Comparing the efficacies of alginate, foam, hydrocolloid, hydrofiber, and hydrogel dressings in the management of diabetic foot ulcers and venous leg ulcers: a systematic review and meta-analysis examining how to dress for success.

Diabetic foot ulcers and venous leg ulcers are chronic wounds frequently encountered by dermatologists. Choosing appropriate wound dressings can effectively promote wound healing and potentially reduce morbidity and financial burden experienced by patients. The objective of our systematic review and meta-analysis was to evaluate wound healing efficacies of synthetic active dressings in diabetic foot ulcer and venous leg ulcer management. For data collection, PubMed, Embase, Cochrane Library, CINAHL, and clinicaltrials.gov online databases were searched from database inception to 10 May 2015. Fixed and random effects modeling were used to calculate pooled risk ratios for complete ulcer healing from pairwise dressing comparisons. The results of our review showed moderate-quality level evidence that hydrogels were more effective in healing diabetic foot ulcers than basic wound contact dressings (RR 1.80 [95% CI, 1.27-2.56]). The other dressing comparisons showed no statistically significant differences between the interventions examined in terms of achieving complete diabetic foot ulcer healing. Non-adherent dressings were more cost-effective than hydrofiber dressings for diabetic foot ulcers in terms of mean total cost per patient of the dressings themselves. All venous leg ulcer pairwise dressing comparisons showed equivalent dressing efficacies in terms of promoting complete ulcer healing. Overall, most synthetic active dressings and traditional wound dressings are equally efficacious in treating diabetic foot ulcers and venous leg ulcers. For treating diabetic foot ulcers, hydrogels are more efficacious than basic wound contact dressings, and non-adherent dressings are more cost-effective than hydrofiber dressings. Ultimately, dressing choice should be tailored to the wound and the patient.

A systematic review of the use of hydrocolloids in the treatment of pressure ulcers.

AIMS AND OBJECTIVES: The aim of this systematic literature review was to describe the current evidence in the field of pressure ulcer treatment with hydrocolloids and to give recommendations for clinical practice and further research. BACKGROUND: Pressure ulcers are a common problem in clinical practice and generate substantial expense. A wide range of dressings is available but little is known about the effect on pressure ulcer healing. METHODS: A Cochrane-based search strategy was used in four databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Cumulative Index to Nursing and Allied Health Literature), manuals and reference lists. Randomised controlled trials on the treatment of pressure ulcers with hydrocolloids, as defined by the British National Formulary, were systematically included and analysed. RESULTS: Twenty-nine publications, dealing with 28 different studies, met the inclusion criteria and were included in the review. Hydrocolloids were most frequently used on pressure ulcers grade 2-3. Concerning the healing of the pressure ulcer, hydrocolloids are more effective than gauze dressings for the reduction of the wound dimensions. The absorption capacity, the time needed for dressing changes, the pain during dressing changes and the side-effects were significantly in favour of hydrocolloids if compared to gauze dressings. Based on the available cost-effectiveness data, hydrocolloids seemed to be less expensive compared with collagen-, saline- and povidine-soaked gauze but more expensive compared to hydrogel, polyurethane foam and collagenase. CONCLUSIONS: This review demonstrates that hydrocolloids are to be preferred to gauze dressings in the treatment of pressure ulcers. Additional research is needed to confirm these results. RELEVANCE TO CLINICAL PRACTICE: Based on the studies included in this review, hydrocolloids are frequently used in the treatment of grade 2 and 3 pressure ulcers and are more effective and less expensive than gauze dressings. Compared with alginates, polyurethane dressings, less-contact layers, topical enzymes and biosynthetic dressings, hydrocolloids are less effective.

The COASST study: cost-effectiveness of albumin in severe sepsis and septic shock.

