Evidence‐based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans

Evidence‐based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence‐based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence‐based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence‐based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer‐etiology groups received the recommended components of evidence‐based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5‐fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence‐based ulcer care. Not all evidence‐based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.     

Pressure ulcers in four Indonesian hospitals: prevalence,patient characteristics,ulcer characteristics,prevention and treatment

The objective of this article was to study characteristics of pressure ulcer patients and their ulcers, pressure ulcer preventive and treatment measures in four Indonesian general hospitals. A multicentre cross‐sectional design was applied to assess pressure ulcers and pressure ulcer care in adult patients in medical, surgical, specialised and intensive care units. Ninety‐one of the 1132 patients had a total of 142 ulcers. Half (44·0%) already had pressure ulcers before admission. The overall prevalence of category I–IV pressure ulcers was 8·0% (95% CI 6·4–9·6), and the overall nosocomial pressure ulcer prevalence was 4·5% (95% CI 3·3–5·7). Most pressure ulcer patients had friction and shear problems, were bedfast, had diabetes and had more bedridden days. Most ulcers (42·3%) were category III and IV. One third of the patients had both pressure ulcers and moisture lesions (36·3%) and suffered from pain (45·1%). The most frequently used prevention measures were repositioning (61·5%), skin moisturising (47·3%), patient education (36·3%) and massage (35·2%). Most pressure ulcer dressings involved saline‐impregnated or antimicrobial gauzes. This study shows the complexities of pressure ulcers in Indonesian general hospitals and reveals that the quality of pressure ulcer care (prevention and treatment) could be improved by implementing the recent evidence‐based international guideline.     

Medical device related pressure ulcers in hospitalized patients

Most pressure ulcers occur over bony prominences such as heels and the sacrum. However, the National Pressure Ulcer Advisory Panel recognises that pressure ulcers can also occur on any tissue under pressure and thereby can develop beneath medical devices. This article reports on results from a secondary analysis of existing data collected by The Nebraska Medical Center on pressure ulcer quality improvement initiatives and outcomes. The purpose of this study was to quantify the extent of the problem and identify risk factors for medical device related (MDR) pressure ulcer development in hospitalised patients. A subset of data collected during eight quarterly pressure ulcer incidence and prevalence studies (N = 2178) was created and analysed. The overall rate of hospital‐acquired pressure ulcers was 5·4% (113 of 2079). The proportion of patients with hospital‐acquired ulcers related to medical devices was 34·5% (39 of 113). Findings indicate that if a patient had a medical device, they were 2·4 times more likely to develop a pressure ulcer of any kind. Numerous risk factors for pressure ulcer development were identified; however, none differentiated between those with MDR and traditional pressure ulcers.     

Getting evidence‐based pressure ulcer prevention into practice: a multi‐faceted unit‐tailored intervention in a hospital setting

The aim of the study was to evaluate whether a multi‐faceted, unit‐tailored intervention using evidenced‐based pressure ulcer prevention affects (i) the performance of pressure ulcer prevention, (ii) the prevalence of pressure ulcers and (iii) knowledge and attitudes concerning pressure ulcer prevention among registered and assistant nurses. A quasi‐experimental, clustered pre‐ and post‐test design was used. Five units at a hospital setting were included. The intervention was based on the PARIHS framework and included a multi‐professional team, training and repeated quality measurements. An established methodology was used to evaluate the prevalence and prevention of pressure ulcers. Nurses' knowledge and attitudes were evaluated using a validated questionnaire. A total of 506 patients were included, of whom 105 patients had a risk to develop pressure ulcer. More patients were provided pressure ulcer prevention care (P = 0·001) and more prevention care was given to each patient (P = 0·021) after the intervention. Corresponding results were shown in the group of patients assessed as being at risk for developing pressure ulcers. Nurses' knowledge about pressure ulcer prevention increased (P < 0·001). Positive attitudes towards pressure ulcer prevention remained high between pre‐ and post‐test surveys. This multi‐faceted unit‐tailored intervention affected pressure ulcer prevention. Facilitation and repeated quality measurement together with constructed feedback of results seemed to be the most important factor for pressure ulcer prevention.     

