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"Spin" in Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review. Plast Reconstr Surg 2023; 151:506e-519e. [PMID: 36442055 DOI: 10.1097/prs.0000000000009937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND "Spin" refers to a manipulation of language that implies benefit for an intervention when none may exist. Randomized controlled trials (RCTs) in other fields have been demonstrated to employ spin, which can mislead clinicians to use ineffective or unsafe interventions. This study's objective was to determine the strategies, severity, and extent of spin in plastic surgery RCTs with nonsignificant primary outcomes. METHODS A literature search of the top 15 plastic surgery journals using MEDLINE was performed (2000 through 2020). Parallel 1:1 RCTs with a clearly identified primary outcome showing statistically nonsignificant results ( P > 0.05) were included. Screening, data extraction, and spin analysis were performed by two independent reviewers. The spin analysis was then independently assessed in duplicate by two plastic surgery residents with graduate-level training in clinical epidemiology. RESULTS From 3497 studies identified, 92 RCTs were included in this study. Spin strategies were identified in 78 RCTs (85%), including 64 abstracts (70%) and 77 main texts (84%). Severity of spin was rated moderate or high in 43 abstract conclusions (47%) and 42 main text conclusions (46%). The most identified spin strategy in the abstract was claiming equivalence for statistically nonsignificant results (26%); in the main text, focusing on another objective (24%). CONCLUSIONS This study suggests that 85% of statistically nonsignificant RCTs in plastic surgery employ spin. Readers of plastic surgery research should be aware of strategies, whether intentional or unintentional, used to manipulate language in reports of statistically nonsignificant RCTs when applying research findings to clinical practice.
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The Effect of Amino Acids on Wound Healing: A Systematic Review and Meta-Analysis on Arginine and Glutamine. Nutrients 2021; 13:nu13082498. [PMID: 34444657 PMCID: PMC8399682 DOI: 10.3390/nu13082498] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 01/08/2023] Open
Abstract
Under stress conditions, the metabolic demand for nutrients increases, which, if not met, may slow down or indeed stop the wound from healing, thus, becoming chronic wounds. This study aims to perform a systematic review and meta-analysis of the effect of arginine and glutamine supplementation on wound healing. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for the systematic review and ten electronic databases were used. Five and 39 human studies met the inclusion criteria for arginine and glutamine, respectively. The overall meta-analysis demonstrated a significant effect of arginine supplementation on hydroxyproline content (MD: 4.49, 95% CI: 3.54, 4.45, p < 0.00001). Regarding glutamine supplementation, there was significant effect on nitrogen balance levels (MD: 0.39, 95% CI: 0.21, 0.58, p < 0.0001), IL-6 levels (MD: −5.78, 95% CI: −8.71, −2.86, p = 0.0001), TNFα levels (MD: −8.15, 95% CI: −9.34, −6.96, p < 0.00001), lactulose/mannitol (L/M) ratio (MD: −0.01, 95% CI: −0.02, −0.01, p < 0.00001), patient mortality (OR: 0.48, 95% CI: 0.32, 0.72, p = 0.0004), C-reactive protein (CRP) levels (MD: −1.10, 95% CI: −1.26, −0.93, p < 0.00001) and length of hospital stay (LOS) (MD: −2.65, 95% CI: −3.10, −2.21, p < 0.00001). Regarding T-cell lymphocytes, a slight decrease was observed, although it failed to reach significance (MD: −0.16, 95% CI: −0.33, 0.01, p = 0.07). Conclusion: The wound healing might be enhanced in one or at various stages by nutritional supplementation in the right dose.
