Systematic review and meta-analysis of wound dressings in the prevention of surgical-site infections in surgical wounds healing by primary intention

Medication-Related Osteonecrosis of the Jaw: A Case Report of an Unusual Side Effect of Adalimumab

Background

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse drug reaction characterized by progressive bone destruction and necrosis of mandibular and/or maxillary jaw bone that occurs in patients undergoing treatments with antiresorptive drugs such as bisphosphonates or denosumab, antiangiogenic agents such as bevacizumab, or other kinds of monoclonal antibodies such as rituximab and ipilimumab, for different oncologic and nononcologic diseases. The aim of this study was to report a case of MRONJ in a patient affected by rheumatoid arthritis disease in treatment with adalimumab. Case Presentation. A 70-year-old female patient affected by rheumatoid arthritis (RA), who had been undergoing adalimumab (40 mg subcutaneous injection) every two weeks for 5 years, with no history of antiresorptive or antiangiogenic agent administration, came to our attention for intraoral necrotic bone exposures of the anterior mandible. After drug withdrawal and antibiotic cycles, the patient underwent surgical treatment with bone resection and debridement of necrotic tissues. After an observation period of 8 months, a complete healing without signs of recurrence was detected.

Conclusions

Based on this study, a correlation between adalimumab and MRONJ is possible. Therefore, we believe that an oral cavity examination should be done in every patients, before starting therapy with adalimumab, to possibly avoid MRONJ onset. Further studies are required to confirm the role of adalimumab in MRONJ.

“Negotiating a new normality” - a longitudinal qualitative exploration of the meaning of living with an open surgical wound

Purpose

Little is known about the experiences of people living with open surgical wounds. These wounds are common and predominantly affect young and actively working people. The aim of this qualitative study was to explore the meaning of living with open surgical wounds.

Methods

A qualitative exploratory study was conducted. We collected data using two individual interviews with each of ten participants (aged between 18–73 years) who had open surgical wounds. Our analytical approach was based on qualitative content analysis. Methods are reported using COREQ guidelines.

Results

We found that the meaning of living with open surgical wounds is shaped by five subthemes: “enduring healing”, “life disruption”, “adapting to a new reality”, “striving for healing” and “returning to normal life;” all under an overarching theme of “negotiating a new normality”.

Conclusion

Participants’ well-being and everyday living are greatly impacted by open surgical wounds. Findings from this study emphasize that open surgical wounds are a long-term condition with a typical “chronicity” trajectory; this brings a new perspective to previous findings of studies on living with complex wounds. This study has also highlighted areas for further research, related to improving individuals’ experience of living with open surgical wounds.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation

INTRODUCTION

The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice.

MATERIALS AND METHODS

Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant.

RESULTS

This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion.

CONCLUSIONS

The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

A Composite Membrane System with Gold Nanoparticles, Hydroxyapatite, and Fullerenol for Dual Interaction for Biomedical Purposes

Background: Wound dressing plays a vital role in post-operative aftercare. There is the necessity to develop dressings for application on the border of soft and hard tissue. This study aimed to develop multifunctional polyelectrolyte layers enhanced by hydroxyapatite nanoparticles, gold nanoparticles (AuNPs), and/or fullerenol nanocomposites to achieve a wound dressing that could be applied on the bone-skin interface. Methods: Constructed shells were examined using TEM, STEM, and EDX techniques. The human osteoblasts or fibroblasts were immobilized within the shells. The systems morphology was assessed using SEM. The functioning of cells was determined by flow cytomery. Moreover, the internalization of AuNPs was assessed. Results: Involvement of fullerenol and/or hydroxyapatite nanoparticles influenced the immobilized cell systems morphology. Membranes with fullerenol and hydroxyapatite nanoparticles were observed to block the internalization of AuNPs by immobilized hFOB cells. Conclusions: The designed bilayer membranes incorporating fullerenol, and bacteriostatic elements, prevented the internalization of AuNPs by hFOB cells and ensured the proper counts and morphology of eukaryotic cells. The developed material can be recommended for dressings at the bone-skin interface.

Antimicrobial Dressing versus Standard Dressing in Obese Women Undergoing Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

This study aimed to evaluate the effect of a novel antimicrobial dressing on patient satisfaction and health-related quality of life (HRQoL) following a cesarean delivery.

STUDY DESIGN

This was an open-label, single-center, two-arm randomized controlled trial. This study was done at the tertiary center, maternal unit, Galveston, TX. Pregnant women with body mass indices ≥35 kg/m2 were screened for eligibility. Women were randomized to ReliaTect Post-Op Dressing (RELIATECT) or standard wound dressing (STANDARD). Primary outcome was patient satisfaction and HRQoL using validated questionnaires. Secondary outcomes were provider satisfaction, surgical site infection (SSI) rates, and wound complications.

RESULTS

In total, 160 women were randomized. Population characteristics were not significant among groups. RELIATECT dressing group had an overall higher score of satisfaction and HRQoL compared with STANDARD group. Women in the RELIATECT group reported less incision odor and incisional pain. Compared with the STANDARD group, most women in RELIATECT dressing group reported better daily activities, self-esteem, personal hygiene, body image, and sleep. Providers reported that the RELIATECT dressing allowed better assessment of the surgical incision site, allowed patients to shower early, and did observe less wound dressing leakage. No differences were found in other secondary end points.

