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de Moraes Silva MA, Nelson A, Bell-Syer SE, Jesus-Silva SGD, Miranda F. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 2024; 3:CD002303. [PMID: 38451842 PMCID: PMC10919450 DOI: 10.1002/14651858.cd002303.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Up to 1% of adults will have a leg ulcer at some time. Most leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or damaged valves. Venous ulcer prevention and treatment typically involves the application of compression bandages/stockings to improve venous return and thus reduce pressure in the legs. Other treatment options involve removing or repairing veins. Most venous ulcers heal with compression therapy, but ulcer recurrence is common. For this reason, clinical guidelines recommend that people continue with compression treatment after their ulcer has healed. This is an update of a Cochrane review first published in 2000 and last updated in 2014. OBJECTIVES To assess the effects of compression (socks, stockings, tights, bandages) for preventing recurrence of venous leg ulcers. SEARCH METHODS In August 2023, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, three other databases, and two ongoing trials registries. We also scanned the reference lists of included studies and relevant reviews and health technology reports. There were no restrictions on language, date of publication, or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated compression bandages or hosiery for preventing the recurrence of venous ulcers. DATA COLLECTION AND ANALYSIS At least two review authors independently selected studies, assessed risk of bias, and extracted data. Our primary outcome was reulceration (ulcer recurrence anywhere on the treated leg). Our secondary outcomes included duration of reulceration episodes, proportion of follow-up without ulcers, ulceration on the contralateral leg, noncompliance with compression therapy, comfort, and adverse effects. We assessed the certainty of evidence using GRADE methodology. MAIN RESULTS We included eight studies (1995 participants), which were published between 1995 and 2019. The median study sample size was 249 participants. The studies evaluated different classes of compression (UK class 2 or 3 and European (EU) class 1, 2, or 3). Duration of follow-up ranged from six months to 10 years. We downgraded the certainty of the evidence for risk of bias (lack of blinding), imprecision, and indirectness. EU class 3 compression stockings may reduce reulceration compared with no compression over six months (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.76; 1 study, 153 participants; low-certainty evidence). EU class 1 compression stockings compared with EU class 2 compression stockings may have little or no effect on reulceration over 12 months (RR 1.70, 95% CI 0.67 to 4.32; 1 study, 99 participants; low-certainty evidence). There may be little or no difference in rates of noncompliance over 12 months between people using EU class 1 stockings and people using EU class 2 stockings (RR 1.22, 95% CI 0.40 to 3.75; 1 study, 99 participants; low-certainty evidence). UK class 2 hosiery compared with UK class 3 hosiery may be associated with a higher risk of reulceration over 18 months to 10 years (RR 1.55, 95% CI 1.26 to 1.91; 5 studies, 1314 participants; low-certainty evidence). People who use UK class 2 hosiery may be more compliant with compression treatment than people who use UK class 3 hosiery over 18 months to 10 years (RR for noncompliance 0.69, 95% CI 0.49 to 0.99; 5 studies, 1372 participants; low-certainty evidence). There may be little or no difference between Scholl UK class 2 compression stockings and Medi UK class 2 compression stockings in terms of reulceration (RR 0.77, 95% CI 0.47 to 1.28; 1 study, 166 participants; low-certainty evidence) and noncompliance (RR 0.97, 95% CI 0.84.1 to 12; 1 study, 166 participants; low-certainty evidence) over 18 months. No studies compared different lengths of compression (e.g. below-knee versus above-knee), and no studies measured duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects. AUTHORS' CONCLUSIONS Compression with EU class 3 compression stockings may reduce reulceration compared with no compression over six months. Use of EU class 1 compression stockings compared with EU class 2 compression stockings may result in little or no difference in reulceration and noncompliance over 12 months. UK class 3 compression hosiery may reduce reulceration compared with UK class 2 compression hosiery; however, higher compression may lead to lower compliance. There may be little to no difference between Scholl and Medi UK class 2 compression stockings in terms of reulceration and noncompliance. There was no information on duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects. More research is needed to investigate acceptable modes of long-term compression therapy for people at risk of recurrent venous ulceration. Future trials should consider interventions to improve compliance with compression treatment, as higher compression may result in lower rates of reulceration.
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Affiliation(s)
- Melissa Andreia de Moraes Silva
- Interdisciplinary Surgical Science Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Vascular Surgery, Hospital de Clinicas de Itajuba - MG, Itajuba, Brazil
| | - Andrea Nelson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Fausto Miranda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
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Mościcka P, Cwajda-Białasik J, Jawień A, Jaraczewski W, Szewczyk MT. Evaluation of factors affecting the healing process of venous ulcers: A 12-week longitudinal study. Wound Repair Regen 2023; 31:783-792. [PMID: 38073173 DOI: 10.1111/wrr.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 12/24/2023]
Abstract
The process of healing venous ulcers is complex and influenced by many factors. By identifying the risk factors that influence a slower healing process, it is possible to predict impending delays and plan an individualised care plan. We analysed our database of patients with venous ulcers and identified clinical and demographic factors that delay the healing process. The research analysed the medical records of 754 patients with VLUs at Chronic Wound Treatment Unit of the University Hospital treated between 2001 and 2019. In study, the majority (64.3%) were women, the mean age was 65.7 years. The median duration of Chronic Venous Insufficiency was 24 years, 52% patients had had the disease >20 years, and 296 (39.3%) had experienced ulceration >12 months. Most of the patients (85.8%) had comorbidities, 84% were obese. At 12-week follow-up, 432 of the 754 ulcers had healed. Identified independent predictors of slower ulcer healing rates: wound area greater than 8.25 cm2 , location of the ulceration other than the medial ankle area, underlying disease >20 years, the presence of multiple comorbidities, depth of the ulcer, the presence of an unpleasant smell and alert pathogens. The presence of redness resulted in faster healing of VLUc. Many factors influence the healing process of venous ulceration. The results of the study can help in planning patient care and implementing appropriate early strategies to promote healing.
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Affiliation(s)
- Paulina Mościcka
- Department of Perioperative Nursing, Department of Surgical Nursing and Chronic Wound Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
- Outpatient Department for Chronic Wound Management, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
| | - Justyna Cwajda-Białasik
- Department of Perioperative Nursing, Department of Surgical Nursing and Chronic Wound Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
- Outpatient Department for Chronic Wound Management, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
| | - Arkadiusz Jawień
- Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Wojciech Jaraczewski
- Department of Vascular Surgery and Angiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Maria T Szewczyk
- Department of Perioperative Nursing, Department of Surgical Nursing and Chronic Wound Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
- Outpatient Department for Chronic Wound Management, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
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Ge Q, Zhou Y, Liu Z. Analysis of pre-hospital delay in Chinese patients with diabetic foot ulcers: Based on 46 cases. Int Wound J 2023; 20:2657-2663. [PMID: 36916307 PMCID: PMC10410325 DOI: 10.1111/iwj.14139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/15/2023] Open
Abstract
To study the causes of pre-hospital delay in Chinese patients with diabetic foot ulcers (DFUs). A retrospective study, investigating a case series of 46 DFUs treated at a single hospital, was conducted to evaluate wound condition, wound treatment, costs, and patients' complete medical records, and analyse the reasons causing the pre-hospital delay. We assessed 46 DFUs aged between 53 and 92 years old. The average pre-hospital delay was 5 months, with nearly 20% being delayed for more than 1 year. The average length of hospital stay in China was 21 days, with an average cost of $8672. Recurrence rate of DFUs was 21%, and three patients were recommended to transfer to upper-level hospital. Besides, the intervention was limited and homogenous and medical records were incomplete. Medical service users' limited understanding of diseases, high costs that patients need to afford, and unsatisfactory treatment by medical service providers are the main reasons for patients' delay in seeking treatment. Recommendations are offered to reduce the pre-hospital delay of Chinese patients with DFUs.
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Affiliation(s)
- Qiaoyue Ge
- West China School of Public HealthSichuan University/West China Fourth Hospital, Sichuan UniversityChengduChina
| | - Yue Zhou
- Health and Social Policy DivisionChengdu Preventive Medicine AssociationChengduChina
| | - Zhenmi Liu
- West China School of Public HealthSichuan University/West China Fourth Hospital, Sichuan UniversityChengduChina
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Horue M, Silva JM, Berti IR, Brandão LR, Barud HDS, Castro GR. Bacterial Cellulose-Based Materials as Dressings for Wound Healing. Pharmaceutics 2023; 15:pharmaceutics15020424. [PMID: 36839745 PMCID: PMC9963514 DOI: 10.3390/pharmaceutics15020424] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/10/2022] [Accepted: 12/23/2022] [Indexed: 01/31/2023] Open
Abstract
Bacterial cellulose (BC) is produced by several microorganisms as extracellular structures and can be modified by various physicochemical and biological strategies to produce different cellulosic formats. The main advantages of BC for biomedical applications can be summarized thus: easy moldability, purification, and scalability; high biocompatibility; and straightforward tailoring. The presence of a high amount of free hydroxyl residues, linked with water and nanoporous morphology, makes BC polymer an ideal candidate for wound healing. In this frame, acute and chronic wounds, associated with prevalent pathologies, were addressed to find adequate therapeutic strategies. Hence, the main characteristics of different BC structures-such as membranes and films, fibrous and spheroidal, nanocrystals and nanofibers, and different BC blends, as well as recent advances in BC composites with alginate, collagen, chitosan, silk sericin, and some miscellaneous blends-are reported in detail. Moreover, the development of novel antimicrobial BC and drug delivery systems are discussed.
