Telemedicine for Preventing and Treating Pressure Injury after Spinal Cord Injury: A Systematic Review and Meta-analysis (Preprint)

Digital Health Interventions for Chronic Wound Management: A Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions (DHIs) have shown promising results for the management of chronic wounds. However, its effectiveness compared to usual care and whether variability in the type of intervention affects wound outcomes are unclear.

OBJECTIVE

The main objective was to determine the effectiveness of DHIs on wound healing outcomes in adult patients with chronic wounds. The secondary objectives were to assess if there was any variation in wound healing outcomes across the various types of DHIs.

METHODS

In total, 9 databases were searched for the literature up to August 1, 2023. Randomized controlled trials (RCTs), cohort studies, and quasi-experimental studies comparing the efficacy of DHIs with controls in improving wound outcomes in adult patients with chronic wounds were included. Study selection, data extraction, and risk of bias assessment were conducted independently by 2 reviewers. We assessed the quality of each RCT, cohort study, and quasi-experimental study separately using the Cochrane risk of bias tool, ROBINS-I, and the Joanna Briggs Institute Critical Appraisal tools checklists. Relative risks (RRs) and 95% CIs were pooled using the random effects model, and heterogeneity was assessed by the I2 statistic. Subgroup analysis and sensitivity analysis were also performed.

RESULTS

A total of 25 studies with 8125 patients were included in this systematic review, while only 20 studies with 6535 patients were included in the meta-analysis. Efficacy outcomes in RCTs showed no significant differences between the DHIs and control groups in terms of wound healing (RR 1.02, 95% CI 0.93-1.12; P=.67) and all-cause mortality around 1 year (RR 1.08, 95% CI 0.55-2.12; P=.83). Compared with the control group, the use of DHIs was associated with significant changes in adverse events (RR 0.44, 95% CI 0.22-0.89; P=.02). Subgroup analysis suggested a positive effect of the digital platforms in improving wound healing (RR 2.19, 95% CI 1.35-3.56; P=.002). Although meta-analysis was not possible in terms of wound size, cost analysis, patient satisfaction, and wound reporting rates, most studies still demonstrated that DHIs were not inferior to usual care in managing chronic wounds.

CONCLUSIONS

The findings of our study demonstrate the viability of adopting DHIs to manage chronic wounds. However, more prominent, high-quality RCTs are needed to strengthen the evidence, and more detailed clinical efficacy research is required.

TRIAL REGISTRATION

PROSPERO CRD42023392415; https://tinyurl.com/4ybz6bs9.

Telemedicine in Improving Glycemic Control Among Children and Adolescents With Type 1 Diabetes Mellitus: Systematic Review and Meta-Analysis

BACKGROUND

Type 1 diabetes mellitus (T1DM) is the most common chronic autoimmune disease among children and adolescents. Telemedicine has been widely used in the field of chronic disease management and can benefit patients with T1DM. However, existing studies lack high-level evidence related to the effectiveness of telemedicine for glycemic control in children and adolescents with T1DM.

OBJECTIVE

This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis.

RESULTS

Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001).

CONCLUSIONS

Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.

Insights into pressure injury prevention: Assessing the knowledge, attitudes, and practices of Palestinian nursing students

AIM

To assess the knowledge, attitudes, and practices of Palestinian nursing students towards pressure injury prevention.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted with 455 nursing students recruited from Arab American University-Palestine, employing a total population sample. Data collection forms include socio-demographic information, the Pressure Ulcer Knowledge Assessment Tool, Attitude towards Pressure Ulcer Prevention Instrument and Pressure Injury Preventive Practices scale.

RESULTS

The study found that students had a mean knowledge score of 54% (14.04/26), a positive attitude score of 75.8% (39.42/52), and demonstrated a fair level of practice 75.3% (30.12/40). Significant differences were observed in the Knowledge, Attitude, and Practice total scores, linked to academic year, clinical experience, and the number of attended departments during clinical training (p < 0.001). Additionally, weak but significant positive relationships were found between practice and attitude scores (r = 0.303, p < 0.001), practice and knowledge score (r = 0.211, p < 0.001), and a moderate positive significant relationship between knowledge and attitude scores (r = 0.567, p < 0.001).

CONCLUSION

The study revealed insufficient knowledge, positive attitudes, and somewhat unsafe practices among nursing students regarding pressure injury prevention. It highlights the need for specific revisions in the nursing curriculum. Improvements can be achieved through detailed coverage in classrooms and laboratories, integrating simulation methods. Additionally, ensuring that students gain adequate experiences in clinical units, with a specific emphasis on pressure injury prevention, is crucial for improving students' capability and contribute to better pressure injury management.

