1
|
Wong AYW, Ong BSY, Lee ARYB, Mai AS, Selvarajan S, Lakshminarasappa SR, Tay SM. Topical Biological Agents as Adjuncts to Improve Wound Healing in Chronic Diabetic Wounds: A Systematic Review of Clinical Evidence and Future Directions. Cureus 2022; 14:e27180. [PMID: 36035037 PMCID: PMC9398533 DOI: 10.7759/cureus.27180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/05/2022] Open
|
2
|
Han CM, Cheng B, Wu P. Clinical guideline on topical growth factors for skin wounds. BURNS & TRAUMA 2020; 8:tkaa035. [PMID: 33015207 PMCID: PMC7520573 DOI: 10.1093/burnst/tkaa035] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/03/2020] [Indexed: 01/13/2023]
Abstract
An increased number of patients with skin wounds have been witnessed in the past decades. Among the various kinds of treatments for skin wounds, topical exogenous growth factors are indispensable and have been used in many countries. However, whether they have reliable effects remains controversial, and their application for skin wound treatment needs to be further standardized and optimized in terms of socio-economic considerations. Thus, the Chinese Burn Association developed this guideline indicating efficacy, application details, adverse reactions and precautions of five clinically common topical growth factors using the Grading of Recommendations Assessment Development and Evaluation method to promote the rational application of topical exogenous growth factors in skin wounds and to benefit more patients.
Collapse
Affiliation(s)
- Chun-Mao Han
- Department of Burns & Wound Care Center, the Second Affiliated Hospital of Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou 310009, China
| | - Biao Cheng
- Department of Burns & Plastic Surgery, General Hospital of Southern Theater Command, PLA, No. 111 Liuhua Road, Guangzhou 510000, China
| | - Pan Wu
- Department of Burns & Wound Care Center, the Second Affiliated Hospital of Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou 310009, China
| | | |
Collapse
|
3
|
Zhao D, Su Y, Li Y, Yu T, Li J, Tu C. Efficacy and safety of recombinant human epidermal growth factor for diabetic foot ulcers: A systematic review and meta-analysis of randomised controlled trials. Int Wound J 2020; 17:1062-1073. [PMID: 32343054 PMCID: PMC7948637 DOI: 10.1111/iwj.13377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/02/2020] [Indexed: 02/05/2023] Open
Abstract
To evaluate the efficacy and safety of recombinant human epidermal growth factor (rhEGF) in treating diabetic foot ulcers (DFUs), we conducted both database searches (PubMed, MEDLINE, EMBASE, CENTRAL, and Web of Science) and reference searches for randomised controlled trials from the inception of databases to 30 January 2020. Two reviewers independently scrutinised the trials, extracted data, and assessed the quality of trials. The primary outcome was the proportion of complete healing. The secondary outcomes were mean time to complete healing and adverse events. A subgroup analysis was performed by different administration routes. Statistical analyses were performed in RevMan 5.3. The time to complete healing Kaplan-Meier curves was pooled in the R software. Of the 156 citations, 9 trials (720 participants) met eligibility criteria and were included. The rhEGF achieved a higher complete healing rate than placebo (OR: 2.79, [95% CI: 1.99, 3.99]). The rhEGF also significantly shorten complete healing time (MD: -14.10 days, [95% CI: -18.03, -10.16]). Subgroup analysis showed that topical application was superior to intralesional injection, but that may be because of different ulcer severity they included. No significant difference was shown in adverse events. Results were coherent with sensitivity analyses. Therefore, rhEGF is an effective and safe treatment for DFUs.
