Background
An acute burn wound is a complex and evolving injury. Extensive burns produce systemic consequences, in addition to local tissue damage. Treatment of partial thickness burn wounds is ...directed towards promoting healing and a wide variety of dressings are currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on their effects on healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered.
Objectives
To assess the effects of burn wound dressings on superficial and partial thickness burns.
Search methods
For this first update we searched The Cochrane Wounds Group Specialised Register (searched 8 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (2008 to October Week 4 2012); Ovid MEDLINE (In‐Process & Other Non‐Indexed Citations, November 07, 2012); Ovid EMBASE (2008 to 2012 Week 44); AND EBSCO CINAHL (1982 to 2 November 2012).
Selection criteria
All randomised controlled trials (RCTs) that evaluated the effects of burn wound dressings on the healing of superficial and partial thickness burns.
Data collection and analysis
Two authors extracted the data independently using standardised forms. We assessed each trial for internal validity and resolved differences by discussion.
Main results
A total of 30 RCTs are included in this review. Overall both the quality of trial reporting and trial conduct were generally poor and meta analysis was largely precluded due to study heterogeneity or poor data reporting. In the context of this poor quality evidence, silver sulphadiazine (SSD) was consistently associated with poorer healing outcomes than biosynthetic (skin substitute) dressings, silver‐containing dressings and silicon‐coated dressings. Burns treated with hydrogel dressings appear to heal more quickly than those treated with usual care.
Authors' conclusions
There is a paucity of high‐quality evidence regarding the effect of different dressings on the healing of superficial and partial thickness burn injuries. The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints and all were at risk of bias. It is impossible to draw firm and confident conclusions about the effectiveness of specific dressings, however silver sulphadiazine was consistently associated with poorer healing outcomes than biosynthetic, silicon‐coated and silver dressings whilst hydrogel‐treated burns had better healing outcomes than those treated with usual care.
Background
Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First‐line treatment options often include ...the use of compression bandages or stockings.
Objectives
To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population.
Search methods
In June 2020 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions by language, date of publication or study setting.
Selection criteria
We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting.
Data collection and analysis
At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk‐of‐bias assessment using the Cochrane risk‐of‐bias tool. We assessed the certainty of the evidence according to GRADE methodology.
Main results
We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute‐care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm2. Studies had a median follow‐up of 12 weeks. Compression bandages or stockings applied included short‐stretch bandage, four‐layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias.
Primary outcomes
There is moderate‐certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time‐to‐complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I2 = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I2 = 65% (8 studies with analysable data, 1120 participants); synthesis without meta‐analysis suggests more completely‐healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants).
It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low‐certainty evidence; 3 studies, 585 participants).
Secondary outcomes
Moderate‐certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference −1.39, 95% CI −1.79 to −0.98; I2 = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta‐analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease‐specific quality of life, but not all aspects of general health status during the follow‐up of 12 weeks to 12 months (four studies with 859 participants; low‐certainty evidence).
It is uncertain if the use of compression bandages or stockings is more cost‐effective than not using them (three studies with 486 participants; very low‐certainty evidence).
Authors' conclusions
If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease‐specific quality of life. There is uncertainty about adverse effects, and cost effectiveness.
Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health‐related quality of life, and should incorporate cost‐effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.
Compression for venous leg ulcers O'Meara, Susan; Cullum, Nicky; Nelson, E Andrea ...
Cochrane database of systematic reviews,
11/2012, Volume:
2013, Issue:
3
Journal Article
Peer reviewed
Open access
Background
Up to one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an ...accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. The main treatment is the application of a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it was unclear whether they are effective in treating venous ulcers and, if so, which method of compression is the most effective.
Objectives
To undertake a systematic review of all randomised controlled trials (RCTs) evaluating the effects on venous ulcer healing of compression bandages and stockings.
Specific questions addressed by the review are:
1. Does the application of compression bandages or stockings aid venous ulcer healing?
2. Which compression bandage or stocking system is the most effective?
Search methods
For this second update we searched: the Cochrane Wounds Group Specialised Register (31 May 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In‐Process & Other Non‐Indexed Citations 30 May 2012); Ovid EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL (1982 to 30 May 2012). No date or language restrictions were applied.
Selection criteria
RCTs recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression stockings were eligible for inclusion. Eligible comparators included no compression (e.g. primary dressing alone, non‐compressive bandage) or an alternative type of compression. RCTs had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). Secondary outcomes of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of RCTs.
Data collection and analysis
Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author.
Main results
Forty‐eight RCTs reporting 59 comparisons were included (4321 participants in total). Most RCTs were small, and most were at unclear or high risk of bias. Duration of follow‐up varied across RCTs. Risk ratio (RR) and other estimates are shown below where RCTs were pooled; otherwise findings refer to a single RCT.
There was evidence from eight RCTs (unpooled) that healing outcomes (including time to healing) are better when patients receive compression compared with no compression.
Single‐component compression bandage systems are less effective than multi‐component compression for complete healing at six months (one large RCT).
