A new "silver-bullet" to treat caries in children--nano silver fluoride: a randomised clinical trial

BACKGROUND

Untreated dental caries in children remains a public health challenge in poor communities.

OBJECTIVES

This prospective controlled clinical trial investigated the effectiveness of a new anti-caries agent, Nano Silver Fluoride (NSF), applied once a year to arrest caries in children.

METHODS

One hundred thirty decayed primary teeth were randomly divided into two groups: NSF as the experimental agent and water as the control group. Teeth were clinically diagnosed and treated by one masked examiner and followed up at seven days and five and 12 months by another calibrated examiner who was blinded to the type of treatment. The criteria of the ICDAS II were followed to determine the activity of lesion and the diagnosis of caries. The Pearson's chi-square test was used to compare the groups during different follow-up exams.

RESULTS

At seven days, 81% of teeth in the NSF group exhibited arrested caries, whereas in controls, no teeth had arrested decay (p<0.001) [PF, prevented fraction=81%]. After five months, the NSF group had 72.7% with arrested decay, and the control group had 27.4% (p<0.001) [PF=62.5%]. At 12 months, 66.7% of the lesions treated with NSF were still arrested, while the control group had 34.7% remaining arrested (p=0.003) [PF=50%]. The number need to treat (NNT) at five months was two, and at 12 months, the number was three.

CLINICAL SIGNIFICANCE

The NSF formulation is effective to arrest active dentine caries and not stain teeth.

CONCLUSIONS

NSF was demonstrated to be effective in arresting caries in children in poor communities.

[Treatment of infected diabetic foot ulcers clinical effectiveness of a dressing of alginate and hydrocolloid, with silver fiber. Analysis of results of a series of cases]

INTRODUCTION

High levels of bacterial load have shown a deleterious influence on wound healing. Using antimicrobial dressings can control ulcers' bioburden. The aim of our study was to evaluate the improving of infected diabetic foot ulcers due an alginate's fiber and hydrocolloid silver dressing.

MATERIAL AND METHODS

We analysed a case series of 6 patients with diabetic foot ulcers without peripheral vascular disease and diagnosed from critical colonization and/or local infection according the presence of inflammation clinical signs. Patients were treated for a minimum period of two weeks. We analysed the percentage reduction in ulcer area from the day of enrolment to antimicrobial dressing removal.

RESULTS

The duration of treatment had a median of 5 weeks with a minimum of 2 weeks and up to 6. The median percentage of area reduction of the wounds was 47.7% (range: 0.5%-90%). The mean percentage reduction on the lesion was 58% from 2 weeks and 67.14% at 3 weeks. All patients had reduced significantly their size at 3 weeks from beginning of treatment (p < 0.05).

CONCLUSION

The use of an alginate's fiber and hydrocolloid silver dressing promotes healing on diabetic foot ulcers with local infection, reducing the inflammatory clinical signs significantly over a period of three weeks.

The use of nanocrystalline silver for the treatment of massive soft tissue defects with exposed bone

BACKGROUND

In a complex wound with exposed tendon, joint or bone caused by trauma, soft tissue reconstruction is required to obtain function and aesthetic coverage. Surgical reconstruction can be performed using a variety of different techniques.

OBJECTIVE

The authors report their experience using a nanocrystalline silver with or without vacuum assisted wound closure to salvage the exposed vital structures such as bone, joint or tendon in traumatic wounds.

MATERIAL AND METHOD

The present study included 12 patients with 15 wounds that exposed vital structures especially in the lower extremities. After adequate debridement, four wounds were treated with nanocrystalline silver dressing and vacuum assisted wound closure, and ten wounds were treated in an out-patient program using nanocrystalline silver dressing.

RESULTS

A preliminary evidence of impressive result was achieved with subsided infection and complete bony coverage by granulation tissue after treatment. Subsequently, a secondary healing or a split thickness skin graft was applied.

CONCLUSION

The authors present the satisfactory results of alternative techniques that may be used for the massive soft tissue defects with exposed bone.

Hidradenitis suppurativa: a case study

This article identifies the care and treatment of a male patient during an acute flare up of hidradenitis suppurativa (HS). This article looks at HS, which can be a progressive chronic condition that impacts heavily on all aspects of a patient's quality of life. The choice of a silver alginate dressing proved effective in managing multiple surgical wounds in a comfortable and effective manner, improving the patient's quality of life.

Alginate dressings for healing diabetic foot ulcers

BACKGROUND

Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use.

OBJECTIVES

To compare the effects of alginate wound dressings with no wound dressing or alternative dressings on the healing of foot ulcers in people with diabetes mellitus.

SEARCH METHODS

For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of alginate dressings with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included six studies (375 participants) in this review; these compared alginate dressings with basic wound contact dressings, foam dressings and a silver-containing, fibrous-hydrocolloid dressing. Meta analysis of two studies found no statistically significant difference between alginate dressings and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI 0.66 to 1.80). Pooled data from two studies comparing alginate dressings with foam dressings found no statistically significant difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08). There was no statistically significant difference in the number of diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid dressing was compared with a standard alginate dressing (RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up times (six to 12 weeks), and small sample sizes.

AUTHORS' CONCLUSIONS

Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.

Wound cleansing for pressure ulcers

BACKGROUND

Pressure ulcers (also called pressure sores, bed sores and decubitus ulcers) are areas of tissue damage that occur in the elderly, malnourished or acutely ill, who cannot reposition themselves. Pressure ulcers impose a significant financial burden on health care systems and negatively affect quality of life. Wound cleansing is considered an important component of pressure ulcer care.

