A randomised controlled trial of compression therapies for the treatment of venous leg ulcers (VenUS 6): study protocol for a pragmatic, multicentre, parallel-group, three-arm randomised controlled trial

BACKGROUND

Venous leg ulcer(s) are common, recurring, open wounds on the lower leg, resulting from diseased or damaged leg veins impairing blood flow. Wound healing is the primary treatment aim for venous leg ulceration, alongside the management of pain, wound exudate and infection. Full (high) compression therapy delivering 40 mmHg of pressure at the ankle is the recommended first-line treatment for venous leg ulcers. There are several different forms of compression therapy available including wraps, two-layer hosiery, and two-layer or four-layer bandages. There is good evidence for the clinical and cost-effectiveness of four-layer bandage and two-layer hosiery but more limited evidence for other treatments (two-layer bandage and compression wraps). Robust evidence is required to compare clinical and cost-effectiveness of these and to investigate which is the best compression treatment for reducing time to healing of venous leg ulcers whilst offering value for money. VenUS 6 will therefore investigate the clinical and cost-effectiveness of evidence-based compression, two-layer bandage and compression wraps for time to healing of venous leg ulcers.

METHODS

VenUS 6 is a pragmatic, multi-centre, three-arm, parallel-group, randomised controlled trial. Adult patients with a venous leg ulcer will be randomised to receive (1) compression wraps, (2) two-layer bandage or (3) evidence-based compression (two-layer hosiery or four-layer bandage). Participants will be followed up for between 4 and 12 months. The primary outcome will be time to healing (full epithelial cover in the absence of a scab) in days since randomisation. Secondary outcomes will include key clinical events (e.g. healing of the reference leg, ulcer recurrence, ulcer/skin deterioration, amputation, admission/discharge, surgery to close/remove incompetent superficial veins, infection or death), treatment changes, adherence and ease of use, ulcer related pain, health-related quality of life and resource use.

DISCUSSION

VenUS 6 will provide robust evidence on the clinical and cost-effectiveness of the different forms of compression therapies for venous leg ulceration. VenUS 6 opened to recruitment in January 2021 and is currently recruiting across 30 participating centres.

TRIAL REGISTRATION

ISRCTN67321719 . Prospectively registered on 14 September 2020.

Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review

AIM

To investigate whether ulceration, amputation and healing of foot ulcers in people living with diabetes are associated with psychosocial and behavioural factors.

METHODS

We searched MEDLINE, Embase, PsychINFO, CINAHL and The Cochrane Library to March 2019 for longitudinal studies with multivariable analyses investigating independent associations. Two reviewers extracted data and assessed risk of bias.

RESULTS

We identified 15 eligible studies involving over 12 000 participants. Clinical and methodological heterogeneity precluded meta-analysis, so we summarize narratively. Risk of bias was moderate or high. For ulceration, we found significantly different results for people with and without an ulcer history. For those with no ulcer history, moderate quality evidence suggests depression increases ulcer risk [three studies; e.g. hazard ratio (HR) 1.68 (1.20, 2.35) per Hospital Anxiety and Depression Scale (HADS) standard unit]. Better foot self-care behaviour reduces ulcer risk [HR 0.61 (0.40, 0.93) per Summary of Diabetes Self-Care Activities scale standard unit; one study]. For people with diabetes and previous ulcers, low- or very low-quality evidence suggests little discernible association between ulcer recurrence and depression [e.g. HR 0.88 (0.61, 1.27) per HADS standard unit], foot self-care, footwear adherence or exercise. Low-quality evidence suggests incomplete clinic attendance is strongly associated with amputation [odds ratio (OR) 3.84 (1.54, 9.52); one study]. Evidence for the effects of other psychosocial or behavioural factors on ulcer healing and amputation is very low quality and inconclusive.

CONCLUSIONS

Psychosocial and behavioural factors may influence the development of first ulcers. More high quality research is needed on ulcer recurrence and healing. (Open Science Framework Registration: https://osf.io/ej689).

Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration

BACKGROUND

Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers.

METHODS

This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol.

RESULTS

After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective.

CONCLUSION

Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

Pilot feasibility randomized clinical trial of negative-pressure wound therapy versus usual care in patients with surgical wounds healing by secondary intention

Background

Surgical wounds healing by secondary intention (SWHSI) are increasingly being treated with negative-pressure wound therapy (NPWT) despite a lack of high-quality research evidence regarding its clinical and cost-effectiveness. This pilot feasibility RCT aimed to assess the methods for and feasibility of conducting a future definitive RCT of NPWT for the treatment of SWHSI.

Methods

Eligible consenting adult patients receiving care at the study sites (2 acute and 1 community) and with a SWHSI appropriate for NPWT or wound dressing treatment were randomized 1 : 1 centrally to receive NPWT or usual care (no NPWT). Participants were followed up every 1-2 weeks for 3 months. Feasibility (recruitment rate, time to intervention delivery) and clinical (time to wound healing) outcomes were assessed.

Results

A total of 248 participants were screened for eligibility; 40 (16·1 per cent) were randomized, 19 to NPWT and 21 to usual care. Twenty-four of the 40 wounds were located on the foot. Participants received NPWT for a median of 18 (range 0-72) days. Two participants in the NPWT group never received the intervention and 14 received NPWT within 48 h of randomization. Five participants in the usual care group received NPWT during the study. Ten of the 40 wounds were deemed to have healed during the study.

Conclusion

A full-scale RCT to investigate the clinical and cost-effectiveness of NPWT for SWHSI is feasible. This study identified crucial information on recruitment rates and data collection methods to consider during the design of a definitive RCT. Registration number: ISRCTN12761776 (http://www.iscrtn.com).

Association between psychological health and wound complications after surgery

Background

Surgical wound complications remain a major cause of morbidity, leading to higher costs and reduced quality of life. Although psychological health is widely considered to affect wound healing, the evidence on wound outcomes after surgery is mixed. Studies generally focus on small samples of patients undergoing a specific procedure and have limited statistical power.

Methods

This study investigated the relationship between three different measures of anxiety and/or depression and seven adverse surgical outcomes using observational data collected before and after surgery between 2009 and 2011. A wide range of confounding factors was adjusted for, including patient demographics, physical co-morbidities, health-related behaviours, month of operation, procedure complexity and treating hospital.