Collapse
Affiliation(s)
- Ding‐Yun Zhao
- Department of Orthopedics, West China HospitalSichuan UniversityChengdu CitySichuan ProvincePR China
| | - Ya‐Na Su
- Department of Evidence‐Based Medicine and Clinical Epidemiology, West China HospitalSichuan UniversityChengdu CitySichuan ProvincePR China
| | - Yong‐Hong Li
- Department of Evidence‐Based Medicine and Clinical Epidemiology, West China HospitalSichuan UniversityChengdu CitySichuan ProvincePR China
| | - Tian‐Qi Yu
- Department of Evidence‐Based Medicine and Clinical Epidemiology, West China HospitalSichuan UniversityChengdu CitySichuan ProvincePR China
| | - Jing Li
- Department of Evidence‐Based Medicine and Clinical Epidemiology, West China HospitalSichuan UniversityChengdu CitySichuan ProvincePR China
- The Chinese Cochrane CenterChengdu CitySichuan ProvincePR China
| | - Chong‐Qi Tu
- Department of Orthopedics, West China HospitalSichuan UniversityChengdu CitySichuan ProvincePR China
| |
Collapse
|
4
|
Vas P, Rayman G, Dhatariya K, Driver V, Hartemann A, Londahl M, Piaggesi A, Apelqvist J, Attinger C, Game F. Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3284. [PMID: 32176446 DOI: 10.1002/dmrr.3284] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022]
Abstract
The management of diabetic foot ulcers (DFU) remains a challenge, and there is continuing uncertainty concerning optimal approaches to wound healing. The International Working Group of the Diabetic Foot (IWGDF) working group on wound healing has previously published systematic reviews of the evidence in 2008, 2012 and 2016 to inform protocols for routine care and to highlight areas which should be considered for further study. The working group has now updated this review by considering papers on the interventions to improve the healing of DFU's published between June 2014 and August 2018. Methodological quality of selected studies was independently assessed by a minimum of two reviewers using the recently published 21-point questionnaire as recommended by IWGDF/European Wound Management Association, as well as the previously incorporated Scottish Intercollegiate Guidelines Network criteria. Of the 2275 papers identified, 97 were finally selected for grading following full text review. Overall, there has been an improvement in study design and a significant rise in the number of published studies. While previous systematic reviews did not find any evidence to justify the use of newer therapies, except for negative pressure wound therapy in post-surgical wounds, in this review we found additional evidence to support some interventions including a sucrose-octasulfate dressing, the combined leucocyte, fibrin and platelet patch as well as topical application of some placental membrane products, all when used in addition to usual best care. Nonetheless, the assessment and comparison of published trials remains difficult with marked clinical heterogeneity between studies: in patient selection, study duration, standard of usual care provision and the timing and description of the clinical endpoints.
Collapse
Affiliation(s)
- Prashanth Vas
- Diabetes Foot Clinic, King's College Hospital, London, UK
| | - Gerry Rayman
- Diabetes Centre and Research Unit, East Suffolk and North East Essex Foundation Trust, Colchester, UK
| | - Ketan Dhatariya
- Department of Diabetes, Norfolk and Norwich University Hospitals NHS Foundation Trust, University of East Anglia, Norwich, UK
| | - Vickie Driver
- School of Medicine, Brown University, Providence, RI
| | - Agnes Hartemann
- Pitié-Salpêtrière Hospital, APHP, Paris 6 University, ICAN, Lyon, France
| | - Magnus Londahl
- Department of Endocrinology, Skane University Hospital, Lund, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Pisa, Italy
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Chris Attinger
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington DC, WA
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| |
Collapse
|
5
|
Yang Q, Zhang Y, Yin H, Lu Y. Topical Recombinant Human Epidermal Growth Factor for Diabetic Foot Ulcers: A Meta-Analysis of Randomized Controlled Clinical Trials. Ann Vasc Surg 2020; 62:442-451. [DOI: 10.1016/j.avsg.2019.05.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/01/2019] [Accepted: 05/18/2019] [Indexed: 01/13/2023]
|
6
|
Bui TQ, Bui QVP, Németh D, Hegyi P, Szakács Z, Rumbus Z, Tóth B, Emri G, Párniczky A, Sarlós P, Varga O. Epidermal Growth Factor is Effective in the Treatment of Diabetic Foot Ulcers: Meta-Analysis and Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16142584. [PMID: 31331038 PMCID: PMC6678975 DOI: 10.3390/ijerph16142584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022]
Abstract
Diabetic foot ulcers (DFUs) are one the common complications of diabetes mellitus. Many trials were performed to evaluate the effect of recombinant human epidermal growth factor (rhEGF) in healing DFUs. This meta-analysis was performed to synthesize the evidence of rhEGF treatment in DFUs in comparison to placebo. Databases included for the search were PubMed, EMBASE, the Cochrane Library, Web of Science, EBSCOhost, ScienceDirect, and Scopus (up to January 2019). The outcome of interest was the complete healing rate of DFUs. We performed random effects meta-analysis stratified by the types of administration route (intralesional injection and topical apply) by calculating the odds ratios (OR) and 95% confidence interval (95% CI). A total of six studies involving 530 patients were eligible for analysis. The combined OR (intralesional injection and topical apply) was 4.005 (95% CI: (2.248; 7.135), p < 0.001). The ORs for intralesional injection and topical application were 3.599 (95% CI: (1.213; 10.677), p = 0.021) and 4.176 (95% CI: (2.112; 8.256), p < 0.001), respectively. Statistical heterogeneity might not be important in overall treatment (I2 = 15.17, p = 0.317) and both of the subgroups (I2: 24.56, p = 0.25 and I2: 33.26, p = 0.213, respectively). Our results support the use of rhEGF in the treatment of DFUs.
