of Breast‐Thyroid SurgeryChangshaChina
| | - Jun Li
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - Jin Hui Tian
- Lanzhou UniversityEvidence‐Based Medicine Center, School of Basic Medical SciencesNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | - KeHu Yang
- Lanzhou UniversityKey Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu ProvinceNo. 199, Donggang West RoadLanzhou CityGansuChina730000
| | | |
Collapse
|
26
|
Hasan MY, Teo R, Nather A. Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments. Diabet Foot Ankle 2015; 6:27618. [PMID: 26140663 PMCID: PMC4490797 DOI: 10.3402/dfa.v6.27618] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/25/2015] [Accepted: 06/07/2015] [Indexed: 01/25/2023]
Abstract
Negative-pressure wound therapy (NPWT) plays an important role in the treatment of complex wounds. Its effect on limb salvage in the management of the diabetic foot is well described in the literature. However, a successful outcome in this subgroup of diabetic patients requires a multidisciplinary approach with careful patient selection, appropriate surgical debridement, targeted antibiotic therapy, and optimization of healing markers. Evolving NPWT technology including instillation therapy, nanocrystalline adjuncts, and portable systems can further improve results if used with correct indications. This review article summarizes current knowledge about the role of NPWT in the management of the diabetic foot and its mode of action, clinical applications, and recent developments.
Collapse
Affiliation(s)
- Muhammed Y Hasan
- Division of Foot and Ankle, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Rachel Teo
- Division of Foot and Ankle, Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Aziz Nather
- Division of Foot and Ankle, Department of Orthopaedic Surgery, National University Hospital, Singapore;
| |
Collapse
|
27
|
Ghatak PD, Schlanger R, Ganesh K, Lambert L, Gordillo GM, Martinsek P, Roy S. A Wireless Electroceutical Dressing Lowers Cost of Negative Pressure Wound Therapy. Adv Wound Care (New Rochelle) 2015; 4:302-311. [PMID: 26005596 DOI: 10.1089/wound.2014.0615] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/27/2015] [Indexed: 01/19/2023] Open
Abstract
Objective: To test whether the use of a wireless electroceutical dressing (WED) (Procellera®) in conjunction with a 5-day negative pressure wound therapy (NPWT) may reduce the number of dressing changes required per week with this therapy. Approach: At the Ohio State University Comprehensive Wound Center, chronic wound patients (n=30) undergoing NPWT were randomized into two arms following consent as approved by the institutional review board. The control arm received standard of care NPWT, where the dressing change was performed thrice a week. The test arm received the same care except that the WED was added as an interface layer and dressing change was limited to twice a week. Results: A reduced cost of care was achieved using the WED in conjunction with NPWT. Despite fewer dressing changes in wounds dressed with the WED, closure outcomes were comparable with no overt signs of any wound complication, including infection. The cost of NPWT care during the week was significantly lower (from $2918 to $2346) in the WED-treated group compared with patients in the control arm. Innovation: This work introduces a novel technology platform involving a WED, which may be used in conjunction with NPWT. If used as such, NPWT is effective in decreasing the frequency of dressing change and lowering the cost of care. Conclusion: This work points toward the benefit of using the WED combined with NPWT. A larger clinical trial investigating the cost-effectiveness of WED in wound care is warranted.
Collapse
Affiliation(s)
- Piya Das Ghatak
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Richard Schlanger
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kasturi Ganesh
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lynn Lambert
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Gayle M. Gordillo
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Patsy Martinsek
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sashwati Roy
- Comprehensive Wound Center, Departments of Surgery and Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
28
|
Marston WA, Armstrong DG, Reyzelman AM, Kirsner RS. A Multicenter Randomized Controlled Trial Comparing Treatment of Venous Leg Ulcers Using Mechanically Versus Electrically Powered Negative Pressure Wound Therapy. Adv Wound Care (New Rochelle) 2015; 4:75-82. [PMID: 25713749 DOI: 10.1089/wound.2014.0575] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/01/2014] [Indexed: 11/12/2022] Open
Abstract
Objective: This study compares two different negative pressure wound therapy (NPWT) modalities in the treatment of venous leg ulcers (VLUs), the ultraportable mechanically powered (MP) Smart Negative Pressure (SNaP®) Wound Care System to the electrically powered (EP) Vacuum-Assisted Closure (V.A.C.®) System. Approach: Patients with VLUs from 13 centers participated in this prospective randomized controlled trial. Each subject was randomly assigned to treatment with either MP NPWT or EP NPWT and evaluated for 16 weeks or complete wound closure. Results: Forty patients (n=19 MP NPWT and n=21 EP NPWT) completed the study. Primary endpoint analysis of wound size reduction found wounds in the MP NPWT group had significantly greater wound size reduction than those in the EP NPWT group at 4, 8, 12, and 16 weeks (p-value=0.0039, 0.0086, 0.0002, and 0.0005, respectively). Kaplan-Meier analyses showed greater acceleration in complete wound closure in the MP NPWT group. At 30 days, 50% wound closure was achieved in 52.6% (10/19) of patients treated with MP NPWT and 23.8% (5/21) of patients treated with EP NPWT. At 90 days, complete wound closure was achieved in 57.9% (11/19) of patients treated with MP NPWT and 38.15% (8/21) of patients treated with EP NPWT. Innovation: These data support the use of MP-NPWT for the treatment of VLUs. Conclusions: In this group of venous ulcers, wounds treated with MP NPWT demonstrated greater improvement and a higher likelihood of complete wound closure than those treated with EP NPWT.