OBJECTIVES

This systematic review seeks to answer the following question: what is the effect of wound cleansing solutions and wound cleansing techniques on the rate of healing of pressure ulcers?

SEARCH METHODS

For this third update, we searched the Cochrane Wounds Group Specialised Register (searched 3 January 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12); Ovid MEDLINE (2010 to November Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations December 31, 2012); Ovid EMBASE (2010 to 2012 Week 52); and EBSCO CINAHL (2010 to 21 December 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or different wound cleansing solutions, or different cleansing techniques, were eligible for inclusion if they reported an objective measure of pressure ulcer healing.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently and resolved disagreements through discussion. A structured narrative summary of the included studies was conducted. For dichotomous outcomes, risk ratio (RR), plus 95% confidence intervals (CI) were calculated; for continuous outcomes, mean difference (MD), plus 95% CI were calculated. Meta analysis was not conducted because of the small number of diverse RCTs identified. Two review authors independently assessed each included study using the Cochrane Collaboration tool for assessing risk of bias.

MAIN RESULTS

One additional eligible study was identified from the updated searches, one study was added to the table of excluded studies. A total of three studies (169 participants) met the inclusion criteria for the review. No studies compared cleansing with no cleansing. Two studies compared different wound cleansing solutions. A statistically significant improvement in Pressure Sore Status Tool scores occurred for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) compared with isotonic saline (P value = 0.025), but no statistically significant change in healing was seen when water was compared with saline (RR 3.00, 95% CI 0.21 to 41.89). One study compared cleansing techniques; for pressure ulcers cleansed with pulsatile lavage, compared with sham (the lavage flow was directed into a wash basin positioned adjacent to the wound and not visible to the participants), there was a statistically significant reduction in ulcer volume at the end of the three week study period in the lavage group compared with the sham group (MD -6.60, 95% CI-11.23, -1.97).

AUTHORS' CONCLUSIONS

We identified three small studies addressing cleansing of pressure ulcers. One reported a statistically significant improvement in pressure ulcer healing for wounds cleansed with saline spray containing Aloe vera, silver chloride and decyl glucoside (Vulnopur) compared with isotonic saline solution, a further study reported no statistically significant change in healing was seen when wounds were cleaned with water was compared with saline. A final study compared pulsatile lavage with sham and found a significantly greater reduction in ulcer volume at the end of the study period in the lavage group compared with the sham group. The authors conclude that there is no good trial evidence to support use of any particular wound cleansing solution or technique for pressure ulcers.

Extending the TIME concept: what have we learned in the past 10 years?(*)

The TIME acronym (tissue, infection/inflammation, moisture balance and edge of wound) was first developed more than 10 years ago, by an international group of wound healing experts, to provide a framework for a structured approach to wound bed preparation; a basis for optimising the management of open chronic wounds healing by secondary intention. However, it should be recognised that the TIME principles are only a part of the systematic and holistic evaluation of each patient at every wound assessment. This review, prepared by the International Wound Infection Institute, examines how new data and evidence generated in the intervening decade affects the original concepts of TIME, and how it is translated into current best practice. Four developments stand out: recognition of the importance of biofilms (and the need for a simple diagnostic), use of negative pressure wound therapy (NPWT), evolution of topical antiseptic therapy as dressings and for wound lavage (notably, silver and polyhexamethylene biguanide) and expanded insight of the role of molecular biological processes in chronic wounds (with emerging diagnostics and theranostics). Tissue: a major advance has been the recognition of the value of repetitive and maintenance debridement and wound cleansing, both in time-honoured and novel methods (notably using NPWT and hydrosurgery). Infection/inflammation: clinical recognition of infection (and non infective causes of persisting inflammation) is critical. The concept of a bacterial continuum through contamination, colonisation and infection is now widely accepted, together with the understanding of biofilm presence. There has been a return to topical antiseptics to control bioburden in wounds, emphasised by the awareness of increasing antibiotic resistance. Moisture: the relevance of excessive or insufficient wound exudate and its molecular components has led to the development and use of a wide range of dressings to regulate moisture balance, and to protect peri-wound skin, and optimise healing. Edge of wound: several treatment modalities are being investigated and introduced to improve epithelial advancement, which can be regarded as the clearest sign of wound healing. The TIME principle remains relevant 10 years on, with continuing important developments that incorporate new evidence for wound care.

Chitin membranes containing silver nanoparticles for wound dressing application

Silver nanoparticles are gaining importance as an antimicrobial agent in wound dressings. Chitin is a biopolymer envisioned to promote rapid dermal regeneration and accelerate wound healing. This study was focused on the evaluation of chitin membranes containing silver nanoparticles for use as an antimicrobial wound dressing. Silver nanoparticles were synthesised by gamma irradiation at doses of 50 kGy in the presence of sodium alginate as stabiliser. The UV-Vis absorption spectra of nanoparticles exhibited an absorption band at 415-420 nm, which is the typical plasmon resonance band of silver nanoparticles. The peaks in the X-ray diffraction (XRD) pattern are in agreement with the standard values of the face-centred cubic silver. Transmission electron microscopy (TEM) images indicate silver nanoparticles with spherical morphology and small particle size in the range of 3-13 nm. In vitro antimicrobial tests were performed using Pseudomonas aeruginosa and Staphylococcus aureus to determine the antimicrobial efficiency of the chitin membranes containing 30, 50, 70 and 100 ppm nanosilver. No viable counts for P. aeruginosa were detected with 70 ppm silver nanoparticles dressing after 1-hour exposure. A 2-log reduction in viable cell count was observed for S. aureus after 1 hour and a 4-log reduction after 6 hours with 100 ppm nanosilver chitin membranes. This study demonstrates the antimicrobial capability of chitin membranes containing silver nanoparticles. The chitin membranes with 100 ppm nanosilver showed promising antimicrobial activity against common wound pathogens.

