Evidence-based recommendations for the use of negative pressure wound therapy in chronic wounds: steps towards an international consensus.

AIM: Negative Pressure Wound Therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer-reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this communication the results of the study of evidence in chronic wounds including pressure ulcers, diabetic foot ulcers (DFU), venous leg ulcers (VLU), and ischaemic lower limb wounds are reported. METHODS: Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% agreement. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. RESULTS: The primary treatment goal of NPWT in most chronic wounds is to achieve wound closure (either by secondary intention or preparing the wound for surgical closure). Secondary goals commonly include: to reduce wound dimensions, and to improve the quality of the wound bed. Thirteen evidence based recommendations were developed in total to address these treatment goals; 4 for pressure ulcers, 4 for DFU, 3 for ischaemic lower limb wounds and 2 for VLU. CONCLUSION: The present evidence base is strongest for the use of NPWT in non-ischaemic DFU and weakest in VLU. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Evidence-based recommendations for negative pressure wound therapy: treatment variables (pressure levels, wound filler and contact layer)--steps towards an international consensus.

Negative pressure wound therapy (NPWT) is becoming a commonplace treatment in many clinical settings. New devices and dressings are being introduced. Despite widespread adoption, there remains uncertainty regarding several aspects of NPWT use. To respond to these gaps, a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In a previous communication, we have reviewed the evidence base for the use of NPWT within trauma and reconstructive surgery. In this communication, we present results of the assessment of evidence relating to the different NPWT treatment variables: different wound fillers (principally foam and gauze); when to use a wound contact layer; different pressure settings; and the impact of NPWT on bacterial bioburden. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence and drafting of the recommendations by a global expert panel. Evidence and recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) classification system. In general, there is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another. Overall, 14 recommendations were developed: five for the choice of wound filler and wound contact layer, four for choice of pressure setting and five for use of NPWT in infected wounds. With respect to bioburden, evidence suggests that reduction of bacteria in wounds is not a major mode of action of NPWT.

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus.

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Law and ethics at the border of viability.

The Supreme Court of Texas in the case of Miller v. HCA announced a rule in 2003 (118 s.w. 3d 758) that a physician attending the delivery of a severely premature infant may provide life-sustaining treatment for that infant under 'emergent circumstances' as a matter of law without first obtaining parental consent. This paper examines issues of law and ethics relevant to decisions about infant resuscitation at the border of viability. It is argued that there is typically no emergency when infants are delivered at 23 weeks gestation, and parents should be asked for informed consent before resuscitation in the delivery room.

Bidirectional fusion of the heart-forming fields in the developing chick embryo.

It is generally thought that the early pre-tubular chick heart is formed by fusion of the anterior or cephalic limits of the paired cardiogenic fields. However, this study shows that the heart fields initially fuse at their midpoint to form a transitory "butterfly"-shaped, cardiogenic structure. Fusion then progresses bi-directionally along the longitudinal axis in both cranial and caudal directions. Using in vivo labeling, we demonstrate that cells along the ventral fusion line are highly motile, crossing future primitive segments. We found that mesoderm cells migrated cephalically from the unfused tips of the anterior/cephalic wings into the head mesenchyme in the region that has been called the secondary heart field. Perturbing the anterior/cranial fusion results in formation of a bi-conal heart. A theoretical role of the ventral fusion line acting as a "heart organizer" and its role in cardia bifida is discussed.

The need for comprehensive and consistent treatment of the nitrogen cycle in nitrogen cycling and mass balance studies: I. Terrestrial nitrogen cycle.

A review of conceptual models that scientists use to characterize the nitrogen (N) cycle and to conduct N mass balance studies at global, regional and local scales is presented. Large uncertainties in processes and process rates make it difficult to conduct precise N mass balances and the dominant conceptual model has changed in recent decades. An earlier conceptual model recognized explicitly that human activities, especially agriculture, have both depleted terrestrial N and increased the fixation of atmospheric N in biologically available forms. The current conceptual model does not include adequate treatment of the depletion of the terrestrial N reservoir, the resulting transfer of N to the hydrosphere and atmosphere, or the cycling of terrestrial N below the plow layer. Thus, it delivers an unrealistically limited view of human influences on the N cycle. It is recommended that a comprehensive and consistent treatment of terrestrial N cycling be developed to better facilitate scientific explanation of historical N-related environmental changes and more closely balance N budgets on a range of geographical and temporal scales. Improved N-cycle models will provide an improved scientific basis for answering important resource management and policy questions.

Epidemiology of violent deaths in the world.

OBJECTIVE: This study describes epidemiologic patterns of mortality due to suicide, homicide, and war for the world in order to serve as a benchmark against which to measure future progress and to raise awareness about violence as a global public health problem. SETTING: The world and its eight major regions. METHOD: Data were derived from The Global Burden of Disease series and the US National Center for Health Statistics to estimate crude rates, age adjusted rates, sex rate ratios, and the health burden for suicide, homicide, and war related deaths for the world and its eight major regions in 1990. RESULTS: In 1990, an estimated 1,851,000 people died from violence (35.3 per 100,000) in the world. There were an estimated 786,000 suicides. Overall suicide rates ranged from 3.4 per 100,000 in Sub-Saharan Africa to 30.4 per 100,000 in China. There were an estimated 563,000 homicides. Overall homicide rates ranged from 1.0 per 100,000 in established market economies to 44.8 per 100,000 in Sub-Saharan Africa with peaks among males aged 15-24 years old, and among females aged 0-4 years old. There were an estimated 502,000 war related deaths with peaks in rates for both sexes among people aged 0-4, 15-29, and 60-69 years old. CONCLUSION: The number of violence related deaths in the world is unacceptably high. Coordinated prevention and control efforts are urgently needed.