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Affiliation(s)
- Manuel Horue
- Laboratorio de Nanobiomateriales, CINDEFI, Departamento de Química, Facultad de Ciencias Exactas, Universidad Nacional de La Plata (UNLP)-CONICET (CCT La Plata), Calle 47 y 115, La Plata B1900, Argentina
| | - Jhonatan Miguel Silva
- Biopolymers and Biomaterials Laboratory—BioPolMat, University of Araraquara—UNIARA, Araraquara 14801-320, SP, Brazil
| | - Ignacio Rivero Berti
- Laboratorio de Nanobiomateriales, CINDEFI, Departamento de Química, Facultad de Ciencias Exactas, Universidad Nacional de La Plata (UNLP)-CONICET (CCT La Plata), Calle 47 y 115, La Plata B1900, Argentina
| | - Larissa Reis Brandão
- Biopolymers and Biomaterials Laboratory—BioPolMat, University of Araraquara—UNIARA, Araraquara 14801-320, SP, Brazil
| | - Hernane da Silva Barud
- Biopolymers and Biomaterials Laboratory—BioPolMat, University of Araraquara—UNIARA, Araraquara 14801-320, SP, Brazil
- Correspondence: (H.d.S.B.); (G.R.C.)
| | - Guillermo R. Castro
- Max Planck Laboratory for Structural Biology, Chemistry and Molecular Biophysics of Rosario (MPLbioR, UNR-MPIbpC), Partner Laboratory of the Max Planck Institute for Biophysical Chemistry (MPIbpC, MPG), Centro de Estudios Interdisciplinarios (CEI), Universidad Nacional de Rosario, Maipú 1065, Rosario S2000, Argentina
- Nanomedicine Research Unit (Nanomed), Center for Natural and Human Sciences (CCNH), Universidade Federal do ABC (UFABC), Santo André 09210-580, SP, Brazil
- Correspondence: (H.d.S.B.); (G.R.C.)
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Pađen L, Griffiths J, Cullum N. “Negotiating a new normality” - a longitudinal qualitative exploration of the meaning of living with an open surgical wound. Int J Qual Stud Health Well-being 2022; 17:2123932. [PMID: 36102138 PMCID: PMC9481149 DOI: 10.1080/17482631.2022.2123932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose Little is known about the experiences of people living with open surgical wounds. These wounds are common and predominantly affect young and actively working people. The aim of this qualitative study was to explore the meaning of living with open surgical wounds. Methods A qualitative exploratory study was conducted. We collected data using two individual interviews with each of ten participants (aged between 18–73 years) who had open surgical wounds. Our analytical approach was based on qualitative content analysis. Methods are reported using COREQ guidelines. Results We found that the meaning of living with open surgical wounds is shaped by five subthemes: “enduring healing”, “life disruption”, “adapting to a new reality”, “striving for healing” and “returning to normal life;” all under an overarching theme of “negotiating a new normality”. Conclusion Participants’ well-being and everyday living are greatly impacted by open surgical wounds. Findings from this study emphasize that open surgical wounds are a long-term condition with a typical “chronicity” trajectory; this brings a new perspective to previous findings of studies on living with complex wounds. This study has also highlighted areas for further research, related to improving individuals’ experience of living with open surgical wounds.
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Affiliation(s)
- Ljubiša Pađen
- Department of Nursing, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
- Division of Nursing, Midwifery and Social Work, the University of Manchester, Manchester, UK
| | - Jane Griffiths
- Division of Nursing, Midwifery and Social Work, the University of Manchester, Manchester, UK
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, the University of Manchester, Manchester, UK
- Research & Innovation Division, Manchester University NHS Foundation Trust Research Office, Manchester, UK
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Prognostic Factors for Delayed Healing of Complex Wounds in Adults: A Scoping Review Protocol. NURSING REPORTS 2022; 12:904-911. [PMID: 36548160 PMCID: PMC9787793 DOI: 10.3390/nursrep12040087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: The high prevalence of persons with wounds and its consequences for a person's quality of life makes the issue a relevant focus of attention for healthcare professionals. Through prognostic factors for healing, the individual risk of complications can be predicted, is possible to predict imminent delays and guide decision-making, thus helping healthcare professionals. (2) Methods: A scoping review performed according to JBI methodology and guided by the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) checklist will aim to identify the studies that meet predefined eligibility criteria. Five databases and gray literature will be the sources used to research adults with pressure ulcers, venous leg ulcers, arterial ulcers, or diabetic foot ulcers and report the prognostic factors for delayed healing in any care setting. (3) Results: This review will consider all quantitative and mixed studies in the last five years. The selection of articles will be carried out by two reviewers independently, using EndNoteWeb and Rayyan. Prognostic factors will be presented by design study, sampling, setting, outcome, wound type, and statistical methods. (4) Conclusions: Mapping prognostic factors for delayed healing could also be a starting point for a systematic review and meta-analyses to quantify the value of each factor.
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Abstract
BACKGROUND There are several possible interventions for managing pressure ulcers (sometimes referred to as pressure injuries), ranging from pressure-relieving measures, such as repositioning, to reconstructive surgery. The surgical approach is usually reserved for recalcitrant wounds (where the healing process has stalled, or the wound is not responding to treatment) or wounds with full-thickness skin loss and exposure of deeper structures such as muscle fascia or bone. Reconstructive surgery commonly involves wound debridement followed by filling the wound with new tissue. Whilst this is an accepted means of ulcer management, the benefits and harms of different surgical approaches, compared with each other or with non-surgical treatments, are unclear. This is an update of a Cochrane Review published in 2016. OBJECTIVES To assess the effects of different types of reconstructive surgery for treating pressure ulcers (category/stage II or above), compared with no surgery or alternative reconstructive surgical approaches, in any care setting. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was January 2022. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that assessed reconstructive surgery in the treatment of pressure ulcers. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies, extracted study data, assessed the risk of bias and undertook GRADE assessments. We would have involved a third review author in case of disagreement. MAIN RESULTS We identified one RCT conducted in a hospital setting in the USA. It enrolled 20 participants aged between 20 and 70 years with stage IV ischial or sacral pressure ulcers (involving full-thickness skin and tissue loss). The study compared two reconstructive techniques for stage IV pressure ulcers: conventional flap surgery and cone of pressure flap surgery, in which a large portion of the flap tip is de-epithelialised and deeply inset to obliterate dead space. There were no clear data for any of our outcomes, although we extracted some information on complete wound healing, wound dehiscence, pressure ulcer recurrence and wound infection. We graded the evidence for these outcomes as very low-certainty. The study provided no data for any other outcomes. AUTHORS' CONCLUSIONS Currently there is very little randomised evidence on the role of reconstructive surgery in pressure ulcer management, although it is considered a priority area. More rigorous and robust research is needed to explore this intervention.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jason Kf Wong
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medical and Health, University of Manchester, Manchester, UK
- Dept of Burns and Plastic Surgery, Manchester University Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kavit Amin
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medical and Health, University of Manchester, Manchester, UK
- Dept of Burns and Plastic Surgery, Manchester University Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susy Pramod
- The Christie NHS Foundation Trust, Manchester, UK
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Perry C, Atkinson RA, Griffiths J, Wilson PM, Lavallée JF, Mullings J, Cullum N, Dumville JC. What promotes or prevents greater use of appropriate compression in people with venous leg ulcers? A qualitative interview study with nurses in the north of England using the Theoretical Domains Framework. BMJ Open 2022; 12:e061834. [PMID: 35914912 PMCID: PMC9345063 DOI: 10.1136/bmjopen-2022-061834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To investigate factors that promote and prevent the use of compression therapy in people with venous leg ulcers. DESIGN Qualitative interview study with nurses using the Theoretical Domains Framework (TDF). SETTING Three National Health Service Trusts in England. PARTICIPANTS Purposive sample of 15 nurses delivering wound care. RESULTS Nurses described factors which made provision of compression therapy challenging. Organisational barriers (TDF domains environmental context and resources/knowledge, skills/behavioural regulation) included heavy/increasing caseloads; lack of knowledge/skills and the provision of training; and prescribing issues (variations in bandaging systems/whether nurses could prescribe). Absence of specialist leg ulcer services to refer patients into was perceived as a barrier to providing optimal care by some community-based nurses. Compression use was perceived to be facilitated by clinics for timely initial assessment; continuity of staff and good liaison between vascular/leg ulcer clinics and community teams; clear local policies and care pathways; and opportunities for training such as 'shadowing' in vascular/leg ulcer clinics. Patient engagement barriers (TDF domains goals/beliefs about consequences) focused on getting patients 'on board' with compression, and supporting them in using it. Clear explanations were seen as key in promoting compression use. CONCLUSIONS Rising workload pressures present significant challenges to enhancing leg ulcer services. There may be opportunities to develop facilitated approaches to enable community nursing teams to make changes to practice, enhancing quality of patient care. The majority of venous leg ulcers could be managed in the community without referral to specialist community services if issues relating to workloads/skills/training are addressed. Barriers to promoting compression use could also be targeted, for example, through the development of clear patient information leaflets. While the patient engagement barriers may be easier/quicker to address than organisational barriers, unless organisational barriers are addressed it seems unlikely that all people who would benefit from compression therapy will receive it.