Results

The estimation sample included 176 827 patients undergoing 59 410 hip replacements, 64 145 knee replacements, 38 328 hernia repairs and 14 944 varicose vein operations. Patients with moderate anxiety or depression had an increased probability of wound complications after a hip replacement (odds ratio (OR) 1·17, 95 per cent c.i. 1·11 to 1·24). They were more likely to be readmitted for a wound complication (OR 1·20, 1·02 to 1·41) and had an increased duration of hospital stay by 0·19 (95 per cent c.i. 0·15 to 0·24) days. Estimated associations were consistent across all four types of operation and for each measure of anxiety and/or depression.

Conclusion

Preoperative psychological health is a significant risk factor for adverse wound outcomes after surgery for four of the procedures most commonly performed in England.

Systematic review and mixed treatment comparison: dressings to heal diabetic foot ulcers

AIMS/HYPOTHESIS

Foot ulcers in people with diabetes are a common and serious global health issue. Dressings form a key part of ulcer treatment. Existing systematic reviews are limited by the lack of head-to-head comparisons of alternative dressings in a field where there are several different dressing options. We aimed to determine the relative effects of alternative wound dressings on the healing of diabetic foot ulcers.

METHODS

This study was a systematic review involving Bayesian mixed treatment comparison. We included randomised controlled trials evaluating the effects on diabetic foot ulcer healing of one or more wound dressings. There were no restrictions based on language or publication status.

RESULTS

Fifteen eligible studies, evaluating nine dressing types, were included. Ten direct treatment comparisons were made. Whilst there was increased healing associated with hydrogel and foam dressings compared with basic wound contact materials, these findings were based on data from small studies at unclear or high risk of bias. The mixed treatment comparison suggested that hydrocolloid-matrix dressings were associated with higher odds of ulcer healing than all other dressing types; there was a high degree of uncertainty around these estimates, which were deemed to be of very low quality.

CONCLUSIONS/INTERPRETATION

These findings summarise all available trial evidence regarding the use of dressings to heal diabetic foot ulcers. More expensive dressings may offer no advantages in terms of healing than cheaper basic dressings. In addition, evidence pointing to a difference in favour of 'advanced' dressing types over basic wound contact materials is of low or very low quality.

VenUS III: a randomised controlled trial of therapeutic ultrasound in the management of venous leg ulcers

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of low-dose ultrasound delivered in conjunction with standard care against standard care alone in the treatment of hard-to-heal venous ulcers.

DESIGN

A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation.

SETTING

Community nurse services; community leg ulcer clinics; hospital outpatient leg ulcer clinics, among both urban and rural settings in England, Scotland, Northern Ireland and Ireland.

PARTICIPANTS

Patients with a venous leg ulcer of > 6 months' duration or > 5 cm2 and an ankle-brachial pressure index of ≥ 0.8. In total, 337 patients were recruited to the study.

INTERVENTIONS

Participants in the intervention group received low-dose ultrasound (0.5 W/cm2) delivered at 1 MHz, pulsed pattern of 1 : 4, applied to periulcer skin (via a water-based contact gel) weekly for up to 12 weeks alongside standard care. Standard care consisted of low-adherent dressings and compression therapy, renewed as recommended by the patient's nurse and modified if required to reflect changes in ulcer and skin condition. The output of the ultrasound machines was checked every 3 months to confirm intervention fidelity.

MAIN OUTCOME MEASURES

The primary end point was time to healing of the largest eligible ulcer (reference ulcer). Secondary outcomes were time to healing of all ulcers, proportion of patients healed, percentage and absolute change in ulcer size, proportion of time patients were ulcer free, cost of treatments, health-related quality of life (HRQoL), adverse events, withdrawal and loss to follow-up.

RESULTS

There was a small, and statistically not significant, difference in the median time to complete ulcer healing of all ulcers in favour of standard care [median 328 days, 95% confidence interval (CI) 235 days, inestimable] compared with ultrasound (median 365 days, 95% CI 224 days, inestimable). There was no difference between groups in the proportion of patients with ulcers healed at 12 months (72/168 in ultrasound vs 78/169 standard care), nor in the change in ulcer size at 4 weeks. There was no evidence of a difference in recurrence of healed ulcers. There was no difference in HRQoL [measured using the Short Form questionnaire-12 items (SF-12)] between the two groups. There were more adverse events with ultrasound than with standard care. Ultrasound therapy as an adjuvant to standard care was found not to be a cost-effective treatment when compared with standard care. The mean cost of ultrasound was £197.88 (bias-corrected 95% CI -£35.19 to £420.32) higher than standard care per participant per year. There was a significant relationship between ulcer healing and area and duration at baseline. In addition, those centres with high recruitment rates had the highest healing rates.

CONCLUSIONS

Low-dose ultrasound, delivered weekly during dressing changes, added to the package of current best practice (dressings, compression therapy) did not increase ulcer healing rates, affect quality of life (QoL) or reduce recurrence. It was associated with higher costs and more adverse events. There is no evidence that adding low-dose ultrasound to standard care for 'hard-to-heal' ulcers aids healing, improves QoL or reduces recurrence. It increases costs and adverse events. The relationship between ulcer healing rates and patient recruitment is worthy of further study.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN21175670.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 13. See the HTA programme website for further project information.

Economic evaluation of a randomized controlled trial of ultrasound therapy for hard-to-heal venous leg ulcers

Background

A pragmatic, multicentre randomized controlled trial (VenUS III) was conducted to determine whether low-dose ultrasound therapy increased the healing rate of hard-to-heal leg ulcers. This study was a cost-effectiveness analysis of the trial data.

Methods

Cost-effectiveness and cost–utility analyses were conducted alongside the VenUS III trial, in which patients were randomly allocated to either ultrasound treatment administered weekly for 12 weeks along with standard care, or standard care alone. The time horizon was 12 months and based on the UK National Health Service (NHS) perspective.

Results

The base-case analysis showed that ultrasound therapy added to standard care was likely to be more costly and provide no extra benefit over standard care alone. Individuals who received ultrasound treatment plus standard care took a mean of 14·7 (95 per cent confidence interval − 32·7 to 56·8) days longer to heal, had 0·009 (−0·042 to 0·024) fewer quality-adjusted life years and had higher treatment costs by £197·88 (−35·19 to 420·32). Based on these point estimates, ultrasound therapy plus standard care for leg ulcers was dominated by standard care alone. The analysis of uncertainty showed that this treatment strategy is unlikely to be cost-effective.

Conclusion

Ultrasound treatment was not cost-effective for hard-to-heal leg ulcers and should not be recommended for adoption in the NHS. Registration number: ISRCTN21175670 (http://www.controlled-trials.com) and N0484162339 (National Research Register).

Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence

AIMS/HYPOTHESIS

Experimental evidence suggests that the healing of diabetic foot ulcers is affected by psychosocial factors such as distress. We examined this proposal in a prospective study, in which we considered the role of psychological distress and coping style in the healing of diabetic foot ulcers over a 24 week period. We also explored the role of salivary cortisol and matrix metalloproteinases (MMPs) as potential mechanisms.

METHODS

For this prospective observational study we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. Clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol and both MMP2 and MMP9 were assessed at baseline. Ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. The primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed.

RESULTS

After controlling for clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping, but not by depression or anxiety. Patients with unhealed ulcers exhibited greater confrontation coping (model including depression: OR 0.809, 95% CI 0.704-0.929, p = 0.003; model including anxiety: OR 0.810, 95% CI 0.704-0.930, p = 0.003). However, change in ulcer size over the observation period was associated with depression only (p = 0.04, d = 0.31). Healed ulcers by 24 weeks were also associated with lower evening cortisol, higher precursor MMP2 and a greater cortisol awakening response.

CONCLUSIONS/INTERPRETATION

Confrontation coping and depression predict ulcer healing. Our preliminary enquiry into biological mechanisms suggests that cortisol and precursor MMP2 may underlie these relationships.

Value of a modified clinical signs and symptoms of infection checklist for leg ulcer management

BACKGROUND

The aim of this study was to analyse the validity of a modified Clinical Signs and Symptoms Checklist used to measure infection in a sample of patients with a leg ulcer.

METHODS

Data from patients recruited to a randomized controlled trial evaluating larval therapy (VenUS II) were analysed using factor analysis to identify the underlying checklist structure. Linear regression analysis identified whether checklist items, patient characteristics and subjective judgement of infection could predict bacterial load.

RESULTS

There were several redundant checklist items when implemented in this sample and items forming the scale had low internal consistency (alpha = 0.27). No clear structure to the checklist was detected, with only one underlying theme revealed which had low internal consistency (alpha = 0.45). Predictions of bacterial count were possible using the emerged theme, some checklist items and ankle circumference, but not using clinicians' subjective judgement alone (P = 0.315).

CONCLUSION

The modified Clinical Signs and Symptoms Checklist does not currently represent a valid tool to measure infection in leg ulcers. Some checklist items may predict bacterial load and may be better than subjective judgement alone.

VenUS II: a randomised controlled trial of larval therapy in the management of leg ulcers

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of larval therapy with a standard debridement technique (hydrogel).

DESIGN

A pragmatic, three-arm, randomised controlled trial with an economic evaluation.

SETTING

Community nursing services, community leg ulcer clinics and hospital outpatient leg ulcer clinics. A range of urban and rural settings.

PARTICIPANTS

Patients with venous or mixed venous/arterial ulcers (minimum ankle brachial pressure index of 0.6) where a minimum of 25% of ulcer area was covered by slough and/or necrotic material.

INTERVENTIONS

Loose larval therapy and bagged larval therapy compared with hydrogel.

MAIN OUTCOME MEASURES

The primary end point was complete healing of the largest eligible ulcer. The primary outcome was time to complete healing of the reference ulcer. Secondary outcomes were: time to debridement, cost of treatments, health-related quality of life (including ulcer-related pain), bacterial load, presence of methicillin-resistant Staphylococcus aureus and staff and patient attitudes to and beliefs about larval therapy.

RESULTS

Between July 2004 and May 2007 the trial recruited 267 people aged 20-94 years at trial entry. There were more female (n = 158) than male (n = 109) participants and most ulcers were classified by the nurse as having an area greater than 5 cm(2). The time to healing for the three treatment arms was compared using the log rank test. The difference in time to healing in the three treatments was not statistically significant at the 5% level. Adjustment was then made for stratification and prespecified prognostic factors (centre, baseline ulcer area, ulcer duration and type of ulcer) using a Cox proportional hazards model. No difference was found in healing rates between the loose and bagged larvae groups. Results for larvae (loose and bagged pooled) compared with hydrogel showed no evidence of a difference in time to healing. When the same analytical steps were used to investigate time to debridement, larvae-treated ulcers debrided significantly more rapidly than hydrogel-treated ulcers; however, the difference in time to debridement between loose and bagged larvae was not significant. The adjusted analysis reported the hazard of debriding at any time for those in loose and bagged larvae groups as approximately twice that of the hydrogel group. No differences in health-related quality of life or bacteriology were observed between trial arms. Larval therapy was associated with significantly more ulcer-related pain than hydrogel. Our base-case economic evaluation showed large decision uncertainty associated with the cost-effectiveness of larval therapy compared with hydrogel, suggesting that larval therapy and hydrogel therapy have similar costs and effects in the treatment of sloughy and/or necrotic leg ulcers.

CONCLUSIONS

Larval therapy significantly reduced the time to debridement of sloughy and/or necrotic, chronic venous and mixed venous/arterial leg ulcers, compared with hydrogel; however, larval therapy did not significantly increase the rate of healing of the ulcers. It was impossible to distinguish between larval therapy and hydrogel in terms of cost-effectiveness. Future research should investigate the association of debridement and healing and the value of debridement as a clinical outcome for patients and clinicians. To inform decision-makers' selection of debriding agents where debridement is the treatment goal, decision analytic modelling of all alternative debridement treatments is required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55114812.

Electromagnetic therapy for treating venous leg ulcers

BACKGROUND

Leg ulceration is a common, chronic, recurring condition. The estimated prevalence of leg ulcers in the UK population is 1.5 to 3 per 1000. Venous ulcers (also called stasis, or varicose ulcers) comprise 80 to 85% of all leg ulcers. Electromagnetic therapy is sometimes used as a treatment to assist the healing of chronic wounds such as venous leg ulcers.

OBJECTIVES

To assess the effects of electromagnetic therapy on the healing of venous leg ulcers.

SEARCH STRATEGY

For this first review update, we searched the Cochrane Wounds Group Specialised Register (last searched October 2005); CENTRAL (The Cochrane Library 2005, Issue 4); MEDLINE (1966 to October 2005); EMBASE (1980 to October 2005); and CINAHL (1982 to October 2005).

SELECTION CRITERIA

Randomised controlled trials comparing electromagnetic therapy with sham electromagnetic therapy or other treatments.

