Randomized controlled trial and cost-effectiveness analysis of silver-donating antimicrobial dressings for venous leg ulcers (VULCAN trial)

Wound, Pressure Ulcer, and Burn Guidelines-5: Guidelines for the management of lower leg ulcers and varicose veins, second edition

"Wound, Pressure Ulcer, and Burn Guidelines-5: Guidelines for the management of lower leg ulcers and varicose veins, second edition" is revised from the first edition, which was published in the Japanese Journal of Dermatology in 2011. The guidelines were drafted by the Wound, Pressure Ulcer, and Burn Guidelines Drafting Committee delegated by the Japanese Dermatological Association and intend to facilitate physicians' clinical decisions in preventing, diagnosing and management of lower leg ulcers and varicose veins. We updated all sections by collecting documents published since the publication of the first edition. In particular, we added clinical question 8 (CQ8), which addresses endovenous laser ablation for varicose veins, a procedure that became covered by the Japanese national health insurance after the writing of the first edition, and endovenous radiofrequency ablation, which became covered by national health insurance in 2014. We also rearranged the subsequent clinical question (CQs) for easier reading. While the addition of these new techniques has increased the number of options available within the treatment algorithm, differences have arisen in the indication for surgery depending on the facility performing the treatment. Therefore, these have been abbreviated.

Commercial Silver-Based Dressings: In Vitro and Clinical Studies in Treatment of Chronic and Burn Wounds

Chronic wounds are a major health problem because of delayed healing, causing hardships for the patient. The infection present in these wounds plays a role in delayed wound healing. Silver wound dressings have been used for decades, beginning in the 1960s with silver sulfadiazine for infection prevention for burn wounds. Since that time, there has been a large number of commercial silver dressings that have obtained FDA clearance. In this review, we examine the literature involving in vitro and in vivo (both animal and human clinical) studies with commercial silver dressings and attempt to glean the important characteristics of these dressings in treating infected wounds. The primary presentation of the literature is in the form of detailed tables. The narrative part of the review focuses on the different types of silver dressings, including the supporting matrix, the release characteristics of the silver into the surroundings, and their toxicity. Though there are many clinical studies of chronic and burn wounds using silver dressings that we discuss, it is difficult to compare the performances of the dressings directly because of the differences in the study protocols. We conclude that silver dressings can assist in wound healing, although it is difficult to provide general treatment guidelines. From a wound dressing point of view, future studies will need to focus on new delivery systems for silver, as well as the type of matrix in which the silver is deposited. Clearly, adding other actives to enhance the antimicrobial activity, including the disruption of mature biofilms is of interest. From a clinical point of view, the focus needs to be on the wound healing characteristics, and thus randomized control trials will provide more confidence in the results. The application of different wound dressings for specific wounds needs to be clarified, along with the application protocols. It is most likely that no single silver-based dressing can be used for all wounds.

Impact of Silver Dressings on Wound Healing Rate in Patients with Lower Extremity Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The ulcers of lower extremities, both venous and diabetic, impose a massive burden on sufferers globally. This meta-analysis evaluates the efficacy of silver dressings in improving healing rate of these ulcers.

METHODS

We carried out comprehensive searches in PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Internet (CNKI) up to March 2024. Two reviewers independently screened the study and extracted data. While the primary outcome was wound healing rate, secondary outcomes included wound healing area and recurrence rate. Data were analyzed using Stata 16.0 software.

RESULTS

A total of 18 studies involving 1,825 participants were included. Silver dressings demonstrated statistically significant effects in improving healing rates for diabetic foot ulcers (DFUs) (OR 2.14, 95% CI: 1.52, 3.00, p = 0.00), whereas the effects were not statistically significant for venous leg ulcers (VLUs) (OR 1.32, 95% CI: 0.97, 1.78, p = 0.07). Silver dressings also reduced ulcer area by 27.44 cm2 (95% CI: 6.96-47.92) and recurrence rate by 45% (95% CI: 0.11-1.79). Subgroup analysis revealed that the Asia-Pacific region and treatments of 6 weeks or less exhibited higher healing rates than their respective counterparts, although there was no statistical significance.

CONCLUSIONS

This study indicated a statistically significant benefit of the treatment for DFU. However, the effect on VLU, though positive, did not reach statistical significance. This distinction should be considered in clinical application and further research.

OBJECTIVE

The ulcers of lower extremities, both venous and diabetic, impose a massive burden on sufferers globally. This meta-analysis evaluates the efficacy of silver dressings in improving healing rate of these ulcers.

METHODS

We carried out comprehensive searches in PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Internet (CNKI) up to March 2024. Two reviewers independently screened the study and extracted data. While the primary outcome was wound healing rate, secondary outcomes included wound healing area and recurrence rate. Data were analyzed using Stata 16.0 software.

RESULTS

A total of 18 studies involving 1,825 participants were included. Silver dressings demonstrated statistically significant effects in improving healing rates for diabetic foot ulcers (DFUs) (OR 2.14, 95% CI: 1.52, 3.00, p = 0.00), whereas the effects were not statistically significant for venous leg ulcers (VLUs) (OR 1.32, 95% CI: 0.97, 1.78, p = 0.07). Silver dressings also reduced ulcer area by 27.44 cm2 (95% CI: 6.96-47.92) and recurrence rate by 45% (95% CI: 0.11-1.79). Subgroup analysis revealed that the Asia-Pacific region and treatments of 6 weeks or less exhibited higher healing rates than their respective counterparts, although there was no statistical significance.

CONCLUSIONS

This study indicated a statistically significant benefit of the treatment for DFU. However, the effect on VLU, though positive, did not reach statistical significance. This distinction should be considered in clinical application and further research.

Analysis of therapeutic effect of silver-based dressings on chronic wound healing

Chronic wounds are susceptible to bacterial infections and at high risk of developing antibiotic-resistant bacterial infections. Silver is an antimicrobial by targeting almost all types of bacteria in chronic wounds to reduce the bacterial load in the infected area and further facilitate the healing process. This study focused on exploring whether silver-based dressings were superior to non-silver dressings in the treatment of chronic wounds. PubMed, Web of Science and Embase were comprehensively searched from inception to March 2024 for randomized clinical trials and observational studies. The endpoints in terms of wound healing rate, complete healing time, reduction on wound surface area and wound infection rate were analysed using Review Manager 5.4 software. A total of 15 studies involving 5046 patients were eventually included. The results showed that compared with patients provided with non-silver dressings, patients provided with silver-based dressings had higher wound healing rate (OR: 1.43, 95% CI: 1.10-1.85, p = 0.008), shorter complete healing time (MD: -0.96, 95% CI: -1.08 ~ -0.85, p < 0.00001) and lower wound infection rate (OR: 0.56, 95% CI: 0.40-0.79, p = 0.001); no significant difference in the reduction on wound surface area (MD: 12.41, 95% CI: -19.59-44.40, p = 0.45) was found. These findings suggested that the silver-based dressings were able to enhance chronic wound healing rate, shorten the complete healing time and reduce wound infection rate, but had no significant improvement in the reduction on wound surface area. Large-scale and rigorous studies are required to confirm the beneficial effects of silver-based dressings on chronic wound healing.