Collapse
Affiliation(s)
- Thien Quoc Bui
- Department of Preventive Medicine, Faculty of Medicine, University of Debrecen, 4028 Debrecen, Hungary.
| | - Quoc Van Phu Bui
- Department of Internal Medicine, Faculty of Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh city 70000, Vietnam
| | - Dávid Németh
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Zoltán Rumbus
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Barbara Tóth
- Department of Pharmacognosy, Faculty of Pharmacy, University of Szeged, 6720 Szeged, Hungary
| | - Gabriella Emri
- Department of Dermatology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Andrea Párniczky
- Heim Pál National Institute of Pediatrics, 1089 Budapest, Hungary
| | - Patricia Sarlós
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Medical School, 7624 Pécs, Hungary
| | - Orsolya Varga
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, 4028 Debrecen, Hungary
| |
Collapse
|
7
|
Zhang J, Hu W, Diao Q, Wang Z, Miao J, Chen X, Xue Z. Therapeutic effect of the epidermal growth factor on diabetic foot ulcer and the underlying mechanisms. Exp Ther Med 2018; 17:1643-1648. [PMID: 30783432 PMCID: PMC6364187 DOI: 10.3892/etm.2018.7133] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 12/15/2017] [Indexed: 01/24/2023] Open
Abstract
The present study aimed to explore the therapeutic effect and underlying mechanism of epidermal growth factor (EGF) on the wound healing of diabetic foot ulcers (DFU). A total of 48 rabbits with DFU were randomly divided into 2 groups, comprising the treatment and control groups. Full-thickness skin (10×10 mm) was excised from the thigh of each rabbit. The wounds in the treatment group were treated with 100 mg/l EGF once a day for 1 month. The control group received no treatment. At 20 days following treatment, new granulation tissues that formed beyond the edge of the wound were collected for subsequent analysis. Tissues from rabbits in the treatment group produced a greater number of fibroblasts, which exhibited a fibroblastic morphology when compared with those in the control group. In the treatment group, a larger number of these fibroblasts were observed as clusters, and there were numerous blood vessels when compared with the control group. The fibroblasts in the control group exhibited an irregular morphology, contained fewer organelles and the surrounding collagenous fibers were sparse. These fibroblasts also demonstrated a disordered arrangement and it was revealed that the wound healed at a slower rate compared with the treatment group. Endogenous EGF mRNA detection revealed that there was a significant difference (P<0.05) in the relative gray value of EGF mRNA between the treatment (103.27±4.27) and control (63.88±4.36) groups. In conclusion, EGF may accelerate the healing of DFU, and exogenous EGF treatment may upregulate the expression of EGF mRNA in newly generated tissues.
Collapse
Affiliation(s)
- Juanzi Zhang
- Department of Vascular Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| | - Wenxian Hu
- Department of Vascular Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| | - Qixian Diao
- Department of General Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| | - Zhaowei Wang
- Department of Vascular Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| | - Jin Miao
- Department of Vascular Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| | - Xiao Chen
- Department of Vascular Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| | - Zhijun Xue
- Department of Vascular Surgery, The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, Shandong 266033, P.R. China
| |
Collapse
|
8
|
Nguyen VN, Miller C, Sunderland J, McGuiness W. Understanding the Hawthorne effect in wound research-A scoping review. Int Wound J 2018; 15:1010-1024. [PMID: 30136375 DOI: 10.1111/iwj.12968] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/15/2018] [Accepted: 06/24/2018] [Indexed: 11/26/2022] Open
Abstract
The Hawthorne Effect (HE) is considered a methodological artefact in research, although its definition and influence on research outcomes lack consensus. This review explored how this term has been mentioned and discussed in the area of wound research. A scoping review was conducted on ProQuest Central, Scopus, EbscoHost, and online databases of indexed wound journals using the methodological framework by Arksey and Malley. A review protocol was applied to detail key terms, truncation and Boolean operators, and inclusion and exclusion criteria. Search findings were reported using PRISMA guidelines. A total of 38 articles reporting primary evidence were identified. Three themes emerged from the review: wound researchers' awareness of HE, the acknowledgement of the existence or otherwise of HE, and the mentioning of HE in passing. These results reflect a lack of attention to and understanding and awareness of the HE in the area of wound research. It is suggested that the HE receives more attention as a methodological concern, and its potential influence is considered and mitigated when planning future studies. Recommendations are provided to minimise the impact of the HE on the rigour of the research and confidence afforded to research findings.