A two‐component system containing an elastic bandage healed more ulcers at one year than one without an elastic component (one small RCT).
Three‐component systems containing an elastic component healed more ulcers than those without elastic at three to four months (two RCTs pooled), RR 1.83 (95% CI 1.26 to 2.67), but another RCT showed no difference between groups at six months.
An individual patient data meta‐analysis of five RCTs suggested significantly faster healing with the four‐layer bandage (4LB) than the short stretch bandage (SSB): median days to healing estimated at 90 and 99 respectively; hazard ratio 1.31 (95% CI 1.09 to 1.58).
High‐compression stockings are associated with better healing outcomes than SSB at two to four months: RR 1.62 (95% CI 1.26 to 2.10), estimate from four pooled RCTs.
One RCT suggested better healing outcomes at 16 months with the addition of a tubular device plus single elastic bandage to a base system of gauze and crepe bandages when compared with two added elastic bandages. Another RCT had three arms; when one or two elastic bandages were added to a base three‐component system that included an outer tubular layer, healing outcomes were better at six months for the two groups receiving elastic bandages.
There is currently no evidence of a statistically significant difference for the following comparisons:
⋅alternative single‐component compression bandages (two RCTs, unpooled);
⋅two‐component bandages compared with the 4LB at three months (three RCTs pooled);
⋅alternative versions of the 4LB for complete healing at times up to and including six months (three RCTs, unpooled);
⋅4LB compared with paste bandage for complete healing at three months (two RCTs, pooled), six months or one year (one RCT for each time point);
⋅adjustable compression boots compared with paste bandages for the outcome of change in ulcer area at three months (one small RCT);
⋅adjustable compression boots compared with the 4LB with respect to complete healing at three months (one small RCT);
⋅single‐layer compression stocking compared with paste bandages for outcome of complete healing at four months (one small RCT) and 18 months (another small RCT);
⋅low compression stocking compared with SSB for complete healing at three and six months (one small RCT);
⋅compression stockings compared with a two‐component bandage system and the 4LB for the outcome of complete healing at three months (one small, three‐armed RCT); and,
⋅tubular compression compared with SSB (one small RCT) for complete healing at three months.
Secondary outcomes: 4LB was more cost‐effective than SSB. It was not possible to draw firm conclusions regarding other secondary outcomes including recurrence, adverse events and health‐related quality of life.
Authors' conclusions
Compression increases ulcer healing rates compared with no compression. Multi‐component systems are more effective than single‐component systems. Multi‐component systems containing an elastic bandage appear to be more effective than those composed mainly of inelastic constituents. Two‐component bandage systems appear to perform as well as the 4LB. Patients receiving the 4LB heal faster than those allocated the SSB. More patients heal on high‐compression stocking systems than with the SSB. Further data are required before the difference between high‐compression stockings and the 4LB can be established.
Compression is an effective and recommended treatment for venous leg ulcers. Although the four-layer bandage (4LB) is regarded as the gold standard compression system, it is recognised that the ...amount of compression delivered might be compromised by poor application technique. Also the bulky nature of the bandages might reduce ankle or leg mobility and make the wearing of shoes difficult. Two-layer compression hosiery systems are now available for the treatment of venous leg ulcers. Two-layer hosiery (HH) may be advantageous, as it has reduced bulk, which might enhance ankle or leg mobility and patient adherence. Some patients can also remove and reapply two-layer hosiery, which may encourage self-management and could reduce costs. However, little robust evidence exists about the effectiveness of two-layer hosiery for ulcer healing and no previous trials have compared two-layer hosiery delivering 'high' compression with the 4LB.
Part I To compare the clinical effectiveness and cost-effectiveness of HH and 4LB in terms of time to complete healing of venous leg ulcers. Part II To synthesise the relative effectiveness evidence (for ulcer healing) of high-compression treatments for venous leg ulcers using a mixed-treatment comparison (MTC). Part III To construct a decision-analytic model to assess the cost-effectiveness of high-compression treatments for venous leg ulcers.
Part I A multicentred, pragmatic, two-arm, parallel, open randomised controlled trial (RCT) with an economic evaluation. Part II MTC using all relevant RCT data - including Venous leg Ulcer Study IV (VenUS IV). Part III A decision-analytic Markov model.
Part I Community nurse teams or services, general practitioner practices, leg ulcer clinics, tissue viability clinics or services and wound clinics within England and Northern Ireland.
Part I Patients aged ≥ 18 years with a venous leg ulcer, who were willing and able to tolerate high compression.
Part I Participants in the intervention group received HH. The control group received the 4LB, which was applied according to standard practice. Both treatments are designed to deliver 40 mmHg of compression at the ankle. Part II and III All relevant high-compression treatments including HH, the 4LB and the two-layer bandage (2LB).
Part I The primary outcome measure was time to healing of the reference ulcer (blinded assessment). Part II Time to ulcer healing. Part III Quality-adjusted life-years (QALYs) and costs.