The Impact of Underlying Conditions on Quality-of-Life Measurement Among Patients with Chronic Wounds, as Measured by Utility Values: A Review with an Additional Study

Significance: Quality of life (QoL) is important to patients with chronic wounds and is rarely formally evaluated. Understanding what comorbidities most affect the individual versus their wounds could be a key metric. Recent Advances: The last 20 years have seen substantial advances in QoL instruments and conversion of patient data to a single value known as the health utilities index (HUI). We review these advances, along with wound-related QoL, and analyze real-world comorbidities challenging wound care. Critical Issues: To understand the impact of underlying comorbidities in a real-world patient population, we examined a convenience sample of 382 patients seen at a hospital-based outpatient wound center. This quality reporting study falls outside the regulations that govern human subject research. Comorbid conditions were used to calculate HUIs using a variety of literature-reported approaches, while Wound-Quality-of-Life (W-QoL) questionnaire data were collected from patients during their first visit. The mean number of conditions per patient was 8; 229 patients (59.9%) had utility values for comorbidities/conditions, which were worse/lower than their wounds' values. Sixty-three (16.5%) patients had depression and/or anxiety, 64 (16.8%) had morbid obesity, and 204 (53.4%) had gait and mobility disorders, all of which could have affected W-QoL scoring. The mean minimum utility value (0.5) was within 0.05 units of an average of 13 studies reporting health utilities from wound care populations using the EuroQol 5 Dimension instrument. Future Directions: The comorbidity associated with the lowest utility value is what might most influence the QoL of patients with chronic wounds. This finding needs further investigation.

Clinical Efficacy of Hyaluronic Acid with Iodine in Hard-to-Heal Wounds

Hard-to-heal wounds do not heal spontaneously and need long-term care provided by specialists. That burdens the patients as well as the healthcare systems. Such wounds arise from several pathologies, which result in venous leg ulcers (VLU), diabetic foot ulcers (DFU), pressure ulcers (PU), or ulcers originating from post-surgical wounds (pSW). Given the complex nature of hard-to-heal wounds, novel treatments are sought to enable wound healing. We tested the clinical efficacy and applicability of fluid comprising hyaluronic acid and iodine complex (HA-I) in the treatment of hard-to-heal wounds. Patients (n = 56) with VLU, DFU, PU, or pSW hospitalised in multiple wound-care centres in the Czech Republic were treated with HA-I. Wound size, classically visible signs of infection, exudation, pain, and wound bed appearance were monitored for 12 weeks. The highest healing rate was in DFU (71.4%), followed by pSW (62.5%), VLU (55.6%), and PU (44.4%). Classical visible signs of infection were resolved within 8 weeks in all types of wounds. Wound bed appearance improved most noticeably in pSW and then in VLU. Exudation was lowered most significantly in DFU and pSW. The highest decrease in pain was in pSW and DFU. The treatment with HA-I successfully led to either complete closure or significant improvement in the wound's healing. Therefore, the complex of hyaluronic acid and iodine is suitable for the treatment of hard-to-heal wounds of various aetiologies.

Do Commonly Used Antimicrobial Topicals Facilitate Venous Leg Ulcer Healing?

OBJECTIVE

To survey which topical antimicrobials are most helpful in treating venous leg ulcers (VLUs).

DATA SOURCES

In this narrative review, the authors searched the databases of Google Scholar, Cochrane Library, and Wiley Online Library.

STUDY SELECTION

Studies were eligible for inclusion if they studied the effects of antimicrobial agents on chronic VLU healing and were published after 1985. Exceptions to this were in vitro studies of manuka honey and Dakin solution (Century Pharmaceuticals). Search terms included "venous leg ulcer", "nonhealing ulcer", "antimicrobial resistance", and "biofilms".

DATA EXTRACTION

Data extracted included design, setting, descriptions of intervention and control groups, outcomes, data collection tools, and potential harms.

DATA SYNTHESIS

A total of 19 articles encompassing 26 studies/trials met the inclusion criteria. Of the 26 studies, 17 were randomized controlled trials; the remaining 9 were a mix of lower-quality case series and comparative, nonrandomized, or retrospective studies.

CONCLUSION

Studies suggest that VLUs can be treated with multiple different topical antimicrobials. Depending on the extent of chronicity and bacterial colonization, some antimicrobials may be better suited than others.

Smart Polymeric Wound Dressing for Treating Partial-Thickness Burns: A Preliminary Preclinical Study on the Porcine Model

Several so-called "smart" dressings are available for burn injuries to promote faster wound healing, and this technology has recently reported substantial advancements. However, the selection of an appropriate dressing for partial-thickness burns requires consideration of several crucial elements, including exudate management, conformability, antimicrobial properties, ease of application and removal, patient comfort, and cost-effectiveness. This preliminary feasibility study uses a porcine model to test the INTELIGELS product (Smart Bandage) for partial-thickness burns treatment. Artificially made wounds, mimicking partial-thickness burns, were assessed in two studies with and without antimicrobial additives, where wounds were randomly assigned to the experimental group treated with Smart Bandage and two control groups treated with a simple saline gauze dressing or Aquacel® products with and without silver additives. In addition, all dressings were evaluated for their ability to reduce wound size, quantified by histological analysis using punch biopsies. This study demonstrates comparable healing properties of Smart Bandage and Aquacel® dressings that are superior to the simple saline gauze dressing. The superiority is demonstrated by better regeneration, less inflammation of the epidermis and dermis, and better dermis remodeling with more granulation tissue maturation within the wound area when Smart Bandage/Aquacel® dressings are applied as compared with the simple gauze dressing.

Hyaluronic acid treatment versus standard of care in chronic wounds in a German setting: Cost-effectiveness analysis

Background and Aims

Chronic wounds are a major burden for worldwide health care systems. In the management of chronic wounds several strategies with innovative and active agents emerged in the past few years, such as hyaluronic acid containing wound dressings. Evidence comparing the cost-effectiveness of hyaluronan and standard of care dressings (hydrofiber with silver) is still missing. The aim of the study is thus, to assess the cost-effectiveness of hyaluronan versus standard of care dressings (hydrofiber with silver) in chronic wounds from a German statutory health insurance perspective.

Methods

A decision tree was modeled to quantify the cost and healing rate at 12 weeks for the hyaluronan and silver dressings strategies. Input parameters were collected literature-based, accounting for healing rates, dressing prices and prices for dressing changes and associated home care. Parameter uncertainty was accounted for by one-way and probabilistic sensitivity analysis.

Results

Hyaluronic acid showed a better healing rate (60.68%) and noticeable lower cost (749.80 Euro) compared to standard of care (silver containing) dressings (59.62%; 883.05 Euro), resulting in an Incremental Cost Effectiveness Ratio of -12,570.57. The hyaluronan approach is hence a dominant strategy in chronic wound management. Sensitivity analysis confirmed these results, giving a range of 60%- 70% of cost-effective scenarios.

Conclusions

Hyaluronic acid dressings showed to be a clinical more effective strategy at significantly lower cost in chronic wounds compared to standard of care (hydrofiber with silver).

Practical extended use of antimicrobial silver (PExUS)

BACKGROUND

Antimicrobial silver has had a role in wound antisepsis throughout history and, with the rise in acquired antibiotic resistance, silver dressings are once again commonly used. Issues with silver dressings include the important environmental consideration of nanoparticle manufacture, and the significant financial cost of these products. One solution to these problems may be to adopt an opened-but-unused model of wound care whereby dressing materials are used in piecemeal fashion and excess stored in between dressing changes. Due to a lack of literature on the topic, this project was designed with the aim of testing the antimicrobial efficacy of available silver dressings during storage after opening.