Clinical effectiveness of an acellular dermal regenerative tissue matrix compared to standard wound management in healing diabetic foot ulcers: a prospective,randomised, multicentre study

This 12‐week, prospective, randomised, controlled multi‐centre study compared the proportion of healed diabetic foot ulcers and mean healing time between patients receiving acellular matrix (AM) (study group) and standard of care (control group) therapies. Eighty‐six patients were randomised into study (47 patients) and control (39 patients) groups. No significant differences in demographics or pre‐treatment ulcer data were calculated. Complete healing and mean healing time were 69·6% and 5·7 weeks, respectively, for the study group and 46·2% and 6·8 weeks, respectively, for the control group. The proportion of healed ulcers between the groups was statistically significant (P = 0·0289), with odds of healing in the study group 2·7 times higher than in the control group. Kaplan–Meier survivorship analysis for time to complete healing at 12 weeks showed a significantly higher non healing rate (P = 0·015) for the control group (53·9%) compared with the study group (30·4%). After adjusting for ulcer size at presentation, which was a statistically significant covariate (P = 0·0194), a statistically significant difference in non healing rate between groups was calculated (P = 0·0233), with odds of healing 2·0 times higher in the study versus control group. This study supports the use of single‐application AM therapy as an effective treatment of diabetic, neuropathic ulcers.     

A large Italian observational multicentre study on vascular ulcers of the lower limbs (Studio Ulcere Vascolari)

An observational study of 2 years was promoted by the Italian Association for Cutaneous Ulcers (AIUC) in order to monitor the epidemiology of leg ulcers, the trend of healing and the more frequent therapeutic approaches in lower limb ulcers. Fifty‐nine sites in 14 different Italian regions involved in the study, with 1333 enrolled patients (1163 patients fully evaluated and followed up for 9 months). A prevalence of females (62%) was observed with a mean age of 70 years and a high rate of hypertension (62%), diabetes (38%) and obesity (29%). Venous ulcer was most frequent (55%), followed by mixed (25%) and diabetic (8·3%) ulcers. Basically, all patients received a local therapy (LT) (compression and advanced local therapies), while 63% of patients have an associated systemic pharmaceutical treatment. Ulcer healing rates progressively increased throughout the study and despite the type of observational study does not allow conclusions on the treatment, it was observed that the patients receiving additional systemic drugs were associated with a more rapid acceleration of healing rates of ulcers compared to LT alone (3 months: 39·7% versus 29·2%; 6 months: 62·0% versus 47·0%; 9 months: 74·7% versus 63·8%). In particular, the Studio Ulcere Vascolari (SUV) study showed that a combination treatment with sulodexide and compression therapy allows for a greater increase in the healing rates in venous ulcers.     

Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team

A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes‐related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty‐three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below‐knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.     

Ulcer‐free survival days and ulcer healing in patients with diabetic foot ulcers: A prospective cohort study

Healing rates may not give a complete indication of the effectiveness and management of diabetic foot ulcers because of high recurrence rates. The most important outcome for patients is remaining ulcer‐free; however, this has hardly been investigated. The aim of our study was to prospectively investigate ulcer‐free survival days and ulcer healing in patients with diabetic foot ulcers. This was a prospective cohort study of all referrals to our diabetic foot expertise centre from December 2014 to April 2017. Outcomes were determined after a minimum follow‐up period of 12 months. Primary outcomes were ulcer‐free survival days and 12‐month healing percentages. Predictors for ulcer‐free survival days and healing were investigated in multivariate analyses. A total of 158 patients were included. Median ulcer‐free survival days in the healed group were 233 days (interquartile range [IQR] 121‐312) and 131 days (IQR 0–298) in the overall population. The healing rate at 12‐month follow up was 67% (106/158), and the recurrence rate was 31% (33/106). Independent predictors of ulcer‐free survival days were duration of diabetes, peripheral artery disease (PAD), cardiovascular disease, end‐stage renal disease (ESRD), and infection. Ulcer‐free survival days are related to PAD and cardiovascular disease, and ulcer‐free survival days should be the main outcome when comparing the effectiveness of management and prevention of the diabetic foot ulcers.     

