Pressure Ulcer Healing Research Articles

Effect of laser therapy on expression of angio- and fibrogenic factors, and cytokine concentrations during the healing process of human pressure ulcers.

Objective: To evaluate the effect of laser irradiation at different wavelengths on the expression of selected growth factors and inflammatory mediators at particular stages of the wound healing process.Methods: Sixty-seven patients were recruited, treated, and analyzed (group A - 940 nm: 17 patients; group B - 808 nm: 18 patients; group C - 658 nm: 16 patients; group D - sham therapy: 17 patients). Patients received a basic treatment, including repositioning and mobilization, air pressure mattress and bed support surfaces, wound cleansing and drug therapy. Additionally, patients received laser therapy once a day, 5 times a week for 1 month in use of a semiconductor lasers (GaAlAs) which emitted a continuous radiation emission at separate wavelengths of 940 nm (group A), 808 nm (group B) and 658 nm (group C). In group D (sham therapy), laser therapy was applied in the same manner, but the device was off during each session (only the applicator was switched on to scan pressure ulcers using none coherent red visible light).Results: The positive changes in the measured serum (IL-2, IL-6 and TNF-α) and wound tissue (TNF-α, VEGF and TGFβ1) parameters appeared to be connected only with the wavelength of 658 nm. The significant change in pro-inflammatory mediator levels [interleukin 2 (IL-2) with p=0.008 and interleukin 6 (IL-6) with p=0.016] was noticed after two weeks of laser therapy. In the other groups, the inflammation was also reduced, but the process was not as marked as in group C. Similarly, in the case of tumor necrosis factor (TNF-α) concentration, where after two weeks of treatment with irradiation at a wavelength of 658 nm, a rapid suppression was observed (p=0.001), whereas in the other groups, these results were much slower and not as obvious. Interestingly, again in the case of group C, the change in TNF-α concentration in wound tissue was most intensive (≈75% reduction), whereas the changes in other groups were not as obvious (≈50% reduction). After irradiation (658 nm), the VEGF expression increased significantly within the first two weeks, and then it decreased and maintained a stable level. In contrast, the TGFβ1 activity remained level, but always higher in comparison to other groupsConclusions: The effective healing of pressure ulcers is connected with laser irradiation at a wavelength of 658 nm. We believe that this effect is related to the inhibition of inflammatory processes in the wound and stimulation of angiogenesis and fibroblast proliferation at this specific radiation (based both on concentration of interleukins and TNF-α serum level and VEGF, TGFβ1, TNF-α activities in wound biopsies). Laser therapy at wavelengths of 940 and 808 nm does not significantly affect the above-mentioned repair processes, which explains its low effectiveness in the treatment of pressure ulcers.

The Impact of Stress on Pressure Ulcer Wound Healing Process and on the Psychophysiological Environment of the Individual Suffering from them.

Introduction:The occurrence of a pressure ulcer constitutes a major psychological and physiological burden and it has been linked with a reduced quality of life and increased stress of the individual.Objective:The main objective was to investigate the impact that stress has on pressure ulcer healing process and on the psychophysiological environment of the individual suffering from them.Method:The scientific literature was reviewed through Cinahl, Pub-med, EBSCO, Medline and Google scholar. The articles were chosen due to their direct correlation with the objective under study and their scientific relevance.Results:Increased stress has been demonstrated to increase the glucocorticoids levels affecting negatively the production of wound healing cytokines (IL1α, IL1β and TNFα). Matrix metalloproteases has been identified to be unregulated in occasions of increased stress in acute wounds. Stress has also been correlated with poor health behaviors that may not have a direct link on the wound healing process, although they can in part explain or enhance some of the effects of stress on wound healing.Conclusion:The correlation between stress and wound healing in acute wounds has been thoroughly investigated and its negative effects have been established. The presence of a pressure ulcer can have a detrimental impact on the stress level of an individual although further investigation is needed to establish the role of stress in chronic wounds such as pressure ulcers.