METHODS

Four commonly used silver dressings were tested for antimicrobial activity using a zone of inhibition assay against clinically important pathogens. The assay was performed on opening of dressings and repeated over 3 months in storage at 4, 25 or 37°C. Analysis was performed using repeated measures ANOVA. Swab cultures were taken at each simulated dressing change to detect microbial contamination of the dressings during storage.

RESULTS

There was no effect of time or storage temperature on the zone of inhibition over the 12 week test period. No swabs taken returned culture consistent with microbial contamination of stored dressings.

CONCLUSION

Opened silver dressings maintain antimicrobial activity for at least 12 weeks in storage and are resistant to contamination. An opened-but-unused model for wound care is likely to improve cost-effectiveness while preserving effectiveness and safety.

Antimicrobial silver dressings: a review of emerging issues for modern wound care

Skin is an important barrier to pathogenic microorganisms and plays a critical role in a ctivation of innate immune responses. When the skin barrier is breached following wounding or burn injury, pathogens can invade and complicate healing with infection resulting in delayed healing and symptomatic scarring. Wound infection is a significant problem after burn injury and in patients with chronic wounds. Antimicrobial silver has had a significant role in wound antisepsis throughout history and, given the rise in community acquired antibiotic resistance, silver dressings are now commonly used to combat wound infection. The multi-modal mechanism of action, low potential for toxicity and formation of microbial resistance makes silver dressings suitable tools against a wide array of clinically important microbes. There are, however, a number of issues with silver dressings including a conflicting evidence base, the important environmental consideration of nanoparticle manufacture, and the significant cost of these products. One solution may be to adopt an 'opened-but-unused' means of wound care whereby bulk dressing materials are used piecemeal and stored in between dressing changes to increase the cost-effectiveness and reduced wastage. There is, however, little literature on this topic and so in vitro and clinical research must be performed to consider the efficacy of active ingredient dressings in wound care including silver dressings once opened and stored.

Hard-to-heal wound treatment medical devices: clinical trial protocol in Japan

In consultation with academia and the Pharmaceuticals and Medical Devices Agency (PMDA), we have developed guidance for drafting protocols for clinical trials concerning medical devices for the healing of hard-to-heal wounds without ischaemia. The guidance summarises the validity of single-arm trials for hard-to-heal wounds, the definition of hard-to-heal wounds without ischaemia, methods of patient enrolment and clinical endpoints. This review focuses on the logical thinking process that was used when establishing the guidance for improving the efficiency of clinical trials concerning medical devices for hard-to-heal wounds. We particularly focused on the feasibility of conducting single-arm trials and also tried to clarify the definition of hard-to-heal wounds. If the feasibility of randomised control trials is low, conducting single-arm trials should be considered for the benefit of patients. In addition, hard-to-heal wounds were defined as meeting the following two conditions: wounds with a wound area reduction <50% at four weeks despite appropriate standards of care; and wounds which cannot be closed by a relatively simple procedure (for example, suture, skin graft and small flaps). Medical devices for hard-to-heal wound healing are classified into two types: (1) devices for promoting re-epithelialisation; and (2) devices for improving the wound bed. For medical devices for promoting re-epithelialisation, we suggest setting complete wound closure, percent wound area reduction or distance moved by the wound edge as the primary endpoint in single-arm trials for hard-to-heal wounds. For medical devices for improving the wound bed, we suggest setting the period in which wounds can be closed by secondary intention or a simple procedure, such as the primary endpoint.

Review of the Current Evidence for Topical Treatment for Venous Leg Ulcers

OBJECTIVE

The development of a venous leg ulcer (VLU) represents the most severe clinical manifestation of a chronic venous disease. Despite major progress, there is a limited understanding of VLU pathogenesis and wound healing biology. Treatment of VLUs remains a serious challenge for physicians of different specialties. This communication focuses on describing the rationale and scientific basis for topical wound care in the management of VLUs.

METHODS

A literature review was performed to summarize methods with proven efficacy in VLU management. A systematic literature search was also performed to identify new evidence from the randomized controlled trials published within 2014-2021. The scientific challenges, clinical practice concerns, economic obstacles, and possible directions for further research have been discussed.

RESULTS

Hundreds of topical products have been advertised for the treatment of VLUs. Published data on topical treatment of venous ulcers is insufficient, scattered, weak, and has significant methodological flaws. Forty-three randomized controlled trials on topical treatment of VLUs have been published within 2014-2021. Clinical practice guidelines need to be updated. Major gaps in knowledge have been identified, and suggestions for future research directions have been provided.

CONCLUSIONS

The American Venous Forum Research Committee would like to bring attention to topical wound care for VLUs as a critical gap in knowledge, and encourage scientists, practitioners, and industry to collaborate to fill this gap.

Topical cannabis-based medicines - A novel adjuvant treatment for venous leg ulcers: An open-label trial

Venous leg ulcers are highly prevalent lower limb integumentary wounds that remain challenging to heal despite the use of evidence-based compression therapies. A multitude of adjuvant treatments has been studied but none have demonstrated enough efficacy to gain adoption into treatment guidelines. Global attention on Cannabis-Based Therapies is increasing and has been driven by quantum scientific advancements in the understanding of the endocannabinoid signalling system. Topical Cannabis-Based Medicines represent a novel treatment paradigm for venous leg ulcers in terms of promoting wound closure. Fourteen complex patients with sixteen recalcitrant leg ulcers were treated with Topical Cannabis-Based Medicines in conjunction with compression bandaging, every second day, to both wound bed and peri-wound tissues. The cohort had a mean age of 75.8 years and was medically complex as reflected by a mean M3 multimorbidity index score of 2.94 and a mean Palliative Performance Scale score of 67.1%. Complete wound closure, defined as being fully epithelialized, was achieved among 11 patients (79%) and 13 wounds (81%) within a median of 34 days. All three remaining patients demonstrated progressive healing trends but were lost to follow-up. The treatments were well tolerated, and no significant adverse reactions were experienced. The rapid wound closure of previously non-healing venous leg ulcers among elderly and highly complex patients suggests that Topical Cannabis-Based Medicines may become effective adjuvants in conjunction with compression therapy. This may also indicate that they may have an even broader role within integumentary and wound management. Therefore, this treatment paradigm warrants being subjected to controlled trials.

Wound Care for Venous Ulceration

Venous leg ulcers (VLUs) affect as many as 20% of patients with advanced chronic venous insufficiency and are associated with significant morbidity and health care costs. VLUs are the most common cause of leg ulcers; however, other etiologies of lower extremity ulcerations should be investigated, most notably arterial insufficiency, to ensure appropriate therapy. Careful clinical examination, standardized documentation, and ultrasound evaluation are needed for diagnosis and treatment success. Reduction of edema and venous hypertension through compression therapy, local wound care, and treatment of venous reflux or obstruction is the foundation of therapy. As key providers in venous disease, interventional radiologists should be aware of current standardized disease classification and scoring systems as well as treatment and wound care guidelines for venous ulcers.