CONCLUSION

Postcesarean RELIATECT dressing for wound care in pregnant women with obesity had better patient and provider satisfaction as well as better HRQoL scores. Further, level 1 evidence is needed to assess its impact on SSI rates and wound complication, as this trial was not powered to accomplish this goal.

KEY POINTS

· This study was conducted to evaluate RELIATECT on patient satisfaction and HRQoL following a cesarean.. · Post-cesarean RELIATECT dressing for wound care had better HRQoL and patient and provider satisfaction scores.. · This is the first randomized controlled trial evaluating RELIATECT dressing in obese pregnant women undergoing cesarean section..

Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care

OBJECTIVE

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

TARGET POPULATION

Women with obesity who are pregnant or planning pregnancies.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

GUIDELINE UPDATE

SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

SPONSORS

This guideline was developed with resources funded by the SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Efficacy of a Natural Topical Skin Ointment for Managing Split-Thickness Skin Graft Donor Sites: A Pilot Double-blind Randomized Controlled Trial

OBJECTIVE

To evaluate the safety and efficacy of a new topical skin ointment with natural ingredients (aloe vera, honey, and peppermint) for dressing skin graft donor sites.

DESIGN

A double-blind, placebo-controlled, randomized clinical trial.

PATIENTS AND INTERVENTION

Researchers enrolled patients who were referred for split-thickness skin graft after burns or surgical wounds on the scalp or face area. For each patient, a thin layer of skin (depth, 0.04 mm; approximate size, less than 15 × 7 cm) was harvested from the thigh by a plastic surgeon with an electric or manual dermatome. The donor sites were divided and randomized to receive either natural ointment or petroleum jelly as a topical agent to dressing. Topical agents were applied on donor site wounds on days 0, 4, 7, and 14.

MAIN OUTCOME MEASURES

Wound size, pain, erythema, pruritus, patient discomfort, complications, and physician satisfaction were evaluated at each visit.

MAIN RESULTS

Among 28 patients, there was no significant difference between the two treatment agents regarding the rate of wound healing (P = .415), pain (P = .081), pruritus (P = .527), and patient discomfort (P = .616). The ointment was superior to petroleum jelly in reducing wound erythema (P = .001) and was associated with significantly better treatment satisfaction (P < .001).

CONCLUSIONS

The natural topical ointment investigated in this study may be an acceptable alternative to petroleum jelly in caring for split-thickness donor skin graft donor site wounds to effectively promote wound healing, prevent infection and scarring, reduce pain, and comfort the patient.

Bluebelle pilot randomised controlled trial of three wound dressing strategies to reduce surgical site infection in primary surgical wounds

OBJECTIVE

Surgical site infection (SSI) affects up to 25% of primary surgical wounds. Dressing strategies may influence SSI risk. The Bluebelle study assessed the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of different dressing strategies to reduce SSI in primary surgical wounds.

DESIGN

A pilot, factorial RCT.

SETTING

Five UK hospitals.

PARTICIPANTS

Adults undergoing abdominal surgery with a primary surgical wound.

INTERVENTIONS

Participants were randomised to 'simple dressing', 'glue-as-a-dressing' or 'no dressing', and to the time at which the treatment allocation was disclosed to the surgeon (disclosure time, before or after wound closure).

PRIMARY AND SECONDARY OUTCOME MEASURES

Feasibility outcomes focused on recruitment, adherence to randomised allocations, reference assessment of SSI and response rates to participant-completed and observer-completed questionnaires to assess SSI (proposed primary outcome for main trial), wound experience and symptoms, and quality of life (EQ-5D-5L).

RESULTS

Between March and November 2016, 1115 patients were screened; 699 (73.4%) were eligible and approached, 415 (59.4%) consented and 394 (35.3%) were randomised (simple dressing=133, glue=129 and 'no dressing'=132). Non-adherence to dressing allocation was 2% (3/133), 6% (8/129) and 15% (20/132), respectively. Adherence to disclosure time was 99% and 86% before and after wound closure, respectively. The overall rate of SSI (reference assessment) was 18.1% (51/281). Response rates to the Wound Healing Questionnaire and other questionnaires ranged from >90% at 4 days to 68% at 4-8 weeks.

CONCLUSIONS

A definitive RCT of dressing strategies including 'no dressing' is feasible. Further work is needed to optimise questionnaire response rates.

TRIAL REGISTRATION NUMBER

49328913; Pre-results.

Directive clinique No 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum

OBJECTIF

La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum. UTILISATEURS CONCERNéS: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité.

POPULATION CIBLE

Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir. DONNéES PROBANTES: Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d'évaluation décrits par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICE ET COûTS: La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l'équipe de soins de santé, la patiente et la famille; et de la planification de l'équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité. MISE à JOUR DE LA DIRECTIVE CLINIQUE: Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.

PROMOTEURS

La présente directive a été élaborée à l'aide de ressources financées par la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Acute surgical wound-dressing procedure: Description of the steps involved in the development and validation of an observational metric

The aim of this study was to develop an observational metric that could be used to assess the performance of a practitioner in completing an acute surgical wound-dressing procedure using aseptic non-touch technique (ANTT). A team of clinicians, academics, and researchers came together to develop an observational metric using an iterative six-stage process, culminating in a Delphi panel meeting. A scoping review of the literature provided a background empirical perspective relating to wound-dressing procedure performance. Video recordings of acute surgical wound-dressing procedures performed by nurses in clinical (n = 11) and simulated (n = 3) settings were viewed repeatedly and were iteratively deconstructed by the metric development group. This facilitated the identification of the discrete component steps, potential errors, and sentinel (serious) errors, which characterise a wound dressing procedure and formed part of the observational metric. The ANTT wound-dressing observational metric was stress tested for clarity, the ability to be scored, and interrater reliability, calculated during a further phase of video analysis. The metric was then subjected to a process of cyclical evaluation by a Delphi panel (n = 21) to obtain face and content validity of the metric. The Delphi panel deliberation verified the face and content validity of the metric. The final metric has three phases, 31 individual steps, 18 errors, and 27 sentinel errors. The metric is a tool that identifies the standard to be attained in the performance of acute surgical wound dressings. It can be used as both an adjunct to an educational programme and as a tool to assess a practitioner's performance of a wound-dressing procedure in both simulated and clinical practice contexts.

