Publicatie zoeken

OBJECTIVE

To assess the potential efficacy of maggot debridement therapy (MDT) compared with standard care for diabetic foot ulcers (DFUs).

METHOD

A meta-analysis was performed on the evidence for MDT for DFUs. Databases, including PubMed, Web of Science, the Cochrane Library, EMbase, EBSCOhost, Springer Link, ScienceDirect and Ovid-Medline, were electronically searched for randomised controlled trials, case-control studies and controlled clinical trials, up to 31 December 2012, and relevant references of the included articles were also manually searched. The literature was screened, the data were extracted and the methodological quality of the included studies was assessed. Meta-analyses were performed on the included data, for the outcomes healing rate, time to healing, incidence of infection, amputation rate and antibiotic-free days or antibiotics usage.

RESULTS

Overall, four studies comparing MDT with standard therapy on a total of 356 participants were included. The results of meta-analyses suggested that the MDT group was significantly superior to the control group in the percentage of DFUs to achieve full healing (RR=1.8, 95%CI=1.07; 3.02; p=0.03), amputation rate (RR=0.41, 95%CI=0.20; 0.85; p=0.02), time to healing (RR=-3.70, 95%CI=-5.76; -1.64; p=0.0004) and number of antibiotic-free days (126.8 ± 30.3 days vs 81.9 ± 42.1 days; p=0.001); however, collated differences in incidence of infection after intervention revealed no evidence of a difference between the MDT and control groups (RR=0.82, 95%CI=0.65; 1.04, p=0.10).

CONCLUSION

Although MDT may be a scientific and effective therapy in treatment of DFUs, the evidence is too weak to routinely recommend it for treatment. Large studies and sample sizes are needed to assess the efficacy and safety of MDT in the treatment of DFUs.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to this work or its contents. X. Tian and X.M. Liang contributed equally to this work.

Impaired wound healing is a frequent and very severe problem in patients with diabetes mellitus, yet little is known about the underlying pathomechanisms. In this paper we review the biology of wound healing with particular attention to the pathophysiology of chronic wounds in diabetic patients. The standard treatment of diabetic ulcers includes measures to optimize glycemic control as well as extensive debridement, infection elimination by antibiotic therapy based on wound pathogen cultures, the use of moisture dressings, and offloading high pressure from the wound bed. In this paper we discuss novel adjuvant therapies with particular reference to the use of autologous skin transplants for the treatment of diabetic foot ulcers which do not respond to standard care.

SIGNIFICANCE

The incidence, cost, morbidity, and mortality associated with non-healing of chronic skin wounds are dramatic. With the increasing numbers of people with obesity, chronic medical conditions, and an increasing life expectancy, the healthcare cost of non-healing ulcers has recently been estimated at $25 billion annually in the United States. The role played by bacterial biofilm in chronic wounds has been emphasized in recent years, particularly in the context of the prolongation of the inflammatory phase of repair.

RECENT ADVANCES

Rapid high-throughput genomic approaches have revolutionized the ability to identify and quantify microbial organisms from wounds. Defining bacterial genomes and using genetic approaches to knock out specific bacterial functions, then studying bacterial survival on cutaneous wounds is a promising strategy for understanding which genes are essential for pathogenicity.

CRITICAL ISSUES

When an animal sustains a cutaneous wound, understanding mechanisms involved in adaptations by bacteria and adaptations by the host in the struggle for survival is central to development of interventions that favor the host.

FUTURE DIRECTIONS

Characterization of microbiomes of clinically well characterized chronic human wounds is now under way. The use of in vivo models of biofilm-infected cutaneous wounds will permit the study of the mechanisms needed for biofilm formation, persistence, and potential synergistic interactions among bacteria. A more complete understanding of bacterial survival mechanisms and how microbes influence host repair mechanisms are likely to provide targets for chronic wound therapy.

Moffat et al (2003) report that 1.33 people in every 1 000 of the UK population have chronic oedema, although the true prevalence is likely to be higher. Chronic oedema is often associated with a range of skin conditions, including hyperkeratosis. This article describes the use of a monofilament fibre debridement pad to reduce hyperkeratosis on the legs of a 57-year-old man with a long-standing history of bilateral lymphovenous oedema. As part of an holistic care programme, the monofilament fibre debridement pad was found to quickly and effectively reduce hyperkeratosis.