Collapse
Affiliation(s)
- Van Nb Nguyen
- Alfred Health Clinical School, La Trobe University, Melbourne, Victoria, Australia
| | - Charne Miller
- Alfred Health Clinical School, La Trobe University, Melbourne, Victoria, Australia
| | - Janine Sunderland
- Alfred Health Clinical School, La Trobe University, Melbourne, Victoria, Australia
| | - William McGuiness
- Alfred Health Clinical School, La Trobe University, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Abstract
Receptor tyrosine kinases (RTKs) are essential components of cell communication pathways utilized from the embryonic to adult stages of life. These transmembrane receptors bind polypeptide ligands, such as growth factors, inducing signalling cascades that control cellular processes such as proliferation, survival, differentiation, motility and inflammation. Many viruses have acquired homologs of growth factors encoded by the hosts that they infect. Production of growth factors during infection allows viruses to exploit RTKs for entry and replication in cells, as well as for host and environmental dissemination. This review describes the genetic diversity amongst virus-derived growth factors and the mechanisms by which RTK exploitation enhances virus survival, then highlights how viral ligands can be used to further understanding of RTK signalling and function during embryogenesis, homeostasis and disease scenarios.
Collapse
Affiliation(s)
- Zabeen Lateef
- a Department of Pharmacology and Toxicology, School of Biomedical Sciences , University of Otago , Dunedin , New Zealand
| | - Lyn M Wise
- a Department of Pharmacology and Toxicology, School of Biomedical Sciences , University of Otago , Dunedin , New Zealand
| |
Collapse
|
10
|
Jere SW, Houreld NN, Abrahamse H. Photobiomodulation at 660 nm stimulates proliferation and migration of diabetic wounded cells via the expression of epidermal growth factor and the JAK/STAT pathway. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2018; 179:74-83. [DOI: 10.1016/j.jphotobiol.2017.12.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/04/2017] [Accepted: 12/30/2017] [Indexed: 12/26/2022]
|
11
|
Sridharan K, Sivaramakrishnan G. Growth factors for diabetic foot ulcers: mixed treatment comparison analysis of randomized clinical trials. Br J Clin Pharmacol 2018; 84:434-444. [PMID: 29148070 DOI: 10.1111/bcp.13470] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 11/06/2017] [Accepted: 11/07/2017] [Indexed: 12/30/2022] Open
Abstract
AIMS Topical growth factors accelerate wound healing in patients with diabetic foot ulcers (DFU). Due to the absence of head-to-head comparisons, we carried out Bayesian network meta-analysis to compare the efficacy and safety of growth factors. METHODS Using an appropriate search strategy, randomized controlled trials on topical growth factors compared with standard of care in patients with DFU, were included. Proportion of patients with complete healing was the primary outcome. Odds ratio (95% confidence interval) was used as the effect estimate and random effects model was used for both direct and indirect comparisons. Markov Chain Monte Carlo simulation was used to obtain pooled estimates. Rankogram was generated based on surface under the cumulative ranking curve (SUCRA). RESULTS A total of 26 studies with 2088 participants and 1018 events were included. The pooled estimates for recombinant epidermal growth factor (rhEGF), autologous platelet rich plasma (PRP), recombinant human platelet-derived growth factor (rhPDGF) were 5.72 [3.34, 10.37], 2.65 [1.60, 4.54] and 1.97 [1.54, 2.55] respectively. SUCRA for rhEGF was 0.95. Sensitivity analyses did not reveal significant changes from the pooled estimates and rankogram. No differences were observed in the overall risk of adverse events between the growth factors. However, the growth factors were observed to lower the risk of lower limb amputation compared to standard of care. CONCLUSION To conclude, rhEGF, rhPDGF and autologous PRP significantly improved the healing rate when used as adjuvants to standard of care, of which rhEGF may perform better than other growth factors. The strength of most of the outcomes assessed was low and the findings may not be applicable for DFU with infection or osteomyelitis. The findings of this study needs to be considered with caution as the results might change with findings from head-to-head studies.