Part I A total of 457 participants were recruited. There was no evidence of a difference in time to healing of the reference ulcer between groups in an adjusted analysis hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.79 to 1.25; p = 0.96. Time to ulcer recurrence was significantly shorter in the 4LB group (HR = 0.56, 95% CI 0.33 to 0.94; p = 0.026). In terms of cost-effectiveness, using QALYs as the measure of benefit, HH had a > 95% probability of being the most cost-effective treatment based on the within-trial analysis. Part II The MTC suggests that the 2LB has the highest probability of ulcer healing compared with other high-compression treatments. However, this evidence is categorised as low to very low quality. Part III Results suggested that the 2LB had the highest probability of being the most cost-effective high-compression treatment for venous leg ulcers.
Trial data from VenUS IV found no evidence of a difference in venous ulcer healing between HH and the 4LB. HH may reduce ulcer recurrence rates compared with the 4LB and be a cost-effective treatment. When all available high-compression treatments were considered, the 2LB had the highest probability of being clinically effective and cost-effective. However, the underpinning evidence was sparse and more research is needed. Further research should thus focus on establishing, in a high-quality trial, the effectiveness of this compression system in particular.
Current Controlled Trials ISRCTN49373072.
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 57. See the NIHR Journals Library website for further project information.
Bleeding complications arising from trauma, surgery, and as congenital, disease‐associated, or drug‐induced blood disorders can cause significant morbidities and mortalities in civilian and military ...populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf‐life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf‐life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state‐of‐art is provided, and challenges and opportunities to help advancement of the field are discussed.
Hemostatic biomaterials and technologies are directed at reducing bleeding complications in trauma, surgery, hematology/oncology, and drug‐induced or congenital blood disorders, to prevent organ damage and improve survival. A comprehensive review and discussion is presented on hemostatic biomaterials and technologies that are currently clinically established, as well as new systems in preclinical and translational development.
•Injectable AP-OC hydrogel was in-situ crosslinked without any chemical crosslinker.•Both of modified natural-polysaccharides were soluble in neutral solution.•Swelling and degradation property of ...AP-OC hydrogel can be tuned by its composition.•Amino site content in the hydrogel was crucial for good biocompatibility.•Hydrogel had desired gelation time and good biocompatibility for skin wound healing.
Hydrogel can provide a favorable moisture environment for skin wound healing. In this study, a novel in-situ crosslinked injectable hydrogel was prepared using the water-soluble amidated pectin (AP) and oxidized chitosan (OC) through Schiff-base reaction without any chemical crosslinker. The influence of AP content on the properties of the hydrogel was systemically investigated. It showed that gelation time, pore structure, swelling capability and degradability of the hydrogel can be tuned by varying the content of amine and aldehyde groups from AP and OC. All the porous hydrogels with various AP contents (65%, 70%, and 80%) presented desirable gelation time, swelling property, high hemocompatibility and biocompatibility. Particularly, AP-OC-65 hydrogel presented superior swelling capability and better hemo- and bio-compatibility, owing to more residual amine sites in the hydrogel. Therefore, the injectable AP-OC-65 hydrogel has a greater potential for application to wound dressing or skin substitute.
Background:
the potential fire risk of fabrics impregnated with emollients has been described within the health service, including ignition of bandages. The role of emollients in fire fatalities have ...also been included in coroner reports, as accelerating fires when present.
Aims:
although changes in burning behaviour is known, no standard tests have been carried out on bandages which are often used in conjunction with emollients.
Method:
using a standard vertical flammability test, the flammability of viscose bandage was compared to when impregnated with nine dried on emollients with low to high and non-paraffin content.
Findings:
the time to ignition was significantly reduced with an emollient present and the glowing time was longer.
Conclusions:
the same safety advice applies to viscose bandages as other fabrics with emollients; do not expose them to naked flames or high heat sources or allow emollients to build up on bandages.
Hydrogels with adhesive properties have potential for numerous biomedical applications. Here, the design of a novel, intrinsically adhesive hydrogel and its use in developing internal therapeutic ...bandages is reported. The design involves incorporation of “triple hydrogen bonding clusters” (THBCs) as side groups into the hydrogel matrix. The THBC through a unique “load sharing” effect and an increase in bond density results in strong adhesions of the hydrogel to a range of surfaces, including glass, plastic, wood, poly(tetrafluoroethylene) (PTFE), stainless steel, and biological tissues, even without any chemical reaction. Using the adhesive hydrogel, tissue‐adhesive bandages are developed for either targeted and sustained release of chemotherapeutic nanodrug for liver cancer treatment, or anchored delivery of pancreatic islets for a potential type 1 diabetes (T1D) cell replacement therapy. Stable adhesion of the bandage inside the body enables almost complete tumor suppression in an orthotopic liver cancer mouse model and ≈1 month diabetes correction in chemically induced diabetic mice.
An adhesive hydrogel based on a “load‐sharing” effect of triple hydrogen bonding clusters is reported. To demonstrate their potential applications, these adhesive hydrogels are engineered into internally applied tissue bandages for delivery of either antitumor drugs directly to the tumor site or insulin‐producing cells to treat type 1 diabetes.
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