Preventing Surgical Site Infections Related to Abdominal Drains in the Intensive Care Unit

Surgical site infections are significant contributors to health care-associated infections. Nursing interventions may help decrease the incidence of surgical site infections, particularly in regards to the management of postsurgical abdominal drains. This comprehensive guide, compiled from evidence-based practice literature, is intended for nurses to use to reduce surgical site infections secondary to postsurgical abdominal drains. This article focuses on drain management in intensive care unit patients, who are at risk for infection because of their immunocompromised state.

Knowledge and Practices of Nurses Regarding Wound Healing

PURPOSE

The purpose of this study was to determine the knowledge and practices of nurses who work at surgical clinics regarding incisional wound healing.

DESIGN

This research was a descriptive study.

METHODS

The sample consisted of 393 nurses who worked at the surgical clinics of public and private hospitals. The questionnaire used to collect data was prepared by use of expert opinion based on the relevant literature review.

FINDINGS

The mean score of knowledge regarding wound healing was found to be 62.0 ± 8.4. It was determined that as the educational level of the nurses increased, their knowledge mean score increased (P < .05). Nearly half of the nurses did not perform wound healing practices regularly, whereas more than half of the nurses did not fulfill discharge education practices on wound care regularly.

CONCLUSIONS

Education should be carried out to improve knowledge, attitude, and skills of nurses concerning wound healing and care.

Developing outcome measures assessing wound management and patient experience: a mixed methods study

OBJECTIVES

To develop outcome measures to assess practical management of primary surgical wounds and patient experience.

DESIGN

Mixed methods, including qualitative interviews and data extraction from published randomised controlled trials (RCTs).

SETTING

Two university-teaching NHS hospitals and three district NHS hospitals in the South West and Midlands regions of England.

PARTICIPANTS

Sixty-four patients and 15 healthcare professionals from abdominal general surgical specialities and obstetrics (caesarean section).

METHODS

Measures were developed according to standard guidelines to identify issues relevant to patients' experiences of surgical wounds and dressings, including analysis of existing RCT outcomes and semi-structured interviews. These were written into provisional questionnaire items for a single outcome measure. Cognitive interviews with patients and healthcare professionals assessed face validity, acceptability and relevance. Findings from interviews were regularly shared with the study team who suggested amendments to modify and reword items to improve understanding before further iterative testing with patients and healthcare professionals.

RESULTS

Analyses of existing RCT outcomes and interviews produced a total of 69 issues. Pretesting and iterative revision established the need for two separate measures. One measure addresses healthcare professionals' experience of wound management in two key areas: exudate and its impact, and allergic reactions to the dressing. The other measure addresses patients' experience of wounds in seven key areas: wound comfort, dressing removal, dressings to protect the wound, impact on daily activities, ease of movement, anxiety about the wound and satisfaction with dressing. Each measure took less than five min to complete and both were understood and acceptable to patients and healthcare professionals.

CONCLUSION

This in-depth study has developed two measures to assess practical management of primary surgical wounds and patient experience. Further work to test their validity, reliability and application to other settings is now required.

TRIAL REGISTRATION NUMBER

HTA - 12/200/04; Pre-results.

Incorporating LsrK AI-2 quorum quenching capability in a functionalized biopolymer capsule

Antibacterial resistance is an issue of increasing severity as current antibiotics are losing their effectiveness and fewer antibiotics are being developed. New methods for combating bacterial virulence are required. Modulating molecular communication among bacteria can alter phenotype, including attachment to epithelia, biofilm formation, and even toxin production. Intercepting and modulating communication networks provide a means to attenuate virulence without directly interacting with the bacteria of interest. In this work, we target communication mediated by the quorum sensing (QS) bacterial autoinducer-2, AI-2. We have assembled a capsule of biological polymers alginate and chitosan, attached an AI-2 processing kinase, LsrK, and provided substrate, ATP, for enzymatic alteration of AI-2 in culture fluids. Correspondingly, AI-2 mediated QS activity is diminished. All components of this system are "biofabricated"-they are biologically derived and their assembly is accomplished using biological means. Initially, component quantities and kinetics were tested as assembled in microtiter plates. Subsequently, the identical components and assembly means were used to create the "artificial cell" capsules. The functionalized capsules, when introduced into populations of bacteria, alter the dynamics of the AI-2 bacterial communication, attenuating QS activated phenotypes. We envision the assembly of these and other capsules or similar materials, as means to alter QS activity in a biologically compatible manner and in many environments, including in humans.