Prevalence,severity, and characteristics of medical device related pressure injuries in adult intensive care patients: A prospective observational study

This study was intended to determine the characteristics of Medical Related Pressure Injury (MDRPI) in adult intensive care patients. MDRIs are recognized as significant and complex health problems among hospitalized patients. Underestimated true scale of the problem is evident because the systematic clinical evaluation of MDRPI occurrence is not part of routine skin assessment among intensive care patients. A prospective approach was used to obtain data of MDRPIs with two weeks follow up to monitor the prevention and treatment strategies. Participants were 329 adult patients from three large referral and teaching centres in Jordan. Data were collected using a screening form that included demographic and clinical characteristics, and a list of medical devices. The primary outcome for this study was MDRPI and defined as a pressure injury (PI) found on the skin or mucous membrane with a medical device in use at the location of the injury (EPUAP, 2019). The patients with MDRPI were followed up for 2 weeks for prevention and treatment strategies. Prevalence of MDRPI was 5.01% (15/299) with 41 injuries, 27/41 (65.8%) were skin injuries and 14/41(34.2%) were mucosal. Most mucous membrane MDRPIs were at mouth/lips and caused by ET tube and meatal orifice caused by foley catheter. Skin MDRPIs were at the nose and caused by NG tube and hands by peripheral intravenous line and arms caused by blood pressure cuff. Inadequate prevention was provided on daily care as only 177 prevention and treatment interventions were provided over 2 weeks for 15 patients. As a growing problem among Jordanian adults in intensive care, MDRPI required the need for effective prevention. About one-thirds of MDRPIs were mucosal, a finding not previously reported, indicating the need to include mucous membrane assessment with skin assessment when a medical device such as NG and ET tubes or foley catheters are in use. Prevention and treatment interventions provided to patients with MDRPIs were not systematic and based on routine care with no clear guidelines. A consensus has yet to be reached suggesting the need to establish effective prevention strategies for medical device-related pressure injuries. Future research is recommended to follow up MDRPI prevention and treatment strategies among patients in ICU. We suggest to continue studying the prevalence of MDRPIs and monitoring the location, prevention and treatment of both skin and mucosal MDRPIs.     

Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals: surveys based on the European Pressure Ulcer Advisory Panel minimum data set

The survey used the European Pressure Ulcer Advisory Panel (EPUAP) methodology for the collection of pressure ulcer prevalence data. The orthopaedic survey was conducted across all National Health Service Trusts in Wales between 2 and 6 July 2007 while the community hospital survey covering 25% of all community hospital beds was conducted between 21 April 2008 and 2 May 2008. Data were gathered upon 1196 patients (581, 48·6% within orthopaedic units with 615 located in community hospitals). Of these patients, 81 (13·9%) and 162 (26·7%) had pressure ulcers in orthopaedic and community hospitals, respectively. Where patients presented with multiple pressure ulcers, the most severe pressure ulcer was recorded. Across both surveys, most pressure ulcers were reported to be either category I or II with 91 category I wounds (33 in orthopaedic units and 58 in community hospitals). Severe (categories III and IV) pressure ulcers affected 78 patients (19 in orthopaedic units and 59 in community hospitals). Adoption of the EPUAP pressure ulcer prevalence methods can help achieve consistent data upon pressure ulcer prevalence in different health care organisations and specialities. The adoption of a consistent data collection capture methodology is a clear prerequisite for the compilation of meaningful pressure ulcer prevalence data sets at a national level.     

Cost consequences due to reduced ulcer healing times – analyses based on the Swedish Registry of Ulcer Treatment

Resource use and costs for topical treatment of hard‐to‐heal ulcers based on data from the Swedish Registry of Ulcer Treatment (RUT) were analysed in patients recorded in RUT as having healed between 2009 and 2012, in order to estimate potential cost savings from reductions in frequency of dressing changes and healing times. RUT is used to capture areas of improvement in ulcer care and to enable structured wound management by registering patients with hard‐to‐heal leg, foot and pressure ulcers. Patients included in the registry are treated in primary care, community care, private care, and inpatient hospital care. Cost calculations were based on resource use data on healing time and frequency of dressing changes in Swedish patients with hard‐to‐heal ulcers who healed between 2009 and 2012. Per‐patient treatment costs decreased from SEK38 223 in 2009 to SEK20 496 in 2012, mainly because of shorter healing times. Frequency of dressing changes was essentially the same during these years, varying from 1·4 to 1·6 per week. The total healing time was reduced by 38%. Treatment costs for the management of hard‐to‐heal ulcers can be reduced with well‐developed treatment strategies resulting in shortened healing times as shown in RUT.     