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Asuku M, Yu TC, Yan Q, Böing E, Hahn H, Hovland S, Donelan MB. Split-thickness skin graft donor-site morbidity: A systematic literature review. Burns 2021; 47:1525-1546. [PMID: 33781633 DOI: 10.1016/j.burns.2021.02.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 12/08/2020] [Accepted: 02/02/2021] [Indexed: 12/21/2022]
Abstract
The purpose of this systematic literature review is to critically evaluate split-thickness skin graft (STSG) donor-site morbidities. The search of peer-reviewed articles in three databases from January 2009 to July 2019 identified 4271 English-language publications reporting STSG donor-site clinical outcomes, complications, or quality of life. Of these studies, 77 met inclusion criteria for analysis. Mean time to donor-site epithelialization ranged from 4.7 to 35.0 days. Mean pain scores (0-10 scale) ranged from 1.24 to 6.38 on postoperative Day 3. Mean scar scores (0-13 scale) ranged from 0 to 10.9 at Year 1. One study reported 28% of patients had donor-site scar hypertrophy at 8 years. Infection rates were generally low but ranged from 0 to 56%. Less frequently reported outcomes included pruritus, wound exudation, and esthetic dissatisfaction. Donor-site wounds underwent days of wound care and were frequently associated with pain and scarring. Widespread variations were noted in STSG donor-site outcomes likely due to inconsistencies in the definition of outcomes and utilization of various assessment tools. Understanding the true burden of donor sites may drive innovative treatments that would reduce the use of STSGs and address the associated morbidities.
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Affiliation(s)
- Malachy Asuku
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Tzy-Chyi Yu
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA.
| | - Qi Yan
- Oxford PharmaGenesis Inc., 4 Caufield Place, Suite 201, Newtown, PA, 18940, USA
| | - Elaine Böing
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Helen Hahn
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Sara Hovland
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Matthias B Donelan
- Shriners Hospital for Children-Boston, 51 Blossom Street, Suite 930, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02114, USA; Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Liu P, Shen WQ, Chen HL. Efficacy of arginine-enriched enteral formulas for the healing of pressure ulcers: a systematic review. J Wound Care 2017; 26:319-323. [DOI: 10.12968/jowc.2017.26.6.319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P. Liu
- Associate Professor, School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - W-Q Shen
- Associate Professor, School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - H-L Chen
- Associate Professor, School of Nursing, Nantong University, Nantong, Jiangsu, PR China
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Reva IV, Odintsova IA, Usov VV, Obydennikova TN, Reva GV. OPTIMIZATION OF SURGICAL APPROACH OF TREATMENT IN PATIENTS WITH FULL-THICKNESS THERMAL BURNS. GREKOV'S BULLETIN OF SURGERY 2017. [DOI: 10.24884/0042-4625-2017-176-2-45-50] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE. The study investigated methods of improving the results of active surgical treatment of patients with severe burns and at the same time the possibility of determination of optimal terms of autografting and shortening the terms of hospital stay. MATERIALS AND METHODS. Researches were carried out in patients aged from 18 to 60 at the period from 2007 to 2015. Immunohistochemical techniques were used to detect an expression of Ki-67 gene and localization of immune cells in dynamics. RESULTS. The authors have obtained the morphological criteria of readiness of burned wound to autografting with following prediction of results. The graft healing processes depended on angiogenesis activity and quantity of functioning blood vessels in the burn wound and at its border of intact skin. The regenerative potential of tissue structures in the burn area and at its border was determined by the expression of Ki67gene. These data allowed the authors to forecast the outcome of skin grafting. CONCLUSIONS. The optimal ratio of immune cells in burn wound at its border with intact skin is a criterion of readiness for autodermoplasty. Autodermoplasty should have been performed in terms of 9 days since the moment of burn injury in order to have a significant advantage compared with subsequent terms of grafting.
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Kindler S, Schuster M, Seebauer C, Rutkowski R, Hauschild A, Podmelle F, Metelmann C, Metelmann B, Müller-Debus C, Metelmann HR, Metelmann I. Triterpenes for Well-Balanced Scar Formation in Superficial Wounds. Molecules 2016; 21:molecules21091129. [PMID: 27618886 PMCID: PMC6273645 DOI: 10.3390/molecules21091129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 08/22/2016] [Accepted: 08/24/2016] [Indexed: 11/16/2022] Open
Abstract
Triterpenes are demonstrably effective for accelerating re-epithelialisation of wounds and known to improve scar formation for superficial lesions. Among the variety of triterpenes, betuline is of particular medical interest. Topical betuline gel (TBG) received drug approval in 2016 from the European Commission as the first topical therapeutic agent with the proven clinical benefit of accelerating wound healing. Two self-conducted randomized intra-individual comparison clinical studies with a total of 220 patients involved in TBG treatment of skin graft surgical wounds have been screened for data concerning the aesthetic aspect of wound healing. Three months after surgery wound treatment with TBG resulted in about 30% of cases with more discreet scars, and standard of care in about 10%. Patients themselves appreciate the results of TBG after 3 months even more (about 50%) compared to standard of care (about 10%). One year after surgery, the superiority of TBG counts for about 25% in comparison with about 10%, and from the patients’ point of view, for 25% compared to 4% under standard of care. In the majority of wound treatment cases, there is no difference visible between TBG treatment and standard of care after 1 year of scar formation. However, in comparison, TBG still offers a better chance for discreet scars and therefore happens to be superior in good care of wounds.