Negative pressure wound therapy versus healing by secondary intention in pressure ulcers

Pressure ulcers are a highly prevalent source of morbidity with an equally high incidence of up to 38.0\% amongst different categories of healthcare institutions. Therefore, the management and therapeutic approach toward these often hospital- or facility-acquired problems remain critical aspects of long-term care. Negative pressure wound therapy (NPWT) has proven effective in addressing the barriers to pressure ulcer healing including increasing blood flow to previously ischemic wound areas by generating subatmospheric pressure which vacuums in circulation. The objective of this study was to compare negative pressure wound therapy (NPWT) versus surgical wounds healing by secondary intention (SWHSI). A systematic literature search was conducted using the PubMed and Scopus search engine up until the 20 Th January 2017 including the terms: “negative pressure wound therapy” and “pressure ulcers”. In this systematic review, six randomized controlled trials were included. NPWT is deemed appropriate and effective method and widely used by clinicians to promote the healing of wounds and ulcers of different etiology. The heterogeneity found in individual trials regarding the inclusion criteria, therapeutic procedures, the criteria and methods of outcome evaluation, however, did not allow for a data evaluation with statistically valid conclusions. It is reasonable to assume that their subset of patients with pressure ulcers that can be effectively treated with NPWT, with optimal results and good cost-benefit ratio, also with respect to the quality of life.

Botulinum Toxin Treatment in the Healing of Pressure Ulcers Resulting from Spasticity in Multiple Sclerosis

Botulinum Toxin Treatment in the Healing of Pressure Ulcers Resulting from Spasticity in Multiple Sclerosis

Foam dressings for treating pressure ulcers.

Foam dressings for treating pressure ulcers.

Grafting with Cryopreserved Amniotic Membrane versus Conservative Wound Care in Treatment of Pressure Ulcers: A Randomized Clinical Trial

To compare the healing process of pressure ulcers treated with cryopreserved human amniotic membrane allograft and routine pressure ulcer care in our hospital.From January 2012 to December 2013, in a prospective randomized clinical trial (IRCT201612041335N2), 24 patients with second and third stage of pressure ulcers were enrolled in this study. All patients needed split-thickness skin grafts for pressure ulcer-wound coverage. Selected patients had symmetric ulcers on both upper and lower extremities. The patients were randomly divided into two groups: amnion and control. In the amnion group, the ulcer was covered with cryopreserved amniotic membrane and in the control group it was treated with local Dilantin powder application. The duration and success rate of complete healing was compared between the two groups.The study group was composed of 24 pressure ulcers in 24 patients (19 males and 5 females) with a mean age of 44±12.70 years. The demographic characteristics, ulcer area, and underlying diseases were similar in both groups. The early sign of response, such as decrease in wound discharge, was detected 12-14 days after biological dressing. Complete pressure ulcer healing occurred only in the amnion group (p< 0.001). Partial healing was significantly higher in the amnion group (p< 0.03). Healing time in this group was faster than that the control group (20 days versus 54 days). No major complication was recorded with amniotic membrane dressing.Cryopreserved amniotic membrane is an effective biologic dressing that promotes re-epithelialization in pressure ulcers.

Grafting with Cryopreserved Amniotic Membrane versus Conservative Wound Care in Treatment of Pressure Ulcers: A Randomized Clinical Trial.

To compare the healing process of pressure ulcers treated with cryopreserved human amniotic membrane allograft and routine pressure ulcer care in our hospital. From January 2012 to December 2013, in a prospective randomized clinical trial (IRCT201612041335N2), 24 patients with second and third stage of pressure ulcers were enrolled in this study. All patients needed split-thickness skin grafts for pressure ulcer-wound coverage. Selected patients had symmetric ulcers on both upper and lower extremities. The patients were randomly divided into two groups: amnion and control. In the amnion group, the ulcer was covered with cryopreserved amniotic membrane and in the control group it was treated with local Dilantin powder application. The duration and success rate of complete healing was compared between the two groups. The study group was composed of 24 pressure ulcers in 24 patients (19 males and 5 females) with a mean age of 44±12.70 years. The demographic characteristics, ulcer area, and underlying diseases were similar in both groups. The early sign of response, such as decrease in wound discharge, was detected 12-14 days after biological dressing. Complete pressure ulcer healing occurred only in the amnion group (p< 0.001). Partial healing was significantly higher in the amnion group (p< 0.03). Healing time in this group was faster than that the control group (20 days versus 54 days). No major complication was recorded with amniotic membrane dressing. Cryopreserved amniotic membrane is an effective biologic dressing that promotes re-epithelialization in pressure ulcers.

