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Skivington K, Craig N, Craig P, Rycroft-Malone J, Matthews L, Simpson SA, Moore L. Introducing the revised framework for developing and evaluating complex interventions: A challenge and a resource for nursing research. Int J Nurs Stud 2024; 154:104748. [PMID: 38564983 DOI: 10.1016/j.ijnurstu.2024.104748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
This invited discussion paper highlights key updates in the MRC/NIHR's revised framework for the development and evaluation of complex nursing interventions and reflects on the implications for nursing research.
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Affiliation(s)
- Kathryn Skivington
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Neil Craig
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, UK
| | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | | | - Sharon Anne Simpson
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Laurence Moore
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Pajarillo C, Sherman RA, Sheridan R, Kazis LE. Health professionals' perceptions of maggot debridement therapy. J Wound Care 2021; 30:VIIi-VIIxi. [PMID: 34570633 DOI: 10.12968/jowc.2021.30.sup9a.vii] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Maggot debridement therapy (MDT), or the use of maggots in dead tissue removal, has been shown to be beneficial in wound healing. Yet MDT in the US is often only used once conventional debridement methods have failed. METHOD In this study, nine health professionals, experienced in MDT, were interviewed in order to identify and analyse the perceived societal barriers to MDT acceptance and usage in the US. RESULTS Through qualitative analysis, using the grounded theory framework, this study found that among those interviewed, insurance reimbursement restrictions and stigmatisation of medicinal maggots were the factors driving resistance to MDT use. CONCLUSION Specifically, the 'yuck' factor and the perception of MDT as an 'ancient' modality contributed towards MDT stigma; in addition, lack of outpatient insurance coverage deterred MDT use. These findings provide useful information regarding the perceptual and systemic barriers that prevent greater acceptance of MDT. Ultimately, these barriers must be understood if we are to facilitate MDT implementation and improve MDT usage in the future.
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Affiliation(s)
| | | | - Robert Sheridan
- Shriners Hospitals for Children and Massachusetts General Hospital, US
| | - Lewis E Kazis
- Boston University School of Public Health, Department of Health Law, Policy, and Management, US
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Khanpour Ardestani S, Robinson JL, Dieleman LA, Huynh HQ, Jou H, Vohra S. Surveys of parents and clinicians concerning the minimally important difference of probiotic therapy for prevention of paediatric antibiotic-associated diarrhoea. BMJ Open 2019; 9:e024651. [PMID: 30944130 PMCID: PMC6500342 DOI: 10.1136/bmjopen-2018-024651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To establish the minimally important difference (MID) that would prompt parents and clinicians to use probiotics for prevention of paediatric antibiotic-associated diarrhoea (AAD) and to obtain parent and clinician opinion about the most important outcomes in clinical trials of AAD. METHODS In this survey, parents of children presenting to the emergency department of a Canadian tertiary care children's hospital and paediatricians working in that hospital were approached. A range of potential MIDs were presented and participants selected one that they would require to use probiotics for AAD prevention. In addition, participants were asked to rate a list of outcomes they would consider to be important in clinical trials of AAD. RESULTS In total, 127 parents and 45 paediatricians participated. About 51% (64/125) of parents and 51% (21/41) of clinicians responding to the MID question reported they would use probiotics if it reduced the risk of AAD by 39% (ie, reduce the risk of AAD from 19% to 12%). The most important outcomes to parents, in descending order, were need for hospitalisation, prevention of dehydration, disruption of normal daily activities, diarrhoea duration and physician revisit. Paediatricians considered need for hospitalisation along with physician revisit as the most important outcomes. They rated prevention of dehydration, diarrhoea duration and stool frequency as important outcomes as well. CONCLUSION There is good agreement between parents and clinicians regarding how effective probiotics would need to be in preventing AAD in order to warrant use. This information, along with outcomes perceived to be most important, will help in the design of future clinical trials.
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Affiliation(s)
- Samaneh Khanpour Ardestani
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Joan L Robinson
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Levinus A Dieleman
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hien Q Huynh
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hsing Jou
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Vohra
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Flying maggots: a smart logistic solution to an enduring medical challenge. JOURNAL OF HUMANITARIAN LOGISTICS AND SUPPLY CHAIN MANAGEMENT 2017. [DOI: 10.1108/jhlscm-02-2017-0003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Whilst there is a growing body of research which discusses the use of remotely piloted aircraft systems (RPAS) (otherwise known as “drones”) to transport medical supplies, almost all reported cases employ short range aircraft. The purpose of this paper is to consider the advantages and challenges inherent in the use of long endurance remotely piloted aircraft systems (LE-RPAS) aircraft to support the provision of medical supplies to remote locations – specifically “medical maggots” used in maggot debridement therapy (MDT) wound care.