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Affiliation(s)
- Catherine Perry
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Ross A Atkinson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jane Griffiths
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
| | - Paul M Wilson
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jacqueline F Lavallée
- Division of Medical Education, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Julie Mullings
- Northenden Health Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
- MAHSC, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, UK
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Tayyib N. Use of topical haemoglobin spray in hard-to-heal wound management: a systematic review. J Wound Care 2022; 31:520-531. [PMID: 35678786 DOI: 10.12968/jowc.2022.31.6.520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To synthesise the best available evidence regarding the effectiveness of using topical haemoglobin spray to promote healing in hard-to-heal wounds in adults. METHOD The search strategy of this systematic review was designed to retrieve studies published across CINAHL, Medline, Cochrane Central Register of Controlled Trials, Web of Science, Embase, ERIC, Scopus and Mednar, before January 2020, and published in English. All study participants were aged ≥18 years. This review included randomised controlled trials, case-control studies and observational studies. The studies selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion using standardised critical appraisal instruments. RESULTS The review included 15 studies. Overall effectiveness was demonstrated for wound closure rates, reductions in wound size, severity of wound pain and patient satisfaction with using a topical haemoglobin spray. The meta-analysis revealed a statistically significant effect of a topical haemoglobin spray in reducing the size of venous leg ulcers (VLU, effect size=0.02; 95% confidence interval: 0.00-0.09; p<0.00001) in adult patients. However, evidence of the effectiveness of using a topical haemoglobin spray in different wound types among adult patients was limited and not high-level, which precludes any strong conclusions. CONCLUSION The review provides an evidence-based guide to future priorities for clinical practice. In particular, a topical haemoglobin spray was shown to have a positive impact in reducing VLU size and promoting wound healing.
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Affiliation(s)
- Nahla Tayyib
- Faculty of Nursing, Umm-AlQura University, Makkah, Saudi Arabia
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10
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Yaden DB, Earp D, Graziosi M, Friedman-Wheeler D, Luoma JB, Johnson MW. Psychedelics and Psychotherapy: Cognitive-Behavioral Approaches as Default. Front Psychol 2022; 13:873279. [PMID: 35677124 PMCID: PMC9169963 DOI: 10.3389/fpsyg.2022.873279] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
The acute subjective effects of psychedelics are responsive to users' expectations and surroundings (i.e., "set and setting"). Accordingly, a great deal of thought has gone into designing the psychosocial context of psychedelic administration in clinical settings. But what theoretical paradigms inform these considerations about set and setting? Here, we describe several historical, sociological influences on current psychedelic administration in mainstream European and American clinical research settings, including: indigenous practices, new age spirituality from the 1960s, psychodynamic/psychoanalytic approaches, and cognitive-behavioral approaches. We consider each of these paradigms and determine that cognitive-behavioral therapies, including newer branches such as acceptance and commitment therapy (ACT), have the strongest rationale for psychedelic-assisted psychotherapy going forward. Our primary reasons for advocating for cognitive-behavioral approaches include, (1) they avoid issues of cultural insensitivity, (2) they make minimal speculative assumptions about the nature of the mind and reality, (3) they have the largest base of empirical support for their safety and effectiveness outside of psychedelic therapy. We then propose several concepts from cognitive-behavioral therapies such as CBT, DBT, and ACT that can usefully inform the preparation, session, and integration phases of psychedelic psychotherapy. Overall, while there are many sources from which psychedelic psychotherapy could draw, we argue that current gold-standard, evidence-based psychotherapeutic paradigms provide the best starting point in terms of safety and efficacy.
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Affiliation(s)
- David B. Yaden
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Dylan Earp
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Marianna Graziosi
- Department of Clinical Psychology, Hofstra University, Hempstead, NY, United States
| | - Dara Friedman-Wheeler
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jason B. Luoma
- Portland Psychotherapy Clinic, Research, and Training Center, Portland, OR, United States
| | - Matthew W. Johnson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Taidouch A, Crouwers MJ, Spigt M. Complex wound care by a nurse practitioner in primary care: a quality improvement evaluation on healing rates, costs and patient satisfaction. Br J Community Nurs 2021; 26:S14-S21. [PMID: 34881648 DOI: 10.12968/bjcn.2021.26.sup12.s14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Complex wounds are a major burden for healthcare professionals. Patients with complex wounds are often referred to hospitals or wound expertise centres. Complex wound care could be organised in primary care, but very little published evidence for this is available. In this study, members of a primary healthcare organisation were interviewed to ascertain how the wound care was organised. Patient characteristics and data regarding wound care, healing rates and costs were collected from medical records. Patients filled in a questionnaire concerning accessibility, communication, medical counselling and the overall experience of their treatment. This study followed 25 patients with a total of 42 wounds. Some 82% of the wounds were healed within a mean treatment duration of 9.7 weeks. Mean treatment costs were calculated at €155 (£130) for healed patients. Patients were generally very satisfied with their treatment, illustrated by an overall 8.7 out of 10 scoring on an amended survey based on the Consumer Quality Index. Treating complex wounds in primary care seemed adequate, with high patient satisfaction and tolerable costs.
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Affiliation(s)
- Amal Taidouch
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Marie-José Crouwers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Mark Spigt
- Care and Public Health Research Institute, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands and the General Practice Research Unit, Department of Community Medicine, Arctic University of Tromsø, Tromsø, Norway
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Shi C, Dumville JC, Cullum N, Connaughton E, Norman G. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane Database Syst Rev 2021; 7:CD013397. [PMID: 34308565 PMCID: PMC8407020 DOI: 10.1002/14651858.cd013397.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment options often include the use of compression bandages or stockings. OBJECTIVES To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population. SEARCH METHODS In June 2020 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 as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions by language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias tool. We assessed the certainty of the evidence according to GRADE methodology. MAIN RESULTS We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute-care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm2. Studies had a median follow-up of 12 weeks. Compression bandages or stockings applied included short-stretch bandage, four-layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias. Primary outcomes There is moderate-certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time-to-complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I2 = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I2 = 65% (8 studies with analysable data, 1120 participants); synthesis without meta-analysis suggests more completely-healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants). It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low-certainty evidence; 3 studies, 585 participants). Secondary outcomes Moderate-certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference -1.39, 95% CI -1.79 to -0.98; I2 = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta-analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease-specific quality of life, but not all aspects of general health status during the follow-up of 12 weeks to 12 months (four studies with 859 participants; low-certainty evidence). It is uncertain if the use of compression bandages or stockings is more cost-effective than not using them (three studies with 486 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease-specific quality of life. There is uncertainty about adverse effects, and cost effectiveness. Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health-related quality of life, and should incorporate cost-effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.
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Affiliation(s)
- Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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13
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McQuilling JP, Carter MJ, Fulton JA, Patel K, Doner B, Serena TE, Mowry KC. A prospective clinical trial evaluating changes in the wound microenvironment in patients with chronic venous leg ulcers treated with a hypothermically stored amniotic membrane. Int Wound J 2021; 19:144-155. [PMID: 33955178 PMCID: PMC8684864 DOI: 10.1111/iwj.13606] [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: 03/03/2021] [Accepted: 04/09/2021] [Indexed: 01/23/2023] Open
Abstract
Amniotic tissues have been long utilised to treat chronic wounds; however, there are few studies evaluating how the wound microenvironment responds to these therapies. The goal of this study was to evaluate the changes in wounds treated with a hypothermically stored amniotic membrane (HSAM). In this prospective single‐arm study, 15 female patients with venous leg ulcers were treated with HSAM from male donors and standard of care for 12 weeks. Over the course of the study, wound exudate was collected and evaluated using proteomic microarrays. Biopsies were collected during the course of treatment to detect the presence of HSAM tissue. By 4 weeks, 60% of subjects achieved 50% or greater reduction in wound size, and by 12 weeks, 53% of subjects achieved 100% re‐epithelialization. HSAM DNA was detected in 20% of biopsies as determined by the detection TSPY4, indicating HSAM was no longer present within the wound bed approximately 7 days from the last treatment for the majority of wounds. Proteomic analysis of wound exudate found that wounds on a healing trajectory had significantly higher levels of MMP‐10, MMP‐7, and TIMP‐4 and significantly lower levels of CX3CL1, FLT‐3 L, IL‐1ra, IL‐1a, IL‐9, IL‐2, IL‐3, MCP‐1, and TNF‐b compared with other wounds.