OBJECTIVES

The aim of this study was to investigate the influence of a biosynthetic cellulose wound dressing (BWD) to stimulate wound healing in patients with a venous leg ulcer on periulcer skin condition when compared with standard care using a foam dressing.

METHODS

Each patient with a venous ulcer received compression therapy with a short stretch bandage system and either a BWD + foam (study group [SG]) or foam (control group [CG]). Periulcer skin condition was compared with the untreated lower leg skin and the forearm skin, using noninvasive parameters, comparing day 0 versus day 28 results. Ulcers were further evaluated for healing rate. The study period was 28 days, and the follow-up period was 12 weeks. Fifty patients were recruited to the study, of which N = 46 (SG, n = 26; CG, n = 20) completed the 28-day study period and were included in the analysis.

RESULTS

The BWD showed a more improved periulcer skin condition versus the CG. Transepidermal water loss was significantly less in the SG (P = .003), as well as the results shown with the chromatometer (P =. 05). Ulcer healing rate was also statistically significant in favor of the SG (P = .0001).

CONCLUSION

Treatment for the BWD + foam group was shown to be safe and significantly improved periwound skin condition, leading to more expeditious wound healing than treatment with foam alone.

OBJECTIVE

To investigate the antimicrobial activity of SAP-containing wound dressings in vitro over a prolonged period of time (7 days) and to assess their ability to sustain the antimicrobial effect.

METHOD

SAP dressings were tested according to the JIS L 1902:2002 against the pathogens Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli and Candida albicans.Additionally, effect on S. aureus and P. aeruginosa growth was investigated after a prolonged incubation period of 7 days. Furthermore, both SAP dressings were repeatedly inoculated with P. aeruginosa suspension and, after 7 days, microbial growth under the dressings was evaluated.

RESULTS

Both SAP-containing wound dressings tested exhibited a significant to strong antimicrobial activity against Staphylococcus aureus, MRSA, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, and Candida albicans in vitro. Moreover, it could be shown that they were able to sustain antibacterial efficacy over a prolonged period of time. Using a direct incubation method with repeated re-inoculation of the dressing samples, it could be shown that growth of P. aeruginosa was reduced after 4 days of treatment and completely inhibited after 7 days. No significant differences were observed between the two SAP-dressings tested.

CONCLUSION

These in vitro experiments impressively demonstrated the antimicrobial mechanism of SAP-containing wound dressings: rapid up-take of fluid, binding of microorganisms to the SAP-core, and retention of the bacteria inside the dressing. Moreover, it could be shown that they are able to exhibit their antimicrobial activity over a prolonged period of time unless the amount of fluid present exceeds their fluid-handling capacity.

The experimental study measured interface pressure and static stiffness index of four different compression systems in fifty-two healthy volunteers. For the study interface pressure (3 cm ø probe was placed at the anatomical B1 point) was recorded on application of the compression systems every 15 min for 4 h, in supine, standing, while sitting and during walking. For this purpose a portable Kikuhime (Harada Corp., Osaka, Japan) device was used. Further static stiffness index (SSI) was calculated. The evaluated systems were: short stretch bandage system (SSB) Rosidal sys (Lohmann & Rauscher, Rengsdorf, Germany), multi-layer bandaging (LSB) Profore (Smith & Nephew, Hull, UK), varistretch bandage (VSB) Proguide (Smith & Nephew) and tubular compression (CS) Rosidal mobil (Lohmann & Rauscher). The mean interface pressure of SSB, LSB and VSB was significantly higher (P<0.05) in each position measured over 4 h, compared to CS. In supine VSB showed high-pressure levels, up to 60 mmHg, which remained high. The other systems had more tolerable levels of about 30 mmHg. Interface pressure exerted on limbs is an indicator of their clinical effect. The experimental study results showed different patterns of interface pressure and SSI, which may enable clinicians to predict the frequency of bandage application, supporting an adequate and safe choice of bandage system.