Collapse
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- Department of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| |
Collapse
|
12
|
Abstract
BACKGROUND Peripheral artery disease (PAD) is associated with a high clinical and socioeconomic burden. Treatments to alleviate the symptoms of PAD and decrease the risks of amputation and death are a high societal priority. A number of growth factors have shown a potential to stimulate angiogenesis. Growth factors delivered directly (as recombinant proteins), or indirectly (e.g. by viral vectors or DNA plasmids encoding these factors), have emerged as a promising strategy to treat patients with PAD. OBJECTIVES To assess the effects of growth factors that promote angiogenesis for treating people with PAD of the lower extremities. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Specialised Register (June 2016) and CENTRAL (2016, Issue 5). We searched trial registries for details of ongoing or unpublished studies. We also checked the reference lists of relevant publications and, if necessary, tried to contact the trialists for details of the studies. SELECTION CRITERIA We included randomised controlled trials comparing growth factors (delivered directly or indirectly) with no intervention, placebo or any other intervention not based on the growth factor's action in patients with PAD of the lower extremities. The primary outcomes were limb amputation, death and adverse events. The secondary outcomes comprised walking ability, haemodynamic measures, ulceration and rest pain. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials and assessed the risk of bias. We used outcomes of the studies at low risk of bias for the main analysis and of all studies in the sensitivity analyses. We calculated odds ratios (OR) for dichotomous outcomes and mean differences for continuous outcomes with 95% confidence intervals (CI). We evaluated statistical heterogeneity using the I2 statistic and Cochrane's Q test. We conducted meta-analysis for the overall effect and for each growth factor as a subgroup analysis using OR in a fixed-effect model. We evaluated the robustness of the results in a sensitivity analysis using risk ratio (RR) and/or a random-effects model. We also assessed the quality of the evidence for each outcome. MAIN RESULTS We included 20 trials in the review and used 14 studies (on approximately 1400 participants) with published results in the analyses. Six published studies compared fibroblast growth factors (FGF), four studies hepatocyte growth factors (HGF) and another four studies vascular endothelial growth factors (VEGF), versus placebo or no therapy. Six of these studies exclusively or mainly investigated participants with intermittent claudication and eight studies exclusively participants with critical limb ischaemia. Follow-up generally ranged from three months to one year. Two small studies provided some data at 2 years and one of them also at 10 years.The direction and size of effects for growth factors on major limb amputations (OR 0.99, 95% CI 0.71 to 1.38; 10 studies, N = 1075) and death (OR 0.99, 95% CI 0.69 to 1.41; 12 studies, N = 1371) at up to two years are uncertain. The quality of the evidence is low due to risk of bias and imprecision (at one year, moderate-quality evidence due to imprecision). However, growth factors may decrease the rate of any limb amputations (OR 0.56, 95% CI 0.31 to 0.99; 6 studies, N = 415). The quality of the evidence is low due to risk of bias and selective reporting.The direction and size of effects for growth factors on serious adverse events (OR 1.09, 95% CI 0.79 to 1.50; 13 studies, N = 1411) and on any adverse events (OR 1.10, 95% CI 0.73 to 1.64; 4 studies, N = 709) at up to two years are also uncertain. The quality of the evidence is low due to risk of bias and imprecision (for serious adverse events at one year, moderate-quality evidence due to imprecision).Growth factors may improve haemodynamic measures (low-quality evidence), ulceration (very low-quality evidence) and rest pain (very low-quality evidence) up to one year, but they have little or no effect on walking ability (low-quality evidence). We did not identify any relevant differences in effects between growth factors (FGF, HGF and VEGF). AUTHORS' CONCLUSIONS The results of this review do not support the use of therapy with the growth factors FGF, HGF or VEGF in people with PAD of the lower extremities to prevent death or major limb amputation or to improve walking ability. However, the use of these growth factors may improve haemodynamic measures and decrease the rate of any limb amputations (probably due to preventing minor amputations) with an uncertain effect on adverse events; an improvement of ulceration and rest pain is very uncertain. New trials at low risk of bias are needed to generate evidence with more certainty.