Percutaneous endoscopic gastrostomy: confirming the clinical benefits far beyond anthropometry.

The real benefit of gastrostomy is still a matter of debate. We aimed to prospectively evaluate the global impact of percutaneous endoscopic gastrostomy (PEG) in patients followed at a specialized multidisciplinary clinic, namely, the impact on the need for healthcare resources, anthropometric measures, pressure ulcers prevention and healing, and nutritional and hydration status. From the 201 patients who underwent PEG between May 2011 and September 2014, 60 were included in a prospective study. Anthropometric, clinical, and laboratorial variables were collected and compared before and after PEG. Follow-up duration, mortality, and number of emergency department visits or hospital admissions were also assessed. Thirty-three (55.0%) patients were women and the median age was 79 years. The main indications for PEG were dementia (43.3%) and poststroke dysphagia (30.0%). Four months following PEG, significant decreases in the tricipital skinfold (P=0.002) and brachial perimeter (P=0.003) were found. A decrease in the mean number of hospitalizations (1.4 vs. 0.3; P<0.001) and visits to emergency department (2.2 vs. 1.1; P=0.003) was noted in the next 6 months after PEG compared with the previous semester. In 53.8% of patients with pressure ulcers, complete healing was observed after PEG. PEG was associated with increases in hemoglobin (P=0.024), lymphocytes (P=0.041), cholesterol (P=0.008), transferrin (P<0.001), albumin (P<0.001), and total proteins (P<0.001), and a decrease in serum sodium (P=0.001). Anthropometric values may not translate the early benefits of a gastrostomy. PEG decreases the need for hospital health care, facilitates healing of pressure ulcers, and induces biochemical changes that may reflect better nutrition and hydration.

Analysis of risk factors of pressure ulcer healing

Objective To investigate the risk factors of wound healing 30 days after treatment in patients with pressure ulcer. Methods Two hundred and forty-five hospitalized patients with pressure ulcer between January 2015 and October 2016 were selected. They were divided into the healed group and the unhealed group 30 days after the treatment. The influencing factors 13 indexes including age, gender, edema, the number of diseases, the number of pressure ulcer, the size of pressure ulcer, PUSH score (Pressure Ulcer Scale Healing), hemoglobin, serum albumin, low density lipoprotein cholesterol and blood homocysteine underwent single factor and Logistic regression analysis. Results Single factor analysis of 12 indicators of risk factors affecting healing were age, Hb, Alb, Hcy, area of ulcer and PUSH scores of the 6 indicators in the regression equation (Z=3.11-6.63, All P < 0.01), gender also entered the regression equation (χ2 = 0.19, P < 0.01); further multivariate regression analysis showed that there were statistically significant differences in PUSH score index (χ2=10.47, P<0.01, OR=0.001, 95% confidence interval were 0.001-0.037). Conclusions Age, gender, Hb, Alb, Hcy and PU area were the risk factors of pressure ulcer healing. Key words: Pressure ulcer; Pressure ulcer scale healing; Wound healing; Regression analysis

Impact of Educational Video Film for Nurses Caring Elders Suffering From Pressure Ulcer about Applying Cutimed Sorbact Dressing On Wound Healing