Comparison of foam dressings with silver versus foam dressings without silver in the care of malodorous malignant fungating wounds

PURPOSE

To investigate the effectiveness of foam dressings with silver vs. foam dressings without silver to reduce malodorous and septic phenomena in malignant fungating wounds (MFWs).

METHODS

The study included 26 patients with malodorous MFWs at home care. Thirteen patients formed the intervention group A (foam dressings with silver), and another 13 patients formed the control group B (foam dressings without silver). The patients' selection was random. The dressing changes were carried out according to the needs of the ulcer and depending on the exudates' level. The evaluation of the odor was 4 weeks after the start of the study. The patients' evaluation was excluded due to familiarization with the odor.

RESULTS

In group A 10/13 (76.9%) patients showed a significant reduction of the odor compared with 4/13 (30.8%) patients in group B (p = 0.049).

CONCLUSION

Microbial activity and septic phenomena in the ulcerated surface of MFWs are the causes of unpleasant odor. This study provided evidence that the antimicrobial property of silver dressings is very useful in the treatment of microbial activity and can reduce malodorous and septic phenomena.

Silver coated bioactive glass particles for wound healing applications

Bioactive glass particles (0.42SiO(2)-0.15CaO-0.23Na(2)O-0.20ZnO) of varying size (<90 μm and 425-850 μm) were synthesized and coated with silver (Ag) to produce Ag coated particles (PAg). These were compared against the uncoated analogous particles (Pcon.). Surface area analysis determined that Ag coating of the glass particles resulted in increased the surface area from 2.90 to 9.12 m(2)/g (90 μm) and 1.09-7.71 m(2)/g (425-850 μm). Scanning electron microscopy determined that the Ag coating remained at the surface and there was little diffusion through the bulk. Antibacterial (Escherichia coli--13 mm and Staphylococcus epidermidis--12 mm) and antifungal testing (Candida albicans--7.7 mm) determined that small Ag-coated glass particles exhibited the largest inhibition zones compared to uncoated particles. pH analysis determined an overall higher pH consider in the smaller particles, where after 24 h the large uncoated and Ag coated particles were 8.27 and 8.74 respectively, while the smaller uncoated and Ag coated particles attained pH values of 9.63 and 9.35 respectively.

Alginate dressings for healing diabetic foot ulcers

BACKGROUND

Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use.

OBJECTIVES

To compare the effects of alginate wound dressings with no wound dressing or alternative dressings on the healing of foot ulcers in people with diabetes mellitus.

SEARCH METHODS

We searched The Cochrane Wounds Group Specialised Register (searched 4 January 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (1950 to December Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to 2011 Week 52); and EBSCO CINAHL (1982 to 30 December 2011). There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of alginate dressings with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included six studies (375 participants) in this review; these compared alginate dressings with basic wound contact dressings, foam dressings and a silver-containing, fibrous-hydrocolloid dressing. Meta analysis of two studies found no statistically significant difference between alginate dressings and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI 0.66 to 1.80). Pooled data from two studies comparing alginate dressings with foam dressings found no statistically significant difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08). There was no statistically significant difference in the number of diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid dressing was compared with a standard alginate dressing (RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up times (six to 12 weeks), and small sample sizes.

AUTHORS' CONCLUSIONS

Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.

Efficacy of a new medical device based on colloidal silver and carbossimetyl beta glucan in treatment of upper airways disease in children

AIM

Nasal congestion is the main symptom in common upper respiratory diseases in childhood. Intranasal administration of sympatheticomimetics decongestants is commonly adopted for this symptom. The Italian Drug Agency stated a warning against the use of these drugs in children under 12 years of age. The aim of this study is to evaluate the efficacy on nasal symptoms and the safety of a new medical device based on colloidal silver and carbossimetyl beta glucan compared with saline solution treatment in a group of children (0-12 years) affected by viral rhinitis.

METHODS

Hundred consecutive outpatient children (0-12 year old), affected by common cold syndrome with evident nasal obstruction were randomly assigned to two type of intervention: group 1. receiving colloidal silver and carbossimetyl beta glucan; group 2. receiving saline solution. Each subject underwent clinical history and objective examination of rhinosinusal district at enrollment. Upper respiratory pathologie-related symptoms were specifically evaluated by using the Canadian Acute Respiratory Illness and Flu Scale (CARIFS).

RESULTS

A significant improvement of CARIFS score was observed into the two groups. The score improvement of these two treatment was confirmed in all the age sub-group. We observed a statistically significant difference in mean post-treatment CARIFS score and CARIFS globas VAS (Visual Analogic Scale) in children of group 1 compared with children in group 2 (2.28 ± 1.58 vs. 5.08 ± 3.39; P<0.001 and VAS: 1.87 ± 1.38 vs. VAS: 3.34 ± 2.19; P=0.012, respectively). At the end of treatment, 90% of subjects in group 1 resulted completely recovered, whereas 10% experienced some degree of complications (otitis, tracheitis, bronchitis). In group 2 a complete recovering was achieved in 66 % of subjects, the remaining 34 % developed complications. Tolerability profiles were similar in the two groups with no statistical differences in side effects in all age subgroups.