Design/methodology/approach
After introducing both MDT and the LE-RPAS technology, the paper first reports on the outcomes of a case study involving 11 semi-structured interviews with individuals who either have experience and expertise in the use of LE-RPAS or in the provision of healthcare to remote communities in Western Australia. The insights gained from this case study are then synthesised to assess the feasibility of LE-RPAS assisted delivery of medical maggots to those living in such geographically challenging locations.
Findings
No insuperable challenges to the concept of using LE-RPAS to transport medical maggots were uncovered during this research – rather, those who contributed to the investigations from across the spectrum from operators to users, were highly supportive of the overall concept.
Practical implications
The paper offers an assessment of the feasibility of the use of LE-RPAS to transport medical maggots. In doing so, it highlights a number of infrastructure and organisational challenges that would need to be overcome to operationalise this concept. Whilst the particular context of the paper relates to the provision of medical support to a remote location of a developed country, the core benefits and challenges that are exposed relate equally to the use of LE-RPAS in a post-disaster response. To this end, the paper offers a high-level route map to support the implementation of the concept.
Social implications
The paper proposes a novel approach to the efficient and effective provision of medical care to remote Australian communities which, in particular, reduces the need to travel significant distances to obtain treatment. In doing so, it emphasises the importance in gaining acceptance of both the use of MDT and also the operation of RPAS noting that these have previously been employed in a military, as distinct from humanitarian, context.
Originality/value
The paper demonstrates how the use of LE-RPAS to support remote communities offers the potential to deliver healthcare at reduced cost compared to conventional approaches. The paper also underlines the potential benefits of the use of MDT to address the growing wound burdens in remote communities. Finally, the paper expands on the existing discussion of the use of RPAS to include its capability to act as the delivery mechanism for medical maggots.
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Franco MR, Howard K, Sherrington C, Rose J, Ferreira PH, Ferreira ML. Smallest worthwhile effect of exercise programs to prevent falls among older people: estimates from benefit-harm trade-off and discrete choice methods. Age Ageing 2016; 45:806-812. [PMID: 27496928 DOI: 10.1093/ageing/afw110] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/05/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND the smallest worthwhile effect (SWE) of an intervention is the smallest treatment effect that justifies the costs, risks and inconveniences associated with that health intervention. OBJECTIVE to estimate the SWE of exercise programs designed to prevent falls among older people and to compare estimates derived by two methodological approaches. STUDY DESIGN AND SETTING discrete choice experiment (n = 220) and benefit-harm trade-off (subsample n = 66) methods were used. PARTICIPANTS community-dwelling older people who reported a past fall or a mobility limitation answered online or face-to-face questionnaires. RESULTS a substantial proportion of participants (82% in the discrete choice experiment and 50% in the benefit-harm trade-off study) did not consider that participation in the proposed exercise programs would be worthwhile, even if it reduced their risk of falling to 0%. Among remaining participants, the average SWE of participation in an exercise program was an absolute reduction in the risk of falling of 35% (standard deviation [SD] = 13) in the discrete choice experiment and 16% (SD = 11) in the benefit-harm trade-off study. CONCLUSIONS many participants did not consider the hypothetical falls' risk reduction of the proposed exercise programs to be worth the associated costs and inconveniences. Greater community awareness of the fall prevention effects of exercise for older people is required.