Using a non-invasive secure skin closure following total knee arthroplasty leads to fewer wound complications and no patient home care visits compared to surgical staples

BACKGROUND

Superficial wound complications occur in up to 10% of total knee arthroplasty (TKA) procedures and have been associated with periprosthetic joint infection. The ideal material for TKA closure should offer: 1) fast intraoperative application, 2) minimal wound complications and 3) removable by patients without assistance. We evaluated a novel, non-invasive, removable skin closure system for TKA to determine its effect on wound complications.

METHODS

We prospectively evaluated 221 consecutive TKA patients who received skin closure using a non-invasive zipper-like system ('Zip'; Zip 16 Surgical Skin Closure System; Zipline Medical). All procedures were performed by a single surgeon using the mini-midvastus approach. Patients received two weeks of rivaroxaban postoperatively. Demographics, comorbidities, in-hospital complications and six-week wound evaluation were recorded. Data was compared to a cohort of 1001 patients from the same surgeon who received staples for closure and coumadin for thromboprophylaxis.

RESULTS

Zip patients had a significantly higher BMI (p=0.001), incidence of diabetes (p=0.035) and smoking (p=0.005). Zip patients removed dressings themselves and did not report problems with dressing care. Rate of readmission for wound-related complications was significantly lower in the Zip closure group (p=0.045). Overall readmission rates were similar between groups.

CONCLUSIONS

In our experience, the Zip 16 Surgical Skin Closure System is easy to apply, avoids home care and has produced fewer wound complications compared to staples. Results have been positive despite the study cohort having a higher number of diabetic patients and using an anticoagulant associated with a higher risk of wound complications.

Surgical-site infection in gynecologic surgery: pathophysiology and prevention

Surgical-site infections (SSIs) represent a well-known cause of patient morbidity as well as added health care costs. In gynecologic surgery, particularly hysterectomy, SSIs are often the result of a number of risk factors that may or may not be modifiable. As both the Centers for Medicaid and Medicare Services and the Joint Commission on the Accreditation of Healthcare Organizations have identified SSIs as a patient safety priority, gynecologic surgeons continue to seek out the most effective interventions for SSI prevention. This review studies the epidemiology and pathophysiology of SSIs in gynecologic surgery and evaluates the current literature regarding possible interventions for SSI prevention, both as individual measures and as bundles. Data from the obstetrical and general surgery literature will be reviewed when gynecological data are either unclear or unavailable. Practitioners and hospitals may use this information as they develop strategies for SSI prevention in their own practice.

The effects of Alkanna tinctoria Tausch on split-thickness skin graft donor site management: a randomized, blinded placebo-controlled trial

BACKGROUND

A prospective, randomized, placebo-controlled clinical trial was conducted to compare the healing effectiveness of Alkanna tinctoria (L.) Tausch (Boraginaceae) with standard dressing on wound healing at the donor site after removal of the skin graft.

METHODS

Enrolled patients were randomly allocated to receive topicalA. tinctoria extract ointment (20%) or standard dressing (dressing with base ointment) daily. Wound healing was assessed using the Bates-Jenson assessment tool at the 2^nd and 4^th weeks after intervention.

RESULTS

Decreases in wound score were significantly greater in the A. tinctoria group compared with the placebo group (P <0.05). The surface areas of graft donor sites in the A. tinctoria group were significantly reduced as compared with the control group at day 28 of the intervention (P < 0.05). The proportion of patients in the A. tinctoria group achieving complete wound healing within 2 to 4 weeks was 50% and 96.66%, respectively, significantly higher than in patients receiving standard care: 0% and 23.3%, respectively.

CONCLUSIONS

This clinical study showed that A. tinctoria dressing accelerates wound healing after graft harvesting.

TRIAL REGISTRATION

IRCT ID: IRCT201511165781N2 .

Postcesarean wound infection: prevalence, impact, prevention, and management challenges

Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%-15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.

The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management

INTRODUCTION

The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique.

METHODS

The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations.

RESULTS

The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices.

CONCLUSION

Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

Dressings for the prevention of surgical site infection

BACKGROUND

Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured, often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate. There are many different types of wound dressings available and wounds can also be left uncovered (exposed). Surgical site infection (SSI) is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing.

OBJECTIVES

To assess the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention.

SEARCH METHODS

We searched the following databases: the Cochrane Wounds Specialised Register (searched 19 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations, MEDLINE Daily and Epub Ahead of Print; 1946 to 19 September 2016); Ovid Embase (1974 to 19 September 2016); EBSCO CINAHL Plus (1937 to 19 September 2016).There were no restrictions based on language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the postoperative management of surgical wounds healing by primary intention.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 29 trials (5718 participants). All studies except one were at an unclear or high risk of bias. Studies were small, reported low numbers of SSI events and were often not clearly reported. There were 16 trials that included people with wounds resulting from surgical procedures with a 'clean' classification, five trials that included people undergoing what was considered 'clean/contaminated' surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications. Four trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings. The review contains 11 comparisons in total.

PRIMARY OUTCOME

SSIIt is uncertain whether wound exposure or any dressing reduces or increases the risk of SSI compared with alternative options investigated: we assessed the certainty of evidence as very low for most comparisons (and low for others), with downgrading (according to GRADE criteria) largely due to risk of bias and imprecision. We summarise the results of comparisons with meta-analysed data below:- film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95% CI 0.70 to 2.55), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95% CI 0.30 to 2.78), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95% CI 0.22 to 1.51), very low certainty evidence downgraded twice for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95% CI 0.47 to 2.62), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95% CI 0.51 to 1.37), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. Secondary outcomesThere was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes.