Driveline exit-site care protocols in patients with left ventricular assist devices: a systematic review

 

OBJECTIVES

Driveline infections continue to be a significant complication following left ventricular assist device (LVAD) implantation. Driveline exit-site care is crucial for the prevention of infections; however, there are no uniform guidelines. The goal of this study was to provide an overview of the currently published driveline exit-site care protocols in patients with LVAD.

METHODS

A systematic literature review was performed. Studies before 15 December 2020 were included if the number of driveline infections was a primary outcome and the driveline exit-site care protocol was explained.

RESULTS

Eleven articles were included in the systematic review, including 1602 patients with LVADs. The median of the frequency of driveline infections in the articles was 13.8% with a range of 0–52.6%. There was a marked variability in the methods of care of driveline exit sites, without a standardized driveline dressing technique in patients with LVADs. The frequency of driveline infections was 6–7.5% in studies using a dressing kit that included chlorhexidine, a silver-based dressing and an anchoring device. Furthermore, there was variability in the anchoring devices and the frequency of dressing changes, which varied from daily to weekly. No specific anchoring device or change frequency was found to be superior.

CONCLUSIONS

Based on this systematic review, driveline exit care protocols that included chlorhexidine, a silver-based dressing, the use of an anchoring device and dressing kits might be best in reducing driveline infection rates. However, prospective studies with larger cohorts are needed to establish the optimal protocol for driveline exit-site care.

Bacteria and bioburden and healing in complex wounds: A prognostic systematic review

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.

Engineered lactobacilli display anti-biofilm and growth suppressing activities against Pseudomonas aeruginosa

Biofilms are an emerging target for new therapeutics in the effort to address the continued increase in resistance and tolerance to traditional antimicrobials. In particular, the distinct nature of the biofilm growth state often means that traditional antimcirobials, developed to combat planktonic cells, are ineffective. Biofilm treatments are designed to both reduce pathogen load at an infection site and decrease the development of resistance by rendering the embedded organisms more susceptible to treatment at lower antimicrobial concentrations. In this work, we developed a new antimicrobial treatment modality using engineered lactic acid bacteria (LAB). We first characterized the natural capacity of two lactobacilli, L. plantarum and L. rhamnosus, to inhibit P. aeruginosa growth, biofilm formation, and biofilm viability, which we found to be dependent upon the low pH generated during culture of the LAB. We further engineered these LAB to secrete enzymes known to degrade P. aeruginosa biofilms and show that our best performing engineered LAB, secreting a pathogen-derived enzyme (PelAh), degrades up to 85% of P. aeruginosa biofilm.

Silver dressings for the healing of venous leg ulcer: A meta-analysis and systematic review

This study was aimed to evaluate whether silver-containing dressings were superior to other types of dressings in the treatment of venous leg ulcers (VLU) and their specific advantages.Eight databases (Cochrane Library, PubMed, Web of Science, Ovid-Medline, Wanfang, VIP, China Biology Medicine, and China National Knowledge Infrastructure) were systematically reviewed from inception to May 2019 for randomized controlled trials (RCTs). The primary outcome was complete wound healing, and the secondary outcomes included absolute wound size changes (change of cm area since baseline), relative changes (percentage change of area relative to baseline), and healing rate. Two reviewers independently evaluated the risk of bias using the Cochrane Collaboration assessment tool and extracted the data according to the predesigned table. All analyses were performed using the latest Review Manager Software (version 5.3).A total of 8 studies qualified and were included in the meta-analysis, including 1057 patients (experiment: 526, control: 531). Both complete wound healing and wound healing rates were reported in 5 studies. Two and 3 studies reported the effect of silver dressings on absolute and relative wound size changes, respectively. Most of the studies used intention-to-treat analysis.There was sufficient evidence that silver-containing dressings can accelerate the healing rate of chronic VLU and improve their healing in a short duration of time. However, compared with other dressings, clinical trials with long-term follow-up data are needed to confirm whether silver dressings have advantages regarding complete wound healing.

New Antivirals and Antibacterials Based on Silver Nanoparticles

The rediscovery of the medical uses of silver provides another noticeable example, this time at the interface of chemistry and medicine, of the real (and nonlinear) progress of scientific research. Several new silver-based antimicrobial products have thus been commercialized in the last two decades. Next-generation antibacterials and antivirals of broad scope, low toxicity and affordable cost, we argue in this study, will be based on microencapsulated Ag nanoparticles.

Wound, pressure ulcer and burn guidelines - 1: Guidelines for wounds in general, second edition

The Japanese Dermatological Association prepared the clinical guidelines for the "Wound, pressure ulcer and burn guidelines", second edition, focusing on treatments. Among them, "Guidelines for wounds in general" is intended to provide the knowledge necessary to heal wounds, without focusing on particular disorders. It informs the basic principles of wound treatment, before explanations are provided in individual chapters of the guidelines. We updated all sections by collecting references published since the publication of the first edition. In particular, we included new wound dressings and topical medications. Additionally, we added "Question 6: How should wound-related pain be considered, and what should be done to control it?" as a new section addressing wound pain, which was not included in the first edition.

The 100 most-cited articles on chronic venous disease: a bibliometric analysis

Objective

To use bibliometric analysis to understand characteristics and trends in the research on chronic venous disease (CVD), which affects patients’ quality of life by causing pain, swelling, and ulceration.

Methods

We searched the Thomson Reuters Web of Science citation indexing database to identify the 100 most-cited manuscripts on CVD. The resulting articles were analyzed by title, author, institution, topic, year of publication, and country of origin.

Results

The Journal of Vascular Surgery published the most manuscripts on CVD (n = 36) and was the most-cited journal (n = 5356). The United Kingdom was the country with the greatest number of publications (n = 32). Imperial College London was the institution with the highest number of publications (n = 6). Endovenous thermal ablation was the most widely studied research specialty (n = 30).

Conclusions

Our analysis showed that the majority of CVD research is carried out in Western countries, and that the number of research studies is increasing in line with recent advances in CVD.

Selection of Appropriate Wound Dressing for Various Wounds

There are many factors involved in wound healing, and the healing process is not static. The therapeutic effect of modern wound dressings in the clinical management of wounds is documented. However, there are few reports regarding the reasonable selection of dressings for certain types of wounds in the clinic. In this article, we retrospect the history of wound dressing development and the classification of modern wound dressings. In addition, the pros and cons of mainstream modern wound dressings for the healing of different wounds, such as diabetic foot ulcers, pressure ulcers, burns and scalds, and chronic leg ulcers, as well as the physiological mechanisms involved in wound healing are summarized. This article provides a clinical guideline for selecting suitable wound dressings according to the types of wounds.