Collapse
Affiliation(s)
- William A Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina School of Medicine , Chapel Hill, North Carolina
| | - David G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine , Tucson, Arizona
| | - Alexander M Reyzelman
- Department of Medicine, California School of Podiatric Medicine at Samuel Merritt University , Oakland, California
| | - Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine , Miami, Florida
| |
Collapse
|
29
|
Seidel D, Mathes T, Lefering R, Storck M, Lawall H, Neugebauer EAM. Negative pressure wound therapy versus standard wound care in chronic diabetic foot wounds: study protocol for a randomized controlled trial. Trials 2014; 15:334. [PMID: 25158846 PMCID: PMC4156638 DOI: 10.1186/1745-6215-15-334] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 08/11/2014] [Indexed: 12/17/2022] Open
Abstract
Background In August 2010, the Federal Joint Committee (G-BA) decided that negative pressure wound therapy (NPWT) would not be reimbursable in German ambulatory care. This decision was based on reports from the Institute for Quality and Efficiency in Health Care (IQWiG), which concluded that there is no convincing evidence in favor of NPWT. The aim of this diabetic foot study (DiaFu study) is to evaluate whether the clinical, safety and economic results of NPWT are superior to the results of standard wound treatment. Methods/Design The DiaFu study is designed as a national, multicenter, randomized controlled clinical superiority trial with a special focus on outpatient care in Germany. Competent patients in inpatient and outpatient care suffering from a chronic diabetic foot wound for a minimum of four weeks may be included in the study. The trial evaluates the treatment outcome of the application of a technical medical device which is based on the principle of NPWT (intervention group) in comparison to standard moist wound therapy (control group). All treatment systems used in the intervention group bear the symbol of free trade capacity in the European Union (CE mark) and will be operated within normal conditions of clinical routine and according to manufacturer’s instructions. Primary endpoints are the time to complete wound healing and the rate of wound healing achieved in each group within the maximum study treatment time of 16 weeks. Primary endpoints will be confirmed by blinded assessment of wound photographs. Discussion The DiaFu study will provide solid evidence regarding the efficacy and effectiveness of NPWT until 31 December 2014, the date when G-BA plans to decide on future reimbursement of NPWT in both ambulatory and in-hospital care. The study is designed to comply with all quality requirements of G-BA and IQWiG and will contribute to evidence-based wound care in Germany. The study has been initiated by the statutory health insurance companies in Germany and is co-funded by two manufacturers of NPWT systems. Trial registration Clinical Trials.gov registration number: NCT01480362 (date of registration: 23 November 2011). German Clinical Trials Register number: DRKS00003347 (date of registration: 22 November 2011).
Collapse
Affiliation(s)
- Dörthe Seidel
- Institute for Research in Operative Medicine (IFOM), Faculty of Health - School of Medicine, University of Witten/Herdecke, Ostmerheimer Str, 200, Building 38, 51109 Cologne, Germany.
| | | | | | | | | | | |
Collapse
|
30
|
Ren H, Li Y. Severe complications after negative pressure wound therapy in burned wounds: two case reports. Ther Clin Risk Manag 2014; 10:513-6. [PMID: 25061310 PMCID: PMC4085333 DOI: 10.2147/tcrm.s66117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We present two typical cases of severe complications (sepsis and hemorrhage) after negative pressure wound therapy (NPWT) in burned patients. Necrotic tissues in some deep burn wounds are difficult to judge correctly and remove thoroughly. An electrically burned blood vessel looks “intact” but can easily break. Necrotic tissue or injured blood vessels when using NPWT are dangerous, both for causing sepsis and hemorrhage. This is the first article that reports the severe complications of NPWT in burned patients. It is imperative to heed indications and avoid contraindications. Proper preparation of wound beds, close observation, and sufficient irrigation are also crucial to avoid these severe complications, and there is an urgent need to substitute the central vacuum system with the low-pressure system.
Collapse
Affiliation(s)
- Haitao Ren
- Department of Burns and Wound Center, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Yuan Li
- Department of Ultrasound, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| |
Collapse
|