Living morphogenesis of the ventricles and congenital pathology of their component parts.

Living morphogenetic studies show that each definitive ventricle is constructed from different primitive cardiac segments, and each has its specific anatomical features. These ventricular segments are the atrioventricular junction; the primitive inlet segment, part of the primary heart tube, which initially provides the inlets of each ventricle; the primitive outlet segment, which gives rise to both ventricular outlets; and the apical trabeculated regions of the right and left ventricles which grow from the primary heart tube, respectively. In this review, we describe regional pathology based on the relationship of these primitive ventricular components. We propose that the abnormal morphogenesis of one of these segments gives origin to regional ventricular pathology. For example, abnormal embryogenesis of the atrioventricular canal produces malformations of the atrioventricular junctions, such as double inlet ventricle, absence of one atrioventricular connection, and straddling and overriding atrioventricular valves. Similarly, abnormal morphogenesis of the primitive outlet segment gives rise to malformations of the subarterial region of each ventricle, along with the valves guarding these vessels. The principal anatomical features of these malformations of the ventricular inlets and outlets are described, and their possible morphogenesis is discussed. Due to the fact that the apical trabeculated region of each ventricle arises from a separate primitive segment, each ventricle can be identified according to the pattern of its apical trabeculations. This feature is crucial in the elucidation of complex congenital pathology, such as discordant atrioventricular connections.

Suicide among adolescents and young adults: a cross-national comparison of 34 countries.

Few cross-national reports have examined suicide rates among adolescents and young adults. A survey of suicides among 15-24-year-olds in 34 of the wealthiest nations demonstrated that 15,555 youths killed themselves in a 1-year study period. Thirty-four percent of these suicides were firearm-related. Finland led the participating nations in total and firearm-related suicide rates. An association was found between divorce rates and youth suicide rates, firearm-related suicide among youths, and suicide rates among young males. For a smaller sample of countries, an association was found between firearm availability and firearm-related suicide rates among youths and suicide rates among young males.

Trends in suicide ideation and suicidal behavior among high school students in the United States, 1991-1997.

To examine trends in suicide ideation and behavior over time, the authors analyze data from nationally representative samples of between 10,904 and 16,296 students participating in the 1991, 1993, 1995, and 1997 Youth Risk Behavior Surveys. These data describe the proportion of United States students in grades 9 through 12 that reported having (1) seriously considered attempting suicide, (2) made a plan to attempt suicide, (3) attempted suicide, and (4) made an injurious suicide attempt. From 1991 to 1997, the percentage of students seriously considering suicide and the percentage that made a suicide plan showed significant linear decreases. However, the percentage of students that made an injurious suicide attempt showed a significant linear increase. These trends make it unlikely that relevant national health objectives for the year 2000 will be met. Additional efforts are needed to identify and disseminate strategies that effectively reduce suicidal thoughts and behaviors among adolescents.

The global burden of injuries.

The traditional view of injuries as "accidents", or random events, has resulted in the historical neglect of this area of public health. However, the most recent estimates show that injuries are among the leading causes of death and disability in the world. They affect all populations, regardless of age, sex, income, or geographic region. In 1998, about 5.8 million people (97.9 per 100,000 population) died of injuries worldwide, and injuries caused 16% of the global burden of disease. Road traffic injuries are the 10th leading cause of death and the 9th leading cause of the burden of disease; self-inflicted injuries, falls, and interpersonal violence follow closely. Injuries affect mostly young people, often causing long-term disability. Decreasing the burden of injuries is among the main challenges for public health in the next century--injuries are preventable, and many effective strategies are available. Public health officials must gain a better understanding of the magnitude and characteristics of the problem, contribute to the development and evaluation of injury prevention programs, and develop the best possible prehospital and hospital care and rehabilitation for injured persons.

Gastroesophageal reflux and Barrett's esophagus in adults born with esophageal atresia.

OBJECTIVE: Postoperative morbidity after correction of esophageal atresia is partly determined by gastroesophageal reflux disease, which has been proven to affect from one-half to two-thirds of patients during childhood. We conducted a follow-up study to test our hypothesis that, if former patients still show gastroesophageal reflux at adult age, they are at high risk for developing Barrett's esophagus, which is considered to be premalignant. METHODS: Of 69 patients born between 1971 and 1978, all having undergone a primary anastomosis, 24 had died, five of them because of aspiration. Of the 45 survivors, 39 could be traced; they all completed a questionnaire inquiring after symptoms related to the esophagus. Of these patients, 34 underwent an additional esophagogastrocopy. RESULTS: Only nine of the 39 patients had no symptoms at all; 30 had mild to severe dysphagia symptoms, and 13 had mild to severe reflux symptoms. Esophagogastrocopy in 34 patients revealed that the anastomosis was still recognizable in all cases, but stenoses were not found. Six patients showed a small hiatal hernia, and one a large one. The incidences of reflux symptoms (13/39, p < 0.01), reflux esophagitis (9/34, p < 0.01) and Barrett's esophagus (2/34, p < 0.001) were significantly higher than in the normal population. CONCLUSIONS: This group seems to be at risk for developing Barrett's esophagus. As this is the first follow-up study of a consecutive group of adult esophageal atresia patients, we think it is advisable to perform an esophagogastroscopy in all patients at adulthood until more long term follow-up data are available.