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Affiliation(s)
| | | | | | - Keyur Patel
- Armstrong CM Hospital, The Snyder Institute, Kittaning, Pennsylvania, USA
| | - Bryan Doner
- SerenaGroup Inc., Cambridge, Massachusetts, USA
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14
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Norman G, Shi C, Westby MJ, Price BL, McBain AJ, Dumville JC, Cullum N. Bacteria and bioburden and healing in complex wounds: A prognostic systematic review. Wound Repair Regen 2021; 29:466-477. [PMID: 33591630 DOI: 10.1111/wrr.12898] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/11/2020] [Accepted: 01/22/2021] [Indexed: 12/13/2022]
Abstract
The wound microbiome may play an important role in the wound healing process. We conducted the first systematic prognosis review investigating whether aspects of the wound microbiome are independent prognostic factors for the healing of complex wounds. We searched Medline, Embase, CINAHL and the Cochrane Library to February 2019. We included longitudinal studies which assessed the independent association of aspects of wound microbiome with healing of complex wounds while controlling for confounding factors. Two reviewers extracted data and assessed risk of bias and certainty of evidence using the GRADE approach. We synthesised studies narratively due to the clinical and methodological heterogeneity of included studies and sparse data. We identified 28 cohorts from 21 studies with a total of 38,604 participants, including people with diabetes and foot ulcers, open surgical wounds, venous leg ulcers and pressure ulcers. Risk of bias varied from low (2 cohorts) to high (17 cohorts); the great majority of participants were in cohorts at high risk of bias. Most evidence related to the association of baseline clinical wound infection with healing. Clinical infection at baseline may be associated with less likelihood of wound healing in foot ulcers in diabetes (HR from cohort with moderate risk of bias 0.53, 95% CI 0.33 to 0.83) or slower healing in open surgical wounds (HR 0.65, 95% CI 0.51 to 0.83); evidence in other wounds is more limited. Most other associations assessed showed no clear relationship with wound healing; evidence was limited and often sparse; and we documented gaps in the evidence. There is low certainty evidence that a diagnosis of wound infection may be prognostic of poorer healing in foot ulcers in diabetes, and some moderate certainty evidence for this in open surgical wounds. Low certainty evidence means that more research could change these findings.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Maggie J Westby
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Bianca L Price
- Division of Pharmacy & Optometry, Lydia Becker Institute of Immunology and Inflammation, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Andrew J McBain
- Division of Pharmacy & Optometry, Lydia Becker Institute of Immunology and Inflammation, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Research and Innovation Division, Manchester University Foundation NHS Trust, Manchester, UK
| | - Nicky Cullum
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Research and Innovation Division, Manchester University Foundation NHS Trust, Manchester, UK
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15
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Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Epstein DM, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH. Early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration: the EVRA RCT. Health Technol Assess 2020; 23:1-96. [PMID: 31140402 DOI: 10.3310/hta23240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous ulceration is a common and costly health-care issue worldwide, with poor healing rates greatly affecting patient quality of life. Compression bandaging has been shown to improve healing rates and reduce recurrence, but does not address the underlying cause, which is often superficial venous reflux. Surgical correction of the reflux reduces ulcer recurrence; however, the effect of early endovenous ablation of superficial venous reflux on ulcer healing is unclear. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of compression therapy with early endovenous ablation of superficial venous reflux compared with compression therapy with deferred endovenous ablation in patients with venous ulceration. DESIGN A pragmatic, two-arm, multicentre, parallel-group, open randomised controlled trial with a health economic evaluation. SETTING Secondary care vascular centres in England. PARTICIPANTS Patients aged ≥ 18 years with a venous leg ulcer of between 6 weeks' and 6 months' duration and an ankle-brachial pressure index of ≥ 0.8 who could tolerate compression and were deemed suitable for endovenous ablation of superficial venous reflux. INTERVENTIONS Participants were randomised 1 : 1 to either early ablation (compression therapy and superficial endovenous ablation within 2 weeks of randomisation) or deferred ablation (compression therapy followed by endovenous ablation once the ulcer had healed). MAIN OUTCOME MEASURES The primary outcome measure was time from randomisation to ulcer healing, confirmed by blinded assessment. Secondary outcomes included 24-week ulcer healing rates, ulcer-free time, clinical success (in addition to quality of life), costs and quality-adjusted life-years (QALYs). All analyses were performed on an intention-to-treat basis. RESULTS A total of 450 participants were recruited (224 to early and 226 to deferred superficial endovenous ablation). Baseline characteristics were similar between the two groups. Time to ulcer healing was shorter in participants randomised to early superficial endovenous ablation than in those randomised to deferred ablation [hazard ratio 1.38, 95% confidence interval (CI) 1.13 to 1.68; p = 0.001]. Median time to ulcer healing was 56 (95% CI 49 to 66) days in the early ablation group and 82 (95% CI 69 to 92) days in the deferred ablation group. The ulcer healing rate at 24 weeks was 85.6% in the early ablation group, compared with 76.3% in the deferred ablation group. Median ulcer-free time was 306 [interquartile range (IQR) 240-328] days in the early ablation group and 278 (IQR 175-324) days in the deferred endovenous ablation group (p = 0.002). The most common complications of superficial endovenous ablation were pain and deep-vein thrombosis. Differences in repeated measures of Aberdeen Varicose Vein Questionnaire scores (p < 0.001), EuroQol-5 Dimensions index values (p = 0.03) and Short Form questionnaire-36 items body pain (p = 0.05) over the follow-up period were observed, in favour of early ablation. The mean difference in total costs between the early ablation and deferred ablation groups was £163 [standard error (SE) £318; p = 0.607]; however, there was a substantial and statistically significant gain in QALY over 1 year [mean difference between groups 0.041 (SE 0.017) QALYs; p = 0.017]. The incremental cost-effectiveness ratio of early ablation at 1 year was £3976 per QALY, with a high probability (89%) of being more cost-effective than deferred ablation at conventional UK decision-making thresholds (currently £20,000 per QALY). Sensitivity analyses using alternative statistical models give qualitatively similar results. LIMITATIONS Only 7% of screened patients were recruited, treatment regimens varied significantly and technical success was assessed only in the early ablation group. CONCLUSIONS Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings, reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective. FUTURE WORK Longer-term follow-up is ongoing and will determine if early ablation will affect recurrence rates in the medium and long term. TRIAL REGISTRATION Current Controlled Trials ISRCTN02335796. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Manjit S Gohel
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Francine Heatley
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Xinxue Liu
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Andrew Bradbury
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard Bulbulia
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicky Cullum
- School of Health Sciences, University of Manchester, Manchester, UK
| | - David M Epstein
- Department of Applied Economics, University of Granada, Granada, Spain
| | | | - Keith R Poskitt
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Jane Warwick
- Imperial Clinical Trials Unit, Imperial College London, London, UK.,Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
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16
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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.
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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
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Norman G, Westby MJ, Vedhara K, Game F, Cullum NA. Effectiveness of psychosocial interventions for the prevention and treatment of foot ulcers in people with diabetes: a systematic review. Diabet Med 2020; 37:1256-1265. [PMID: 32426913 DOI: 10.1111/dme.14326] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
AIM To identify and synthesize the evidence for the effectiveness of psychosocial interventions to promote the healing, and/or reduce the occurrence of, foot ulceration in people with diabetes. METHODS In March 2019 we searched CENTRAL, Medline, Embase and PsycInfo for randomized controlled trials of interventions with psychosocial components for people with diabetes. The primary outcomes of this review were foot ulceration and healing. We assessed studies using the Cochrane risk-of-bias tool, the TIDieR checklist and GRADE. We conducted narrative synthesis and random-effects meta-analysis. RESULTS We included 31 randomized controlled trials (4511 participants), of which most (24 randomized controlled trials, 4093 participants) were prevention studies. Most interventions were educational with a modest psychosocial component. Ulceration and healing were not reported in most studies; secondary outcomes varied. Evidence was of low or very low quality because of high risks of bias and imprecision, and few studies reported adherence or fidelity. In groups where participants had prior ulceration, educational interventions had no clear effect on new ulceration (low-quality evidence). Two treatment studies, assessing continuous pharmacist support and an intervention to promote understanding of well-being, reported healing but their evidence was also of very low quality. CONCLUSION Most psychosocial intervention randomized controlled trials assessing foot ulcer outcomes in people with diabetes were prevention studies, and most interventions were primarily educational. Ulcer healing and development were not well reported. There is a need for better understanding of psychological and behavioural influences on ulcer incidence, healing and recurrence in people with diabetes. Randomized controlled trials of theoretically informed interventions, which assess clinical outcomes, are urgently required. (PROSPERO registration: CRD42016052960).
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Affiliation(s)
- G Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M J Westby
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - K Vedhara
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - F Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - N A Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Research and Innovation Division, Manchester University Foundation NHS Trust, Manchester, UK
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18
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Multicentre study of pressure ulcer point prevalence in a Portuguese region. J Tissue Viability 2020; 29:12-18. [DOI: 10.1016/j.jtv.2019.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/20/2019] [Accepted: 11/09/2019] [Indexed: 01/10/2023]
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19
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Zhao WY, Fang QQ, Wang XF, Wang XW, Zhang T, Shi BH, Zheng B, Zhang DD, Hu YY, Ma L, Tan WQ. Chitosan-calcium alginate dressing promotes wound healing: A preliminary study. Wound Repair Regen 2019; 28:326-337. [PMID: 31868976 DOI: 10.1111/wrr.12789] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/18/2019] [Accepted: 11/22/2019] [Indexed: 11/29/2022]
Abstract
Dressings are necessary during the process of wound healing. Since the early 1980s, several types of wound dressings have been produced, but they cannot always take into account some effects include antibacterial effect, wound healing promotion, and other properties. In this study, we would like to develop an effective dressing with the above properties, especially accelerating wound healing effect. A chitosan-calcium alginate dressing (CCAD) was developed by coating mixture of chitosan with high-low molecular weight on calcium alginate dressing (CAD). We investigated the structural characteristics of CCAD with Fourier-transform infrared spectroscopy (FTIR) and electron microscopy. The cytotoxicity and antibacterial property were evaluated in vitro using CCK-8 and inhibition zone method. Moisture retention was tested on the skin of Sprague-Dawley (SD) rats, and wound healing studies were performed on a full-thickness skin wound model in SD rats. CCAD showed good moisturizing and antibacterial properties with no cytotoxicity. CCAD could inhibit inflammation by decreasing IL-6, and it could also promote angiogenesis by increasing VEGF, resulting in better wound healing than CAD. CCAD is a better choice in wound care due to its antibacterial property, biocompatibility, moisture retention, healing promotion, and non-cytotoxicity characteristics.