CONCLUSION

Despite both treatments reached significative improvements in CARIFS global score and VAS and in physical examination of nasal mucosa and secretion at the end of the therapy, colloidal silver and carbossimetyl beta glucan showed a better performance with a significant difference in mean post-treatment CARIFS global score and CARIFS VAS compared to treatment with saline solution.

Nanosilver in consumer products and human health: more information required!

Commenting on "120 Years of Nanosilver History: Implications for Policy Makers" (Environ. Sci. Technol.2011, 45, 1177-1183). The title of the article seduces readers to the impression that we can look back at more than a century of safe use of nanosilver. In this context, colloidal silver and nanosilver have been sometimes used as synonyms. Historically, the term "colloidal silver" refers to dispersed silver particles encompassing a size range of 10-1000 nm. Following scientific definitions, "colloid" stands for freely dispersed particles in a fluid (heterogenic) phase irrespective of its size distribution, while the term "nanosilver" is used for categorization by size. Of course, just the labeling as such neither necessarily implies new hazard properties nor any specific risks; however, uncertainties and data gaps at many levels call for careful consideration and usually should take effect as alert signal for regulatory toxicologists all over the world. Within the frame of this short commentary, we would like to focus on some unclarified issues related to consumer products.

Evaluating antimicrobial efficacy of new commercially available silver dressings

Prevention and treatment of bacterial colonised/infected wounds are critical. Many commercially available silver dressings claim broad-spectrum bactericidal activity over days and are indicated for serious conditions including burns and ulcers. However, there is no peer-reviewed literature available for many newer dressings. This study compared the activity of some of these dressings. Six silver-containing dressings were compared using log reduction, silver release and corrected zone of inhibition assays. Only the nanocrystalline silver dressing was bactericidal against Staphylococcus aureus, and the only other dressing that produced any log reduction was a silver collagen matrix dressing. These two dressings and a silver alginate dressing produced zones of inhibition, although the collagen matrix and alginate dressings had decreasing zone sizes over time, and the latter liquefied after five transfers. The remaining dressings (two ionic silver foam dressings and a silver sulphate dressing) did not produce zones of inhibition. For the foam, alginate and collagen matrix dressings, antimicrobial activity was related to silver release. The silver sulphate dressing released large quantities of silver, but only through the dressing edges, as the wound-contacting surface appeared to be hydrophobic. The results of this study emphasise the importance of confirming product claims regarding silver dressing efficacy.

[Dressings for local treatment of leg ulcers]

The beneficial effect of a moist wound environment has been well established for healing rate of acute wounds, pain relief and debridement of chronic wounds. Modern dressings are occlusive or semi occlusive, classified according to their physical composition and to their performances such as absorbent capacity, hydrating ability, adhesive components and debridement capacity. They are used to control the exudates and to maintain the wound in a moist environment. Published systematic reviews of the value of different types of dressings in the management of chronic wounds provide only weak levels of evidence of their clinical efficacy, in terms of healing rate. Nevertheless, the indications of modern dressings were recently determined according to a systematic review of the literature and to a formal consensus process. Despite the lack of appropriate studies, modern dressings remains a part of the standard of care and are widely used according to the experience of the clinicians, in larger indications than what may be recommended by evidence-based medicine.

A prospective randomised open label study to evaluate the potential of a new silver alginate/carboxymethylcellulose antimicrobial wound dressing to promote wound healing

The aim of this study was to observe both the clinical signs and symptoms of wounds at risk of infection, that is critically colonised (biofilm infected) and antimicrobial-performance of an ionic silver alginate/carboxymethylcellulose (SACMC) dressing, in comparison with a non silver calcium alginate fibre (AF) dressing, on chronic venous leg and pressure ulcers. Thirty-six patients with venous or pressure ulcers, considered clinically to be critically colonised (biofilm infected), were randomly chosen to receive either an SACMC dressing or a non silver calcium AF dressing. The efficacy of each wound dressing was evaluated over a 4-week period. The primary study endpoints were prevention of infection and progression to wound healing. The SACMC group showed a statistically significant (P = 0.017) improvement to healing as indicated by a reduction in the surface area of the wound, over the 4-week study period, compared with AF controls. In conclusion, the SACMC dressing showed a greater ability to prevent wounds progressing to infection when compared with the AF control dressing. In addition, the results of this study also showed an improvement in wound healing for SACMC when compared with a non silver dressing.

Venous and diabetic ulcerations: management with topical multivalent silver oxide ointment

AIM

In addition to contemporary compression therapy, one of the therapeutic approaches is the use of a topical wound care agent. The goal of this pilot registry study is to evaluate the efficacy and safety of a uniquely designed ointment containing multivalent silver oxide (Ag4O4) in the healing of difficult diabetic or venous ulcerations.