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Affiliation(s)
- M R Franco
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - K Howard
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - C Sherrington
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - J Rose
- School of Commerce, University of South Australia, South Australia, Australia
| | - P H Ferreira
- Faculty of Health Science, The University of Sydney, Sydney, New South Wales, Australia
| | - M L Ferreira
- The George Institute for Global Health & Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Ferreira ML, Herbert RD, Ferreira PH, Latimer J, Ostelo RW, Grotle M, Barrett B. The smallest worthwhile effect of nonsteroidal anti-inflammatory drugs and physiotherapy for chronic low back pain: a benefit-harm trade-off study. J Clin Epidemiol 2013; 66:1397-404. [PMID: 24021611 DOI: 10.1016/j.jclinepi.2013.02.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 01/29/2013] [Accepted: 02/18/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to determine the smallest worthwhile effects of two treatments for nonspecific low back pain (LBP). STUDY DESIGN AND SETTING The benefit-harm trade-off method was used to estimate the smallest worthwhile effect of nonsteroidal anti-inflammatory drugs (NSAIDs) and physiotherapy for LBP. Patients seeking care for chronic LBP were interviewed by telephone before treatment commenced and 4 weeks later. RESULTS Patients need to see a median of 30% (interquartile range [IQR]: 10-40) more improvement in pain and 20% (IQR: 10-40) more improvement in disability than would occur without intervention to perceive the effect of NSAIDs are worthwhile. They would need to see 20% (IQR: 0-30) more improvement on pain and disability over natural recovery to perceive that the effect of physiotherapy was worthwhile. There was no difference in estimates of the smallest worthwhile effect elicited at baseline and 4 weeks later. CONCLUSIONS People with chronic back pain need to see larger effects on pain of NSAIDS than physiotherapy to consider the effects of these interventions worthwhile. These estimates of the smallest worthwhile effect can be used to interpret the findings of clinical trials and to design adequately powered clinical trials.
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Affiliation(s)
- Manuela L Ferreira
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia.
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Nelson EA. Venous leg ulcers. BMJ CLINICAL EVIDENCE 2011; 2011:1902. [PMID: 22189344 PMCID: PMC3275133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Leg ulcers usually occur secondary to venous reflux or obstruction, but 20% of people with leg ulcers have arterial disease, with or without venous disorders. Between 1.5 and 3.0/1000 people have active leg ulcers. Prevalence increases with age to about 20/1000 in people aged over 80 years. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of standard treatments, adjuvant treatments, and organisational interventions for venous leg ulcers? What are the effects of advice about self-help interventions in people receiving usual care for venous leg ulcers? What are the effects of interventions to prevent recurrence of venous leg ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 101 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: compression bandages and stockings, cultured allogenic (single or bilayer) skin replacement, debriding agents, dressings (cellulose, collagen, film, foam, hyaluronic acid-derived, semi-occlusive alginate), hydrocolloid (occlusive) dressings in the presence of compression, intermittent pneumatic compression, intravenous prostaglandin E1, larval therapy, laser treatment (low-level), leg ulcer clinics, multilayer elastic system, multilayer elastomeric (or non-elastomeric) high-compression regimens or bandages, oral treatments (aspirin, flavonoids, pentoxifylline, rutosides, stanozolol, sulodexide, thromboxane alpha(2) antagonists, zinc), peri-ulcer injection of granulocyte-macrophage colony-stimulating factor, self-help (advice to elevate leg, to keep leg active, to modify diet, to stop smoking, to reduce weight), short-stretch bandages, single-layer non-elastic system, skin grafting, superficial vein surgery, systemic mesoglycan, therapeutic ultrasound, and topical treatments (antimicrobial agents, autologous platelet lysate, calcitonin gene-related peptide plus vasoactive intestinal polypeptide, freeze-dried keratinocyte lysate, mesoglycan, negative pressure, recombinant keratinocyte growth factor, platelet-derived growth factor).
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Ferreira ML, Herbert RD, Ferreira PH, Latimer J, Ostelo RW, Nascimento DP, Smeets RJ. A critical review of methods used to determine the smallest worthwhile effect of interventions for low back pain. J Clin Epidemiol 2011; 65:253-61. [PMID: 22014888 DOI: 10.1016/j.jclinepi.2011.06.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 05/19/2011] [Accepted: 06/08/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To critically and systematically review methods used to estimate the smallest worthwhile effect of interventions for nonspecific low back pain. STUDY DESIGN AND SETTING A computerized search was conducted of MEDLINE, CINAHL, LILACS, and EMBASE up to May 2011. Studies were included if they were primary reports intended to measure the smallest worthwhile effect of a health intervention (although they did not need to use this terminology) for nonspecific low back pain. RESULTS The search located 31 studies, which provided a total of 129 estimates of the smallest worthwhile effect. The estimates were given a variety of names, including the Minimum Clinically Important Difference, Minimum Important Difference, Minimum Worthwhile Reductions, and Minimum Important Change. Most estimates were obtained using anchor- or distribution-based methods. These methods are not (or not directly) based on patients' perceptions, are not intervention-specific, and are not formulated in terms of differences in outcomes with and without intervention. CONCLUSION The methods used to estimate the smallest worthwhile effect of interventions for low back pain have important limitations. We recommend that the benefit-harm trade-off method be used to estimate the smallest worthwhile effects of intervention because it overcomes these limitations.