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Affiliation(s)
- Wan-Yi Zhao
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Qing-Qing Fang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Xiao-Feng Wang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Xiao-Wei Wang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Tao Zhang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Bang-Hui Shi
- Department of Plastic Surgery, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Province, Yiwu, China
| | - Bin Zheng
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Ding-Ding Zhang
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Yan-Yan Hu
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China
| | - Lie Ma
- Department of Polymer Science and Engineering, Zhejiang University, Zhejiang Province, Hangzhou, China
| | - Wei-Qiang Tan
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang Province, Hangzhou, China.,Department of Plastic Surgery, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Province, Yiwu, China
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Shi C, Bonnett L, Dumville J, Cullum N. Nonblanchable erythema for predicting pressure ulcer development: a systematic review with an individual participant data meta‐analysis. Br J Dermatol 2019; 182:278-286. [DOI: 10.1111/bjd.18154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2019] [Indexed: 12/16/2022]
Affiliation(s)
- C. Shi
- Division of Nursing, Midwifery& Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health University of Manchester, Manchester Academic Health Science Centre Manchester M13 9PL U.K
| | - L.J. Bonnett
- Department of Biostatistics University of Liverpool Waterhouse Building, Block F, 1–5 Brownlow Street Liverpool L69 3GL U.K
| | - J.C. Dumville
- Division of Nursing, Midwifery& Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health University of Manchester, Manchester Academic Health Science Centre Manchester M13 9PL U.K
| | - N. Cullum
- Division of Nursing, Midwifery& Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health University of Manchester, Manchester Academic Health Science Centre Manchester M13 9PL U.K
- Research and Innovation Division Manchester University NHS Foundation Trust Manchester Academic Health Science Centre 1st Floor, Nowgen Building, 29 Grafton Street Manchester M13 9WU U.K
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21
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Shi C, Dumville JC, Cullum N. Compression bandages or stockings versus no compression for treating venous leg ulcers. Hippokratia 2019. [DOI: 10.1002/14651858.cd013397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Chunhu Shi
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health; Manchester Greater Manchester UK M13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health; Manchester Greater Manchester UK M13 9PL
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health; Manchester Greater Manchester UK M13 9PL
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Gray TA, Wilson P, Dumville JC, Cullum NA. What factors influence community wound care in the UK? A focus group study using the Theoretical Domains Framework. BMJ Open 2019; 9:e024859. [PMID: 31371284 PMCID: PMC6678001 DOI: 10.1136/bmjopen-2018-024859] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Research has found unwarranted variation across community wound care services in the North of England, with underuse of evidence-based practice and overuse of interventions where there is little or no known patient benefit. This study explored the factors that influence care in community settings for people with complex wounds, to develop a deeper understanding of the current context of wound care and variation in practice. DESIGN Qualitative focus group study using the Theoretical Domains Framework (TDF) to structure the questions, prompts and analyses. SETTING Community healthcare settings in the North of England, UK. PARTICIPANTS Forty-six clinical professionals who cared for patients with complex wounds and eight non-clinical professionals who were responsible for procuring wound care products participated across six focus group interviews. RESULTS We found the TDF domains: environmental context and resources, knowledge, skills, social influences and behaviour regulation to best explain the variation in wound care and the underuse of research evidence. Factors such as financial pressures were perceived as having a negative effect on the continuity of care, the availability of wound care services and workloads. We found practice to be mainly based on experiential knowledge and personal preference and highly influenced by colleagues, patients and the pharmaceutical industry, although not by research evidence. CONCLUSIONS Our study provides new insight into the role that experiential learning and social influences play in determining wound care and on the limited influence of research. Workforce pressures and limited resources are perceived to impede care by reducing patient access to services and the ability to provide holistic care. Participative collaboration between university and healthcare organisations may offer a supportive route to addressing issues, implementing sustainable changes to practice and service delivery and a resolute commitment to research use among clinical professionals.
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Affiliation(s)
- Trish A Gray
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR CLAHRC Greater Manchester, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Paul Wilson
- NIHR CLAHRC Greater Manchester, Salford Royal NHS Foundation Trust, Manchester, UK
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR CLAHRC Greater Manchester, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Nicky A Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR CLAHRC Greater Manchester, Salford Royal NHS Foundation Trust, Manchester, UK
- Research and Innovation Division, Manchester University NHS Foundation Trust, Manchester, UK
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Jenkins DA, Mohamed S, Taylor JK, Peek N, van der Veer SN. Potential prognostic factors for delayed healing of common, non-traumatic skin ulcers: A scoping review. Int Wound J 2019; 16:800-812. [PMID: 30821117 PMCID: PMC6563199 DOI: 10.1111/iwj.13100] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/04/2019] [Indexed: 01/08/2023] Open
Abstract
Healing of non-traumatic skin ulcers is often suboptimal. Prognostic tools that identify people at high risk of delayed healing within the context of routine ulcer assessments may improve this, but robust evidence on which factors to include is lacking. Therefore, we scoped the literature to identify which potentially prognostic factors may warrant future systematic reviews and meta-analyses. We conducted electronic searches in MEDLINE and Embase to identify studies in English published between 1997 and 2017 that tested the association between healing of the three most common non-traumatic skin ulcers encountered by health care professionals (venous leg, diabetic foot, and pressure ulcers) and patient characteristics, ulcer characteristics, and results from clinical investigations. We included 42 studies that investigated factors which may be associated with the healing of venous leg ulcers (n = 17), diabetic foot ulcers (n = 15), and pressure ulcers (n = 10). Across ulcer types, ulcer characteristics were most commonly reported as potential prognostic factors for healing (n = 37), including the size of the ulcer area (n = 29) and ulcer duration at first assessment (n = 16). A total of 35 studies investigated the prognostic value of patient characteristics (n = 35), including age (n = 31), gender (n = 30), diabetes (n = 22), smoking status (n = 15), and history of deep vein thrombosis (DVT) (n = 13). Of these studies, 23 reported results from clinical investigations as potential prognostic factors, with the majority regarding vessel quality. Age, gender, diabetes, smoking status, history of DVT, ulcer area, and ulcer duration at time of first assessment warrant a systematic review and meta-analysis to quantify their prognostic value for delayed ulcer healing.
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Affiliation(s)
- David A. Jenkins
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchesterUK
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Sundus Mohamed
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
| | - Joanne K. Taylor
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - Niels Peek
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchesterUK
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
- NIHR Manchester Biomedical Research Centre, Faculty of Biology Medicine and HealthThe University of ManchesterManchesterUK
| | - Sabine N. van der Veer
- NIHR Greater Manchester Patient Safety Translational Research CentreThe University of ManchesterManchesterUK
- Health e‐Research Centre, Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Manchester Academic Health Science CentreThe University of ManchesterManchesterUK
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24
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Moore Z, Dowsett C, Smith G, Atkin L, Bain M, Lahmann NA, Schultz GS, Swanson T, Vowden P, Weir D, Zmuda A, Jaimes H. TIME CDST: an updated tool to address the current challenges in wound care. J Wound Care 2019; 28:154-161. [DOI: 10.12968/jowc.2019.28.3.154] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Zena Moore
- Professor and Head, School of Nursing and Midwifery. Director, Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | | | - Leanne Atkin
- Mid Yorkshire NHS Trust/University of Huddersfield, UK
| | | | - Nils A. Lahmann
- Deputy Director, Geriatrics Research Group, Charité University Berlin, Germany
| | - Gregory S. Schultz
- Professor of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, US
| | | | - Peter Vowden
- Bradford Teaching Hospitals NHS Foundation Trust, UK
| | - Dot Weir
- Catholic Health Advanced Wound Healing Centres, Buffalo, New York, US
| | - Ann Zmuda
- Associate Professor, University of Chicago, Illinois, US
| | - Henry Jaimes
- Global Medical Director Wounds, Smith & Nephew, London, UK
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25
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Tilbrook H, Clark L, Cook L, Bland M, Buckley H, Chetter I, Dumville J, Fenner C, Forsythe R, Gabe R, Harding K, Layton A, Lindsay E, McDaid C, Moffatt C, Rolfe D, Sbizzera I, Stansby G, Torgerson D, Vowden P, Williams L, Hinchliffe R. AVURT: aspirin versus placebo for the treatment of venous leg ulcers - a Phase II pilot randomised controlled trial. Health Technol Assess 2018; 22:1-138. [PMID: 30325305 DOI: 10.3310/hta22550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) are the most common cause of leg ulceration, affecting 1 in 100 adults. VLUs may take many months to heal (25% fail to heal). Estimated prevalence is between 1% and 3% of the elderly population. Compression is the mainstay of treatment and few additional therapies exist to improve healing. Two previous trials have indicated that low-dose aspirin, as an adjunct to standard care, may improve healing time, but these trials were insufficiently robust. Aspirin is an inexpensive, widely used medication but its safety and efficacy in the treatment of VLUs remains to be established. OBJECTIVES Primary objective - to assess the effects of 300 mg of aspirin (daily) versus placebo on the time to healing of the reference VLU. Secondary objectives - to assess the feasibility of leading into a larger pragmatic Phase III trial and the safety of aspirin in this population. DESIGN A multicentred, pilot, Phase II randomised double-blind, parallel-group, placebo-controlled efficacy trial. SETTING Community leg ulcer clinics or services, hospital outpatient clinics, leg ulcer clinics, tissue viability clinics and wound clinics in England, Wales and Scotland. PARTICIPANTS Patients aged ≥ 18 years with a chronic VLU (i.e. the VLU is > 6 weeks in duration or the patient has a history of VLU) and who are not regularly taking aspirin. INTERVENTIONS 300 mg of daily oral aspirin versus placebo. All patients were offered care in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidance with multicomponent compression therapy aiming to deliver 40 mmHg at the ankle when possible. RANDOMISATION Participants were allocated in a 1 : 1 (aspirin : placebo) ratio by the Research Pharmacy, St George's University Hospitals NHS Foundation Trust, using a randomisation schedule generated in advance by the investigational medicinal product manufacturer. Randomisation was stratified according to ulcer size (≤ 5cm2 or > 5cm2). MAIN OUTCOME MEASURE The primary outcome was time to healing of the largest eligible ulcer (reference ulcer). FEASIBILITY RESULTS – RECRUITMENT 27 patients were recruited from eight sites over a period of 8 months. The target of 100 patients was not achieved and two sites did not recruit. Barriers to recruitment included a short recruitment window and a large proportion of participants failing to meet the eligibility criteria. RESULTS The average age of the 27 randomised participants (placebo, n = 13; aspirin, n = 14) was 62 years (standard deviation 13 years), and two-thirds were male (n = 18). Participants had their reference ulcer for a median of 15 months, and the median size of ulcer was 17.1 cm2. There was no evidence of a difference in time to healing of the reference ulcer between groups in an adjusted analysis for log-ulcer area and duration (hazard ratio 0.58, 95% confidence interval 0.18 to 1.85; p = 0.357). One expected, related serious adverse event was recorded for a participant in the aspirin group. LIMITATIONS The trial under-recruited because many patients did not meet the eligibility criteria. CONCLUSIONS There was no evidence that aspirin was efficacious in hastening the healing of chronic VLUs. It can be concluded that a larger Phase III (effectiveness) trial would not be feasible. TRIAL REGISTRATION Clinical Trials.gov NCT02333123; European Clinical Trials Database (EudraCT) 2014-003979-39. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 55. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Helen Tilbrook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Clark
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Martin Bland
- Department of Health Sciences, University of York, York, UK
| | - Hannah Buckley
- Cancer Division, Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ian Chetter
- Academic Vascular Surgical Unit, Hull Royal Infirmary, Hull, UK
| | - Jo Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Chris Fenner
- Orthopaedic Department, West Middlesex Hospital, Isleworth, UK
| | - Rachael Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rhian Gabe
- Hull York Medical School and York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Keith Harding
- Wound Healing, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Layton
- Harrogate and District NHS Foundation Trust, Harrogate, UK
| | | | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Christine Moffatt
- School of Health Sciences, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Debbie Rolfe
- Joint Research and Enterprise Office, St George's University of London, London, UK
| | - Illary Sbizzera
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Peter Vowden
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, UK
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, National Institute for Health Research (NIHR) Biomedical Research Centre, University of Bristol, Bristol, UK
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Westby MJ, Dumville JC, Stubbs N, Norman G, Wong JKF, Cullum N, Riley RD. Protease activity as a prognostic factor for wound healing in venous leg ulcers. Cochrane Database Syst Rev 2018; 9:CD012841. [PMID: 30171767 PMCID: PMC6513613 DOI: 10.1002/14651858.cd012841.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Venous leg ulcers (VLUs) are a common type of complex wound that have a negative impact on people's lives and incur high costs for health services and society. It has been suggested that prolonged high levels of protease activity in the later stages of the healing of chronic wounds may be associated with delayed healing. Protease modulating treatments have been developed which seek to modulate protease activity and thereby promote healing in chronic wounds. OBJECTIVES To determine whether protease activity is an independent prognostic factor for the healing of venous leg ulcers. SEARCH METHODS In February 2018, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and CINAHL. SELECTION CRITERIA We included prospective and retrospective longitudinal studies with any follow-up period that recruited people with VLUs and investigated whether protease activity in wound fluid was associated with future healing of VLUs. We included randomised controlled trials (RCTs) analysed as cohort studies, provided interventions were taken into account in the analysis, and case-control studies if there were no available cohort studies. We also included prediction model studies provided they reported separately associations of individual prognostic factors (protease activity) with healing. Studies of any type of protease or combination of proteases were eligible, including proteases from bacteria, and the prognostic factor could be examined as a continuous or categorical variable; any cut-off point was permitted. The primary outcomes were time to healing (survival analysis) and the proportion of people with ulcers completely healed; the secondary outcome was change in ulcer size/rate of wound closure. We extracted unadjusted (simple) and adjusted (multivariable) associations between the prognostic factor and healing. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion at each stage, and undertook data extraction, assessment of risk of bias and GRADE assessment. We collected association statistics where available. No study reported adjusted analyses: instead we collected unadjusted results or calculated association measures from raw data. We calculated risk ratios when both outcome and prognostic factor were dichotomous variables. When the prognostic factor was reported as continuous data and healing outcomes were dichotomous, we either performed regression analysis or analysed the impact of healing on protease levels, analysing as the standardised mean difference. When both prognostic factor and outcome were continuous data, we reported correlation coefficients or calculated them from individual participant data.We displayed all results on forest plots to give an overall visual representation. We planned to conduct meta-analyses where this was appropriate, otherwise we summarised narratively. MAIN RESULTS We included 19 studies comprising 21 cohorts involving 646 participants. Only 11 studies (13 cohorts, 522 participants) had data available for analysis. Of these, five were prospective cohort studies, four were RCTs and two had a type of case-control design. Follow-up time ranged from four to 36 weeks. Studies covered 10 different matrix metalloproteases (MMPs) and two serine proteases (human neutrophil elastase and urokinase-type plasminogen activators). Two studies recorded complete healing as an outcome; other studies recorded partial healing measures. There was clinical and methodological heterogeneity across studies; for example, in the definition of healing, the type of protease and its measurement, the distribution of active and bound protease species, the types of treatment and the reporting of results. Therefore, meta-analysis was not performed. No study had conducted multivariable analyses and all included evidence was of very low certainty because of the lack of adjustment for confounders, the high risk of bias for all studies except one, imprecision around the measures of association and inconsistency in the direction of association. Collectively the research indicated complete uncertainty as to the association between protease activity and VLU healing. AUTHORS' CONCLUSIONS This review identified very low validity evidence regarding any association between protease activity and VLU healing and there is complete uncertainty regarding the relationship. The review offers information for both future research and systematic review methodology.
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Affiliation(s)
- Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 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 HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Nikki Stubbs
- St Mary's HospitalLeeds Community Healthcare NHS Trust3 Greenhill RoadLeedsUKLS12 3QE
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jason KF Wong
- Manchester University NHS Foundation TrustManchester Centre for Plastic Surgery and Burns, Wythenshawe HospitalSouthmoor Road, WythenshaweManchesterUKM23 9LT
| | - 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 HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Richard D Riley
- Keele UniversityResearch Institute for Primary Care and Health SciencesDavid Weatherall Building, Keele University CampusKeeleStaffordshireUKST5 5BG
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Illescas-Montes R, Atkinson RA, Cullum N. Low-level light therapy for treating venous leg ulcers. Hippokratia 2018. [DOI: 10.1002/14651858.cd013061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rebeca Illescas-Montes
- Universidad de Granada; Departamento de Enfermería, Facultad de Enfermería de Melilla; Granada Spain
| | - Ross A Atkinson
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health; Manchester UK M13 9PL
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health; Manchester UK M13 9PL
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28
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Norman G, Westby MJ, Rithalia AD, Stubbs N, Soares MO, Dumville JC. Dressings and topical agents for treating venous leg ulcers. Cochrane Database Syst Rev 2018; 6:CD012583. [PMID: 29906322 PMCID: PMC6513558 DOI: 10.1002/14651858.cd012583.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decision-making challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents. OBJECTIVES To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality. SEARCH METHODS In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification. SELECTION CRITERIA We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We conducted this NMA using frequentist meta-regression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole. MAIN RESULTS We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts.The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty.The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency. AUTHORS' CONCLUSIONS More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.The results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost.
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Affiliation(s)
- Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Nikki Stubbs
- St Mary's HospitalLeeds Community Healthcare NHS Trust3 Greenhill RoadLeedsUKLS12 3QE
| | - Marta O Soares
- University of YorkCentre for Health EconomicsAlcuin 'A' BlockHeslingtonYorkUKYO10 5DD
| | - 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 HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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Green J, Jester R, McKinley R, Pooler A. Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care. Part 1: exploring the consultation. Br J Community Nurs 2018; 23:S30-S38. [PMID: 29493307 DOI: 10.12968/bjcn.2018.23.sup3.s30] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This article, the first of two, summarises a study that explored the lived experiences of patients with leg ulcers and the impact of this condition on their quality of life. The study had four study phases; phases 1 and 2 employed qualitative methods and are reported here. Initially, unstructured interviews were held; these revealed significant issues for the patients including the dominance of pain, issues relating to exudate and odour, social isolation and psychological effects. A checklist based on these issues was completed by the researcher during observations of routine care for these same patients; this revealed the extent and depth to which these matters were addressed. On many occasions, significant issues were not disclosed or explored during consultations. These findings confirmed that participants with chronic venous leg ulcers have concerns far beyond wound care.