DATA COLLECTION AND ANALYSIS

For the original review, details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. A second reviewer checked data extraction. Meta-analysis was applied to combine the results of trials where the interventions and outcome measures were adequately similar. For this first update, two reviewers independently scrutinized the results of the search to identify relevant RCTs and obtained full reports of potentially eligible studies. In the case of disagreements, a final decision was made either after discussion between two reviewers or consultation with a third party (a member of the Cochrane Wounds Group).

MAIN RESULTS

This update identified no new trials. A total of three eligible RCTs were identified by the original review. Two trials compared the use of electromagnetic therapy with sham therapy and one trial compared it with standard topical treatments. One trial found a difference in healing rates of borderline statistical significance between electromagnetic therapy and sham therapy, although the direction of treatment effect was consistently in favour of electromagnetic therapy, the difference was not statistically significant.

AUTHORS' CONCLUSIONS

There is currently no reliable evidence of benefit of electromagnetic therapy in the healing of venous leg ulcers. Further research is needed.

Brief report on the experience of using proxy consent for incapacitated adults

The Medicines for Human Use (Clinical Trials) Regulations 2004, which came into force in the UK in May 2004, cover the conduct of clinical trials on medicinal products. They allow a legal representative (a person not connected with the conduct of the trial) to consent to the participation of incompetent adults in medical research. Currently, very little is known about how such representatives will make their decisions. We have experience with proxy consent for older adults in a large, national trial. From 2445 potentially eligible but incapacitated patients, proxy, relative assent resulted in trial participation of only 87 (3.6%) patients. The reasons for this were that a large number of incapacitated patients had no relative available for assent (2286), but also a high proportion of relatives approached refused to provide assent (72/159, 45.3%). In comparison, 17.7% of patients declined participation in the trial.Proxy consent allowed only a small increase in trial recruitment of incapacitated patients. The fact that a greater proportion of relatives than patients refused to provide assent implies that they were more cautious than the patients themselves, or perhaps used different criteria, when making their decision. In future research involving incapacitated older patients there is likely to be heavy reliance on proxy consent provision by legal representatives. Our findings imply that consent decisions of legal representatives will not necessarily reflect those of patients themselves.

Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers

BACKGROUND

The study investigated the cost-effectiveness of four-layer and short-stretch compression bandages for treating venous leg ulcers.

METHODS

Cost-effectiveness and cost-utility analyses were performed using patient-level data collected alongside the VenUS I leg ulcer study. The perspective for the economic analysis was that of the UK National Health Service (NHS) and Personal Social Service. The time horizon for the analysis was 1 year after recruitment. Health benefit was measured as differences in ulcer-free days and quality-adjusted life years (QALYs).

RESULTS

The mean healing time for ulcers treated with four-layer bandages was 10.9 (95 per cent confidence interval (c.i.) -6.8 to 29.1) days less than that for ulcers treated with short-stretch bandages. Mean average difference in QALYs between compression systems was -0.02 (95 per cent c.i. -0.08 to 0.04). The four-layer bandage cost a mean of pound 227.32 (95 per cent c.i. pound 16.53 to pound 448 .30) less per patient per year than the short-stretch bandage.

CONCLUSION

On average, four-layer bandaging was associated with greater health benefits and lower costs than short-stretch bandaging.

Randomized clinical trial of four-layer and short-stretch compression bandages for venous leg ulcers (VenUS I)

BACKGROUND

A randomized clinical trial was undertaken to determine the relative effectiveness of four-layer and short-stretch bandaging for venous ulceration.

METHODS

A total of 387 adults with a venous ulcer, who were receiving leg ulcer treatment either in primary care or as a hospital outpatient, were recruited to this parallel-group open study and randomized to either four-layer or short-stretch bandages. Follow-up continued until the patient's reference leg was ulcer free or for a minimum of 12 months. The primary endpoint was time to complete healing of all ulcers on the reference leg. Secondary outcomes included proportion of ulcers healed, health-related quality of life, withdrawals and adverse events. Analysis was by intention to treat.

RESULTS

Unadjusted analysis identified no statistically significant difference in median time to healing: 92 days for four-layer and 126 days for short-stretch bandages. However, when prognostic factors were included in a Cox proportional hazards regression model, ulcers treated with the short-stretch bandage had a lower probability of healing than those treated with the four-layer bandage: hazard ratio 0.72 (95 per cent confidence interval 0.57 to 0.91). More adverse events and withdrawals were reported with the short-stretch bandage.

CONCLUSION

Venous leg ulcers treated using a four-layer bandage healed more quickly than those treated with a short-stretch bandage.

Support surfaces for pressure ulcer prevention

BACKGROUND

Pressure ulcers (also known as bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue due to pressure, shear or friction. They are common in the elderly and immobile and costly in financial and human terms. Pressure-relieving beds, mattresses and seat cushions are widely used as aids to prevention in both institutional and non-institutional settings.

OBJECTIVES

This systematic review seeks to answer the following questions: to what extent do pressure-relieving cushions, beds, mattress overlays and mattress replacements reduce the incidence of pressure ulcers compared with standard support surfaces? how effective are different pressure-relieving surfaces in preventing pressure ulcers, compared to one another?

SEARCH STRATEGY

The Specialised Trials Register of the Cochrane Wounds Group (compiled from regular searches of many electronic databases including MEDLINE, CINAHL and EMBASE plus handsearching of specialist journals and conference proceedings) was searched up to January 2004, Issue 3, 2004 of the Cochrane Central Register of Controlled Trials was also searched. The reference sections of included studies were searched for further trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs), published or unpublished, which assessed the effectiveness of beds, mattresses, mattress overlays, and seating cushions for the prevention of pressure ulcers, in any patient group, in any setting. RCTs were eligible for inclusion if they reported an objective, clinical outcome measure such as incidence and severity of new of pressure ulcers developed. Studies which only reported proxy outcome measures such as interface pressure were excluded.

DATA COLLECTION AND ANALYSIS

Trial data were extracted by one researcher and checked by a second. The results from each study are presented as relative risk for dichotomous variables. Where deemed appropriate, similar studies were pooled in a meta analysis.

MAIN RESULTS

41 RCTs were included in the review. Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk. The relative merits of alternating and constant low pressure devices, and of the different alternating pressure devices for pressure ulcer prevention are unclear.Pressure-relieving overlays on the operating table have been shown to reduce postoperative pressure ulcer incidence, although one study indicated that an overlay resulted in adverse skin changes. One trial indicated that Australian standard medical sheepskins prevented pressure ulcers. There is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices as pressure ulcer prevention strategies.A study of Accident & Emergency trolley overlays did not identify a reduction in pressure ulcer incidence. There are tentative indications that foot waffle heel elevators, a particular low air loss hydrotherapy mattress and an operating theatre overlay are harmful.