AUTHORS' CONCLUSIONS

It is uncertain whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI, or whether any particular wound dressing is more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or is easier to remove. Most studies in this review were small and at a high or unclear risk of bias. Based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.

Factors associated with the healing of complex surgical wounds in the breast and abdomen: retrospective cohort study

Objective:

to estimate the healing rate of complex surgical wounds and its associated factors.

Method:

retrospective cohort study from 2003 to 2014 with 160 outpatients of a Brazilian university hospital. Data were obtained through consultation of the medical records. Survival function was estimated using the Kaplan-Meier method and Cox regression model to estimate the likelihood of the occurrence of healing.

Results:

the complex surgical wound healing rate was 67.8% (95% CI: 60.8-74.9). Factors associated with a higher likelihood of wound healing were segmentectomy/quadrantectomy surgery, consumption of more than 20 grams/day of alcohol, wound extent of less that 17.3 cm2 and the length of existence of the wound prior to outpatient treatment of less than 15 days, while the use of hydrocolloid covering and Marlex mesh were associated with a lower likelihood of healing.

Conclusion:

the wound healing rate was considered high and was associated with the type of surgical intervention, alcohol consumption, type of covering, extent and length of wound existence. Preventive measures can be implemented during the monitoring of the evolution of the complex surgical wound closure, with possibilities of intervention in the modifiable risk factors.

Reproducibility of Search Strategies Is Poor in Systematic Reviews Published in High-Impact Pediatrics, Cardiology and Surgery Journals: A Cross-Sectional Study

Background

A high-quality search strategy is considered an essential component of systematic reviews but many do not contain reproducible search strategies. It is unclear if low reproducibility spans medical disciplines, is affected by librarian/search specialist involvement or has improved with increased awareness of reporting guidelines.

Objectives

To examine the reporting of search strategies in systematic reviews published in Pediatrics, Surgery or Cardiology journals in 2012 and determine rates and predictors of including a reproducible search strategy.

Methods

We identified all systematic reviews published in 2012 in the ten highest impact factor journals in Pediatrics, Surgery and Cardiology. Each search strategy was coded to indicate what elements were reported and whether the overall search was reproducible. Reporting and reproducibility rates were compared across disciplines and we measured the influence of librarian/search specialist involvement, discipline or endorsement of a reporting guideline on search reproducibility.

Results

272 articles from 25 journals were included. Reporting of search elements ranged widely from 91% of articles naming search terms to 33% providing a full search strategy and 22% indicating the date the search was executed. Only 22% of articles provided at least one reproducible search strategy and 13% provided a reproducible strategy for all databases searched in the article. Librarians or search specialists were reported as involved in 17% of articles. There were strong disciplinary differences on the reporting of search elements. In the multivariable analysis, only discipline (Pediatrics) was a significant predictor of the inclusion of a reproducible search strategy.

Conclusions

Despite recommendations to report full, reproducible search strategies, many articles still do not. In addition, authors often report a single strategy as covering all databases searched, further decreasing reproducibility. Further research is needed to determine how disciplinary culture may encourage reproducibility and the role that journal editors and peer reviewers could play.

Early wound dressing removal after scheduled cesarean delivery: a randomized controlled trial

BACKGROUND

Following cesarean delivery, wound dressings are typically left over the incision for 24-48 hours.

OBJECTIVE

The objective of this study was to determine if early removal of the wound dressing at 6 hours postsurgery has any effect on wound complications.

STUDY DESIGN

This was a randomized, controlled study from August 2013 through January 2015 in which 320 low-risk women aged 18-44 years having scheduled primary, first repeat, or second repeat cesarean delivery were randomized for wound dressing removal at either 6 or 24 hours postsurgery. Skin closure was with staples in all cases. The primary outcome was postoperative wound complications, defined as infection, disruption (skin dehiscence or deeper), or seroma/hematoma. Also examined was patient satisfaction with timing of their ability to wash or shower after wound dressing removal. A sample size of 160 women in each group was needed to show a 100% increase in the wound complication incidence from 12-24%.

RESULTS

A total of 320 women were randomized, 160 in the 6-hour group and 160 in the 24-hour group. The proportion of primary and repeat cesarean deliveries was similar. The incidence of wound complications was not significantly different between the groups, 13.8% in the 6-hour group and 12.5% in the 24-hour group (odds ratio, 1.16; 95% confidence interval, 0.58-2.14). More women were pleased and satisfied with their ability to wash or shower soon after wound dressing removal in the 6-hour group (75.6%) compared to the 24-hour group (56.9%; odds ratio, 2.35; 95% confidence interval, 1.46-3.79).

CONCLUSION

Early removal of the wound dressing at 6 hours following cesarean delivery has no detrimental effect on incision healing. Early removal permits the woman to attend to personal hygiene earlier, making her more satisfied with her postoperative recovery.

Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial

Objectives

Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties.

Methods

A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group.

Results

An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06).

Conclusions

Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications.

Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany

BACKGROUND

There are various recommendations, but no generally accepted guidelines, to reduce the risk of external ventricular drainage (EVD)-associated infections. The primary objective of the present study was to evaluate the current practice of EVD in a European country and to set the results in perspective to published data.

METHOD

A standardised questionnaire prepared by the Commission of Technical Standards and Norms of the German Society of Neurosurgery was sent to 127 neurosurgical units in Germany.