Effects and formulation of silver nanoscaffolds on cytotoxicity dependent ion release kinetics towards enhanced excision wound healing patterns in Wistar albino rats

Wound tissue regeneration and angiogenesis are dynamic processes that send physiological signals to the body. Thus, designing novel nanoscaffolds by understanding their surface modifications and toxicological response in a biological system with a potent anti-inflammatory response is a viable solution. In this respect, inspired by the surface chemistry, in the present work we focus on the chemical optimization of silver nanoscaffolds using surface cappings in order to understand their kinetic release behaviour in simulated wound fluids (SWF), to analyze their blood compatibility in human lymphocytes and erythrocytes and then embed them in a chitosan-agarose matrix (CAM) as a productive drug delivery system to evaluate in vivo excision wound tissue regeneration efficiency in Wistar rats. In this regard, polyvinyl alcohol capped silver nanocomposites (PVA-AgNPs) exhibit a dominant antibacterial efficacy with the sustained and controlled release of silver ions and percentage cell mortality and percentage hemolysis of only 10% and 16% compared with uncapped-AgNPs or silver bandaids (SBDs). Also, PVA-AgNP impregnated CAM (PVA-CAM) shows positive effects through their anti-inflammatory and angiogenic properties, with a nearly 95% healing effect within 9 days. The complete development of collagen and fibroblast constituents was also monitored in PVA-CAM by hematoxylin & eosin (H & E) and Masson trichrome (MT) staining. These results provide a clear insight into the development of a potent therapeutic formulation using CAM as a scaffold incorporated with surface functionalized PVA-AgNPs as a bioeffective and biocompatible polymer for the fabrication of efficacious silver wound dressing scaffolds in clinical practice.

Antimicrobial Silver Nanoparticles for Wound Healing Application: Progress and Future Trends

Recent data have reported that the burden of infections related to antibiotic-resistant bacteria in the European Union and European Economic Area (EEA) can be estimated as the cumulative burden of tuberculosis, influenza, and human immunodeficiency virus (HIV). In wound management, the control of infections represents a crucial issue and a multi-billion dollar industry worldwide. For diabetic wounds ulcers, in particular, infections are related to the majority of amputations in diabetic patients, which today represent an increasing number of the elderly. The greatest barrier to healing is represented by the biofilm, an organized consortium of bacteria encapsulated in a self-produced extracellular polymeric substance with high resistance to conventional antimicrobial therapies. There is an urgent need for novel anti-biofilm strategies and novel antimicrobial agents and, in this scenario, silver nanotechnology has received tremendous attention in recent years in therapeutically enhanced healthcare. Due to its intrinsic therapeutic properties and the broad-spectrum antimicrobial efficacy, silver nanoparticles have opened new horizons towards novel approaches in the control of infections in wound healing. This review aims at providing the reader with an overview of the most recent progress in silver nanotechnology, with a special focus on the role of silver in the wound healing process.

Silver in Wound Care-Friend or Foe?: A Comprehensive Review

Due to its strong antimicrobial activity, silver is a commonly used adjunct in wound care. However, it also has the potential to impair healing by exerting toxic effects on keratinocytes and fibroblasts. The published literature on the use of silver in wound care is very heterogeneous, making it difficult to generate useful treatment guidelines.

METHODS

A search of high-quality studies on the use of silver in wound care was performed on PubMed. A detailed qualitative analysis of published articles was performed to evaluate the evidence for the use of silver in infected wounds, clean wounds, burns, and over closed surgical incisions.

RESULTS

Fifty-nine studies were included in this qualitative analysis. We found that, overall, the quality of the published research on silver is poor. While there is some evidence for short-term use of dressings containing nanocrystalline silver in infected wounds, the use of silver-containing dressings in clean wounds and over closed surgical incisions is not indicated. Negative-pressure wound therapy accelerates the healing of contaminated wounds, especially when silver is used as an adjunct. For burns, silver sulfadiazine slows healing and should not be used. Instead, nanocrystalline silver, or alternatives such as octenidine and polyhexanide, lead to less infection and faster healing.

CONCLUSIONS

In infected wounds, silver is beneficial for the first few days/weeks, after which nonsilver dressings should be used instead. For clean wounds and closed surgical incisions, silver confers no benefit. The ideal silver formulations are nanocrystalline silver and silver-coated polyurethane sponge for negative-pressure wound therapy. Silver sulfadiazine impairs wound healing. Proper use of silver-containing dressings is essential to optimize wound healing.

Treatment of Infected Wounds in the Age of Antimicrobial Resistance: Contemporary Alternative Therapeutic Options

As antibiotic resistance increases and antimicrobial options diminish, there is a pressing need to identify and develop new and/or alternative (non-antimicrobial-based) wound therapies. The authors describe the implications of antibiotic resistance on their current wound treatment paradigms and review the most promising non-antibiotic-based antimicrobial agents currently in research and development, with a focus on preclinical and human studies of therapeutic bacteriophages, antimicrobial peptides, cold plasma treatment, photodynamic therapy, honey, silver, and bioelectric dressings.

Appropriate use of dressings containing nanocrystalline silver to support antimicrobial stewardship in wounds

Antimicrobial resistance is an ever-increasing global concern, with the era of untreatable infection becoming a reality. Wound care is no exception, with increasing issues of antibiotic-resistant infections across different wound types and care settings. Antibiotic resistance and stewardship have been the priority for most strategic interventions so far; however, in wound care, alternative or supplementary strategies using antiseptics should be considered. Antiseptics such as silver can provide effective cidal activity across a broad range of wound pathogens, assuming they are used at the correct level for an appropriate duration. Evidence summarised in this manuscript suggests that effective antiseptics, such as nanocrystalline silver, have an increasing body of evidence in support of their use to minimise transmission of antibiotic-resistant organisms as part of institutional infection control procedures and, in addition, through appropriate early use and stewardship on local wound infections, in conjunction with local procedures, to minimise the need for systemic antibiotic therapy. Engagement, alignment, and collaboration between wound care professionals and wider related teams and governments on antimicrobial stewardship, and the potential role of antiseptics within this, will help to generate further evidence for such interventions in the fight against antimicrobial-resistant infections in wound care.

The Management of Critically Colonized and Locally Infected Leg Ulcers with an Acid-Oxidizing Solution: A Pilot Study

OBJECTIVE:

Critical colonization or local infection is very common in chronic wounds, but clinically problematic. Because therapeutic options for these conditions are limited in number and efficacy, the study authors tested a new acid-oxidizing solution (AOS [Nexodyn]; APR Applied Pharma Research S.A., Balerna, Switzerland) to determine its ancillary antimicrobial properties and potential support for wound healing.

DESIGN AND SETTING:

This open-label clinical case series was conducted with a prospective, single-arm design at the Federal County Hospital in Bregenz, Austria.

PATIENTS:

In the study, 30 patients with critically colonized or locally infected chronic leg ulcers of any origin were included.

INTERVENTIONS:

The AOS was applied on each leg ulcer at every dressing change for 35 days.

MAIN OUTCOME MEASURES:

The tolerability and performance of the AOS were assessed by evaluating the ulcer characteristics and comparing them with those at baseline. The clinical course of wounds was analyzed using standard measures for bioburden, local infection, pain, pH, and wound healing.

MAIN RESULTS:

Application of the solution was well tolerated, and no adverse events were recorded. In all patients, local infection was overcome, and wound bed pH and wound area decreased significantly. In addition, patient pain levels decreased to a level where interventions were not required after study day 7. In 37% of all patients, a complete resolution of chronic ulcers was achieved by the end of the study period.

CONCLUSION:

According to these results, the AOS seems to be a valid and highly tolerable treatment to support wound healing in locally infected ulcers. Nevertheless, larger controlled cohort studies are needed to substantiate these findings.