REVIEWERS' CONCLUSIONS

In people at high risk of pressure ulcer development, consideration should be given to the use of higher specification foam mattresses rather than standard hospital foam mattresses. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear. Organisations might consider the use of pressure relief for high risk patients in the operating theatre, as this is associated with a reduction in post-operative incidence of pressure ulcers. Seat cushions and overlays designed for use in Accident & Emergency settings have not been adequately evaluated.

Systematic reviews of wound care management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot ulceration

BACKGROUND

Chronic wounds, including pressure sores, leg ulcers, diabetic foot ulcers and other kinds of wounds, healing by secondary intention are common in both acute and community settings. The prevention and treatment of chronic wounds includes many strategies, including the use of various wound dressings, bandages, antimicrobial agents, footwear, physical therapies and educational strategies. This review is one of a series of reviews, and focuses on the prevention and treatment of diabetic foot ulcers and the role of antimicrobial agents in chronic wounds in general.

OBJECTIVES

To assess the clinical- and cost-effectiveness of (1) prevention and treatment strategies for diabetic foot ulcers and (2) systemic and topical antimicrobial agents in the prevention and healing of chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases were searched, including MEDLINE, CINAHL, Embase and the Cochrane Library. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. An expert panel was consulted.

METHODS - STUDY SELECTION

Randomised and non-randomised trials with a concurrent control group, which evaluated any intervention for the prevention or treatment of diabetic foot ulcers, or systemic or topical antimicrobials for chronic wounds (diabetic foot ulcers, pressure ulcers, leg ulcers of various aetiologies, pilonidal sinuses, non-healing surgical wounds, and cavity wounds) and used objective measures of outcome such as: (1) development or resolution of callus; (2) incidence of ulceration (for diabetic foot ulcer prevention studies); (3) incidence of pressure sores (pressure sore prevention studies); (4) any objective measure of wound healing (frequency of complete healing, change in wound size, time to healing, rate of healing); (5) ulcer recurrence rates; (6) side-effects; (7) amputation rates (diabetic foot ulcer treatment studies); (8) healing rates and recurrence of disease, among others, for pilonidal sinuses. Studies reporting solely microbiological outcomes were excluded. Decisions on the inclusion of primary studies were made independently by two reviewers. Disagreements were resolved through discussion. Data were extracted by one reviewer into structured summary tables. Data extraction was checked independently by a second reviewer and discrepancies resolved by discussion. All included studies were assessed against a comprehensive checklist for methodological quality. INCLUDED STUDIES - DIABETIC FOOT ULCERS: Thirty-nine trials which evaluated various prevention and treatment modalities for diabetic foot ulcers: footwear (2), hosiery (1), education (5), screening and foot protection programme (1); podiatry (1) for the prevention of diabetic foot ulcers; and footwear (1), skin replacement (2), hyperbaric oxygen (2), ketanserin (3), prostaglandins (3), growth factors (5), dressings and topical applications (9), debridement (2) and antibiotics (2) for the treatment of diabetic foot ulcers. INCLUDED STUDIES - ANTIMICROBIALS: Thirty studies were included, 25 with a randomised design. There were nine evaluations of systemic antimicrobials and 21 of topical agents.

QUALITY OF STUDIES

The methodological and reporting quality was generally poor. Commonly encountered problems of reporting included lack of clarity about randomisation and outcome measurement procedures, and lack of baseline descriptive data. Common methodological weaknesses included: lack of blinded outcome assessment and lack of adjustment for baseline differences in important variables such as wound size; large loss to follow-up; and no intention-to-treat analysis. RESULTS - PREVENTION OF DIABETIC FOOT ULCERS: There is some evidence (1 large trial) that a screening and foot protection programme reduces the rate of major amputations. The evidence for special footwear (2 small trials) and educational programmes (5 trials) is equivocal. A single trial of podiatric care reported a significantly greater reduction in callus in patients receiving podiatric care. RESULTS - TREATMENT OF DIABETIC FOOT ULCERS: Total contact casting healed significantly more ulcers than did standard treatment in one study. There is evidence from 5 trials of topical growth factors to suggest that these, particularly platelet-derived growth factor, may increase the healing rate of diabetic foot ulcers. Although these studies were of relatively good quality, the sample sizes were far too small to make any definitive conclusions, and growth factors should be compared with current standard treatments in large, multicentre studies. Topical ketanserin increased ulcer healing rate in 2 studies, while systemic hyperbaric oxygen therapy reduced the rate of major amputations in 1 study. Preliminary research into the effects of iloprost and prostaglandin E1 (PGE1) on diabetic foot ulcer healing suggests possible benefits. However, good quality, large-scale confirmatory research is needed. (ABSTRACT TRUNCATED)

Pressure ulcer prevention and treatment. A synopsis of the current evidence from research

Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk. The relative merits of AP and CLP devices and of the different AP devices for pressure ulcer prevention are unclear. There is some evidence from one study to suggest that LAL beds may reduce the incidence of pressure ulcers compared with standard intensive care beds. There is insufficient evidence to make conclusions on the value of various CLP devices and sheepskins as pressure ulcer prevention strategies, although Australian Medical Sheepskin was an effective preventive strategy in a recent study. There is evidence from two trials that air-fluidized therapy may improve pressure ulcer healing rates. There is insufficient evidence to make conclusions on the value of other beds and mattresses as pressure ulcer treatments. There is insufficient evidence to recommend any particular wound dressing or debridement technique. Research about pressure ulcer prevention and treatment is generally conducted on a small scale and is of poor quality; few economic evaluations have been undertaken of pressure area care strategies. Only when a clinically relevant research agenda has been developed and appropriate research methods have been used in sufficiently large studies can evidence-based pressure ulcer prevention and treatment be a possibility. Until then, nurses and other health care professionals can only rely on what little research evidence exists together with their professional judgment to make decisions in this field.

Research information in nurses' clinical decision-making: what is useful?

AIM

To examine those sources of information which nurses find useful for reducing the uncertainty associated with their clinical decisions.

BACKGROUND

Nursing research has concentrated almost exclusively on the concept of research implementation. Few, if any, papers examine the use of research knowledge in the context of clinical decision-making. There is a need to establish how useful nurses perceive information sources are, for reducing the uncertainties they face when making clinical decisions.