RESULTS

Data were analysed from 99 out of 127 neurosurgical units which had been contacted. Overall, more than 10,000 EVD procedures appear to be performed in Germany annually. There is disagreement about the location where the EVD is inserted, and most EVDs are still inserted in the operation theatre. Most units apply subcutaneous tunnelling. Impregnated EVD catheters are used regularly in only about 20 % of units. Single-shot antibiotic prophylaxis is given in more than half of the units, while continued antibiotic prophylaxis is installed in only 15/99 units at a regular basis. There are discrepancies in the management of prolonged EVD use with regard to replacement policies. Regular cerebrospinal fluid (CSF) sampling is still performed widely. There were no statistical differences in policies with regard to academic versus non-academic units.

CONCLUSIONS

This survey clearly shows that some newer recommendations drawn from published studies penetrate much slower into clinical routine, such as the use of impregnated catheters, for example. It remains unclear how different policies actually impact quality and outcome in daily routine.

Skin surgery, an evidence-based update: meeting report

The Evidence Based Update on Skin Surgery was held in Nottingham in May 2015. The meeting featured presentations on new diagnostic techniques, trials in development, discussions of recently published trials, and a question and answer session with an expert panel. This report aims to summarize the presentations and discussions from the day.

Surgical site infections in dermatologic surgery: etiology, pathogenesis, and current preventative measures

BACKGROUND

Surgical site infections (SSIs) after dermatologic surgery continue to represent undesirable complications that affect patients in several aspects. The etiology and pathogenesis of SSIs are not completely understood, and as a result, current preventative measures are debatable.

OBJECTIVE

To review and summarize the current available literature specific to SSIs in dermatologic surgery. The pathogenesis of SSIs, factors contributing to SSIs, current preventative guidelines, and evidence supporting their use are explored.

METHODS

A review of the medical literature.

RESULTS AND CONCLUSIONS

Most measures used to prevent SSIs in dermatologic surgery are based on studies of wounds in general surgery. Evidence specific to dermatologic surgery is scarce. More research related to the pathogenesis of SSIs is needed to establish effective preventative measures that are key to reducing incidences of SSIs.

A Prospective Randomized Trial of Open Wound Treatment vs Occlusive Dressings in Elective Surgical Cases with Respect to Surgical Site Infections

BACKGROUND

Surgical wounds heal by primary intention in all the elective and emergency surgical procedures. Current practice is to place dressing over the closed wound before the patient leaves the sterile environment of the operating theatre. Dressing is a material applied to protect a wound and favour its healing. However, to leave wound open in direct contact to environment following any procedure by just applying some ointment on it, the so called open wound treatment is still controversial one. In the present study we have compared open wound treatment vs occlusive dressings in elective surgical cases with respect to surgical site infections.

MATERIALS AND METHODS

The present study was conducted on 100 patients admitted for elective general surgery after taking written informed consent. Patients were divided randomly in to two equal groups each comprising of 50 patients. In Group A, patients had occlusive dressing till removal of stitches and in Group B, patients wounds were kept exposed to environment after the surgical procedure.

RESULTS

In present study we observed total 7% of postoperative wounds were infected of all the clean and clean contaminated wounds we studied. In Group A, patients had occlusive dressing and these patients had 8% infection rate whereas in Group B patients, wounds were kept exposed to environment and these patients had 6% infection rate.

CONCLUSION

It is hereby concluded that in the elective surgical cases there is no harm in leaving the wounds open postoperatively. This method not only helps in arresting the infective pathology at a lesser stage but also saves surgeon's time and patient's money.

Development of a Hybrid Tracer for SPECT and Optical Imaging of Bacterial Infections

In trauma and orthopedic surgery, infection of implants has a major impact on the outcome for patients. Infections may develop either during the initial implantation or during the lifetime of an implant. Both infections, as well as aseptic loosening of the implant, are reasons for revision of the implants. Therefore, discrimination between aseptic-mechanical-loosening and septic-bacterial-loosening of implants is critical during selection of a patient-tailored treatment policy. Specific detection and visualization of infections is a challenge because it is difficult to discriminate infections from inflammation. An imaging tracer that facilitates bacterial identification in a pre- and intraoperative setting may aid the workup for patients suspicious of bacterial infections. In this study we evaluated an antimicrobial peptide conjugated to a hybrid label, which contains both a radioisotope and a fluorescent dye. After synthesis of DTPA-Cy5-UBI29-41 and-when necessary-radiolabeling with (111)In (yield 96.3 ± 2.7%), in vitro binding to various bacterial strains was evaluated using radioactivity counting and confocal fluorescence microscopy. Intramuscular bacterial infections (S. aureus or K. pneumoniae) were also visualized in vivo using a combined nuclear and fluorescence imaging system. The indium-111 was chosen as label as it has a well-defined coordination chemistry, and in pilot studies labeling DTPA-Cy5-UBI29-41 with technetium-99m, we encountered damage to the Cy5 dye after the reduction with SnCl2. As a reference, we used the validated tracer (99m)Tc-UBI29-41. Fast renal excretion of (111)In-DTPA-Cy5-UBI29-41 was observed. Target to nontarget (T/NT) ratios were highest at 2 h post injection: radioactivity counting yielded T/NT ratios of 2.82 ± 0.32 for S. aureus and 2.37 ± 0.05 for K. pneumoniae. Comparable T/NT ratios with fluorescence imaging of 2.38 ± 0.09 for S. aureus and 3.55 ± 0.31 for K. pneumoniae were calculated. Ex vivo confocal microscopy of excised infected tissues showed specific binding of the tracer to bacteria. Using a combination of nuclear and fluorescence imaging techniques, the hybrid antimicrobial peptide conjugate DTPA-Cy5-UBI29-41 was shown to specifically accumulate in bacterial infections. This hybrid tracer may facilitate integration of noninvasive identification of infections and their extent as well as real-time fluorescence guidance during surgical resection of infected areas.