METHODS

Patients who had ulcers resulting from chronic venous insufficiency or diabetes participated in this open-label, randomized registry study. All patients were evaluated by measuring both the area of the ulceration and microcirculatory parameters. 148 patients were included in the study and categorized into two main groups: venous ulcers and diabetic ulcers. Each main group was then randomized into two sub-groups: topical treatment with silver oxide ointment and the control group (standard cleaning and compression management methods, without silver ointment). All patients were treated with accepted cleaning and compression management. RESULTS. In subjects with venous ulcers: After 4 weeks, the silver treatment was more effective than the control group treatment: Skin PO2 was increased 2.1 times more than the control group (17.4% to 8.2%) and skin flux (RF) was improved 1.6 times more than the control group (-38.7% to -24.2%). The total surface area of the ulcer was significantly reduced in the silver treatment group by 1.9 times the control group (-88.7% to -46.9%). In addition, in the silver treatment group we observed complete closure of the ulceration in 42% of subjects compared to 22% in the control group (P=<0.05). In subjects with diabetic ulcers: after 4 weeks, the silver treatment was more effective than the control group treatment: Skin PO2 increased 2.6 times more than the control group (23.3% to 9.1%) and skin flux (RF) was significantly improved 4.3 times more than the control group(-26.7% to -6.2%). The total surface area of the ulcer was significantly reduced in the silver treatment group by 3.7 times the control group (-89.0% to -23.9%). In addition, in the silver treatment group we observed complete closure of the ulceration in 39% of subjects compared to 16% in the control group (P</=0.05).

CONCLUSION

This pilot study provides observational data on the efficacy of local treatment of ulcers with a multivalent silver oxide containing ointment. The silver ointment improved microcirculation and the healing rate of all 78 patients that were treated with multivalent silver ointment and closed twice as many ulcers in 4 weeks compared to the control groups (40.7% silver treatment compared to 19.4% for the control). This study demonstrates the feasibility of this type of treatment and provides evidence of efficacy to plan larger randomized controlled studies. The large number of patients that were helped in this study demonstrates the efficacy of multivalent silver oxide topical ointment and its important role in ulcer therapy.

Topical wound oxygen therapy in the treatment of severe diabetic foot ulcers: a prospective controlled study

Diabetic foot ulcers (DFU) are common, difficult-to-treat, and prone to complications. A prospective, controlled study was conducted to: 1) examine the clinical efficacy of a pressurized topical oxygen therapy (TWO(2)) device in outpatients (N = 28) with severe DFU referred for care to a community wound care clinic and 2) assess ulcer reoccurrence rates after 24 months. Seventeen (17) patients received TWO(2) five times per week (60-minute treatment, pressure cycles between 5 and 50 mb) and 11 selected a silver-containing dressing changed at least twice per week (control). Patient demographics did not differ between treatment groups but wounds in the treatment group were more severe, perhaps as a result of selection bias. Ulcer duration was longer in the treatment (mean 6.1 months, SD 5.8) than in the control group (mean 3.2 months, SD 0.4) and mean baseline wound area was 4.1 cm2 (SD 4.3) in the treatment and 1.4 cm2 (SD 0.6) in the control group (P = 0.02). Fourteen (14) of 17 ulcers (82.4%) in the treatment group and five of 11 ulcers (45.5%) in the control group healed after a median of 56 and 93 days, respectively (P = 0.04). No adverse events were observed and there was no reoccurrence at the ulcer site after 24 months' follow-up in either group. Although the absence of randomization and blinding may have under- or overestimated the treatment effect of either group, the significant differences in treatment outcomes confirm the potential benefits of TWO(2) in the management of difficult-to-heal DFUs. Clinical efficacy and cost-effectiveness studies as well as studies to elucidate the mechanisms of action of TWO(2) are warranted.

Topical silver for preventing wound infection

BACKGROUND

Silver-containing treatments are popular and used in wound treatments to combat a broad spectrum of pathogens, but evidence of their effectiveness in preventing wound infection or promoting healing is lacking.

OBJECTIVES

To establish the effects of silver-containing wound dressings and topical agents in preventing wound infection and healing of wounds.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (6 May 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) (2009 Issue 2); Ovid MEDLINE (1950 to April Week 4 2009); Ovid EMBASE (1980 to 2009 Week 18); EBSCO CINAHL (1982 to April Week 4 2009) and Digital Dissertations (to May 2009) for relevant trials. We contacted manufacturers and distributors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing silver-containing wound dressings and topical agents with silver-containing and non silver-containing comparators on uninfected wounds.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed risk of bias, and extracted data.

MAIN RESULTS

We identified 26 RCTs (2066 patients). Heterogeneity of treatments and outcomes precluded meta-analysis. We grouped results according to wound type, and silver preparation.BurnsThirteen trials compared topical silver (in a variety of formulations - including silver sulphadiazine (SSD) cream) with non-silver dressings. One trial showed fewer infections with silver nitrate when compared with a non-silver dressing, but three trials showed significantly more infection with SSD than with the non-silver dressing.Six trials compared SSD cream with silver-containing dressings. One showed significantly fewer infections with the silver-containing dressing (Hydron AgSD) compared with SSD, the remaining five found no evidence of a difference.One trial compared two silver-containing dressings, and showed a significantly lower infection rate with silver-coated gauze (Acticoat(R)) than with silver nitrate gauze.Other woundsSix trials compared SSD/silver-containing dressings with non-silver dressings (nine dressings in total). Most comparisons (seven) found no significant differences in infection rates; one trial in a variety of wounds exhibited significantly fewer infections with SSD/hydrocolloid, but another, in acute wounds, found significantly more infections with SSD. Only one comparison showed a significant reduction in healing time associated with a silver-containing hydrofibre dressing in diabetic foot ulcers.

AUTHORS' CONCLUSIONS

There is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection; some poor quality evidence for SSD suggests the opposite.