A Gold/Silver Hybrid Nanoparticle for Treatment and Photoacoustic Imaging of Bacterial Infection

Ag+ ions are a well-known antibacterial agent, and Ag nanoparticles act as a reservoir of these Ag+ ions for targeted therapy of bacterial infections. However, there are no tools to effectively trigger and monitor the release of Ag+ ions from Ag nanoparticles. Photoacoustic (PA) imaging is an emerging noninvasive imaging tool, and gold nanorods (AuNRs) are an excellent contrast agent for PA imaging. In this work, we developed Au/Ag hybrid nanoparticles by coating AuNRs with silver (Ag), which decreased their photoacoustic signal. The as-prepared, Ag-coated Au nanorods (Au/AgNRs) are stable under ambient conditions, but the addition of ferricyanide solution (1 mM) results in oxidative etching of the silver shell. The PA contrast is simultaneously recovered as the silver is released, and this PA signal offers noninvasive monitoring of localized release of Ag+ ions. The released Ag+ ions exhibit a strong bactericidal efficacy similar to equivalent free Ag+ ions (AgNO3), and the nanoparticles killed >99.99% of both (Gram-positive) methicillin-resistant Staphylococcus aureus (MRSA, 32 μM Ag+ equivalent) and (Gram-negative) Escherichia coli (8 μM Ag+ equivalent). The theranostic potential of these nanoparticles was demonstrated in a pilot in vivo study. Mice were inoculated with MRSA and Au/AgNRs were subcutaneously implanted followed by silver etching. There was a 730% increase in the PA signal ( p < 0.01) pre- and post-etching, and the bacterial counts in infected tissues of the treated group were reduced by 1000-fold (log CFU/g = 4.15 vs 7.75) versus the untreated control; this treatment efficacy was confirmed with histology. We further showed that these hybrid nanoparticles could release Ag+ after stimulation by reactive oxygen species including hydrogen peroxide and peroxynitrite. These hybrid Au/Ag nanoparticles are a useful theranostic agent for the photoacoustic imaging and treatment of bacterial infections.

Barriers and enablers to patient recruitment for randomised controlled trials on treatment of chronic wounds: A systematic review

Randomised controlled trials represent the gold standard in intervention efficacy evaluation. However, suboptimal recruitment affects completion and the power of a therapeutic trial in detecting treatment differences. We conducted a systematic review to examine the barriers and enablers to patient recruitment for randomised controlled trials on chronic wound treatment. Review registration was under PROSPERO 2017:CRD42017062438. We conducted a systematic search of Ovid MEDLINE, EBSCOhost CINAHL, Ovid Cochrane Library, Ovid EMBASE, and Ovid PsycINFO databases in June 2017 for chronic wound treatment randomised controlled trials. Twenty-seven randomised controlled trials or qualitative studies met the inclusion criteria. Among the 24 randomised controlled trials, 21 were assessed as low quality in relation to recruitment, and 3 were assessed as high quality. All 27 studies reported barriers to recruitment in chronic wound randomised controlled trials. The reported barriers to recruitment were: study-related, patient-related, clinician-related, health system-related, and/or operational-related. No study reported recruitment enablers. To enhance randomised controlled trial recruitment, we propose the need for improved integration of research and clinical practice. To alleviate the problems arising from inadequate reporting of randomised controlled trials, the Consolidated Standards of Reporting Trials Statement could include an additional item on recruitment barriers. This approach will allow for increased awareness of the potential barriers to recruitment for Randomised controlled trials (RCTs) in both wound management and other health care research.

Dressings and topical agents for treating venous leg ulcers

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.

Venous leg ulcer management in clinical practice in the UK: costs and outcomes

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to managing venous leg ulcers (VLUs) in clinical practice by the UK's National Health Service (NHS) and the associated costs of patient management. This was a retrospective cohort analysis of the records of 505 patients in The Health Improvement Network (THIN) Database. Patients' characteristics, wound-related health outcomes and health care resource use were quantified, and the total NHS cost of patient management was estimated at 2015/2016 prices. Overall, 53% of all VLUs healed within 12 months, and the mean time to healing was 3·0 months. 13% of patients were never prescribed any recognised compression system, and 78% of their wounds healed. Of the 87% who were prescribed a recognised compression system, 52% of wounds healed. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 30% of all the VLUs may have been clinically infected at the time of presentation, and only 22% of patients had an ankle brachial pressure index documented in their records. The mean NHS cost of wound care over 12 months was an estimated £7600 per VLU. However, the cost of managing an unhealed VLU was 4·5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU). This study provides important insights into a number of aspects of VLU management in clinical practice that have been difficult to ascertain from other studies and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.

Biofilms and delayed healing - an in vitro evaluation of silver- and iodine-containing dressings and their effect on bacterial and human cells

This study investigated whether there are differences in the ability of wound dressings to modulate certain factors known to affect wound healing. A selection of antimicrobial dressings (AQUACEL® Ag Extra™ , AQUACEL® Ag+ Extra™ , IODOFLEX™ , ACTICOAT™ 7 and PROMOGRAN PRISMA™ matrix) were tested for their effect on both bacterial bioburden and human dermal fibroblasts. Some dressings underwent further evaluation for activity against Pseudomonas aeruginosa biofilms using a colony-drip flow reactor model. The ability of in vitro biofilms to produce proteases, and the effect of PROMOGRAN PRISMA matrix on such proteases, was also investigated. All antimicrobial dressings tested reduced vegetative bacterial load; however, only PROMOGRAN PRISMA matrix was able to significantly reduce biofilm populations (P = 0·01). Additionally, PROMOGRAN PRISMA matrix was the only dressing that did not inhibit dermal fibroblast growth. All other dressings were detrimental to cell viability. In vitro biofilms of Pseudomonas aeruginosa were demonstrated as being capable of releasing bacterial proteases into their surroundings, and incubation with PROMOGRAN PRISMA matrix led to a 77% reduction in activity of such proteases (P = 0·002). The unique ability of PROMOGRAN PRISMA matrix to reduce in vitro vegetative bacteria, biofilm bacteria and bacterial proteases while still allowing dermal fibroblast proliferation may help rebalance the wound environment and reduce the occurrence of infection.

Role of slough and biofilm in delaying healing in chronic wounds

The management of biofilms with maintenance desloughing and antimicrobial therapy is fast becoming the accepted treatment strategy for chronic wounds.

Sub-cytotoxic concentrations of ionic silver promote the proliferation of human keratinocytes by inducing the production of reactive oxygen species

Silver-containing preparations are widely used in the management of skin wounds, but the effects of silver ions on skin wound healing remain poorly understood. This study investigated the effects of silver ions (Ag⁺) on the proliferation of human skin keratinocytes (HaCaT) and the production of intracellular reactive oxygen species (ROS). After treating HaCaT cells with Ag⁺ and/or the active oxygen scavenger N-acetyl cysteine (NAC), cell proliferation and intracellular ROS generation were assessed using CCK-8 reagent and DCFH-DA fluorescent probe, respectively. In addition, 5-bromo-2-deoxyUridine (BrdU) incorporation assays, cell cycle flow cytometry, and proliferating cell nuclear antigen (PCNA) immunocytochemistry were conducted to further evaluate the effects of sub-cytotoxic Ag⁺ concentrations on HaCaT cells. The proliferation of HaCaT cells was promoted in the presence of 10^-6 and 10^-5 mol/L Ag⁺ at 24, 48, and 72 h. Intracellular ROS generation also significantly increased for 5-60 min after exposure to Ag⁺. The number of BrdU-positive cells and the presence of PCNA in HaCaT cells increased 48 h after the addition of 10^-6 and 10^-5 mol/L Ag⁺, with 10^-5 mol/L Ag⁺ markedly increasing the cell proliferation index. These effects of sub-cytotoxic Ag⁺ concentrations were repressed by 5 mmol/L NAC. Our results suggest that sub-cytotoxic Ag⁺ concentrations promote the proliferation of human keratinocytes and might be associated with a moderate increase in intracellular ROS levels. This study provides important experimental evidence for developing novel silver-based wound agents or dressings with few or no cytotoxicity.