Pressure ulcer is a serious and common health problem in critical care setting; it has been described as one of the most costly and physically debilitating complications in the 20th century. The prevalence of advanced pressure ulcer is high in older persons; about 70% occur in patients 65 years or older peaking in those between age 70 and 80 years. Most pressure ulcers are believed to be treated if the appropriate measures are implemented to maintain skin integrity by applying the cutimed sorbact dressing. Objectives: to determine the impact of an educational video film for nurses caring elders suffering from pressure ulcer about applying cutimed sorbact dressing on wound healing. Materials and Method. A quasi experimental design used in this study, the study carried in the intensive Care Units of the Specialized Medical Hospital, Emergency Hospital and General Mansoura Hospital in Dakhalia governorate, the study subjects included in this study are 76 elderly patients and 69 nurses. Three tools were used in this study namely; Structured interview schedule sheet, Pressure Ulcer Scale for Healing, Video Film about prevention and applying cutimed sorbact dressing. Results: There is improvement in wound healing of pressure ulcer after applying Cutimed Sorbact dressing compared to the usual dressing. Moreover, the nurses became more knowledgeable after the educational video film concerning caring of elderly suffering from pressure ulcer. Conclusion and recommendation: This study concluded that the elderly patients suffering from pressure ulcers when applying the Cutimed Sorbact dressing intervention faster wound healing and free from bacteria than those who receive usual dressing, moreover, the nurse's knowledge improved after displaying the educational video film program Also, it recommended using the cutimed dressing in treatment of pressure ulcer as aresult of  his fast effect on wound healing.

Therapeutic effects of dermlin and the combination of dermlin and pressure dressing on pressure ulcers in elderly patients

Objective To explore the therapeutic effect of dermlin and the combination of dermlin and pressure dressing in elderly patients with pressure ulcer. Methods From January 2011 to August 2016, a total of 120 hospitalized elderly patients with pressure ulcers in First Affiliated Hospital of PLA General Hosptial were chosen as research objects. Patients with blister diameter less than 5 mm were defined as small blister group, and patients with blister diameter equal to or more than 5 mm were defined as big blister group. Each group containing 60 patients was divided into the observation group and the control group. In the small blister group, there were 30 cases in the control group with 41 blisters and 30 cases in the observation group with 37 blisters. Blisters in small blister groups were not pumped, of which the control group was treated by iodine while the observation group was treated by dermlin. In the big blister group, there were 30 cases in the control group with 42 blisters and 30 cases in the observation group with 41 blisters. Blisters in big blister groups were pumped, of which the control group was firstly treated by iodine and then applied with pressure dressing, while the observation group was firstly treated by dermlin and then applied with pressure dressing. The evaluation standard of therapeutic effect contained recovery, efficiency, improvement and non-effect. All the groups' healing situations were observed and recorded within 7 days. Results In the small blister group, the effective rates were 100.0% in the observation group and 97.6% in the control group. The therapeutic effects in the observation group were statistically significant better than the control group (Z=-2.347, P=0.019) . The therapeutic time in the observation group was significantly shorter than the control group (P<0.01) . In the big blister group, the effective rates were 97.5% in the observation group and 92.9% in the control group. The therapeutic effects in the observation group were statistically significant better than the control group (Z=-3.495, P<0.001) . The therapeutic time in the observation group was significantly shorter than the control group (P<0.01) . Conclusions Both dermlin and the combination of dermlin and pressure dressing could significantly enhance the healing of elderly patients' pressure ulcers and reduce the healing time. Key words: Aged; Pressure ulcer; Dermlin; Pressure dressing

Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission

BackgroundPressure ulcers increase the risk of costly hospitalization and mortality of nursing home residents, so timely healing is important. Disparities in healthcare have been identified in the nursing home population but little is known about disparities in the healing of pressure ulcers. PurposeTo assess racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Multi-levels predictors, at the individual resident, nursing home, and community/Census tract level, were examined in three large data sets. MethodsMinimum Data Set records of older individuals admitted to one of 439 nursing homes of a national, for-profit chain over three years with a stages 2–4 pressure ulcer (n=10,861) were searched to the 90-day assessment for the first record showing pressure ulcer healing. Predictors of pressure ulcer healing were analyzed for White admissions first using logistic regression. The Peters-Belson method was used to assess racial or ethnic disparities among minority group admissions. ResultsA significantly smaller proportion of Black nursing home admissions had their pressure ulcer heal than expected had they been part of the White group. There were no disparities in pressure ulcer healing disadvantaging other minority groups. Significant predictors of a nonhealing of pressure ulcer were greater deficits in activities of daily living and pressure ulcer severity. ConclusionsReducing disparities in pressure ulcer healing is needed for Blacks admitted to nursing homes. Knowledge of disparities in pressure ulcer healing can direct interventions aiming to achieve equity in healthcare for a growing number of minority nursing home admissions.