Silver dressings: more evidence is needed to support their widespread clinical use

Anecdotal and clinical evidence suggests that silver dressings have a role to play in controlling local wound infection, but there is very little high-quality evidence to inform their use. Well-designed trials are needed to fill this evidence gap.

Acoustic pressure wound therapy in the treatment of stage II pressure ulcers

Pressure ulcers are localized skin injuries secondary to unrelieved pressure or friction. Patients with immobility issues are at increased risk for developing pressure ulcers. In 2004, stricter federal regulations for prevention and treatment of pressure ulcers in institutional settings--eg, long-term care facilities--were introduced. Effective, low-cost treatments for pressure ulcers are needed; acoustic pressure wound therapy (APWT), a noncontact, low-frequency, therapeutic ultrasound system, is one option. A retrospective case series of six long-term care patients (two men and one woman, age range 61 to 92 years), each with one Stage II pressure ulcer, is presented. Acoustic pressure wound therapy was provided as an adjunct to standard treatment that included balsam of Peru/castor oil/trypsin ointment, hydrogel, hydrocolloid dressings, silver dressings, and offloading. Outcomes (days to healing) were determined through changes in wound dimensions. Study participants each received APWT for 3 to 4 minutes three to four times weekly. In four of the six wounds, the average number of days to healing was 22. One of the two remaining patients discontinued treatment at 95% healed; treatment for the sixth patient was ongoing due to hospitalization that delayed APWT. In a long-term care setting, APWT added to standard of care may accelerate healing of Stage II pressure ulcers.

Interventions to reduce Staphylococcus aureus in the management of atopic eczema

BACKGROUND

Staphylococcus aureus can cause secondary infection in atopic eczema, and it may promote inflammation in eczema that does not look infected. Many antimicrobial products exist for eczema, but it is unclear if they work or if they promote bacterial resistance.

OBJECTIVES

To assess the effects of interventions to reduce Staphylococcus aureus for treating infected or uninfected atopic eczema.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (March 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 1, 2008), MEDLINE (OVID) (from 2002 to March 2008), EMBASE (OVID) (from 2002 to March 2008), Ongoing trials registers (March 2008). References from trials and reviews were searched, pharmaceutical companies were contacted for unpublished trials. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of people with atopic eczema who have been treated with a product intended to reduce S. aureus on the skin.

DATA COLLECTION AND ANALYSIS

Two people independently performed the study selection, data abstraction and quality assessment.

MAIN RESULTS

We included 21 studies (1018 participants) covering 7 treatment categories. Most studies were poorly reported and study differences limited pooling of results. Adverse effects were especially poorly reported, and only one study reported the emergence of resistant bacterial strains following oral antibiotics. Oral antibiotics were not associated with benefit in non-infected (2 trials, 66 participants) or infected eczema (1 trial, 33 participants). We did not find any benefit for antibacterial soaps (1 trial, 50 participants), or antibacterial bath additives (2 trials, 41 participants), or topical antibiotics/antiseptics (4 studies, 95 participants). Adding antibiotics to topical corticosteroids reduced numbers of Staphylococcus aureus in 4 trials (302 participants), but there was no evidence of any clinical benefit in 9 trials involving 677 participants: betamethasone plus neomycin vs clobetasol (MD 1.2; 95% CI 0.25, 2.15), prednicarbate plus antimicrobial vs prednicarbate (RR 0.64; 95% CI 0.25, 1.68), or betamethasone valerate plus gentamicin vs betamethasone (RR 0.31; 95% CI 0.07, 1.35). One trial (30 participants) showed no significant improvement in eczema for those using silver textiles (RR 2.67; 95% CI 0.98, 7.22), despite using 10 times the amount of topical steroids.

AUTHORS' CONCLUSIONS

We failed to find clear evidence of benefit for antimicrobial interventions for people with atopic eczema, despite their widespread use. This does not necessarily mean they do not work because the studies were small and poorly reported. Further large studies with long-term outcomes and clearly defined participants are urgently required.

A rehabilitation hospital's experience with ionic silver Foley catheters

A small rehabilitation hospital in northern Arkansas had a problem with catheter-associated urinary tract infections (CAUTI). A review of practices and policies provided no reason for the trend. The facility trialed an ionic silver Foley catheter finding that it dramatically reduced the incidence of CAUTI in their patient population.

Ion uptake into demineralized dentine from glass ionomer cement following pretreatment with silver fluoride and potassium iodide

BACKGROUND

Diamine silver fluoride (Ag(NH3)2F), referred to as AgF, has been shown to provide a pronounced antimicrobial action against caries. The clinical application of this material has been limited by the staining associated with both teeth and tooth coloured restorative materials. The application of potassium iodide (KI) after AgF eliminates stain formation. The purpose of this study was to determine if a prior application of silver fluoride and potassium iodine to demineralized dentine affected the uptake of strontium and fluoride from a glass ionomer cement restoration.

METHOD

Three cavities were prepared in each of five recently extracted human third molars. The cavities were demineralized and treated as follows. In each tooth, one cavity was left as a control, one cavity was restored with glass ionomer cement and one cavity was treated with 1.8M AgF and a saturated KI solution and then restored with glass ionomer cement. The penetration of the various elements into demineralized dentine was measured by their relative percentage weights using electron probe microanalysis (EPMA).

RESULTS

Fluoride uptake was significantly higher in the AgF and KI treated samples compared to the other two samples and significantly higher in the glass ionomer restored sample compared to the control. The application of AgF and KI did not significantly interfere with the transfer of strontium from glass ionomer cement into dentine. Silver and iodine deposits were present in the demineralized dentine treated with AgF and KI.