Cost-utility analysis and impact on the environment of videoconference in pressure injury. A randomized controlled trial in individuals with spinal cord injury

STUDY DESIGN

A prospective randomized controlled trial (RCT) in persons with spinal cord injury (SCI) and ongoing pressure injury (PI).

OBJECTIVES

The main aim was to perform a cost-utility analysis (CUA) alongside the RCT comparing regular care to regular care with additional videoconference consultations. Secondary aims were to assess costs and greenhouse gas emission related to transportation in the two study groups.

SETTING

Two spinal cord units in Norway.

METHODS

Participants were allocated to a regular care group (RCG) and a regular care group with additional videoconference (VCG), in a 1-year follow-up between 2016 and 2018. Costs were prospectively collected, and health-related quality of life (HRQoL) data were collected at baseline and 12 months. The outcome was quality-adjusted life years (QALYs), derived from the EQ-5D-5L questionnaire. Results are reported as incremental cost-effectiveness ratio (ICER), expressed as the cost per additional QALY gained. Transportation related costs and environmental emissions were compared by t-tests.

RESULTS

There were 56 participants included, 28 in each group. Of these 27 in the VCG and 26 in the RCG completed. Three participants died. The mean cost per patient was € 8819 in the VCG and € 3607 in the RCG, with 0.1 QALYs gained in the VCG. No significant differences were identified regarding HRQoL or secondary outcomes.

CONCLUSION

The VCG costs € 5212 more for an additional 0.1 QALYs, giving an ICER of € 52,120 per QALY. No significant differences were found regarding transportation-related costs, or emission of greenhouse gases.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov ; NCT02800915, TeleSCIpi. CRISTIN.no. https://app.cristin.no/projects/show.jsf?id=545284 . Sunnaas Rehabilitation hospital's web page, available at https://www.sunnaas.no/fag-og-forskning/fagstoff/sar .

Pressure and Skin: A Review of Disease Entities Driven or Influenced by Mechanical Pressure

Skin perceives and reacts to external mechanical forces to create resistance against the external environment. Excessive or inappropriate stimuli of pressure may lead to cellular alterations of the skin and the development of both benign and malignant skin disorders. We conducted a comprehensive literature review to delve into the pressure-induced and aggravated skin disorders and their underlying pressure-related mechanisms. Dysregulated mechanical responses of the skin give rise to local inflammation, ischemia, necrosis, proliferation, hyperkeratosis, impaired regeneration, atrophy, or other injurious reactions, resulting in various disease entities. The use of personal devices, activities, occupations, weight bearing, and even unintentional object contact and postures are potential scenarios that account for the development of pressure-related skin disorders. The spectrum of these skin disorders may involve the epidermis (keratinocytes and melanocytes), hair follicles, eccrine glands, nail apparatuses, dermis (fibroblasts, mast cells, and vasculature), subcutis, and fascia. Clarifying the clinical context of each patient and recognizing how pressure at the cellular and tissue levels leads to skin lesions can enhance our comprehension of pressure-related skin disorders to attain better management.

Nurses' and nursing students' knowledge and attitudes to pressure injury prevention: A meta-analysis based on APUP and PUKAT

BACKGROUND

Morbidity and mortality among patients due to pressure injuries continue to rise. Nurses play a critical role in preventing pressure injuries. However, published results on nurses' knowledge and attitudes for pressure injury prevention are often contradictory.

OBJECTIVES

To conduct a meta-analysis of nurses' and nursing students' knowledge and attitudes toward pressure injury prevention.

DESIGN

A meta-analysis of cross-sectional studies.

DATA SOURCES

Ten databases were queried for the meta-analysis. The search period was from the time of the databases' establishment to February 2023.

REVIEW METHODS

This review followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The Agency for Healthcare Research and Quality (AHRQ) was used to assess the methodological quality of the included studies. Statistical analysis was conducted with the Stata 15.0 software, and the quantitative data of knowledge and attitude toward preventing PI in all studies were summarized.

RESULTS

Thirteen studies from 9 countries were included. The meta-analysis showed that nurses and nursing students had low knowledge but positive attitudes toward pressure injury prevention. Subgroup analysis showed that the pooled proportion of both knowledge and attitudes was higher in Asia than in Europe. Nurses had higher knowledge than nursing students, however, the former had a more negative attitude than the latter. Sensitivity analyses were robust. Egger's test showed no significant publication bias.

CONCLUSION

The knowledge of nurses and nursing students about pressure injury prevention is not promising and there is an urgent need for continuous learning. Attitudes are more positive but there is room for improvement. The relevant departments should strengthen nurses' and nursing students' knowledge of pressure injury prevention and further improve their attitudes toward pressure injury prevention.