Systematic review of patient-reported outcome measures in patients with varicose veins

Background

Varicose veins can affect quality of life. Patient-reported outcome measures (PROMs) provide a direct report from the patient about the impact of the disease without interpretation from clinicians or anyone else. The aim of this study was to examine the quality of the psychometric evidence for PROMs used in patients with varicose veins.

Methods

A systematic review was undertaken to identify studies that reported the psychometric properties of generic and disease-specific PROMs in patients with varicose veins. Literature searches were conducted in databases including MEDLINE, up to July 2016. The psychometric criteria used to assess these studies were adapted from published recommendations in accordance with US Food and Drug Administration guidance.

Results

Nine studies were included which reported on aspects of the development and/or validation of one generic (36-Item Short Form Health Survey, SF-36®) and three disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ; Varicose Veins Symptoms Questionnaire, VVSymQ®; Specific Quality-of-life and Outcome Response – Venous, SQOR-V) PROMs. The evidence from included studies provided data to support the construct validity, test–retest reliability and responsiveness of the AVVQ. However, its content validity, including weighting of the AVVQ questions, was biased and based on the opinion of clinicians, and the instrument had poor acceptability. VVSymQ® displayed good responsiveness and acceptability rates. SF-36® was considered to have satisfactory responsiveness and internal consistency.

Conclusion

There is a scarcity of psychometric evidence for PROMs used in patients with varicose veins. These data suggest that AVVQ and SF-36® are the most rigorously evaluated PROMs in patients with varicose veins.

Targeting biofilms of multidrug-resistant bacteria with silver oxynitrate

A topical antimicrobial, silver oxynitrate (Ag₇NO₁₁), has recently become available that exploits the antimicrobial activity of ionic silver but has enhanced activity because highly oxidised silver atoms are stabilised with oxygen in a unique chemical formulation. The objective of this study was to use a multifaceted approach to characterise the spectrum of antimicrobial and antibiofilm activity of a wound dressing coated with Ag₇NO₁₁ at a concentration of 0.4 mg Ag/cm². Physiochemical properties that influence efficacy were also evaluated, and Ag₇NO₁₁ was found to release a high level of Ag ions, including Ag²⁺ and Ag³⁺, without influencing the pH of the medium. Time-kill analysis demonstrated that a panel of multidrug-resistant pathogens isolated from wound specimens remained susceptible to Ag₇NO₁₁ over a period of 7 days, even with repeated inoculations of 1 × 10⁶ CFU/mL to the dressing. Furthermore, established 72-h-old biofilms of Pseudomonas aeruginosa, Staphylococcus aureus and two carbapenem-resistant Gram-negative bacteria (bla_NDM-1-positive Klebsiella pneumoniae and bla_VIM-2-positive P. aeruginosa) were disrupted and eradicated by Ag₇NO₁₁ in vitro. Ag₇NO₁₁ is a proprietary compound that exploits novel Ag chemistry and can be considered a new class of topical antimicrobial agent. Biocompatibility testing has concluded Ag₇NO₁₁ to be non-toxic for cytotoxicity, acute systemic toxicity, irritation and sensitisation.

Infection in Venous Leg Ulcers: Considerations for Optimal Management in the Elderly

Venous leg ulcers are the most common cause of chronic leg wounds, accounting for up to 70 % of all chronic leg ulcers and carrying with them a significant morbidity, especially for elderly patients. Among people aged 65 years and older, the annual prevalence is 1.7 %. Billions of dollars per year are spent caring for patients with these often difficult-to-heal and sometimes recurrent chronic wounds. Chronic non-healing wounds of the lower extremities are susceptible to microbial invasion and can lead to serious complications, such as delayed healing, cellulitis, enlargement of wound size, debilitating pain, and deeper wound infections causing systemic illness. Recognition and treatment of the infected venous leg ulcer is an essential skill set for any physician caring for geriatric patients. Most physicians rely on subjective clinical signs and patient-reported symptoms in the evaluation of infected chronic wounds. The conventional bacterial culture is a widely available tool for the diagnosis of bacterial infection but can have limitations. Systemic antibiotics, as well as topical antiseptics and antibiotics, can be employed to treat and control infection and critical colonization. Better understanding of microbial biofilms in the wound environment have caused them to emerge as an important reason for non-healing and infection due to their increased resistance to antimicrobial, immunological, and chemical attack. A sound understanding of the microbial-host environment and its complexities, as well as the pathophysiology of venous hypertension, must be appreciated to understand the need for a multimodality approach to treating an infected venous leg ulcer. Other treatment measures are often required, in addition to systemic and topical antibiotics, such as the application of wound bandages, compression therapy, and wound debridement, which can hasten clearance of the infection and help to promote healing.

Wounds research for patient benefit: a 5-year programme of research

Background

Complex wounds are those that heal by secondary intention and include lower-limb ulcers, pressure ulcers and some surgical wounds. The care of people with complex wounds is costly, with care mainly being delivered by community nurses. There is a lack of current, high-quality data regarding the numbers and types of people affected, care received and outcomes achieved.

Objectives

To (1) assess how high-quality data about complex wounds can be captured effectively for use in both service planning and research while ensuring integration with current clinical data collection systems and minimal impact on staff time; (2) investigate whether or not a clinical register of people with complex wounds could give valid estimates of treatment effects, thus reducing dependence on large-scale randomised controlled trials (RCTs); (3) identify the most important research questions and outcomes for people with complex wounds from the perspectives of patients, carers and health-care professionals; (4) evaluate the potential contributions to decision-making of individual patient data meta-analysis and mixed treatment comparison meta-analysis; and (5) complete and update systematic reviews in topic areas of high priority.

Methods

To meet objectives 1 and 2 we conducted a prevalence survey and developed and piloted a longitudinal disease register. A consultative, deliberative method and in-depth interviews were undertaken to address objective 3. To address objectives 4 and 5 we conducted systematic reviews including mixed treatment comparison meta-analysis.