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Affiliation(s)
- Stefan Kindler
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Matthias Schuster
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Christian Seebauer
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Rico Rutkowski
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Anna Hauschild
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Fred Podmelle
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Camilla Metelmann
- Department of Anesthesiology, Anesthesia, Intensive Care-, Emergency- and Pain Medicine, Greifswald University Medicine, Ferdinand-Sauerbruch-Str., Greifswald 17475, Germany.
| | - Bibiana Metelmann
- Department of Anesthesiology, Anesthesia, Intensive Care-, Emergency- and Pain Medicine, Greifswald University Medicine, Ferdinand-Sauerbruch-Str., Greifswald 17475, Germany.
| | - Charlotte Müller-Debus
- Department of Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str., Greifswald 17475, Germany.
| | - Hans-Robert Metelmann
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
| | - Isabella Metelmann
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Greifswald University Medicine, Ferdinand-Sauerbruch-Str. DZ 7, Greifswald 17475, Germany.
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Ellinger S. Micronutrients, Arginine, and Glutamine: Does Supplementation Provide an Efficient Tool for Prevention and Treatment of Different Kinds of Wounds? Adv Wound Care (New Rochelle) 2014; 3:691-707. [PMID: 25371852 DOI: 10.1089/wound.2013.0482] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Indexed: 11/12/2022] Open
Abstract
Significance: Wound-healing complications are a clinical problem with a considerable socioeconomic burden. Since several nutrients play a physiological role in wound healing, supplementation of these nutrients may improve wound healing. Recent Advances: Oral nutritional supplements and enteral formulas providing arginine, glutamine, and micronutrients such as ascorbic acid and zinc should improve the healing of pressure ulcers (PU) and the healing of surgical, traumatic, and burned wounds. Is their efficacy proved from clinical intervention trials? Critical Issues: Formulas that are rich in energy, protein, arginine, vitamin C, and zinc can improve PU healing, whereas their efficacy for PU prevention is less clear. High-dose supplementation of vitamin C, zinc, and pantothenic acid may improve the healing of surgical wounds in healthy subjects. Arginine lowers the risk of fistulas in patients undergoing elective surgery due to gastrointestinal cancer. However, formulations also enriched with n-3-fatty acids and ribonucleic acids lower the risk of several wound complications, thus being more effective than isolated arginine. Glutamine and antioxidant micronutrients (vitamin C and E, zinc, selenium, and copper) can improve the healing of surgical, traumatic, and burned wounds. Future Directions: Considerable evidence suggests that formulations, indicated especially for critically ill patients, support the healing of PU and the healing of surgical and burned wounds. However, their optimal composition with regard to the dose of individual components has to be determined in future studies. Further well-designed trials should investigate the impact of certain nutrients for the prevention of PU and for the healing of surgical wounds in healthy subjects.
