Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 176
Filtrar
1.
Trials ; 21(1): 24, 2020 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-31907033

RESUMO

BACKGROUND: Although the wound-healing period for purse-string closure (PSC) after stoma reversal is longer than that required for the primary closure method, the rate of wound infection is reduced. The application of negative-pressure wound therapy (NPWT) can reduce the healing period for many types of wounds. Herein, we describe a planned trial to test the hypothesis that NPWT can reduce the healing period for PSC after stoma reversal. METHODS/DESIGN: Patients undergoing stoma reversal will be recruited and allocated into intervention and control groups, with 1:1 randomisation. Patients in the control group will receive standard postsurgical wound care; patients in the intervention group will receive NPWT using the PICO™ system. The target sample size will be 38 patients, as this will provide 80% power at the 5% level of significance to detect a 7-day reduction in the wound-healing period in the intervention group compared to that in the control group. The primary endpoint will be the duration to wound healing, defined as the time to nearly complete epithelisation of the wound, without any discharge or surgical site infection (SSI). Secondary endpoints will be the SSI rate, length of postoperative hospital stay, number of wound dressings and visits to the hospital for wound dressing after discharge, total cost of wound dressings, and patient and observer scar assessment scale scores. DISCUSSION: The results of this planned randomised controlled study will clarify the role of NPWT in patients undergoing stoma reversal and strengthen the rationale for choosing a dressing technique. TRIAL REGISTRATION: Clinical Research Information Service (CRIS), KCT0004063. Registered on 6 June 2019.


Assuntos
Tratamento de Ferimentos com Pressão Negativa , Reepitelização , Estomas Cirúrgicos/efeitos adversos , Infecção da Ferida Cirúrgica/prevenção & controle , Técnicas de Fechamento de Ferimentos/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bandagens/economia , Bandagens/estatística & dados numéricos , Ensaios Clínicos Fase IV como Assunto , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/economia , Tratamento de Ferimentos com Pressão Negativa/instrumentação , Tratamento de Ferimentos com Pressão Negativa/estatística & dados numéricos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Pele/fisiopatologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
2.
World J Emerg Surg ; 14: 52, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31798672

RESUMO

Background: Tractotomy has become the standard of care for transfixing through-and-through lung injuries as it can be performed quickly with little blood loss and a low risk of complications. However, packing with laparotomy pads could be a feasible alternative to tractotomy on selected patients. We describe a series of four patients with lung trauma in which packing of the pulmonary wound tract was used as the primary and unique surgical strategy for arresting hemorrhage from injuries of the lung parenchyma. Methods: Packing of the traumatic tract is achieved by gently pulling a laparotomy pad with a Rochester clamp and adjusting it to the cavity to stop the bleeding. The pack is removed in a subsequent surgery by moistening and tractioning it softly to avoid additional damage. The operation is completed by manual compression of the wounded lobe. We present a case series of our experience with this approach. Results: From 2012 to 2016, we treated four patients with the described method. The mechanism was penetrating in all them. The clinical condition was of exsanguinations with multiple sources of hemorrhage. There were three patients with peripheral injuries to the lung and one with a central injury to the pulmonary parenchyma. Bleeding was stopped in all the cases. Three patients survived. A patient had recurrent pneumothorax which was resolved with a second chest tube. Conclusion: Packing of the traumatic tract allowed rapid and safe treatment of transfixing through-and-through pulmonary wounds in exsanguinating patients under damage control from several bleeding sources.