Results

From the prevalence survey we estimated the point prevalence of all complex wounds to be 1.47 per 1000 people (95% confidence interval 1.38 to 1.56 per 1000 people). Pressure ulcers and venous leg ulcers were the most common type of complex wound. A total of 195 people with a complex wound were recruited to a complex wounds register pilot. We established the feasibility of correctly identifying, extracting and transferring routine NHS data into the register; however, participant recruitment, data collection and tracking individual wounds in people with multiple wounds were challenging. Most patients and health professionals regarded healing of the wound as the primary treatment goal. Patients were greatly troubled by the social consequences of having a complex wound. Complex wounds are frequently a consequence of, and are themselves, a long-term condition but treatment is usually focused on healing the wound. Consultative, deliberative research agenda setting on pressure ulcer prevention and treatment with patients, carers and clinicians yielded 960 treatment uncertainties and a top 12 list of research priorities. Of 167 RCTs of complex wound treatments in a systematic review of study quality, 41% did not specify a primary outcome and the overall quality of the conduct and reporting of the research was poor. Mixed-treatment comparison meta-analysis in areas of high priority identified that matrix hydrocolloid dressings had the highest probability (70%) of being the most effective dressing for diabetic foot ulcers, whereas a hyaluronan fleece dressing had the highest probability (35%) of being the most effective dressing for venous ulcers; however, the quality of this evidence was low and uncertainty is high.

Conclusions

Complex wounds are common and costly with a poor evidence base for many frequent clinical decisions. There is little routine clinical data collection in community nursing. A prospective complex wounds register has the potential to both assist clinical decision-making and provide important research evidence but would be challenging to implement without investment in information technology in NHS community services. Future work should focus on developing insights into typical wound healing trajectories, identifying factors that are prognostic for healing and assessing the cost-effectiveness of selected wound treatments.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

[Venous ulcer]

Venous disorders causing a permanent increase in venous pressure are by far the most frequent reason for ulcers of the lower extremity. With a prevalence of 1 % in the general population rising to 4 % in the elderly over 80 and its chronic character, 1 % of healthcare budgets of the western world are spent on treatment of venous ulcers. A thorough investigation of the underlying venous disorder is the prerequisite for a differenciated therapy. This should comprise elimination of venous reflux as well as local wound management. Chronic ulcers can successfully be treated by shave therapy and split skin grafting. Compression therapy is a basic measure not only in venous ulcer treatment but also in prevention of ulcer recurrence. Differential diagnosis which have to be considered are arterial ulcers, vasculitis and neoplasms.

Wound infection: a knowledge deficit that needs addressing

A survey was undertaken at a recent large wound-care exhibition, aimed at generalist nurses, podiatrists and other allied health professionals, to ascertain delegates' understanding of wound infection and its treatment options. The sample comprised 116 delegates, although not all of them answered every question. Results showed good knowledge in some areas, with most (90%) correctly identifying the symptoms of localised wound infection and the characteristics of an infected wound (97%). However, the results did reveal some alarming gaps in knowledge, with 64% unable to identify that it is the inability of the host to mount a robust immune response that can tip the balance between colonisation and infection. Similarly, over a third (38%) incorrectly considered that wounds should always be cleansed, regardless of the wound characteristics, while 5% stated that antimicrobial dressings should be used continuously until epithelialisation occurs. The results suggest that there is still a worrying trend for ritualistic wound care and that more ongoing education is needed on the core aspects of wound management.

A national survey by the SDMA: use of evidence in nursing practice

OBJECTIVE

Recently, two surveys were conducted by the Surgical Dressing Manufacturers Association (SDMA) to investigate the evidence required to support wound care products. These showed very clearly that industry provides significant amounts of evidence in a way that appears to meet the expectations of relevant health professionals and their practice for treating patients with wounds. The responses of health professionals refuted the opinion that evidence may be lacking for wound care products. Hopefully, the results of these surveys also add weight to the argument that the Cochrane Review approach is not always the most appropriate for wound care-where the comorbidities of patients are variable and often plural.

[Efficiency of minimally invasive methods in treatment of varicose veins]

It was analyzed the results of studies comparing an efficiency of minimally invasive methods in treatment of varicose veins of lower extremities. Based on presented data similar efficiency of minimally invasive methods and conventional surgical treatment was proved. The graph reflecting remote results was made.

VenUS IV (Venous leg Ulcer Study IV) - compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model

BACKGROUND

Compression is an effective and recommended treatment for venous leg ulcers. Although the four-layer bandage (4LB) is regarded as the gold standard compression system, it is recognised that the amount of compression delivered might be compromised by poor application technique. Also the bulky nature of the bandages might reduce ankle or leg mobility and make the wearing of shoes difficult. Two-layer compression hosiery systems are now available for the treatment of venous leg ulcers. Two-layer hosiery (HH) may be advantageous, as it has reduced bulk, which might enhance ankle or leg mobility and patient adherence. Some patients can also remove and reapply two-layer hosiery, which may encourage self-management and could reduce costs. However, little robust evidence exists about the effectiveness of two-layer hosiery for ulcer healing and no previous trials have compared two-layer hosiery delivering 'high' compression with the 4LB.

OBJECTIVES

Part I To compare the clinical effectiveness and cost-effectiveness of HH and 4LB in terms of time to complete healing of venous leg ulcers. Part II To synthesise the relative effectiveness evidence (for ulcer healing) of high-compression treatments for venous leg ulcers using a mixed-treatment comparison (MTC). Part III To construct a decision-analytic model to assess the cost-effectiveness of high-compression treatments for venous leg ulcers.

DESIGN

Part I A multicentred, pragmatic, two-arm, parallel, open randomised controlled trial (RCT) with an economic evaluation. Part II MTC using all relevant RCT data - including Venous leg Ulcer Study IV (VenUS IV). Part III A decision-analytic Markov model.

SETTINGS

Part I Community nurse teams or services, general practitioner practices, leg ulcer clinics, tissue viability clinics or services and wound clinics within England and Northern Ireland.

PARTICIPANTS

Part I Patients aged ≥ 18 years with a venous leg ulcer, who were willing and able to tolerate high compression.

INTERVENTIONS

Part I Participants in the intervention group received HH. The control group received the 4LB, which was applied according to standard practice. Both treatments are designed to deliver 40 mmHg of compression at the ankle. Part II and III All relevant high-compression treatments including HH, the 4LB and the two-layer bandage (2LB).

MAIN OUTCOME MEASURES

Part I The primary outcome measure was time to healing of the reference ulcer (blinded assessment). Part II Time to ulcer healing. Part III Quality-adjusted life-years (QALYs) and costs.

RESULTS

Part I A total of 457 participants were recruited. There was no evidence of a difference in time to healing of the reference ulcer between groups in an adjusted analysis [hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.79 to 1.25; p = 0.96]. Time to ulcer recurrence was significantly shorter in the 4LB group (HR = 0.56, 95% CI 0.33 to 0.94; p = 0.026). In terms of cost-effectiveness, using QALYs as the measure of benefit, HH had a > 95% probability of being the most cost-effective treatment based on the within-trial analysis. Part II The MTC suggests that the 2LB has the highest probability of ulcer healing compared with other high-compression treatments. However, this evidence is categorised as low to very low quality. Part III Results suggested that the 2LB had the highest probability of being the most cost-effective high-compression treatment for venous leg ulcers.

CONCLUSIONS

Trial data from VenUS IV found no evidence of a difference in venous ulcer healing between HH and the 4LB. HH may reduce ulcer recurrence rates compared with the 4LB and be a cost-effective treatment. When all available high-compression treatments were considered, the 2LB had the highest probability of being clinically effective and cost-effective. However, the underpinning evidence was sparse and more research is needed. Further research should thus focus on establishing, in a high-quality trial, the effectiveness of this compression system in particular.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49373072.

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. 18, No. 57. See the NIHR Journals Library website for further project information.