Dressings and topical agents for treating pressure ulcers.

Dressings and topical agents for treating pressure ulcers.

Anabolic steroids for treating pressure ulcers.

Pressure ulcers, also known as bed sores, pressure sores or decubitus ulcers develop as a result of a localised injury to the skin or underlying tissue, or both. The ulcers usually arise over a bony prominence, and are recognised as a common medical problem affecting people confined to a bed or wheelchair for long periods of time. Anabolic steroids are used as off-label drugs (drugs which are used without regulatory approval) and have been used as adjuvants to usual treatment with dressings, debridement, nutritional supplements, systemic antibiotics and antiseptics, which are considered to be supportive in healing of pressure ulcers. Anabolic steroids are considered because of their ability to stimulate protein synthesis and build muscle mass. Comprehensive evidence is required to facilitate decision making, regarding the benefits and harms of using anabolic steroids. To assess the effects of anabolic steroids for treating pressure ulcers. In March 2017 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 with respect to language, date of publication or study setting. Published or unpublished randomised controlled trials (RCTs) comparing the effects of anabolic steroids with alternative treatments or different types of anabolic steroids in the treatment of pressure ulcers. Two review authors independently carried out study selection, data extraction and risk of bias assessment. The review contains only one trial with a total of 212 participants, all with spinal cord injury and open pressure ulcers classed as stage III and IV. The participants were mainly male (98.2%, 106/108) with a mean age of 58.4 (standard deviation 10.4) years in the oxandrolone group and were all male (100%, 104/104) with a mean age of 57.3 (standard deviation 11.6) years in the placebo group. This trial compared oxandrolone (20 mg/day, administered orally) with a dose of placebo (an inactive substance consisting of 98% starch and 2% magnesium stearate) and reported data on complete healing of ulcers and adverse events. There was very low-certainty evidence on the relative effect of oxandrolone on complete ulcer healing at the end of a 24-week treatment period (risk ratio RR) 0.81, 95% confidence interval (CI) 0.52 to 1.26) (downgraded twice for imprecision due to an extremely wide 95% CI, which spanned both benefit and harm, and once for indirectness, as the participants were mostly male spinal cord injury patients). Thus, we are uncertain whether oxandrolone improves or reduces the complete healing of pressure ulcers, as we assessed the certainty of the evidence as very low.There was low-certainty evidence on the risk of non-serious adverse events reported in participants treated with oxandrolone compared with placebo (RR 3.85, 95% CI 1.12 to 13.26) (downgraded once for imprecision and once for indirectness, as the participants were mostly male spinal cord injury patients). Thus, the treatment with oxandrolone may increase the risk of non-serious adverse events reported in participants.There was very low-certainty evidence on the risk of serious adverse events reported in participants treated with oxandrolone compared with placebo (RR 0.54, 95% CI 0.25 to 1.17) (downgraded twice for imprecision due to an extremely wide 95% CI, which spanned both benefit and harm, and once for indirectness, as the participants were mostly male spinal cord injury patients). Of the five serious adverse events reported in the oxandrolone-treated group, none were classed by the trial teams as being related to treatment. We are uncertain whether oxandrolone increases or decreases the risk of serious adverse events as we assessed the certainty of the evidence as very low.Secondary outcomes such as pain, length of hospital stay, change in wound size or wound surface area, incidence of different type of infection, cost of treatment and quality of life were not reported in the included trial.Overall the evidence in this study was of very low quality (downgraded for imprecision and indirectness). This trial stopped early when the futility analysis (interim analysis) in the opinion of the study authors showed that oxandrolone had no benefit over placebo for improving ulcer healing. There is no high quality evidence to support the use of anabolic steroids in treating pressure ulcers.Further well-designed, multicenter trials, at low risk of bias, are necessary to assess the effect of anabolic steroids on treating pressure ulcers, but careful consideration of the current trial and its early termination are required when planning future research.