Hyperhomocysteinaemia and chronic venous ulcers

Chronic venous ulceration (CVU) is the major cause of chronic wounds of lower extremities, and is a part of the complex of chronic venous disease. Previous studies have hypothesised that several thrombophilic factors, such as hyperhomocysteinaemia (HHcy), may be associated with chronic venous ulcers. In this study, we evaluated the prevalence of HHcy in patients with venous leg ulcers and the effect of folic acid therapy on wound healing. Eighty‐seven patients with venous leg ulcers were enrolled in this study to calculate the prevalence of HHcy in this population. All patients underwent basic treatment for venous ulcer (compression therapy ± surgical procedures). Patients with HHcy (group A) received basic treatment and administered folic acid (1·2 mg/day for 12 months) and patients without HHcy (group B) received only basic treatment. Healing was assessed by means of computerised planimetry analysis. The prevalence of HHcy among patients with chronic venous ulcer enrolled in this study was 62·06%. Healing rate was significantly higher (P < 0·05) in group A patients (78·75%) compared with group B patients (63·33%). This study suggests a close association, statistically significant, between HHcy and CVU. Homocysteine‐lowering therapy with folic acid seems to expedite wound healing. Despite these aspects, the exact molecular mechanisms between homocysteine and CVU have not been clearly defined and further studies are needed.     

The efficacy of removable devices to offload and heal neuropathic plantar forefoot ulcers in people with diabetes: a single‐blinded multicentre randomised controlled trial

Non‐removable offloading is the ‘gold standard’ treatment for neuropathic diabetic plantar forefoot ulcers. However, removable offloading is the common ‘standard of care’. We compared three removable offloading devices for ulcer healing efficacy. In this multicentre, randomised controlled trial, 60 persons with neuropathic diabetic plantar forefoot ulcers were randomly assigned to wear a custom‐made knee‐high cast [BTCC (bivalved TCC)], custom‐made ankle‐high cast shoe or a prefabricated ankle‐high forefoot‐offloading shoe (FOS). Primary outcome was healing at 12 weeks. Dynamic plantar pressures, daily stride count and treatment adherence were assessed on a randomly selected subset (n = 35). According to intention‐to‐treat analysis, 58% of patients healed with BTCC [OR 0·77 (95% CI 0·41–1·45) versus FOS], 60% with cast shoe [OR 0·81 (95% CI 0·44–1·49) versus FOS] and 70% with FOS (P = 0·70). Mean ± SD peak pressure in kPa at the ulcer site was 81 ± 55 for BTCC, 176 ± 80 for cast shoe and 107 ± 52 for FOS (P = 0·005); stride count was 4150 ± 1626, 3514 ± 1380 and 4447 ± 3190, respectively (P = 0·71); percentage of 2‐week intervals that patients wore the device <50% of time was 17·3%, 5·2% and 4·9%, respectively. Non‐significant differences in healing efficacy between the three devices suggest that, when non‐removable offloading is contraindicated or not available, each can be used for plantar forefoot ulcer offloading. Efficacy is lower than previously found for non‐removable offloading maybe because suboptimal adherence and high stride count expose the patient to high repetitive stresses. These factors should be carefully considered in decision making regarding ulcer treatment.     

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9‐year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual‐care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital‐acquired pressure ulcers decreased following implementation of an evidence‐based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual‐care nurses under‐estimated patients' risk of pressure ulcer development and under‐utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital‐acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.     