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Affiliation(s)
- Manuela L Ferreira
- The George Institute for Global Health, Missenden Road, NSW 2050, Australia.
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Gottrup F, Jørgensen B. Maggot debridement: an alternative method for debridement. EPLASTY 2011; 11:e33. [PMID: 21776326 PMCID: PMC3136394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
UNLABELLED Debridement is an essential component to promote healing in a problem wound. Several techniques are available including maggot debridement therapy (MDT). OBJECTIVE To describe the efficacy of MDT for treating problem wound especially diabetic foot ulcers. METHODS The topic is elucidated from different points of view: the mode of action, when to use, use in a practice, clinical results, and discussing the problem of creating evidence for the clinical effect. RESULTS Literature and own results demonstrate that MDT is a safe method with few side effects. Maggot debridement therapy is as good as or better than conventional often surgical debridement, is more selective than surgical debridement, decreases time to healing and stay of patients in the ward, and may decrease the risk of major amputations. However, the evidence of these effects of MDT on the highest level is presently lacking. A detailed description of how to use MDT in practice is provided including a visual demonstration in a video. CONCLUSION In spite of lacking clinical evidence, MDT clinical experience strongly suggests that this technique is effective and safe. It can be used for most types of problem wounds, but our indication is primarily diabetic foot ulcers, because of its selectivity for debriding necrotic dead tissue. It may be a valuable alternative surgical/sharp debridement.
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Affiliation(s)
- Finn Gottrup
- Copenhagen Wound Healing Center, Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark,Correspondence:
| | - Bo Jørgensen
- Copenhagen Wound Healing Center, Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark
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Calvert M, Wood J, Freemantle N. Designing "Real-World" trials to meet the needs of health policy makers at marketing authorization. J Clin Epidemiol 2011; 64:711-7. [PMID: 21454048 DOI: 10.1016/j.jclinepi.2010.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 12/02/2010] [Accepted: 12/10/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE There is increasing interest in conducting "Real-World" trials that go beyond traditional assessment of efficacy and safety to examine market access and value for money questions before marketing authorization of a new pharmaceutical product or health technology. This commentary uses practical examples to demonstrate how high-quality evidence of the cost-effectiveness of an intervention may be gained earlier in the development process. STUDY DESIGN Issues surrounding the design and analysis of "Real-World" trials to demonstrate relative cost-effectiveness early in the life of new technologies are discussed. The modification of traditional phase III trial designs, de novo trial designs, the combination of trial-based and epidemiological data, and the use of simulation model-based approaches to address reimbursement questions are described. RESULTS Modest changes to a phase III trial protocol and case report form may be undertaken at the design stage to provide valid estimates of health care use and the benefits accrued; however, phase III designs often preclude "real-life" practice. Relatively small de novo trials may be used to address adherence to therapy or patient preference, although simply designed studies with active comparators enrolling large numbers of patients may provide evidence on long-term safety and rare adverse events. CONCLUSIONS Practical examples demonstrate that it is possible to provide high-quality evidence of the cost-effectiveness of an intervention earlier in the development process. Payers and decision makers should preferentially adopt treatments with such evidence than treatments for which evidence is lacking or of lower quality.
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Affiliation(s)
- Melanie Calvert
- Health Care Evaluation Group, School of Health and Population Sciences, Primary Care and Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
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Cartier E, Combemale P. [Maggot therapy with Lucilia sericata for debridement of chronic wounds]. Ann Dermatol Venereol 2008; 135:685-8. [PMID: 18929922 DOI: 10.1016/j.annder.2008.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 05/16/2008] [Indexed: 11/30/2022]
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Spilsbury K, Cullum N, Dumville J, O'Meara S, Petherick E, Thompson C. Exploring patient perceptions of larval therapy as a potential treatment for venous leg ulceration. Health Expect 2008; 11:148-59. [PMID: 18494959 DOI: 10.1111/j.1369-7625.2008.00491.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES To explore patient preferences and acceptability of two forms of larval therapy ('bagged' and 'loose'). BACKGROUND Larval therapy is frequently used to treat patients with leg ulcers. However, patient preferences and acceptability of larval therapy when compared with other treatments is not established. DESIGN A survey of patient preferences between larvae and standard therapy (hydrogel) using randomized allocation of two questionnaires ('bagged' or 'loose' questionnaire). The questionnaire contained closed and open-response questions and was administered by a nurse researcher. Open responses enabled exploration of patients' preferences and the acceptability of larval therapy when compared with a standard treatment. Qualitative data were analysed for thematic content. SETTING AND PARTICIPANTS Thirty-five participants, aged 18 years and above, with at least one venous leg ulcer were recruited from a UK Hospital Vascular Outpatients Clinic. FINDINGS Majority of participants stated that they would consider larval therapy, irrespective of method of containment. Acceptance of therapy was influenced by length of time with (or recurrence of) ulceration, experiences of other treatments, social contact in hospitals and the experiences of others. Visual imagery was a key influence among participants who would refuse larval therapy. Refusal was mostly among older women (aged 70 years or above). CONCLUSIONS Eliciting patient preferences and increasing patient involvement in treatment decisions is an important part of quality improvement and improved health outcomes. These findings have relevance for practitioners offering larval therapy as a treatment option and for the feasibility of clinical trials.