CONCLUSIONS

The application of AgF and KI onto dentine prior to the placement of glass ionomer cement did not significantly affect the strontium uptake into the subjacent demineralized dentine and the fluoride levels in this zone were significantly increased.

[Clinical evaluation of a silver dressing in the treatment of infected and colonized ulcers]

In the event of ulcers with critical colonization, a correct diagnosis and adequate treatment are vital for healing to occur since the presence of a possible infection would impede an adequate evolution leading to healing the ulcer The authors publish a prospective and multi-centric study which included 375 patients who were evaluated regarding the healing of their ulcers over a 12 week period in which the "Biatain Plata" dressing was used. The average initial size of their ulcers was 30 cm2 +/- 67. After 72 weeks of treatment, patients' ulcers were reduced by 80% in relative value. 33% of these ulcers showed a complete healing, while another 47.4% evidenced a noticeable improvement. The product studied proved to be highly effective in the treatment of chronic ulcers with critical colonization. Regarding the safety of this dressing, the authors did not observe any adverse reaction to it, nor did they observe any toxicity associated with the release of silver, in spite of having used this dressing over 12 weeks. In the same way, the authors did not notice any indications of possible development of bacterial resistance to the dressing's anti-bacterial action.

Prevalence of silver resistance in bacteria isolated from diabetic foot ulcers and efficacy of silver-containing wound dressings

Silver dressings are used to manage wounds at risk of infection or locally infected. This in vitro study was conducted to assess the prevalence of silver resistance genes in 112 bacterial isolates obtained from the diabetic foot ulcers of patients attending the Diabetic Foot Clinic at Tameside General Hospital, UK. Using polymerase chain reaction to screen for three silver-resistance transcriptional units--silE, silS and silP--two silver-resistant bacteria were identified; both are strains of Enterobacter cloacae, an organism rarely implicated as a primary pathogen in chronic wounds. No recognized wound pathogens (Staphylococcus aureus-24 isolates and Pseudomonas aeruginosa-nine isolates) were found to contain silver-resistant genes. Analysis of the efficacy of silver-containing dressings on the silver-resistant strains of Enterobacter cloacae using confocal laser microscopy showed that, despite evidence of genetic resistance to silver, all strains were killed following a maximum of 48 hours of exposure to the dressings. Results suggest that presence of silver resistance genes is rare and that genetic resistance does not necessarily translate to phenotypic resistance to silver. While silver resistance in wound care should be monitored, the threat of widespread resistance is low and silver-containing dressings remain an extremely important tool in managing wound infection.

[Ophthalmia neonatorum of the newborn and its treatments in Canadian medical publications: 1872-1985]

In the 19th century the occurrence of ophthalmia neonatorum had reached alarming rates in the maternity wards not only of Europe but also across Canada. The impact of this blinding ocular infection on Canadian medicine from 1872 to 1985 is examined through a review of 80 medical journals, books, and lay press articles of that period. The prophylactic and therapeutic use of 2% silver nitrate introduced by Credé in 1880 to prevent neonatal blindness is reviewed. The signs, symptoms, and corneal complications of this disease as well as the multiple ocular drugs used during this era will be presented. The judicial consequences on midwives and obstetricians will be discussed. The subsequent use of colloidal silver based agents such as collargol, protargol and argyrol followed by the introduction of sulfonamides and finally the routine use of prophylactic topical antibiotics will be reviewed.

Differences between normal and demineralized dentine pretreated with silver fluoride and potassium iodide after an in vitro challenge by Streptococcus mutans

BACKGROUND

The application of diamine silver fluoride (Ag(NH3)2F) and potassium iodide (KI) to demineralized dentine has been shown to inhibit the growth of Streptococcus mutans. The purpose of this study was to observe the differences between demineralized and non-demineralized dentine treated with AgF/KI.

METHODS

Thirty-five dentine discs were bonded to the bases of 5 mL polycarbonate screw top vials which were filled with nutrient medium, sterilized and placed into the overflow from a continuous culture of S. mutans. Samples were divided as follows: 10 samples of demineralized dentine; 10 samples of demineralized dentine treated with AgF/KI; 5 samples of non-demineralized dentine; and 10 samples of non-demineralized dentine treated with AgF/KI. Following two weeks connected to the Chemostat, an electron probe microanalysis (EPMA) of percentage weights and penetration depths of calcium, phosphorous silver and fluoride was conducted. Bacterial growth was monitored by taking optical density readings of the growth medium in each vial and outer surfaces of the specimens were examined by scanning electron microscopy (SEM).

RESULTS

AgF/KI treatment of demineralized and non-demineralized dentine prevented biofilm formation and reduced further demineralization by S. mutans. AgF/KI treatment of demineralized dentine was more effective in reducing dentine breakdown and the growth of S. mutans. Significantly higher levels of silver and fluoride were deposited within demineralized dentine.

CONCLUSIONS

A topical treatment with AgF/KI on dentine reduced in vitro caries development and inhibited surface biofilm formation. Reduction of in vitro caries development and viability of S. mutans was more pronounced on the dentine samples that had been demineralized prior to the application of

Use of a nanocrystalline silver dressing on lymphatic ulcers in patients with chronic lymphoedema

OBJECTIVE

A prospective evaluation to explore the effect of treating patients with chronic lower limb lymphoedema and lymphatic ulcers using a nanocrystalline dressing and multilayer bandaging.