Collapse
Affiliation(s)
- Vitali Gorenoi
- Hannover Medical SchoolEvidence based Medicine & Health Technology Assessment Working Group, Institute for Epidemiology, Social Medicine and Health Systems ResearchCarl‐Neuberg‐Str. 1HannoverGermany30625
| | - Michael U Brehm
- Hannover Medical SchoolDepartment for Cardiology and AngiologyCarl‐Neuberg‐Str. 1HannoverGermany30265
| | - Armin Koch
- Institute for Biometry, Hannover Medical SchoolCarl‐Neuberg‐Str. 1HannoverGermany30625
| | - Anja Hagen
- Hannover Medical SchoolEvidence based Medicine & Health Technology Assessment Working Group, Institute for Epidemiology, Social Medicine and Health Systems ResearchCarl‐Neuberg‐Str. 1HannoverGermany30625
| | | |
Collapse
|
13
|
|
14
|
Martinez‐Zapata MJ, Martí‐Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, Garcia J, Zaror C. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev 2016; 2016:CD006899. [PMID: 27223580 PMCID: PMC9308064 DOI: 10.1002/14651858.cd006899.pub3] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Autologous platelet-rich plasma (PRP) is a treatment that contains fibrin and high concentrations of growth factors with the potential to improve the healing of chronic wounds. This is the first update of a review first published in 2012. OBJECTIVES To determine whether autologous PRP promotes the healing of chronic wounds. SEARCH METHODS In June 2015, for this first update, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library): Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched for ongoing and unpublished clinical trials in the WHO International Clinical Trials Registry Platform (ICTRP) (searched January 2015). We did not impose any restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared autologous PRP with placebo or alternative treatments for any type of chronic wound in adults. We did not apply any date or language restrictions. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology, including two reviewers independently selecting studies for inclusion, extracting data, and assessing risk of bias. MAIN RESULTS The search identified one new RCT, making a total of 10 included RCTs (442 participants, 42% women). The median number of participants per RCT was 29 (range 10 to 117). Four RCTs recruited people with a range of chronic wounds; three RCTs recruited people with venous leg ulcers, and three RCTs considered foot ulcers in people with diabetes. The median length of treatment was 12 weeks (range 8 to 40 weeks).It is unclear whether autologous PRP improves the healing of chronic wounds generally compared with standard treatment (with or without placebo) (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.95 to 1.50; I(2) = 27%, low quality evidence, 8 RCTs, 391 participants). Autologous PRP may increase the healing of foot ulcers in people with diabetes compared with standard care (with or without placebo) (RR 1.22, 95% CI 1.01 to 1.49; I(2) = 0%, low quality evidence, 2 RCTs, 189 participants). It is unclear if autologous PRP affects the healing of venous leg ulcers (RR 1.02, 95% CI 0.81 to 1.27; I(2) = 0% ). It is unclear if there is a difference in the risk of adverse events in people treated with PRP or standard care (RR 1.05, 95% CI 0.29 to 3.88; I(2) = 0%, low quality evidence from 3 trials, 102 participants). AUTHORS' CONCLUSIONS PRP may improve the healing of foot ulcers associated with diabetes, but this conclusion is based on low quality evidence from two small RCTs. It is unclear whether PRP influences the healing of other chronic wounds. The overall quality of evidence of autologous PRP for treating chronic wounds is low. There are very few RCTs evaluating PRP, they are underpowered to detect treatment effects, if they exist, and are generally at high or unclear risk of bias. Well designed and adequately powered clinical trials are needed.
Collapse
Affiliation(s)
- Maria José Martinez‐Zapata
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | | | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP) ‐ Universitat Autònoma de BarcelonaIberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 167Pavilion 18BarcelonaCatalunyaSpain08025
| | - José Angel Expósito
- Agency for Health Quality and Assessment of Catalonia (AQuAS)Roc Boronat, 81‐95BarcelonaCataloniaSpain08805
| | - Ignasi Bolíbar
- Hospital de la Santa Creu i Sant PauEpidemiología Clínica y Salud PúblicaSant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
| | - Luciano Rodríguez
- Banc de Sang i TeixitsTissue BankPasseig Taulat 106‐116BarcelonaCatalunyaSpain080035
| | - Joan Garcia
- Departament de Salut. Generalitat de CatalunyaCentre de Teixits i Teràpia CellularAutovia de Castelldedels, Km 2.7L'Hospitalet de LLobregatBarcelonaCatalunyaSpain08907
| | - Carlos Zaror
- Faculty of Dentistry, Universidad de la FronteraDepartment of Pediatric Dentistry and OrthodonticTemucoChile
| | | |
Collapse
|
15
|
Game FL, Apelqvist J, Attinger C, Hartemann A, Hinchliffe RJ, Löndahl M, Price PE, Jeffcoate WJ. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:154-68. [PMID: 26344936 DOI: 10.1002/dmrr.2707] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The outcome of management of diabetic foot ulcers remains a challenge, and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012, the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas, which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies, which did not fit in the aforementioned categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews, and the conclusion is similar: that with the possible exception of negative pressure wound therapy in post-operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality.