Efficacy of arginine-enriched enteral formulas for the healing of pressure ulcers: a systematic review.

Arginine improves healing and modulates inflammation and the immune response. This systematic review aimed to assess the effect of arginine-enriched enteral formulas in pressure ulcer (PU) healing. Systematic computerised searches of PubMed, Web of Knowledge, Scopus, ENTRAL and CINAHL databases were performed from their inception to 20 January 2016. Randomised controlled trials (RCTs) were included in this systematic review. We used the Jadad scale as a quality assessment tool. There were seven RCTs with 369 patients included in this systematic review; four RCTs assessed healing by PU area reduction. All of them reported arginine-enriched enteral nutrition led to a significant improved PU healing compared with standard hospital diet in 2-12 weeks follow-up. Among these four RCTs, one enrolled malnourished patients, one enrolled non-malnourished patients, and the other two studies did not restrict the nutritional status of the patients. Using the Pressure Ulcer Scale for Healing (PUSH) four RCTs assessed healing of PU, all reporting arginine-enriched enteral nutrition resulted in a significant PUSH score improvement compared with control at follow-up. Using the Pressure Sore Status Tool (PSST) one RCT assessed healing of PUs, finding patients receiving arginine had the lowest PSST scores compared with controls. An RCT compared healing with two doses of arginine (4.5g versus 9g), but no difference was found between the doses. Evidence showed that arginine-enriched enteral nutrition led to a significant improvement in PU healing. It was effective not only in malnourished patients, but also in non-malnourished patients.

A multicenter, randomized, controlled study of the use of nutritional supplements containing collagen peptides to facilitate the healing of pressure ulcers

Since collagen peptide stimulates fibroblast growth in skin, it may accelerate the healing of pressure ulcers. Therefore, the purpose of our study was to verify whether the intake of collagen peptides in the form of a supplement drink facilitates the healing of pressure ulcers. We conducted a multicenter, randomized, controlled trial in patients with pressure ulcers. Patients were randomized into 3 groups at a 1:1:1 ratio; control group (usual care), collagen peptide-containing drink group and arginine-containing drink group. The DESIGN-R tool was used to assess healing of pressure ulcers, and nutritional status was measured for 4 weeks while consuming the usual daily meals. Out of 66 patients randomized, 51 patients were analyzed, since 15 patients were excluded from the final analysis. The total DESIGN-R score in patients who received the collagen peptide-containing drink (n = 18) was significantly lower than that in patients in the control group (n = 16) after 2 weeks as well as at the final value. However, the DESIGN-R score in the arginine-containing drink group (n = 17) did not show difference from the control group. There was no significant difference in nutrition status among the 3 groups through the study. Our results indicated that a supplemental addition of the collagen peptide-containing drink to the usual meal facilitated pressure ulcer healing, since the collagen peptide-containing drink led to more changes in the DESIGN-R scores.

Topical phenytoin for treating pressure ulcers.