A prospective,multicentre, randomised controlled study of human fibroblast‐derived dermal substitute (Dermagraft) in patients with venous leg ulcers

This was an open‐label, prospective, multicentre, randomised controlled study to evaluate the efficacy and safety of human fibroblast‐derived dermal substitute (HFDS) plus four‐layer compression therapy compared with compression therapy alone in the treatment of venous leg ulcers. The primary outcome variable was the proportion of patients with completely healed study ulcers by 12 weeks. The number healed was further summarised by ulcer duration and baseline ulcer size. Sixty‐four (34%) of 186 patients in the HFDS group experienced healing by week 12 compared with 56 (31%) of 180 patients in the control group (P = 0·235). For ulcers ≤ 12 months duration, 49 (52%) of 94 patients in the HFDS group versus 36 (37%) of 97 patients in the control group healed at 12 weeks (P = 0·029). For ulcers ≤ 10 cm², complete healing at week 12 was observed in 55 (47%) of 117 patients in the HFDS group compared with 47 (39%) of 120 patients in the control group (P = 0·223). The most common adverse events (AEs) were wound infection, cellulitis and skin ulcer. The frequency of AEs did not markedly differ between the treatment and control groups.     

A retrospective cohort study evaluating efficacy in high‐risk patients with chronic lower extremity ulcers treated with negative pressure wound therapy

The purpose of this study was to evaluate the efficacy of negative pressure wound therapy (NPWT) compared with standard of care on wound healing in high‐risk patients with multiple significant comorbidities and chronic lower extremity ulcers (LEUs) across the continuum of care settings. A retrospective cohort study of ‘real‐world’ high‐risk patients was conducted using Boston University Medical Center electronic medical records, along with chart abstraction to capture detailed medical history, comorbidities, healing outcomes and ulcer characteristics. A total of 342 patients, 171 NPWT patients with LEUs were matched with 171 non‐NPWT patients with respect to age and gender, were included in this cohort from 2002 to 2010. The hazard ratios (HRs) were estimated by COX proportional hazard models after adjusting for potential confounders. The NPWT patients were 2·63 times (95% CI = 1·87–3·70) more likely to achieve wound closure compared with non‐NPWT patients. Moreover, incidence of wound closure in NPWT patients were increased in diabetic ulcers (HR = 3·26, 95% CI = 2·21–4·83), arterial ulcers (HR = 2·27, CI = 1·56–3·78) and venous ulcers (HR = 6·31, 95% CI = 1·49–26·6) compared with non‐NPWT patients. In addition, wound healing appeared to be positively affected by the timing of NPWT application. Compared with later NPWT users (1 year or later after ulcer onset), early NPWT users (within 3 months after ulcer onset) and intermediate NPWT users (4–12 months after ulcer onset) were 3·38 and 2·18 times more likely to achieve wound healing, respectively. This study showed that despite the greater significant comorbidities, patients receiving NPWT healed faster. Early use of NPWT demonstrated better healing. The longer the interval before intervention is with NPWT, the higher the correlation is with poor outcome.     

Healing of chronic venous ulcer with topical sevoflurane

The present study assesses the efficacy and safety of topical sevoflurane in chronic venous ulcers and its impact on analgesia and healing. This retrospective study included 30 patients older than 65 years with painful refractory chronic venous ulcers. Patients were treated with topical sevoflurane prior to the usual ulcer cleaning every 2 days for a period of 1 month. Treatment was initiated with a saline solution, followed by direct irrigation of 1 ml of liquid sevoflurane over the wound size, which was measured as cm². Sevoflurane had a fast, intense and long‐lasting analgesic effect. Latency time ranged from 2 to 7 minutes (3·9 ± 1·5 minutes), and duration varied from 8 to 18 hours (12 ± 2·9). The mean ulcer size was 8·4 ± 9·7 cm². There was a progressive decrease in size in all patients, with a mean size of 4·2 ± 5·4 cm² at the end of the study. There were no adverse systemic effects. Local adverse effects were mild and transient, including pruritus, erythema and heat. Topical sevoflurane is a new, efficient and safe therapeutic alternative in painful chronic venous ulcers, refractory to usual analgesic treatment. It can improve the ulcer‐healing process that shortens the cicatrisation period.     