METHOD

Ulcers were cleansed and dressed with a nanocrystalline silver dressing, an alginate dressing and a hydrocellular dressing, followed by multilayer short-stretch compression bandages. A digital planimetry system was used to calculate the ulcer surface area. In cases of multiple ulcers, the areas were added together.

RESULTS

Eight patients with chronic lower limb lymphoedema plus ulcers were included. Median age was 53.7 years (range 39.2-72.3). Mean ulcer size was 10.5cm2 (range: 0.8-33.8). All ulcers completely healed after one to nine weeks of treatment.

CONCLUSION

This protocol has been effective in healing lymphatic ulcers and was well accepted by patients. There were no adverse effects or withdrawals. Further studies with larger numbers of patients are required to support these results.

Evaluation of a new silver foam dressing in patients with critically colonised venous leg ulcers

OBJECTIVE

To evaluate the performance (efficacy and safety) of an absorbent dressing impregnated with silver salts (UrgoCell Silver) in the management of leg ulcers with clinical signs of critical colonisation.

METHOD

This was a prospective multicentre non-comparative phase III clinical trial. Patients were assessed weekly for up to four weeks. Assessment included clinical assessment of critical colonisation (severe spontaneous pain between dressing changes, erythema, oedema, malodour and heavy exudate), wound area tracing and photography. Acceptability was documented by the nursing staff when dressings were changed between two weekly evaluations.

RESULTS

Forty-five leg ulcers were included. At baseline the mean number of clinical signs of critical colonisation per ulcer was 3.6 +/- 0.7, which decreased to 1.2 +/- 1.2 at the end of the fourth week of follow-up (an average reduction of 2.3 +/- 1.3, p < 0.001). Oedema, malodour, erythema and spontaneous pain disappeared at the fourth week in 80%, 70%, 69% and 65% of the treated ulcers respectively. Compared with baseline, the mean reduction in ulcer area was 35.0 +/- 58.0% (median 33%, p < 0.001) after the four weeks treatment. Granulation tissue covered a mean 77% of the ulcer surface area at four weeks, compared with 41% at baseline. Only three local events were documented: contact dermatitis, a burning sensation and erythema.

CONCLUSION

The results suggest that the test dressing had a favourable influence on the wound prognosis, and was well tolerated and accepted in the treatment of venous leg ulcers with clinical signs of critical colonisation.

Prontosan wound irrigation and gel: management of chronic wounds

Chronic wounds present a challenge that is costly in terms of quality of life to the patient and in financial terms for the NHS. Several factors contribute to the development of a chronic wound, in particular the influence of bacteria as a biofilm within the wound environment. Irrigating a wound with normal saline has long been advocated as the most appropriate method of wound irrigation but biofilms are now known to be resistant to this method of cleansing. A small (10 patient) evaluation of the use of Prontosan in patients whose duration of chronic wounds exceeded 1 year has demonstrated that Prontosan wound irrigation and Prontosan gel are an appropriate alternative for cleaning, moistening and decontaminating encrusted, contaminated and chronic skin wounds, and can have a dramatic influence of the quality of life for such patients. This article discusses the cause of chronicity within a wound and discusses in depth three of the ten patients in the evaluation.

A palliative approach to the management of malodour from malignant fungating tumours

The aim of this case study is to explore the role of palliative care and the importance of a multidisciplinary team approach for the management of malodour from malignant fungating tumours. Nurses in my practice area in the UK rarely see them, find them particularly difficult to manage and the experience is often personally distressing. The disturbing nature of these tumours inflicts so much suffering on the patient and those around them that the concept of palliative care is often severely challenged and can prove to be difficult for nurses to achieve. Palliative care aims to provide a holistic team approach in addressing the complex individual needs of these patients and their families.

Prospective randomized controlled study of Hydrofiber dressing containing ionic silver or calcium alginate dressings in non-ischaemic diabetic foot ulcers

AIMS

Diabetic foot ulcers (DFUs) are at risk of infection and impaired healing, placing patients at risk of lower extremity amputation. DFU care requires debridement and dressings. A prospective, multicentre study compared clinical efficacy and safety of AQUACEL Hydrofiber dressings containing ionic silver (AQAg) with those of Algosteril calcium alginate (CA) dressings in managing out-patients with Type 1 or 2 diabetes mellitus and non-ischaemic Wagner Grade 1 or 2 DFUs.

METHODS

Patients stratified by antibiotic use on enrolment were randomly assigned to similar protocols including off-loading, AQAg (n = 67) or CA (n = 67) primary dressings and secondary foam dressings for 8 weeks or until healing. Clinical efficacy measures were healing outcomes and primarily healing speed. Adverse events were recorded.

RESULTS

AQAg and CA groups were comparable at baseline. All ulcer healing outcomes improved in both groups. The mean time to healing was 53 days for AQAg ulcers and 58 days for CA ulcers (P = 0.34). AQAg-treated ulcers reduced in depth nearly twice as much as CA-treated ulcers (0.25 cm vs. 0.13 cm; P = 0.04). There was more overall ulcer improvement and less deterioration in AQAg subjects (P = 0.058), particularly in the subset initially using antibiotics (P = 0.02). Safety profiles of both groups were similar.

CONCLUSION

When added to standard care with appropriate off-loading, AQAg silver dressings were associated with favourable clinical outcomes compared with CA dressings, specifically in ulcer depth reduction and in infected ulcers requiring antibiotic treatment. This study reports the first significant clinical effects of a primary wound dressing containing silver on DFU healing.