Pressure ulcers are common in clinical practice and pose a significant health problem worldwide. Apart from causing suffering to patients, they also result in longer hospital stays and increase the cost of health care. A variety of methods are used for treating pressure ulcers, including pressure relief, patient repositioning, biophysical strategies, nutritional supplementation, debridement, topical negative pressure, and local treatments including dressings, ointments and creams such as bacitracin, silver sulphadiazine, neomycin, and phenytoin. Phenytoin is a drug more commonly used in the treatment of epilepsy, but may play an important role in accelerating ulcer healing. To assess the effects of topical phenytoin on the rate of healing of pressure ulcers of any grade, in any care setting. In September 2016, we searched the following electronic databases to identify relevant randomized clinical trials: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid Embase; and EBSCO CINAHL Plus. We handsearched conference proceedings from the European Pressure Ulcer Advisory Panel, European Wound Management Association and the Tissue Viability Society for all available years. We searched the references of the retrieved trials to identify further relevant trials. We also searched clinical trials registries to identify ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting. We included all randomized controlled trials (RCTs) addressing the effects (both benefits and harms) of topical phenytoin on the healing of pressure ulcers of any grade compared with placebo or alternative treatments or no therapy, irrespective of blinding, language, and publication status. Two review authors independently selected studies, extracted information on participants, interventions, methods and results and assessed risk of bias using Cochrane methodological procedures. For dichotomous variables, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables, we calculated the mean difference with 95% CI. We rated the quality of the evidence by using Grading of Recommendations, Assessment, Development and Evaluation approach (GRADE). Three small RCTs met our inclusion criteria and included a total of 148 participants. These compared three treatments with topical phenytoin: hydrocolloid dressings, triple antibiotic ointment and simple dressings. In the three RCTs, 79% of participants had grade II ulcers, and 21% of participants had grade I ulcers; no participants had grade III or IV ulcers. Two RCTs had a high risk of bias overall and the other RCT was at unclear risk of bias due to poor reporting. Two RCTs had three intervention arms and the other had two intervention arms.Two studies compared topical phenytoin with hydrocolloid dressing (84 participants analysed). The available data suggest that hydrocolloid dressings may improve ulcer healing compared to topical phenytoin (39.3% ulcers healed for phenytoin versus 71.4% ulcers healed for hydrocolloid dressings (RR 0.55, 95% CI 0.33 to 0.92; 56 participants, 1 study; low quality evidence). We downgraded the evidence twice: once due to serious limitations (high risk of bias) and once due to the small sample size and small number of events. Two studies compared topical phenytoin with simple dressings (81 participants analysed). From the available data, we are uncertain whether topical phenytoin improves ulcer healing compared to simple dressings (39.3% ulcers healed for phenytoin versus 29.6% ulcers healed for the simple dressing (RR 1.33, 95% CI 0.63 to 2.78; 55 participants, 1 study; very low quality evidence). This evidence was downgraded once due to serious limitations (high risk of bias) and twice due to the low number of outcome events and resulting wide CI which included the possibility of both increased healing and reduced healing. We therefore considered it to be insufficient to determine the effect of topical phenytoin on ulcer healing. One study compared topical phenytoin with triple antibiotic ointment, however, none of the outcomes of interest to this review were reported. No adverse drug reactions or interactions were detected in any of the three RCTs. Minimal pain was reported in all groups in one trial that compared topical phenytoin with hydrocolloid dressings and triple antibiotic ointment. This review has considered the available evidence and the result shows that it is uncertain whether topical phenytoin improves ulcer healing for patients with grade I and II pressure ulcers. No adverse events were reported from three small trials and minimal pain was reported in one trial. Therefore, further rigorous, adequately powered RCTs examining the effects of topical phenytoin for treating pressure ulcers, and to report on adverse events, quality of life and costs are necessary.

Efficacy of mummy on healing of pressure ulcers: A randomized controlled clinical trial on hospitalized patients in intensive care unit.

BackgroundMummy is a mineral substance which according to Persian medicine texts, may be useful in treatment of chronic ulcers.ObjectiveThe present study was performed with the aim of determining the effect of mummy on healing of pressure in male patients who had been hospitalized due to cerebrospinal injury in the Intensive Care Unit.MethodsThis randomized, placebo-controlled clinical trial was performed on 75 patients who had pressure ulcer at Shahid Bahonar Hospital in Kerman, Iran, from September 2016 to March 2017. The control group received normal saline and routine wound dressing, while the intervention group received mummy water solution 20% in addition to normal saline and routine wound dressing on a daily basis. Data was recorded based on the PUSH method. In both groups, ulcers were evaluated on days 0, 7, 14, 21 and 28 for the variables of ulcer surface area, the amount of exudate and type of tissue. Data analysis was done through SPSS 21 and using t-test, Repeated Measure Analysis, Cox Regression and Chi-square.ResultsBoth groups showed reduction in the average ulcer surface area (3.26 to 0.53 in the intervention group and 5.1 to 3.46 in the control group), the average exudate amount (1.26 to 0.26 in the intervention group and 1.83 to 1.06 in the control group) and the average tissue score (1.36 to 0.23 in the intervention group and 2.13 to 1.26 in the control group). Over the entire study period, the intervention group showed more acceptable signs of healing compared to the control group (p<0.05).ConclusionThe healing process was more prominent in the intervention group than the control group.Clinical trial registrationThe trial was registered at the Iranian Registry of Clinical Trials with registered NO. (IRCT2014042917494N1) (29/04/2014).FundingNo financial support for the research.