INTRODUCTION: The cost-effectiveness of albumin-based fluid support in patients with severe sepsis is not known. METHODS: We compared standard medical practice and systematic albumin infusion. The study population consisted of patients with severe sepsis and/or septic shock admitted to one of the 35 intensive care units belonging to the Cub-Réa regional database between 1 January 1998 and 31 December 2002. Only stays longer than 24 hours and only patients with a minimum of circulatory, renal, or respiratory failure were considered. Cost estimates were based on French diagnosis-related groups and fixed daily prices. A 4.6% reduction in mortality was expected in the albumin arm, as observed in the Saline vs Albumin Fluid Evaluation (SAFE) Study. Life expectancy was estimated with the declining exponential approximation of life expectancy method, based on age, sex, Simplified Acute Physiology Score II, and McCabe score. RESULTS: The number of lives saved among the 11137 patients was 513. The average life expectancy of the 5156 patients who left the hospital alive was estimated to be 9.78 years. The costs per life saved and per year life saved were 6037 euro and 617 euro, respectively. Sensitivity analyses confirmed the robustness of the results. CONCLUSION: The application of the SAFE Study results to CUB-Réa data shows that albumin infusion is cost-effective in severe sepsis.

Crystalloids versus colloids for fluid resuscitation in critically-ill patients.

The choice of crystalloid or colloid for fluid resuscitation has been debated for the last few years. Although colloids seems to be more interesting when taking into account their physiological properties, their effect on mortality is not better than crystalloids if they are used in an adequate amount. Moreover, colloids' side effects are far more important than those of crystalloids. Several randomised studies pointed out the renal effects of colloids including acute renal injury with an increased need of renal replacement therapy. An unacceptably high rate of renal side effects has resulted in premature termination of some clinical trials. In addition, homeostatic and anaphylactoid effects of colloids on coagulation and on anaphylaxis may increase the risk of death associated with their use. Finally, colloids are much more expensive than crystalloids. For all these reasons, we conclude that crystalloids should be preferred to colloids for fluid resuscitation.

Colloid or crystalloid for resuscitation of major burns.

There is continuing debate over the merits of colloid versus crystalloids for the resuscitation of major burns. This article reviews fluids used in burn resuscitation and discusses potential advantages and disadvantages of colloid and crystalloid.

Unexpected economics of ulcer care protocols.

The cost of managing chronic ulcers, both venous leg and decubiti (sacral pressure), was reviewed using 36 randomized, controlled studies with a focus on saline, hydrocolloid, and a human skin construct. When one includes the labor intensiveness of dressing changes three to four times per day, the application of hydrocolloid dressings becomes the most cost-effective.

Effect of three wound dressings on infection, healing comfort, and cost in patients with sternotomy wounds: a randomized trial.

STUDY OBJECTIVE: To compare three dressing types in terms of their ability to protect against infection and promote healing, patient comfort, and cost-effectiveness. DESIGN: Prospective, randomized controlled trial. SETTING: Major metropolitan, academically affiliated, tertiary referral center. PATIENTS: Seven hundred thirty-seven patients were randomized to receive a dry absorbent dressing (n = 243) [Primapore; Smith & Nephew; Sydney, NSW, Australia], a hydrocolloid dressing (n = 267) [Duoderm Thin ConvaTec; Mulgrave, VIC, Australia], or a hydroactive dressing (n = 227) [Opsite; Smith & Nephew] in the operating theater on skin closure. RESULTS: There was no difference in the rate of wound infection or wound healing between treatment groups. The Primapore dressing was the most comfortable and cost-effective dressing option for the sternotomy wound. Duoderm Thin dressings were associated with increased wound exudate (p < 0.001), poor dressing integrity (p < 0.001), more frequent dressing changes (p < 0.001), more discomfort with removal (p < 0.05), and increased cost (p < 0.001). CONCLUSIONS: In the context of no additional benefit for the prevention of wound infection or the rate of wound healing for any of the three dressing products examined, dry absorbent dressings are the most comfortable and cost-effective products for sternotomy wounds following cardiac surgery.

Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial.