Application time for postoperative wound dressing following breast augmentation with implants: study protocol for a randomized controlled trial

Background

Breast augmentation with silicone implants is one of the most frequently performed cosmetic surgeries worldwide. Surgical site infection (SSI) remains an important complication of this procedure. One of the most important risk factors for SSI is the presence of microorganisms on the skin surrounding the wound. Guidelines by the Centers for Disease Control (CDC) recommend that surgical wounds be covered with a sterile dressing for 24 to 48 hours. However, a recent study showed that the application of a dressing for six days after breast reduction reduced wound colonization by coagulase-negative staphylococci.

Methods/Design

A randomized clinical trial was designed to assess two protocols of postoperative wound care to determine how the application duration of the postoperative dressing influences wound colonization in patients undergoing breast augmentation with silicone implants. Women aged between 18 and 60 years who are candidates for breast augmentation with silicone implants will be randomly allocated to group I (n = 48), in which the dressing will be removed on the first postoperative day, or group II (n = 48), in which the dressing will be removed on the sixth postoperative day. Cutaneous colonization will be assessed by cultures of samples of skin flora taken from the wound region. The incidence of SSI, using standardized CDC criteria, and the perceptions of patients towards the dressing will be secondary outcomes.

Discussion

An important component of SSI prevention is to minimize all possible risk factors, and the application of postoperative dressing plays a key role in this endeavor. The results of this clinical trial may help to standardize postoperative wound care after breast augmentation with silicone implants.

Trial registration

This trial was registered on 12 March 2012 with ClinicalTrials.gov (identifier: NCT01553604).

Plastic surgeons' self-reported operative infection rates at a Canadian academic hospital

BACKGROUND

Surgical site infection rates are of great interest to patients, surgeons, hospitals and third-party payers. While previous studies have reported hospital-acquired infection rates that are nonspecific to all surgical services, there remain no overall reported infection rates focusing specifically on plastic surgery in the literature.

OBJECTIVE

To estimate the reported surgical site infection rate in plastic surgery procedures over a 10-year period at an academic hospital in Canada.

METHODS

A review was conducted on reported plastic surgery surgical site infection rates from 2003 to 2013, based on procedures performed in the main operating room. For comparison, prospective infection surveillance data over an eight-year period (2005 to 2013) for nonplastic surgery procedures were reviewed to estimate the overall operative surgical site infection rates.

RESULTS

A total of 12,183 plastic surgery operations were performed from 2003 to 2013, with 96 surgical site infections reported, corresponding to a net operative infection rate of 0.79%. There was a 0.49% surgeon-reported infection rate for implant-based procedures. For non-plastic surgery procedures, surgical site infection rates ranged from 0.04% for cataract surgery to 13.36% for high-risk abdominal hysterectomies.

DISCUSSION

The plastic surgery infection rate at the study institution was found to be <1%. This rate was equal to, or somewhat less than, surgical site infection rates. However, these results do not report patterns of infection rates germane to procedures, season, age groups or sex. To provide more in-depth knowledge of this topic, multicentre studies should be conducted.

Plastic surgeons' self-reported operative infection rates at a Canadian academic hospital

Background

Surgical site infection rates are of great interest to patients, surgeons, hospitals and third-party payers. While previous studies have reported hospital-acquired infection rates that are nonspecific to all surgical services, there remain no overall reported infection rates focusing specifically on plastic surgery in the literature.

Objective

To estimate the reported surgical site infection rate in plastic surgery procedures over a 10-year period at an academic hospital in Canada.

Methods

A review was conducted on reported plastic surgery surgical site infection rates from 2003 to 2013, based on procedures performed in the main operating room. For comparison, prospective infection surveillance data over an eight-year period (2005 to 2013) for nonplastic surgery procedures were reviewed to estimate the overall operative surgical site infection rates.

Results

A total of 12,183 plastic surgery operations were performed from 2003 to 2013, with 96 surgical site infections reported, corresponding to a net operative infection rate of 0.79%. There was a 0.49% surgeon-reported infection rate for implant-based procedures. For non-plastic surgery procedures, surgical site infection rates ranged from 0.04% for cataract surgery to 13.36% for high-risk abdominal hysterectomies.

Discussion

The plastic surgery infection rate at the study institution was found to be <1%. This rate was equal to, or somewhat less than, surgical site infection rates. However, these results do not report patterns of infection rates germane to procedures, season, age groups or sex. To provide more in-depth knowledge of this topic, multicentre studies should be conducted.

Dressings for the prevention of surgical site infection

BACKGROUND

Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured - often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing.

OBJECTIVES

To assess the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention.

SEARCH METHODS

In February 2014 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); The Health Technology Assessment Database (HTA) (The Cochrane Library); NHS Economic Evaluation Database (NHSEED) (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 or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressing with no dressing (wound exposure) for the postoperative management of surgical wounds healing by primary intention.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Twenty RCTs were included (3623 participants). All trials were at unclear or high risk of bias. Twelve trials included people with wounds resulting from surgical procedures with a contamination classification of 'clean', two trials included people with wounds resulting from surgical procedures with a 'clean/contaminated' contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 18 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by primary intention.