Comparing turmeric extract plus animal butter synthetic poultice effect in two home-based and aseptic-based preparation methods in terms of microbial load

Background and Objective: Based on increase in individuals' inclinations toward the use of natural and traditional products in curing some diseases in a systemic and localized manner, the survey of the pathogenic factors which are transferred through such products is of a great importance from the health perspectives. Furthermore, because the emergence of infections due to nonstandard method of preparing some of these natural drugs has not been accurately determined, a poultice mixture consisting of turmeric extract and animal butter was compared in two home-based and aseptic-based preparation methods in terms of microbial load and their effects on the process of pressure ulcer healing is investigated in this study. Materials and Methods: In this study, two poultice mixtures were initially prepared in a home-based method and the other under aseptic conditions, transferred to the laboratory where the specimens were cultured under sterile conditions, in microbe-culturing plates under microbiological hood with a dilution rate of 1–10. After the specified time duration elapsed, the plates containing the culture media were evaluated in terms of bacterial and fungal growth. To prepare a poultice based on standardized methods, turmeric was sufficiently bought from the medicinal herbs market and then put in ethanol 95% v/v. Animal butter underwent separation during a 24 h period in rotary evaporation device under reduced condensation pressure, and after its water was oozed out in 70°C, the concentrate was placed in the incubator. Turmeric extract and animal butter were mixed under bacteriology hood with sterilized wheat flour in autoclave. Finally, the poultice prepared aseptically was tested on seven human specimens and the results were evaluated using pressure ulcer scale for healing (PUSH). Results: Based on the experiments, the homemade poultice mixture was found contaminated with Gram-positive microbial factors, but when the poultice mixture was prepared seven times in the laboratory, no microbial load was found (above USP standard). The mean area of the ulcer was 13.41 before the study, but in the last evaluation, value decreased to 2.21. PUSH mean score from the 1st day until the 4th week reduced from 13.42 to 5.85. It was shown that the ulcer recovery trend decreased considerably. Furthermore, regarding the tissue surveys through observing the samples at the end of intervention, it was seen that the ulcer was free of necrosis and granulated tissues were visible on the ulcer. Conclusion: The aseptic specimen was found in an standard level in terms of microbial load and practically caused effective recovery of the pressure ulcer through increasing the circulation in blood veins, reducing the secretions and edema, and is not indicative of traces of any infection; thus the consumption of this poultice was recognized as safe in improving the pressure ulcers.

Reconstructive surgery for treating pressure ulcers.

The management of pressure ulcers involves several interventions ranging from pressure-relieving measures such as repositioning, to treatments that can include reconstructive surgery. Such surgery may be considered for recalcitrant wounds when full thickness skin loss arises and deeper structures such as muscle fascia and even bone are exposed. The surgery commonly involves wound debridement followed by the addition of new tissue into the wound. Whilst reconstructive surgery is an accepted means of ulcer management, the benefits and harms of surgery compared with non-surgical treatments, or alternative surgical approaches are not clear. To assess the effects of reconstructive surgery for healing pressure ulcers (stage II or above), comparing surgery with no surgery or comparing alternative forms of surgery in any care setting. We searched the following electronic databases to identify reports of relevant randomised clinical trials (searched 26 September 2016): the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. We also searched three clinical trials registers and reference lists of relevant systematic reviews, meta-analyses and health technology assessment reports. Published or unpublished randomised controlled trials that assessed reconstructive surgery in the treatment of pressure ulcers. Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias and extract study data. We did not identify any studies that met the review eligibility criteria nor any registered studies investigating the role of reconstructive surgery in the management of pressure ulcers. Currently there is no randomised evidence that supports or refutes the role of reconstructive surgery in pressure ulcer management. This is a priority area and there is a need to explore this intervention with more rigorous and robust research.