OBJECTIVES: To compare the effects of topical collagen and hydrocolloid on pressure ulcer healing. DESIGN: Randomized (allocation concealed), single-blind (outcome assessors), controlled trial with 8-week follow-up. SETTING: Eleven nursing homes in central Illinois. PARTICIPANTS: Sixty-five patient-residents with Stage II or III pressure ulcers: median age 83.1, median Braden score 12, 63% female, 80% Stage II ulcers, and 20% Stage III ulcers. Exclusion criteria included cellulitis and osteomyelitis. INTERVENTION: Thirty-five patients were allocated to topical collagen daily, 30 to topical hydrocolloid twice weekly. MEASUREMENTS: The primary outcome was complete healing within 8 weeks. Secondary outcomes were time to heal, ulcer area healed per day, linear healing of wound edge, and cost of therapy. RESULTS: Analysis by intention to treat revealed similar complete ulcer healing within 8 weeks in collagen (51%) and hydrocolloid (50%) recipients (difference 1%, 95% confidence interval (CI) = 26-29%). Mean healing time was similar: collagen healed in 5 weeks (95% CI = 4-6), hydrocolloid healed in 6 weeks (95% CI = 5-7). Mean area healed per day was 6 mm(2)/d in both treatment groups. Mean linear healing of the wound edge was 3 mm in both groups. In multivariate analysis, baseline ulcer depth was the only independent predictor of complete ulcer healing within 8 weeks (odds ratio = 0.56, 95% CI = 0.38-0.81). Cost analysis favored hydrocolloid. CONCLUSIONS: There were no significant differences in healing outcome between collagen and hydrocolloid. Collagen was more expensive and offered no major benefits to patients otherwise eligible for hydrocolloid treatment.

Evaluation of a new composite dressing for the management of chronic leg ulcer wounds.

OBJECTIVES: A new composite dressing (Versiva, ConvaTec) combines three technologies: hydrocolloid, hydrofibre and a foam-film layer. This study aimed to assess the safety of the dressing in the management of patients with venous leg ulcers. Clinical performance was also assessed. METHOD: This multicentre, non-randomised, open-label, phase II study assessed the safety (via adverse-effect reporting) and performance, including weartime, absorption, dressing integrity, ease of use and wound progression, of Versiva. Up to 10 dressing changes were assessed within a five-week study period. RESULTS: In 75 dressing changes of 11 ulcers, the mean wear time was approximately five days. No or minimal leakage was observed in 81% of changes. In 93%, the dressing was 'very easy' to remove, with no trauma to surrounding skin. Most changes (77%) were painless. CONCLUSION: Versiva met or exceeded the investigators' expectations for exudate absorption, protection of peri-wound skin and reduction in wound pain and ulcer area. Healing or marked improvement was observed in 82% of leg ulcers within the five-week study. The relatively long wear-time of five days represents a cost-effective advantage for this dressing compared with other available adhesive foams for the management of chronic wounds.

Economic evaluation of collagenase-containing ointment and hydrocolloid dressing in the treatment of pressure ulcers.

OBJECTIVE: To evaluate the efficacy and cost effectiveness of two treatments of pressure sores on the heel: a collagenase-containing ointment and a hydrocolloid dressing. DESIGN: Study and cost data were collected prospectively in a randomised clinical trial in The Netherlands by counting the resource use for each patient until wound healing occurred. STUDY PARTICIPANTS: All 24 female study participants were inpatients from the same hospital with grade IV pressure sores on the heel following orthopaedic surgery. INTERVENTIONS: Two different treatment strategies were analysed: a collagenase-containing ointment (Novuxol) and a hydrocolloid dressing (Duoderm). PERSPECTIVE: Hospital perspective. MAIN OUTCOME MEASURES AND RESULTS: The average costs per patient for treatment with the hydrocolloid dressing were about 5% higher than those with the collagenase-containing ointment. The treatment costs were similarly distributed within both groups, with 34% for materials and 66% for personnel. The cost-effectiveness analysis revealed that cost savings of 899 Dutch guilders (1998 values) per successfully treated patient could be expected using the collagenase-containing ointment instead of the hydrocolloid dressing. In addition, wound healing was achieved, on average, within a shorter time period with the collagenase treatment (10 weeks) compared with the hydrocolloid treatment (14 weeks). The robustness of the results were also tested using sensitivity analyses. These analyses served to confirm that collagenase treatment provides a better cost-effectiveness ratio than hydrocolloid treatment. CONCLUSIONS: With regard to overall costs and costs per successfully treated patient, this study showed collagenase treatment to be more cost effective than the hydrocolloid treatment in patients with grade IV pressure sores on the heel and that the amount of time needed for wound healing was shorter.

Outcomes of venous ulcer care: results of a longitudinal study.