DESIGN

Cross-case analysis involving qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England, United Kingdom. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 hours and 122 nurses were involved in the Q modelling exercise.

RESULTS

Text-based and electronic sources of research-based information yielded only small amounts of utility for practising clinicians. Despite isolating four significantly different perspectives on what sources were useful for clinical decision-making, it was human sources of information for practice that were overwhelmingly perceived as the most useful in reducing the clinical uncertainties of nurse decision-makers.

CONCLUSIONS

It is not research knowledge per se that carries little weight in the clinical decisions of nurses, but rather the medium through which it is delivered. Specifically, text-based and electronic resources are not viewed as useful by nurses engaged in making decisions in real time, in real practice, but those individuals who represent a trusted and clinically credible source are. More research needs to be carried out on the qualities of people regarded as clinically important information agents (specifically, those in clinical nurse specialist and associated roles) whose messages for practice appear so useful for clinicians.

Resources to enhance evidence-based nursing practice

Evidence-based practice means integrating the best available research evidence with information about patient preferences, clinician skill level, and available resources to make decisions about patient care. Barriers to the use of research-based evidence occur when time, access to journal articles, search skills, critical appraisal skills, and understanding of the language used in research are lacking. Resources are available to overcome these barriers and support an evidence-based nursing practice. This article highlights available resources and describes strategies that nurses can use to develop and sustain an evidence-based nursing practice.

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings

BACKGROUND

The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions.

AIM

To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use.

DESIGN

Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals.

RESULTS

Three perspectives on accessibility were identified: (a) the humanist--in which human sources of information were the most accessible; (b) local information for local needs--in which locally produced resources were seen as the most accessible and (c) moving towards technology--in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such as clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely to perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses on the wards had any explicit research base. These, and the remainder were out of date (mean age of textbooks 11 years), and authorship hard to ascertain.

CONCLUSION

A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced.

Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy

BACKGROUND

Chronic wounds such as leg ulcers, diabetic foot ulcers and pressure sores are common in both acute and community healthcare settings. The prevention and treatment of these wounds involves many strategies: pressure-relieving beds, mattresses and cushions are universally used as measures for the prevention and treatment of pressure sores; compression therapy in a variety of forms is widely used for venous leg ulcer prevention and treatment; and a whole range of therapies involving laser, ultrasound and electricity is also applied to chronic wounds. This report covers the final three reviews from a series of seven.

AIMS

To assess the clinical effectiveness and cost- effectiveness of: (1) pressure-relieving beds, mattresses and cushions for pressure sore prevention and treatment; (2) compression therapy for the prevention and treatment of leg ulcers; (3) low-level laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy for the treatment of chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases, including MEDLINE, CINAHL, EMBASE and the Cochrane Controlled Trials Register (CENTRAL), were searched. Relevant journals, conference proceedings and bibliographies of retrieved papers were handsearched. An expert panel was also consulted.

METHODS - STUDY SELECTION

Randomised controlled trials (RCTs) which evaluated these interventions were eligible for inclusion in this review if they used objective measures of outcome such as wound incidence or healing rates. RESULTS - BEDS, MATTRESSES AND CUSHIONS FOR PRESSURE SORE PREVENTION AND TREATMENT: A total of 45 RCTs were identified, of which 40 compared different mattresses, mattress overlays and beds. Only two trials evaluated cushions, one evaluated the use of sheepskins, and two looked at turning beds/kinetic therapy. RESULTS - COMPRESSION FOR LEG ULCERS: A total of 24 trials reporting 26 comparisons were included (two of prevention and 24 of treatment strategies). RESULTS - LOW-LEVEL LASER THERAPY, THERAPEUTIC ULTRASOUND, ELECTROTHERAPY AND ELECTROMAGNETIC THERAPY: Four RCTs of laser (for venous leg ulcers), 10 of therapeutic ultrasound (for pressure sores and venous leg ulcers), 12 of electrotherapy (for ischaemic and diabetic ulcers, and chronic wounds generally) and five of electromagnetic therapy (for venous leg ulcers and pressure sores) were included. Studies were generally small, and of poor methodological quality. CONCLUSIONS (1) Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure sores in people at risk, as can pressure-relieving overlays on the operating table. One study suggests that air-fluidised therapy may increase pressure sore healing rates. (2) Compression is more effective in healing venous leg ulcers than is no compression, and multi-layered high compression is more effective than single-layer compression. High-compression hosiery was more effective than moderate compression in preventing ulcer recurrence. (3) There is generally insufficient reliable evidence to draw conclusions about the contribution of laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy to chronic wound healing.

Electromagnetic therapy for the treatment of venous leg ulcers

BACKGROUND

Electromagnetic therapy is used with the aim of improving the healing of chronic wounds such as pressure sores and venous leg ulcers

OBJECTIVES

To assess the effectiveness of electromagnetic therapy in the treatment of venous leg ulcers

SEARCH STRATEGY

The Cochrane Wounds group search strategy was used (see Scope) to search for randomised controlled trials (RCTs) of electromagnetic therapy for the treatment of venous leg ulcers

SELECTION CRITERIA

Randomised controlled trials comparing electromagnetic therapy with sham electromagnetic therapy or other (standard) treatment

DATA COLLECTION AND ANALYSIS

Results of searches were scrutinised by one reviewer (and checked by a second) to identify possible RCTs and full reports of these were obtained. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. Data extraction was checked by a second reviewer.

MAIN RESULTS

A total of three eligible RCTs were identified. Two trials compared the use of electromagnetic therapy to sham (Ieran 1990; Kenkre 1996) and one trial (Stiller 1992) compared it with standard topical treatments. One of the trials found a difference in healing rates of borderline statistical significance between electromagnetic therapy and sham, although the direction of treatment effect was consistently in favour of electromagnetic therapy the difference was not statistically significant.

REVIEWER'S CONCLUSIONS

There is currently no reliable evidence of benefit of electromagnetic therapy in the healing of venous leg ulcers.

Electromagnetic therapy for the treatment of pressure sores

BACKGROUND

Electromagnetic therapy is used with the aim of improving the healing of chronic wounds such as pressure sores and venous leg ulcers

OBJECTIVES

To assess the effectiveness of electromagnetic therapy in the treatment of pressure sores

SEARCH STRATEGY

The Cochrane Wounds Group search strategy was used (see Scope) to search for randomised controlled trials (RCTs) of electromagnetic therapy for the treatment of pressure sores

SELECTION CRITERIA

Randomised controlled trials comparing electromagnetic therapy with sham electromagnetic therapy, or other (standard) treatment

DATA COLLECTION AND ANALYSIS

Results of searches were scrutinised by one reviewer (and checked by a second) to identify possible RCTs and full reports of these were obtained. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. Data extraction was checked by a second reviewer.