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Affiliation(s)
- Sabine Ellinger
- Faculty of Food, Nutrition and Hospitality Sciences, Hochschule Niederrhein, University of Applied Sciences, Mönchengladbach, Germany
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Metelmann HR, Brandner JM, Schumann H, Bross F, Fimmers R, Böttger K, Scheffler A, Podmelle F. Accelerated reepithelialization by triterpenes: proof of concept in the healing of surgical skin lesions. Skin Pharmacol Physiol 2014; 28:1-11. [PMID: 25034442 DOI: 10.1159/000357501] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 11/21/2013] [Indexed: 11/19/2022]
Abstract
The acceleration of wound healing is a major surgical concern. A triterpene extract from birch bark (Betulae cortex) experimentally enhances keratinocyte differentiation in vitro and accelerates wound healing ex vivo. We conducted an open, blind-evaluated, controlled, prospective, randomized (1:1) phase II clinical trial in patients requiring split-thickness skin graft transplantation at two university hospitals in Germany. Donor sites on the upper legs were covered with a moist silicone-coated dressing. Oleogel-S10 ointment containing 10% birch bark extract was randomly applied to the distal or proximal half of the wound, with the other half serving as an intraindividual control, for 14 days after the skin graft surgery. The primary efficacy variable was faster reepithelialization as determined from macrophotographs by independent, blinded experts. Twenty-four patients were randomized and completed the trial. After the 14-day test period, the planned interim analysis revealed a highly significant (p < 0.0001) superiority of Oleogel-S10 in the primary efficacy variable and the trial was terminated early due to ethical concerns. The treatment side was also better reepithelialized and more similar to normal skin after 3 months. In conclusion, Oleogel-S10 significantly accelerated reepithelialization at split-thickness skin graft donor sites. Treatment with Oleogel-S10 was safe and well tolerated.
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Affiliation(s)
- Hans-Robert Metelmann
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, Medical School, Greifswald University, Greifswald, Germany
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Bozkırlı BO, Gündoğdu RH, Ersoy E, Lortlar N, Yıldırım Z, Temel H, Oduncu M, Karakaya J. Pilot Experimental Study on the Effect of Arginine, Glutamine, and β-Hydroxy β-Methylbutyrate on Secondary Wound Healing. JPEN J Parenter Enteral Nutr 2014; 39:591-7. [DOI: 10.1177/0148607113520433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 12/24/2013] [Indexed: 11/16/2022]
Affiliation(s)
| | - Rıza H. Gündoğdu
- Department of General Surgery, Ankara Atatürk Training and Research Hospital, Ankara, Turkey
| | - Eren Ersoy
- Department of General Surgery, Ankara Atatürk Training and Research Hospital, Ankara, Turkey
| | - Neşe Lortlar
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - Zuhal Yıldırım
- Department of Biochemistry, Etimesgut Public Health Laboratory, Ankara, Turkey
| | - Hande Temel
- Department of General Surgery, Gemerek State Hospital, Sivas, Turkey
| | - Mehmet Oduncu
- Department of General Surgery, Siverek State Hospital, Şanlıurfa, Turkey
| | - Jale Karakaya
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
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Chow O, Barbul A. Immunonutrition: Role in Wound Healing and Tissue Regeneration. Adv Wound Care (New Rochelle) 2014; 3:46-53. [PMID: 24761344 DOI: 10.1089/wound.2012.0415] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 01/14/2013] [Indexed: 12/21/2022] Open
Abstract
Significance: The role of immunonutrition in wound healing has been an area of both interest and controversy for many years. Although deficiencies in certain nutrients have long been known to impair healing, supplementation of specific immune modulating nutrients has not consistently yielded improvements in wound healing. Still, the prospect of optimizing nutrition to assist the immune system in wound repair bears great significance in both medical and surgical fields, as the costs of wound care and repair cannot be ignored. Recent Advances: Recent studies have rekindled efforts to elucidate the roles of specific immunonutrients, and we now have a better understanding of the conditionally essential role of various nutrients such as arginine, which becomes essential in certain clinical situations such as for the trauma patient or patients at high risk for malnutrition. Immunonutrition in its current formulation usually includes supplementation with arginine, glutamine, omega-3 fatty acids, vitamins, and trace minerals, and its use has often been associated with decreased infectious complications and sometimes with improvements in wound healing. Critical Issues: A key to understanding the role of immunonutrition in wound healing is recognizing the distinct contributions and importance of the various elements utilized. Future Directions: Critical areas for future study include identifying the specific populations, timing, and ideal composition of immunomodulating diets in order to optimize the wound healing process.
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Affiliation(s)
- Oliver Chow
- Department of Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
| | - Adrian Barbul
- Department of Surgery, Washington Hospital Center, Washington, District of Columbia
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