A longitudinal study involving 81 patients with venous ulcers was conducted to explore the outcomes and cost of wound care in a home healthcare (HHC) setting and an outpatient care setting. Ulcers were managed with a saline gauze or hydrocolloid dressing and compression hosiery, or covered with an Unna's boot. Outcomes did not vary between physician's office and home care. Patients preferred home care, but costs and charges were much higher for HHC than for patients managed in the physician's office. Recurrence rates and costs varied greatly. Eighty-eight percent of ulcers in the saline dressing group did not heal or recurred compared to 21% of ulcers in the Unna's boot and 13% of ulcers in the hydrocolloid dressing group. The data also suggest hydrocolloid dressings are more cost-effective than Unna's boot or saline-gauze dressings. Controlled clinical studies to ascertain the cost-effectiveness of venous ulcer care in different patient care settings and the use of different treatment modalities, as well as care system oriented toward outcome for the patient rather than service, design, and distribution, are needed.

A comparison of two hydrocolloid sheet dressings.

This article examines the clinical application of hydrocolloid dressings as a whole. Two thin hydrocolloid sheets - Tegasorb thin and Duoderm extra thin - were essayed in the clinical area, and compared for their ease of application and removal, conformability, wear time and patient comfort. Both dressings were found to be highly acceptable in clinical practice, with advantages and disadvantages to each type of dressing. There was a high level of patient acceptability and no adverse reactions were noted during this evaluation. Pain reduction was noted by patients with superficial pressure sores and trauma wounds that were treated with thin hydrocolloid sheets.

Costs of dressings in the community.

This study compares the costs of dressings used in the treatment of patients with a variety of wound aetiologies. The two dressings investigated were a hydrocolloid dressing and a hydrocellular dressing. Secondary objectives included a comparison of dressing durability, time to complete healing, ease of wound cleansing and dressing removal. The study was an open prospective single-centre randomised parallel group trial involving 100 patients, treated in the community, who were randomised to the two dressing groups. For all aetiologies except pressure sores, the costs of the hydrocolloid dressing were less than the costs of the hydrocellular dressings. Similar healing rates were observed in the leg ulcer and 'other wound' groups. There were, however, significant differences in the number of healed wounds observed in patients with pressure sores treated with the hydrocellular dressing.

Nuclear medicine approaches for detection of axillary lymph node metastases.

In breast cancer patients the detection of axillary lymph node involvement is a very critical issue, in view of the earlier diagnosis of the disease in recent years, and the increased frequency of very small tumors at first presentation. The size of cancer is related to the risk of axillary metastases, and this may affect the prognosis and the therapeutic strategies. Axillary lymph node involvement is generally recognized as an index of distant microdiffusion, and as it affects overall and disease-free survival, represents the basis for adoption of adjuvant chemotherapy. Routine axillary lymph node dissection (ALND) is expensive, and does not benefit about 70% of early breast cancer patients which are node negative (pN-). Today most of these patients have to sustain the potential morbidity and the economic costs of ALND. The clinical approach is known to be an unreliable diagnostic tool, and for the detection of axillary metastases, conventional X-ray techniques are also unable to solve the problem. By contrast, nuclear medicine procedures have revealed a very interesting diagnostic potential in recent years. This paper analyzes the numerous studies conducted in the field of lymph node visualization and the heterogeneity of the published experiences, taking into account the different approaches proposed in the literature: a) imaging with gamma-emitting tumor seeking agents; b) radioimmunoscintigraphy intravenous (i.v.) or by the interstitial route; c) lymphoscintigraphy with colloids and gamma probe sentinel biopsy; d) positron emission tomography (PET). Although it is very difficult to make a definitive statement about the clinical efficacy of all these methods, this paper reports the most important series of patients examined in the literature as well as the author's own experiences. This can serve as the basis for a better understanding of the potential of nuclear medicine procedures, and gives the reader the opportunity to weigh advantages and drawbacks of each method. At present, lymphoscintigraphy with gamma probe sentinel biopsy and FDG-PET are the nuclear medicine approaches with the best diagnostic performance. However, a correct comparison of the methods will not be possible, until their careful assessment in the same patients is performed. In addition, a final statement today should consider also the increasing need to carry out an economic analysis by evaluating the cost-effectiveness of the examinations.