MAIN RESULTS

A total of two eligible RCTs were identified for inclusion in this review. The first of these studies (Comorosan 1993) was a three armed study comparing electromagnetic therapy, electromagnetic therapy in combination with standard therapy, and standard therapy alone. The second study (Salzburg 1995) was a comparison between electromagnetic therapy and sham therapy on 30 male patients with a spinal cord injury and a grade two or grade three pressure sore. Neither study found a statistically significant difference between the healing rates of electromagnetic therapy treated and control group patients.

REVIEWER'S CONCLUSIONS

The results suggest no evidence of a benefit in using electromagnetic therapy to treat pressure sores. However the possibility of a beneficial or harmful effect cannot be ruled out due to the fact there were only two trials with methodological limitations and small numbers of patients.

The development of a national guideline on the management of leg ulcers

This paper describes the development of an evidence-linked clinical guideline for the management of uncomplicated venous leg ulcers. Guidelines are developed to provide recommendations for clinical practice which are based on summaries of good quality research evidence. The aim of the guideline discussed in this article is to direct primary health care practitioners to the most effective method of assessment and treatment of venous leg ulcers and to discourage practices that do not have convincing or sufficient evidence of effectiveness. The three most important steps to the development of a valid clinical guideline are: basing recommendations on the best available evidence; explicit linkage between guideline recommendations and quality of evidence; and the involvement of a multidisciplinary group. The steps are discussed in relation to the development of the guideline alongside an introductory presentation on the role guidelines can play in improving practice. Issues arising from guideline development such as valid ways of obtaining patient input and lack of evidence are also discussed.

Laser therapy for venous leg ulcers

OBJECTIVES

To assess the effectiveness of low level laser therapy in the treatment of venous leg ulcers.

SEARCH STRATEGY

Searches of 19 databases, hand searching of journals and conference proceedings from 1948 onwards, and examination of bibliographies.

SELECTION CRITERIA

Randomised controlled trials comparing low level laser therapy with: sham laser; no laser; non-coherent light. There was no restriction on date or language. The main outcome measure used was complete healing of the ulcers.

DATA COLLECTION AND ANALYSIS

Data extraction was done by one reviewer and checked by a second. Meta analysis was used to combine the results of trials where the interventions and outcome measures were sufficiently similar.

MAIN RESULTS

There were 4 eligible trials. Two RCTs compared laser therapy with sham, 1 with ultraviolet therapy and 1 with non-coherent, unpolarised red light. Neither of the two RCTs comparing laser with sham found a significant difference in healing rates; there was no significant of laser evident when the trials were pooled. A three-arm study compared: - laser therapy alone - laser therapy plus infrared light - non-coherent, unpolarised red light. Significantly more ulcers completely healed in the group receiving a combination of laser and infrared light compared with non-coherent, unpolarised red light. A fourth trial compared laser and ultraviolet light and found no difference.

REVIEWER'S CONCLUSIONS

We have found no evidence of any benefit associated with low level laser therapy on venous leg ulcer healing. One small study suggests that a combination of laser and infrared light may promote the healing of venous ulcers, however more research is needed.

Therapeutic ultrasound for pressure sores

BACKGROUND

Pressure sores have been recorded as occurring in 4-10% of patients admitted to a UK District General Hospital (the precise rate depends on case-mix) and in an unknown proportion of patients in the community. They represent a major burden of sickness and reduced quality of life for patients and their carers, and are costly to health service providers. Pressure sores can be treated by using wound dressings, relieving pressure on the wound, by treating concurrent conditions which may delay healing, and by the use of physical therapies such as electrical stimulation, laser therapy and ultrasound.

OBJECTIVES

To assess the effectiveness of the use of therapeutic ultrasound in the treatment of pressure sores.

SEARCH STRATEGY

The Cochrane Wounds Groups search strategy was used (see Scope) to search for randomised controlled trials (RCTs) of therapeutic ultrasound for the treatment of pressure sores up to December 1999.

SELECTION CRITERIA

Randomised controlled trials comparing therapeutic ultrasound with sham ultrasound or other (standard) treatment.

DATA COLLECTION AND ANALYSIS

Results of searches were scrutinised by one reviewer to identify possible RCTs and full reports of these were obtained. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing information by contacting authors. Data extraction was checked by a second reviewer. Meta-analysis was used to combine the results of trials where the interventions and outcome measures were sufficiently similar.

MAIN RESULTS

A total of 3 eligible RCTs were identified. Two RCTs compared ultrasound therapy with sham and the third compared a combination of ultrasound and ultraviolet light with laser and with standard treatment. Neither of the two RCTs comparing ultrasound with sham found a significant difference in healing rates. The trials were pooled, in the absence of significant heterogeneity. There was no evidence of benefit associated with the use of ultrasound in the treatment of pressure sores. In the three-arm comparison there was a significant increase in the weekly healing rates associated with the ultrasound/ultraviolet combination compared with laser but no statistically significant difference between ultrasound/ultraviolet and control.

REVIEWER'S CONCLUSIONS

The results suggest no apparent evidence of a benefit of ultrasound therapy in the treatment of pressure sores. However the possibility of a beneficial or a harmful effect cannot be ruled out due to the small number of trials with methodogical limitations and small numbers of participants.

Therapeutic ultrasound for venous leg ulcers

BACKGROUND

Ultrasound therapy is commonly used with the aim of improving the healing of chronic wounds such as pressure ulcers and venous leg ulcers.

OBJECTIVES

To assess the effectiveness of therapeutic ultrasound in the treatment of venous leg ulcers.

SEARCH STRATEGY

The Cochrane Wounds Group search strategy was used (see Scope) to search for randomised controlled trials (RCTs) of therapeutic ultrasound for the treatment of venous leg ulcers.

SELECTION CRITERIA

Randomised controlled trials comparing therapeutic ultrasound with sham ultrasound, or other (standard) treatment

DATA COLLECTION AND ANALYSIS

Results of searches were scrutinised by one reviewer (and checked by a second) to identify possible RCTs and full reports of these were obtained. Details of eligible studies were extracted and summarised using a data extraction sheet. Attempts were made to obtain missing data by contacting authors. Data extraction was checked by a second reviewer.