AUTHORS' CONCLUSIONS

At present, there is insufficient evidence as to whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or whether any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

Should a drain be placed in early breast cancer surgery?

BACKGROUND

The current surgical debate has led to a reduction in the extent of surgery performed and thereby to a reduced occurrence of surgical trauma and, over the recent years, reduced seroma formation. This reduction in surgical procedures calls the need for a drain into question.

METHOD

Using Google Scholar and the National Library of Medicine (PubMed), a literature review was performed on systematic reviews and meta-analyses regarding breast cancer surgery ± axillary dissection. Additionally, randomized trials for the time period after the last systematic review were included and evaluated according to the Jadad score.

RESULTS

The search returned 5 systematic reviews, in which a total of 1,075 patients were included (537 cases and 538 controls). Since the last review, no prospective randomized trial meeting the inclusion criteria has been published. The current reviews conclude that insertion of a drain is associated with a longer hospital stay and reduced seroma formation. The data regarding wound infection and drain insertion is inconclusive. The omission of a drain is associated with early discharge, reduced postsurgical pain, and early mobilization, but also with an increase in outpatient seroma aspirations.

CONCLUSION

The omission of a drain is possible in early breast cancer surgery (wide local excision and sentinel node biopsy) with adequate surgical techniques and instruments.

Utilization of silver hydrogel sheet dressing on postsurgical incisions: a pilot study in foot and ankle surgery

Silver hydrogel dressings are antimicrobial, nonadherent, and have an absorptive capacity many times their weight. Fifty-nine (49.44 ± 16.85 years) foot and ankle patients with incisions >1 cm were prospectively enrolled to compare infection, scarring, and complication rates between the postoperative use of a silver hydrogel sheet (SHS) dressing and a standard petroleum-based (P) dressing. Overall, there were 5 (8.47%) infections; 4 (6.78%) superficial and 1 (1.69%) deep. The SHS group had 1 (3.45%) superficial infection, whereas the P group had 3 (10.00%) superficial infections and 1 (3.33%) deep infection. Infection incidence was similar for both groups (P = .37). However, in the P group, 3 (10.00%) patients developed wound dehiscence and 1 (1.69%) patient developed a fibrinous scab. Compared with SHS patients, the P patients had a greater incidence of incisional complications (1 [3.45%] vs 8 [26.67%], respectively; P = .03). The percent change in scar length was greater in the SHS group (18.04 ± 41.10%) when compared with the P group (2.00 ± 9.93%; P < .001) while the percent change in scar width was similar in the 2 groups (P = .19). The lower incidence of incisional complications and the greater reduction in scar length suggest that the inherent properties of the silver hydrogel dressing aid in postsurgical healing.

Effects of a new pocket device for negative pressure wound therapy on surgical wounds of patients affected with Crohn's disease: a pilot trial

INTRODUCTION

Surgical site infections (SSIs) affect costs of care and prolong length of stay. Crohn's disease (CD) represents an independent risk factor for SSI. The risk can be further increased by concomitant administration of immunosuppressive drugs and poor performance status at the time of surgery. Patients suffering from CD often need more than one surgical intervention during life, sometimes requiring fashioning of a stoma. The aim of this pilot study was to compare a portable device for negative pressure wound therapy (PICO, Smith & Nephew, London, UK) to conventional gauze dressings in patients undergoing surgery for stricturing CD.

METHODS

Between January 2010 and November 2011, this controlled trial enrolled 30 patients, who were assigned to treatment with either PICO (n = 13) or conventional dressings (n = 17). Each patient completed a 3-month follow-up.

RESULTS

Patients receiving PICO experienced significantly less postoperative wound complications (P = .001) and SSI (P = .017) compared with those who received conventional dressings. This resulted in shorter hospital stay (P = .0007). No significant differences in cosmetic results were found.

CONCLUSION

These data suggest that PICO allows faster and safe discharge by reducing the incidence of SSI and wound-related complications in selected patients undergoing surgical intervention for stricturing CD. This could be particularly useful in patients receiving steroids.

Use of antibacterial sutures for skin closure in controlling surgical site infections: a systematic review of published randomized, controlled trials

Objective: The objective of this article is to systematically analyse the randomized, controlled trials that compare the use of antibacterial sutures (ABS) for skin closure in controlling surgical site infections.

Methods: Randomized, controlled trials on surgical patients comparing the use of ABS for skin closure in controlling the surgical site infections were analysed systematically using RevMan® and combined outcomes were expressed as odds ratios (OR) and standardized mean differences (SMD).

Results: Seven randomized, controlled trials evaluating 1631 patients were retrieved from electronic databases. There were 760 patients in the ABS group and 871 patients in the simple suture group. There was moderate heterogeneity among trials (Tau² = 0.12; chi² = 8.40, df = 6 [P < 0.01]; I² = 29%). Therefore in the random-effects model, the use of ABS for skin closure in surgical patients was associated with a reduced risk of developing surgical site infections (OR, 0.16; 95% CI, 0.37, 0.99; z = 2.02; P < 0.04) and postoperative complications (OR, 0.56; 95% CI, 0.32, 0.98 z = 2.04; P = 0.04). The durations of operation and lengths of hospital stay were similar following the use of ABS and SS for skin closure in patients undergoing various surgical procedures.

Conclusion: Use of ABS for skin closure in surgical patients is effective in reducing the risk of surgical site infection and postoperative complications. ABS is comparable with SS in terms of length of hospital stay and duration of operation.