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Affiliation(s)
- Julie Green
- Queen's Nurse, Royal College of Nursing, Professional Nursing Committee member, Royal College of Nursing, District Nurse, Forum Chair and member of the Association of District Nurse Educators: Director of Postgraduate Studies and Senior Lecturer, Keele University School of Nursing and Midwifery, Clinical Education Centre, University Hospitals of North Midlands NHS Trust, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG
| | - Rebecca Jester
- Professor of Nursing, Faculty of Education, Health and Wellbeing, Institute of Health, University of Wolverhampton, WV1 1LY
| | - Robert McKinley
- Professor of Nursing, Faculty of Education, Health and Wellbeing, Institute of Health, University of Wolverhampton, WV1 1LY
| | - Alison Pooler
- Lecturer, Director of Learning and Teaching, School of Nursing and Midwifery, Keele University, Staffordshire, ST4 6QG
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Interventions for pressure ulcers: a summary of evidence for prevention and treatment. Spinal Cord 2018; 56:186-198. [DOI: 10.1038/s41393-017-0054-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 11/08/2022]
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Do systematic reviews address community healthcare professionals' wound care uncertainties? Results from evidence mapping in wound care. PLoS One 2018; 13:e0190045. [PMID: 29320522 PMCID: PMC5761849 DOI: 10.1371/journal.pone.0190045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 12/07/2017] [Indexed: 11/19/2022] Open
Abstract
Background Complex wounds such as leg and foot ulcers are common, resource intensive and have negative impacts on patients’ wellbeing. Evidence-based decision-making, substantiated by high quality evidence such as from systematic reviews, is widely advocated for improving patient care and healthcare efficiency. Consequently, we set out to classify and map the extent to which up-to-date systematic reviews containing robust evidence exist for wound care uncertainties prioritised by community-based healthcare professionals. Methods We asked healthcare professionals to prioritise uncertainties based on complex wound care decisions, and then classified 28 uncertainties according to the type and level of decision. For each uncertainty, we searched for relevant systematic reviews. Two independent reviewers screened abstracts and full texts of reviews against the following criteria: meeting an a priori definition of a systematic review, sufficiently addressing the uncertainty, published during or after 2012, and identifying high quality research evidence. Results The most common uncertainty type was ‘interventions’ 24/28 (85%); the majority concerned wound level decisions 15/28 (53%) however, service delivery level decisions (10/28) were given highest priority. Overall, we found 162 potentially relevant reviews of which 57 (35%) were not systematic reviews. Of 106 systematic reviews, only 28 were relevant to an uncertainty and 18 of these were published within the preceding five years; none identified high quality research evidence. Conclusions Despite the growing volume of published primary research, healthcare professionals delivering wound care have important clinical uncertainties which are not addressed by up-to-date systematic reviews containing high certainty evidence. These are high priority topics requiring new research and systematic reviews which are regularly updated. To reduce clinical and research waste, we recommend systematic reviewers and researchers make greater efforts to ensure that research addresses important clinical uncertainties and is of sufficient rigour to inform practice.
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Gray TA, Dumville JC, Christie J, Cullum NA. Rapid research and implementation priority setting for wound care uncertainties. PLoS One 2017; 12:e0188958. [PMID: 29206884 PMCID: PMC5716549 DOI: 10.1371/journal.pone.0188958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/10/2017] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION People with complex wounds are more likely to be elderly, living with multimorbidity and wound related symptoms. A variety of products are available for managing complex wounds and a range of healthcare professionals are involved in wound care, yet there is a lack of good evidence to guide practice and services. These factors create uncertainty for those who deliver and those who manage wound care. Formal priority setting for research and implementation topics is needed to more accurately target the gaps in treatment and services. We solicited practitioner and manager uncertainties in wound care and held a priority setting workshop to facilitate a collaborative approach to prioritising wound care-related uncertainties. METHODS We recruited healthcare professionals who regularly cared for patients with complex wounds, were wound care specialists or managed wound care services. Participants submitted up to five wound care uncertainties in consultation with their colleagues, via an on-line survey and attended a priority setting workshop. Submitted uncertainties were collated, sorted and categorised according professional group. On the day of the workshop, participants were divided into four groups depending on their profession. Uncertainties submitted by their professional group were viewed, discussed and amended, prior to the first of three individual voting rounds. Participants cast up to ten votes for the uncertainties they judged as being high priority. Continuing in the professional groups, the top 10 uncertainties from each group were displayed, and the process was repeated. Groups were then brought together for a plenary session in which the final priorities were individually scored on a scale of 0-10 by participants. Priorities were ranked and results presented. Nominal group technique was used for generating the final uncertainties, voting and discussions. RESULTS Thirty-three participants attended the workshop comprising; 10 specialist nurses, 10 district nurses, seven podiatrists and six managers. Participants had been qualified for a mean of 20.7 years with a mean of 16.8 years of wound care experience. One hundred and thirty-nine uncertainties were submitted electronically and a further 20 were identified on the day of the workshop following lively, interactive group discussions. Twenty-five uncertainties from the total of 159 generated made it to the final prioritised list. These included six of the 20 new uncertainties. The uncertainties varied in focus, but could be broadly categorised into three themes: service delivery and organisation, patient centred care and treatment options. Specialist nurses were more likely to vote for service delivery and organisation topics, podiatrists for patient centred topics, district nurses for treatment options and operational leads for a broad range. CONCLUSIONS This collaborative priority setting project is the first to engage front-line clinicians in prioritising research and implementation topics in wound care. We have shown that it is feasible to conduct topic prioritisation in a short time frame. This project has demonstrated that with careful planning and rigor, important questions that are raised in the course of clinicians' daily decision making can be translated into meaningful research and implementation initiatives that could make a difference to service delivery and patient care.
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Affiliation(s)
- Trish A. Gray
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Jo C. Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Janice Christie
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Nicky A. Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- Research and Innovation Division, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
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Samuriwo R. Grand convergence in wound healing - The imperative for collaboration in research, innovation and quality improvement. J Tissue Viability 2017; 27:80-81. [PMID: 29103915 DOI: 10.1016/j.jtv.2017.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/16/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Ray Samuriwo
- Chair of the Tissue Viability Society Board of Trustees, UK; School of Healthcare Sciences, Cardiff University, UK; Wales Centre for Evidence Based Care, Cardiff University, UK; Cardiff Institute for Tissue Engineering and Repair (CITER), Cardiff University, UK.
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Westby MJ, Dumville JC, Stubbs N, Norman G, Wong JKF, Cullum N, Riley R. Protease activity as a prognostic factor for wound healing in venous leg ulcers. Hippokratia 2017. [DOI: 10.1002/14651858.cd012841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Maggie J Westby
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's Hospital; Wound Prevention and Management Service; 3 Greenhill Road Leeds UK LS12 3QE
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Jason KF Wong
- University Hospital South Manchester; Plastic and Reconstructive Surgery; Southmoor Road, Wythenshawe Manchester UK M23 9LT
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Richard Riley
- Keele University; Research Institute for Primary Care and Health Sciences; David Weatherall Building, Keele University Campus Keele Staffordshire UK ST5 5BG
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Jackson D, Durrant L, Bishop E, Walthall H, Betteridge R, Gardner S, Coulton W, Hutchinson M, Neville S, Davidson PM, Usher K. Pain associated with pressure injury: A qualitative study of community-based, home-dwelling individuals. J Adv Nurs 2017; 73:3061-3069. [DOI: 10.1111/jan.13370] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Debra Jackson
- Oxford Institute for Nursing; Midwifery & Allied Health Research (OxINMAHR). The Colonnade; Oxford Brookes University; Oxford UK
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
- Faculty of Health; University of Technology; Sydney Australia
| | - Lisa Durrant
- Oxford Institute for Nursing; Midwifery & Allied Health Research (OxINMAHR). The Colonnade; Oxford Brookes University; Oxford UK
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | | | - Helen Walthall
- Oxford Institute for Nursing; Midwifery & Allied Health Research (OxINMAHR). The Colonnade; Oxford Brookes University; Oxford UK
| | - Ria Betteridge
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | | | - Wendy Coulton
- Oxford Institute for Nursing; Midwifery & Allied Health Research (OxINMAHR). The Colonnade; Oxford Brookes University; Oxford UK
| | - Marie Hutchinson
- School of Nursing; Southern Cross University; Lismore New South Wales Australia
| | - Stephen Neville
- School of Nursing; Auckland University of Technology; Auckland New Zealand
| | | | - Kim Usher
- Oxford Institute for Nursing; Midwifery & Allied Health Research (OxINMAHR). The Colonnade; Oxford Brookes University; Oxford UK
- School of Health; University of New Zealand; Australia
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Westby MJ, Dumville JC, Soares MO, Stubbs N, Norman G. Dressings and topical agents for treating pressure ulcers. Cochrane Database Syst Rev 2017; 6:CD011947. [PMID: 28639707 PMCID: PMC6481609 DOI: 10.1002/14651858.cd011947.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from including alginate, hydrocolloid and protease-modulating dressings. Topical agents have also been used as alternatives to dressings in order to promote healing.A clear and current overview of all the evidence is required to facilitate decision-making regarding the use of dressings or topical agents for the treatment of pressure ulcers. Such a review would ideally help people with pressure ulcers and health professionals assess the best treatment options. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents. OBJECTIVES To assess the effects of dressings and topical agents for healing pressure ulcers in any care setting. We aimed to examine this evidence base as a whole, determining probabilities that each treatment is the best, with full assessment of uncertainty and evidence quality. SEARCH METHODS In July 2016 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) comparing the effects of at least one of the following interventions with any other intervention in the treatment of pressure ulcers (Stage 2 or above): any dressing, or any topical agent applied directly to an open pressure ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factor treatments, platelet gels and larval therapy. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. We conducted network meta-analysis using frequentist mega-regression methods for the efficacy outcome, probability of complete healing. We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals for individual treatments compared with every other, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole. MAIN RESULTS We included 51 studies (2947 participants) in this review and carried out NMA in a network of linked interventions for the sole outcome of probability of complete healing. The network included 21 different interventions (13 dressings, 6 topical agents and 2 supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed wounds.We judged the network to be sparse: overall, there were relatively few participants, with few events, both for the number of interventions and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high imprecision in the evidence, and this, coupled with the (mainly) high risk of bias in the studies informing the network, means that we judged the vast majority of the evidence to be of low or very low certainty. We have no confidence in the findings regarding the rank order of interventions in this review (very low-certainty evidence), but we report here a summary of results for some comparisons of interventions compared with saline gauze. We present here only the findings from evidence which we did not consider to be very low certainty, but these reported results should still be interpreted in the context of the very low certainty of the network as a whole.It is not clear whether regimens involving protease-modulating dressings increase the probability of pressure ulcer healing compared with saline gauze (risk ratio (RR) 1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence: low risk of bias, downgraded for imprecision). This risk ratio of 1.65 corresponds to an absolute difference of 102 more people healed with protease modulating dressings per 1000 people treated than with saline gauze alone (95% CI 13 fewer to 302 more). It is unclear whether the following interventions increase the probability of healing compared with saline gauze (low-certainty evidence): collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95% CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58) and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the latter two interventions both had confidence intervals consistent with both a clinically important benefit and a clinically important harm, and the former two interventions each had high risk of bias as well as imprecision. AUTHORS' CONCLUSIONS A network meta-analysis (NMA) of data from 39 studies (evaluating 21 dressings and topical agents for pressure ulcers) is sparse and the evidence is of low or very low certainty (due mainly to risk of bias and imprecision). Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze.More research is needed to determine whether particular dressings or topical agents improve the probability of healing of pressure ulcers. The NMA is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference and cost.