MAIN RESULTS

A total of seven eligible RCTs were identified. Four trials compared ultrasound therapy with sham ultrasound, three trials compared ultrasound therapy with standard treatment. None of the trials found a difference in healing rates between any of the therapies, though it is noteworthy that the direction of treatment effect was consistently in favour of ultrasound (though this did not reach significance in the individual studies).

REVIEWER'S CONCLUSIONS

There is no good evidence of a benefit of ultrasound therapy in the healing of venous leg ulcers.

Guidelines in professions allied to medicine

BACKGROUND

Clinical practice guidelines aim to reduce inappropriate variations in practice and to promote the delivery of evidence-based health care.

OBJECTIVES

To identify and assess the effects of studies of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (1975 to 1996), EMBASE, Cinahl and Sigle to 1996, the NHS Economic Evaluations Database (1994 to 1996), DHSS-Data (1983 to 1996), the Database of Abstracts of Reviews of Effectiveness (1994 to 1996) and reference lists of articles. We also hand searched the journal Quality in Health Care, made personal contact with content experts and contacted libraries identified by an expert panel.

SELECTION CRITERIA

Randomised trials, controlled before-and-after studies and interrupted time series analyses of the introduction of interventions comparing 1. Clinical guidelines plus dissemination and/or implementation strategies versus no guidelines; 2. Guidelines plus dissemination and/or implementation strategies versus guidelines plus alternative dissemination and/or implementation strategies; and 3. (post hoc) Guidelines used by professions allied to medicine versus standard physician care. The participants were nurses, midwives and other professions allied to medicine.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eighteen studies were included involving more than 467 health care professionals. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. The various behaviours targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies were identified for comparison 1. Three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies were identified for comparison 2 but it was difficult to draw firm conclusions because of poor methods. Six studies were identified for comparison 3 (post hoc). These studies generally supported the hypothesis that there was no difference between care given by nurses using clinical guidelines and standard physician care.

REVIEWER'S CONCLUSIONS

There is some evidence that guideline-driven care is effective in changing the process and outcome of care provided by professions allied to medicine. However, caution is needed in generalising findings to other professions and settings.

Beds, mattresses and cushions for pressure sore prevention and treatment

OBJECTIVES

To assess the effectiveness of pressure relieving beds, mattresses and cushions (support surfaces) in the prevention and treatment of pressure sores.

SEARCH STRATEGY

Searches of 19 databases, hand searching of journals, conference proceedings, and bibliographies.

SELECTION CRITERIA

Randomised controlled trials evaluating support surfaces for the prevention or treatment of pressure sores. There was no restriction on articles based on language or publication status.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study quality was undertaken by two reviewers independently. Trials with similar patients, comparisons, and outcomes were pooled. Where pooling was inappropriate, trials are discussed in a narrative review.

PREVENTION

29 RCTs of support surfaces for pressure sore prevention were identified. Some high specification foam mattresses were more effective than 'standard' hospital foam mattresses in moderate-high risk patients. Pressure relieving mattresses in the operating theatre reduced the incidence of pressure sores post-operatively. The relative merits of alternating and constant low pressure, and of the different alternating pressure devices are unclear. Seat cushions and simple, constant low-pressure devices have not been adequately evaluated. Limited evidence suggests that low air loss beds reduce the incidence of pressure sores in intensive care.

TREATMENT

6 RCTs of support surfaces for pressure sore treatment were identified. There is good evidence that air-fluidised and low air loss beds improve healing rates. Seat cushions have not been adequately evaluated. 2 RCTs evaluated surfaces for both prevention and treatment in the same trial.

REVIEWER'S CONCLUSIONS

PREVENTION - There is good evidence of the effectiveness of high specification foam over standard hospital foam, and pressure relief in the operating theatre. Treatment - There is good evidence of the effectiveness of air-fluidised and low air loss devices as treatments. Overall, however, it is impossible to determine the most effective surface for either prevention or treatment.

Compression bandages and stockings for venous leg ulcers

OBJECTIVES

To assess the effectiveness and cost-effectiveness of compression bandaging and stockings in the treatment of venous leg ulcers.

SEARCH STRATEGY

Searches of 19 databases, hand searching of journals, conference proceedings and bibliographies. Manufacturers of compression bandages and stockings and an Advisory Panel were contacted for unpublished studies.

SELECTION CRITERIA

Trials that evaluated compression bandaging or stockings, as a treatment for venous leg ulcers. There was no restriction on date or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Details of eligible studies were extracted and summarised using a data extraction sheet. Data extraction was verified by two reviewers independently.

MAIN RESULTS

Twenty two trials reporting 24 comparisons were identified. Compression was more effective than no compression (4/6 trials). When multi-layered systems were compared, elastic compression was more effective than non-elastic compression (5 trials). There was no difference in healing rates between 4-layer bandaging and other high compression multi-layered systems (3 trials). There was no difference in healing rates between elastomeric multi-layered systems (4 trials). Multi-layered high compression was more effective than single layer compression (4 trials). Compression stockings were evaluated in two trials. One found a high compression stocking plus a thrombo stocking to be more effective than a short stretch bandage. The second small trial reported no difference between the compression stockings and Unna's boot. There was insufficient data to draw conclusion about the relative cost-effectiveness of different regimens.

REVIEWER'S CONCLUSIONS

Compression increases ulcer healing rates compared with no compression. Multi-layered systems are more effective than single-layered systems. High compression is more effective than low compression but there are no clear differences in the effectiveness of different types of high compression.

Clinical guidelines in nursing, midwifery and the therapies: a systematic review

BACKGROUND

While nursing, midwifery and professions allied to medicine (PAMs) are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness in relation to these professions. We identified 18 evaluations of guidelines which met established quality for evaluations of interventions aimed at changing professional practice. This paper describes characteristics of guidelines evaluated and the effectiveness of different dissemination and implementation strategies used.

METHODS

Guideline evaluations conducted since 1975 which used a randomized controlled trial, controlled before-and-after, or interrupted time-series design, were identified using a combination of database and hand searching.

FINDINGS

It is mostly impossible to tell whether the guidelines evaluated were based on evidence. The most common method of guideline dissemination was the distribution of printed educational materials. Three studies compared different dissemination and/or implementation strategies: findings suggest educational interventions may be of value in the dissemination of guidelines and confer a benefit over passive dissemination.