A single‐arm trial indirect comparison investigation: a proof‐of‐concept method to predict venous leg ulcer healing time for a new acellular synthetic matrix matched to standard care control

To compare data on time to healing from two separate cohorts: one treated with a new acellular synthetic matrix plus standard care (SC) and one matched from four large UK pragmatic, randomised controlled trials [venous leg ulcer (VLU) evidence network]. We introduce a new proof‐of‐concept strategy to a VLU clinical evidence network, propensity score matching and sensitivity analysis to predict the feasibility of the new acellular synthetic matrix plus SC for success in future randomised, controlled clinical trials. Prospective data on chronic VLUs from a safety and effectiveness study on an acellular synthetic matrix conducted in one wound centre in the UK (17 patients) and three wound centres in Australia (36 patients) were compared retrospectively to propensity score‐matched data from patients with comparable leg ulcer disease aetiology, age, baseline ulcer area, ulcer duration, multi‐layer compression bandaging and majority of care completed in specialist wound centres (average of 1 visit per week), with the outcome measures at comparable follow‐up periods from patients enrolled in four prospective, multicentre, pragmatic, randomised studies of venous ulcers in the UK (the comparison group; VLU evidence network). Analysis using Kaplan–Meier survival curves showed a mean healing time of 73·1 days for ASM plus SC (ASM) treated ulcers in comparison with 83·5 days for comparison group ulcers treated with SC alone (Log rank test, χ² 5·779, P = 0·016) within 12 weeks. Sensitivity analysis indicates that an unobserved covariate would have to change the odds of healing for SC by a factor of 1·1 to impact the baseline results. Results from this study predict a significant effect on healing time when using a new ASM as an adjunct to SC in the treatment of non‐healing venous ulcers in the UK, but results are sensitive to unobserved covariates that may be important in healing time comparison.     

A systematic review of the effectiveness of negative pressure wound therapy in the management of diabetes foot ulcers

Foot ulcers are a common complication in patients with diabetes. Negative pressure wound therapy (NPWT) is a wound care therapy that is being increasingly used in the management of foot ulcers. This article presents a systematic review examining the effectiveness of this therapy. The review question is how effective is NPWT in achieving wound healing in diabetes foot ulcers? The primary outcome for this study was the number of patients achieving complete wound healing (secondary outcomes, other markers of wound healing, adverse events and patient satisfaction). A systematic literature review and tabulative synthesis of randomised controlled trials (RCTs). The review identified four RCTs of weak to moderate quality. Only one study examining NPWT in postamputation wound healing reported data on the primary outcome. These data show a 20% improvement in wound healing [odds ratios = 2·0%, confidence interval (CI) ?1·0 to 4·0] and number needed to treat = 6 (CI 4–64). No serious treatment‐related complications were reported by any of the studies. One study suggested a reduction in the risk of secondary amputation (absolute risk reduction = 7·9%, CI 0·5–15·43). Studies also reported an increase in granulation and wound‐healing rates in patients treated with NPWT therapy. No data on patient satisfaction or experience were reported. While all the studies included in the review indicated that the NPWT therapy is more effective than conventional dressings, the quality of the studies were weak and the nature of the inquiries in terms of outcome and patient selection divergent. There is a strong need for larger trials to assess NPWT therapy in diabetes care with different groups of patients and in relation to different clinical objectives and parameters.     

Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: a prospective cohort study

The purpose of this study was to identify pressure ulcer (PU) incidence and risk factors that are associated with PU development in patients in two adult intensive care units (ICU) in Saudi Arabia. A prospective cohort study design was used. A total of 84 participants were screened second daily basis until discharge or death, over a consecutive 30‐day period, out of which 33 participants with new PUs were identified giving a cumulative hospital‐acquired PU incidence of 39·3% (33/84 participants). The incidence of medical devices‐related PUs was 8·3% (7/84). Age, length of stay in the ICU, history of cardiovascular disease and kidney disease, infrequent repositioning, time of operation, emergency admission, mechanical ventilation and lower Braden Scale scores independently predicted the development of a PU. According to binary logistic regression analyses, age, longer stay in ICU and infrequent repositioning were significant predictors of all stages of PUs, while the length of stay in the ICU and infrequent repositioning were associated with the development of stages II–IV PUs. In conclusion, PU incidence rate was higher than that reported in other international studies. This indicates that urgent attention is required for PU prevention strategies in this setting.