Collapse
Affiliation(s)
- F L Game
- Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS FT, Derby, UK
| | - J Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - C Attinger
- Department of Plastic Surgery, Medstar Georgetown University, Hospital, Washington D.C., USA
| | - A Hartemann
- Pitié-Salpêtrière Hospital, APHP, Paris 6 University, ICAN, France
| | - R J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - M Löndahl
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - P E Price
- Vice-Chancellors' Office, Cardiff University, Cardiff, Wales, UK
| | - W J Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
16
|
Martí‐Carvajal AJ, Gluud C, Nicola S, Simancas‐Racines D, Reveiz L, Oliva P, Cedeño‐Taborda J. Growth factors for treating diabetic foot ulcers. Cochrane Database Syst Rev 2015; 2015:CD008548. [PMID: 26509249 PMCID: PMC8665376 DOI: 10.1002/14651858.cd008548.pub2] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Foot ulcers are a major complication of diabetes mellitus, often leading to amputation. Growth factors derived from blood platelets, endothelium, or macrophages could potentially be an important treatment for these wounds but they may also confer risks. OBJECTIVES To assess the benefits and harms of growth factors for foot ulcers in patients with type 1 or type 2 diabetes mellitus. SEARCH METHODS In March 2015 we searched the Cochrane Wounds Group Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations, Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Randomised clinical trials in any setting, recruiting people with type 1 or type 2 diabetes mellitus diagnosed with a foot ulcer. Trials were eligible for inclusion if they compared a growth factor plus standard care (e.g., antibiotic therapy, debridement, wound dressings) versus placebo or no growth factor plus standard care, or compared different growth factors against each other. We considered lower limb amputation (minimum of one toe), complete healing of the foot ulcer, and time to complete healing of the diabetic foot ulcer as the primary outcomes. DATA COLLECTION AND ANALYSIS Independently, we selected randomised clinical trials, assessed risk of bias, and extracted data in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We subjected our analyses to both fixed-effect and random-effects model analyses. MAIN RESULTS We identified 28 randomised clinical trials involving 2365 participants. The cause of foot ulcer (neurologic, vascular, or combined) was poorly defined in all trials. The trials were conducted in ten countries. The trials assessed 11 growth factors in 30 comparisons: platelet-derived wound healing formula, autologous growth factor, allogeneic platelet-derived growth factor, transforming growth factor β2, arginine-glycine-aspartic acid peptide matrix, recombinant human platelet-derived growth factor (becaplermin), recombinant human epidermal growth factor, recombinant human basic fibroblast growth factor, recombinant human vascular endothelial growth factor, recombinant human lactoferrin, and recombinant human acidic fibroblast growth factor. Topical intervention was the most frequent route of administration. All the trials were underpowered and had a high risk of bias. Pharmaceutical industry sponsored 50% of the trials.Any growth factor compared with placebo or no growth factor increased the number of participants with complete wound healing (345/657 (52.51%) versus 167/482 (34.64%); RR 1.51, 95% CI 1.31 to 1.73; I(2) = 51%, 12 trials; low quality evidence). The result is mainly based on platelet-derived wound healing formula (36/56 (64.28%) versus 7/27 (25.92%); RR 2.45, 95% 1.27 to 4.74; I(2) = 0%, two trials), and recombinant human platelet-derived growth factor (becaplermin) (205/428 (47.89%) versus 109/335 (32.53%); RR 1.47, 95% CI 1.23 to 1.76, I(2)= 74%, five trials).In terms of lower limb amputation (minimum of one toe), there was no clear evidence of a difference between any growth factor and placebo or no growth factor (19/150 (12.66%) versus 12/69 (17.39%); RR 0.74, 95% CI 0.39 to 1.39; I(2) = 0%, two trials; very low quality evidence). One trial involving 55 participants showed no clear evidence of a difference between recombinant human vascular endothelial growth factor and placebo in terms of ulcer-free days following treatment for diabetic foot ulcers (RR 0.64, 95% CI 0.14 to 2.94; P value 0.56, low quality of evidence)Although 11 trials reported time to complete healing of the foot ulcers in people with diabetes , meta-analysis was not possible for this outcome due to the unique comparisons within each trial, failure to report data, and high number of withdrawals. Data on quality of life were not reported. Growth factors showed an increasing risk of overall adverse event rate compared with compared with placebo or no growth factor (255/498 (51.20%) versus 169/332 (50.90%); RR 0.83; 95% CI 0.72 to 0.96; I(2) = 48%; eight trials; low quality evidence). Overall, safety data were poorly reported and adverse events may have been underestimated. AUTHORS' CONCLUSIONS This Cochrane systematic review analysed a heterogeneous group of trials that assessed 11 different growth factors for diabetic foot ulcers. We found evidence suggesting that growth factors may increase the likelihood that people will have complete healing of foot ulcers in people with diabetes. However, this conclusion is based on randomised clinical trials with high risk of systematic errors (bias). Assessment of the quality of the available evidence (GRADE) showed that further trials investigating the effect of growth factors are needed before firm conclusions can be drawn. The safety profiles of the growth factors are unclear. Future trials should be conducted according to SPIRIT statement and reported according to the CONSORT statement by independent investigators and using the Foundation of Patient-Centered Outcomes Research recommendations.