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Affiliation(s)
- Karen Spilsbury
- Department of Health Sciences, University of York, York, UK.
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Nelson EA, Jones J. Venous leg ulcers. BMJ CLINICAL EVIDENCE 2008; 2008:1902. [PMID: 19445798 PMCID: PMC2908003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Leg ulcers usually occur secondary to venous reflux or obstruction, but 20% of people with leg ulcers have arterial disease, with or without venous disorders. Between 1.5 and 3.0/1000 people have active leg ulcers. Prevalence increases with age to about 20/1000 in people aged over 80 years. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of standard treatments, adjuvant treatments, and organisational interventions for venous leg ulcers? What are the effects of interventions to prevent recurrence of venous leg ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: compression bandages and stockings, cultured allogenic (single or bilayer) skin replacement, debriding agents, dressings (cellulose, collagen, film, foam, hyaluronic acid-derived, semi-occlusive alginate), hydrocolloid (occlusive) dressings in the presence of compression, intermittent pneumatic compression, intravenous prostaglandin E1, larval therapy, laser treatment (low-level), leg ulcer clinics, multilayer elastic system, multilayer elastomeric (or non-elastomeric) high-compression regimens or bandages, oral treatments (aspirin, flavonoids, pentoxifylline, rutosides, stanozolol, sulodexide, thromboxane alpha(2) antagonists, zinc), peri-ulcer injection of granulocyte-macrophage colony-stimulating factor, short-stretch bandages, single-layer non-elastic system, skin grafting, superficial vein surgery, systemic mesoglycan, therapeutic ultrasound, self-help (advice to elevate leg, advice to keep leg active, advice to modify diet, advice to stop smoking, advice to reduce weight), and topical treatments (antimicrobial agents, autologous platelet lysate, calcitonin gene-related peptide plus vasoactive intestinal polypeptide, freeze-dried keratinocyte lysate, mesoglycan, negative-pressure recombinant keratinocyte growth factor, platelet-derived growth factor).
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Is Larval (Maggot) Debridement Effective for Removal of Necrotic Tissue From Chronic Wounds? J Wound Ostomy Continence Nurs 2008; 35:378-84. [DOI: 10.1097/01.won.0000326655.50316.0e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Whitaker IS, Twine C, Whitaker MJ, Welck M, Brown CS, Shandall A. Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J 2007; 83:409-13. [PMID: 17551073 PMCID: PMC2600045 DOI: 10.1136/pgmj.2006.055905] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
When modern medicine fails, it is often useful to draw ideas from ancient treatments. The therapeutic use of fly larvae to debride necrotic tissue, also known as larval therapy, maggot debridement therapy or biosurgery, dates back to the beginnings of civilisation. Despite repeatedly falling out of favour largely because of patient intolerance to the treatment, the practice of larval therapy is increasing around the world because of its efficacy, safety and simplicity. Clinical indications for larval treatment are varied, but, in particular, are wounds infected with multidrug-resistant bacteria and the presence of significant co-morbidities precluding surgical intervention. The flies most often used in larval therapy are the facultative calliphorids, with the greenbottle blowfly (Lucilia sericata) being the most widely used species. This review summarises the fascinating and turbulent history of larval therapy from its origin to the present day, including mechanisms of action and evidence for its clinical applications. It also explores future research directions.
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Affiliation(s)
- Iain S Whitaker
- Department of Burns and Plastic Surgery, Morriston Hospital, Swansea, UK.
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