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Affiliation(s)
- Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Marta O Soares
- University of YorkCentre for Health EconomicsAlcuin 'A' BlockHeslingtonYorkUKYO10 5DD
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's HospitalWound Prevention and Management Service3 Greenhill RoadLeedsUKLS12 3QE
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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Abstract
BACKGROUND Pressure ulcers, also known as bed sores, pressure sores or decubitus ulcers develop as a result of a localised injury to the skin or underlying tissue, or both. The ulcers usually arise over a bony prominence, and are recognised as a common medical problem affecting people confined to a bed or wheelchair for long periods of time. Anabolic steroids are used as off-label drugs (drugs which are used without regulatory approval) and have been used as adjuvants to usual treatment with dressings, debridement, nutritional supplements, systemic antibiotics and antiseptics, which are considered to be supportive in healing of pressure ulcers. Anabolic steroids are considered because of their ability to stimulate protein synthesis and build muscle mass. Comprehensive evidence is required to facilitate decision making, regarding the benefits and harms of using anabolic steroids. OBJECTIVES To assess the effects of anabolic steroids for treating pressure ulcers. SEARCH METHODS In March 2017 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 as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) comparing the effects of anabolic steroids with alternative treatments or different types of anabolic steroids in the treatment of pressure ulcers. DATA COLLECTION AND ANALYSIS Two review authors independently carried out study selection, data extraction and risk of bias assessment. MAIN RESULTS The review contains only one trial with a total of 212 participants, all with spinal cord injury and open pressure ulcers classed as stage III and IV. The participants were mainly male (98.2%, 106/108) with a mean age of 58.4 (standard deviation 10.4) years in the oxandrolone group and were all male (100%, 104/104) with a mean age of 57.3 (standard deviation 11.6) years in the placebo group. This trial compared oxandrolone (20 mg/day, administered orally) with a dose of placebo (an inactive substance consisting of 98% starch and 2% magnesium stearate) and reported data on complete healing of ulcers and adverse events. There was very low-certainty evidence on the relative effect of oxandrolone on complete ulcer healing at the end of a 24-week treatment period (risk ratio RR) 0.81, 95% confidence interval (CI) 0.52 to 1.26) (downgraded twice for imprecision due to an extremely wide 95% CI, which spanned both benefit and harm, and once for indirectness, as the participants were mostly male spinal cord injury patients). Thus, we are uncertain whether oxandrolone improves or reduces the complete healing of pressure ulcers, as we assessed the certainty of the evidence as very low.There was low-certainty evidence on the risk of non-serious adverse events reported in participants treated with oxandrolone compared with placebo (RR 3.85, 95% CI 1.12 to 13.26) (downgraded once for imprecision and once for indirectness, as the participants were mostly male spinal cord injury patients). Thus, the treatment with oxandrolone may increase the risk of non-serious adverse events reported in participants.There was very low-certainty evidence on the risk of serious adverse events reported in participants treated with oxandrolone compared with placebo (RR 0.54, 95% CI 0.25 to 1.17) (downgraded twice for imprecision due to an extremely wide 95% CI, which spanned both benefit and harm, and once for indirectness, as the participants were mostly male spinal cord injury patients). Of the five serious adverse events reported in the oxandrolone-treated group, none were classed by the trial teams as being related to treatment. We are uncertain whether oxandrolone increases or decreases the risk of serious adverse events as we assessed the certainty of the evidence as very low.Secondary outcomes such as pain, length of hospital stay, change in wound size or wound surface area, incidence of different type of infection, cost of treatment and quality of life were not reported in the included trial.Overall the evidence in this study was of very low quality (downgraded for imprecision and indirectness). This trial stopped early when the futility analysis (interim analysis) in the opinion of the study authors showed that oxandrolone had no benefit over placebo for improving ulcer healing. AUTHORS' CONCLUSIONS There is no high quality evidence to support the use of anabolic steroids in treating pressure ulcers.Further well-designed, multicenter trials, at low risk of bias, are necessary to assess the effect of anabolic steroids on treating pressure ulcers, but careful consideration of the current trial and its early termination are required when planning future research.
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Affiliation(s)
- Cho Naing
- James Cook UniversityCollege of Public Health, Medical and Veterinary Sciences, Division of Tropical Health and MedicineTownsvilleAustralia
- International Medical UniversitySchool of Postgraduate StudiesKuala LumpurMalaysia
| | - Maxine A Whittaker
- James Cook UniversityCollege of Public Health, Medical and Veterinary Sciences, Division of Tropical Health and MedicineTownsvilleAustralia
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39
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Norman G, Dumville JC, Westby MJ, Stubbs N, Soares MO. Dressings and topical agents for treating venous leg ulcers. Hippokratia 2017. [DOI: 10.1002/14651858.cd012583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Gill Norman
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science Centre; Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health; Jean McFarlane Building Oxford Road Manchester UK M13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's Hospital; Wound Prevention and Management Service; 3 Greenhill Road Leeds UK LS12 3QE
| | - Marta O Soares
- University of York; Centre for Health Economics; Alcuin 'A' Block Heslington York UK YO10 5DD
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40
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Britteon P, Cullum N, Sutton M. Association between psychological health and wound complications after surgery. Br J Surg 2017; 104:769-776. [DOI: 10.1002/bjs.10474] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/29/2016] [Accepted: 11/30/2016] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Surgical wound complications remain a major cause of morbidity, leading to higher costs and reduced quality of life. Although psychological health is widely considered to affect wound healing, the evidence on wound outcomes after surgery is mixed. Studies generally focus on small samples of patients undergoing a specific procedure and have limited statistical power.
Methods
This study investigated the relationship between three different measures of anxiety and/or depression and seven adverse surgical outcomes using observational data collected before and after surgery between 2009 and 2011. A wide range of confounding factors was adjusted for, including patient demographics, physical co-morbidities, health-related behaviours, month of operation, procedure complexity and treating hospital.
Results
The estimation sample included 176 827 patients undergoing 59 410 hip replacements, 64 145 knee replacements, 38 328 hernia repairs and 14 944 varicose vein operations. Patients with moderate anxiety or depression had an increased probability of wound complications after a hip replacement (odds ratio (OR) 1·17, 95 per cent c.i. 1·11 to 1·24). They were more likely to be readmitted for a wound complication (OR 1·20, 1·02 to 1·41) and had an increased duration of hospital stay by 0·19 (95 per cent c.i. 0·15 to 0·24) days. Estimated associations were consistent across all four types of operation and for each measure of anxiety and/or depression.
Conclusion
Preoperative psychological health is a significant risk factor for adverse wound outcomes after surgery for four of the procedures most commonly performed in England.
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Affiliation(s)
- P Britteon
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - N Cullum
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - M Sutton
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
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Abstract
BACKGROUND The management of pressure ulcers involves several interventions ranging from pressure-relieving measures such as repositioning, to treatments that can include reconstructive surgery. Such surgery may be considered for recalcitrant wounds when full thickness skin loss arises and deeper structures such as muscle fascia and even bone are exposed. The surgery commonly involves wound debridement followed by the addition of new tissue into the wound. Whilst reconstructive surgery is an accepted means of ulcer management, the benefits and harms of surgery compared with non-surgical treatments, or alternative surgical approaches are not clear. OBJECTIVES To assess the effects of reconstructive surgery for healing pressure ulcers (stage II or above), comparing surgery with no surgery or comparing alternative forms of surgery in any care setting. SEARCH METHODS We searched the following electronic databases to identify reports of relevant randomised clinical trials (searched 26 September 2016): the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. We also searched three clinical trials registers and reference lists of relevant systematic reviews, meta-analyses and health technology assessment reports. SELECTION CRITERIA Published or unpublished randomised controlled trials that assessed reconstructive surgery in the treatment of pressure ulcers. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias and extract study data. MAIN RESULTS We did not identify any studies that met the review eligibility criteria nor any registered studies investigating the role of reconstructive surgery in the management of pressure ulcers. AUTHORS' CONCLUSIONS Currently there is no randomised evidence that supports or refutes the role of reconstructive surgery in pressure ulcer management. This is a priority area and there is a need to explore this intervention with more rigorous and robust research.
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Affiliation(s)
- Jason KF Wong
- University Hospital South ManchesterPlastic and Reconstructive SurgerySouthmoor Road, WythenshaweManchesterUKM23 9LT
| | - Kavit Amin
- University Hospital South ManchesterPlastic and Reconstructive SurgerySouthmoor Road, WythenshaweManchesterUKM23 9LT
| | - Jo C Dumville
- University of ManchesterDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthManchesterUKM13 9PL
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