Collapse
Affiliation(s)
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Susana Nicola
- Universidad Tecnológica EquinoccialFacultad de Ciencias de la Salud Eugenio EspejoQuitoEcuador
| | - Daniel Simancas‐Racines
- Universidad Tecnológica EquinoccialFacultad de Ciencias de la Salud Eugenio EspejoQuitoEcuador
| | | | - Patricio Oliva
- Universidad del DesarrolloFaculty of DentistryBarros Arana 1735ConcepciónChileCP. 4070553
| | - Jorge Cedeño‐Taborda
- Centro de Investigación UNILIME / Universidad de CaraboboCoordinador de la Sección de EndocrinologíaAltos de Colinas de BárbulaValenciaEstado CaraboboVenezuela2001
| | | |
Collapse
|
17
|
Martí-Carvajal AJ, Rojas-Reyes MX, Reveiz L, Rodriguez-Malagon N, Cedeño-Taborda J. Growth factors for treating diabetic foot ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
18
|
Dogan S, Demirer S, Kepenekci I, Erkek B, Kiziltay A, Hasirci N, Müftüoglu S, Nazikoglu A, Renda N, Dincer UD, Elhan A, Kuterdem E. Epidermal growth factor-containing wound closure enhances wound healing in non-diabetic and diabetic rats. Int Wound J 2009; 6:107-15. [PMID: 19432660 DOI: 10.1111/j.1742-481x.2009.00584.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND This study was designed to elucidate the in vivo efficacy of epidermal growth factor (EGF) on wound healing in non diabetic and diabetic rats. METHODS Ninety-six male Wistar-Albino rats were randomly divided into six groups. Saline-moistened gauze, pure gelatin or EGF in gelatin-microsphere dressings were used in a dermal excision model in both normal and streptomycin-induced diabetic rats. Wound healing was evaluated on day 7 and 14. Reduction in wound area, hydroxypyroline content and tensile strength of the wound were evaluated in each rat. Tissue samples taken from the wounds were examined histopathologically for reepithelialisation, cellular infiltration, number of fibroblasts, granulation and neovascularisation. RESULTS On day 7, the use of EGF-containing dressing was observed to reduce the wound area better when compared with the other dressings tested. This effect was significant in normal rats rather than diabetic rats. The difference in reduction of wound area did not persist on day 14. No significant effect on hydroxyproline content of the wound was found with EGF-containing dressing in either normal or diabetic rats. There was a statistically significant increase in tensile strength values of EGF-applied non diabetic rats over the 14 day period. An increase in tensile strength was prominent in also EGF-applied diabetic rats on day 14. Histological examination revealed higher histopathologic scores in EGF-applied diabetic and non diabetic rats. CONCLUSION These findings implicate that use of EGF in gelatin-microsphere dressings improves wound healing both in normal and diabetic rats.
Collapse
Affiliation(s)
- S Dogan
- Ankara University School of Medicine, Department of General Surgery, Ankara, Turkey
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Hinchliffe RJ, Valk GD, Apelqvist J, Armstrong DG, Bakker K, Game FL, Hartemann-Heurtier A, Löndahl M, Price PE, van Houtum WH, Jeffcoate WJ. A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2008; 24 Suppl 1:S119-44. [PMID: 18442185 DOI: 10.1002/dmrr.825] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The outcome of management of diabetic foot ulcers is poor and there is uncertainty concerning optimal approaches to management. We have undertaken a systematic review to identify interventions for which there is evidence of effectiveness. A search was made for reports of the effectiveness of interventions assessed in terms of healing, ulcer area or amputation in controlled clinical studies published prior to December 2006. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Selected studies fell into the following categories: sharp debridement and larvae; antiseptics and dressings; chronic wound resection; hyperbaric oxygen (HBO); reduction of tissue oedema; skin grafts; electrical and magnetic stimulation and ultrasound. Heterogeneity of studies prevented pooled analysis of results. Of the 2251 papers identified, 60 were selected for grading following full text review. Some evidence was found to support hydrogels as desloughing agents and to suggest that a systemic (HBO) therapy may be effective. Topical negative pressure (TNP) may promote healing of post-operative wounds, and resection of neuropathic plantar ulcers may be beneficial. More information was needed to confirm the effectiveness and cost-effectiveness of these and other interventions. No data were found to justify the use of any other topically applied product or dressing, including those with antiseptic properties. Further evidence to substantiate the effect of interventions designed to enhance the healing of chronic ulcers is urgently needed. Until such evidence is available from robust trials, there is limited justification for the use of more expensive treatments and dressings.
Collapse
Affiliation(s)
- R J Hinchliffe
- Department of Vascular Surgery, Nottingham University Hospitals Trust, Nottingham, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|