Assuntos
Bandagens/normas , Hemorragia/cirurgia , Tecido Parenquimatoso/cirurgia , Cicatrização/fisiologia , Adulto , Bandagens/estatística & dados numéricos , Humanos , Laparoscopia/métodos , Pulmão/fisiopatologia , Pulmão/cirurgia , Masculino , Tecido Parenquimatoso/lesões , Ferimentos e Lesões/complicações , Ferimentos e Lesões/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/cirurgia
4.
Medicina (Kaunas) ; 55(8)2019 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-31394888

RESUMO

Background and objectives: Supracondylar humerus fractures are common in children andcan be surgically treated. However, the general surgical procedures involving reduction andfixation might lead to reduction loss, failure to direct the Kirschner (K)-wire toward the desiredposition, prolonged surgery, or chondral damage. This study aimed to show that temporaryfixation of closed reduction with a fabric adhesive bandage in pediatric supracondylar humerusfractures could maintain reduction so that surgical treatment can be easily performed by a singlephysician. Materials and Methods: Forty-six patients with Gartland type 3 supracondylar humerusfractures who underwent surgical treatment between May 2017 and June 2018 were retrospectivelyevaluated. Fluoroscopy-guided reduction and fixation were performed from the distal third of theforearm to the proximal third of the humerus using a fabric adhesive bandage. Two crossed pinswere applied on the fracture line by first inserting a lateral-entry K-wire and then inserting anotherK-wire close to the anterior aspect of the medial epicondyle and diverging from the ulnar nervetunnel. A tourniquet was not applied in any patient and no patients required open reduction.Results: The study included 32 boys (69.6%) and 14 girls (30.4%) (mean age, 7.1; range, 2-16 years).The mean hospital stay and follow-up duration were 4.3 ± 3.9 days and 48.1 ± 14.3 weeks,respectively. Heterotopic ossification was detected in one patient, and ulnar nerve neuropraxia wasdetected in another patient. Functional (according to Flynn criteria) and cosmetic outcomes wereexcellent in 95.6%, moderate in 2.2%, and poor in 2.2% of patients. The mean duration of fixation ofthe closed reduction with a fabric adhesive bandage was 8.1 ± 3.9 min, and the mean duration ofpinning was 7.9 ± 1.4 min. Conclusions: Temporary preoperative fixation of supracondylar humerusfractures that require surgical treatment with a fabric adhesive bandage may be significantlyconvenient in practice.


Assuntos
Bandagens/normas , Fixação de Fratura/instrumentação , Fraturas Ósseas/cirurgia , Úmero/lesões , Adolescente , Bandagens/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Fluoroscopia/métodos , Fixação de Fratura/métodos , Fixação de Fratura/normas , Fraturas Ósseas/diagnóstico , Humanos , Úmero/cirurgia , Masculino , Estudos Retrospectivos , Fita Cirúrgica/normas , Fita Cirúrgica/estatística & dados numéricos , Resultado do Tratamento , Turquia
5.
Ann Surg Oncol ; 26(12): 3883-3891, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31346895

RESUMO

BACKGROUND: Breast surgery is considered a clean surgery. However, surgical-site infection (SSI) rates are currently higher than predicted. Postoperative drains remain in situ for several days, with inevitable bacterial colonization and increased SSI risk. METHODS: This randomized controlled trial from October 2016 to January 2018 analyzed patients undergoing breast cancer surgery. The patients were randomized to either the standard drain care group or the antiseptic dressing group (3M® Tegaderm® CHG). Drain samples taken on postoperative days (PODs) 7 and 14 were cultured as standardized in the laboratory. Colonization rates and SSI were compared between the two groups. RESULTS: The study enrolled 104 patients with 167 surgical drains. The patients' clinical characteristics were similar in the two groups, with no statistically significant differences. Bulb fluid cultures at postoperative week (POW) 1 were positive for 42.9% of the control group and 28.9% of the antiseptic group (p = 0.06). Cultures from the POW 2 assessment were positive for 79.7% of the control group versus 54.9% of the antiseptic group (p = 0.001). Cultures from drain tubes were positive for 79.8% of the control group and 50.7% of the antiseptic group (p = < 0.001). In 11 patients, an SSI developed, 3 (5.8%) from the intervention and 8 (15.4%) from the control procedure (p = 0.11). CONCLUSION: The study findings demonstrated that the use of antiseptics at the drain exit site significantly reduced bacterial colonization of the closed drainage system in breast cancer surgery. Semi-permeable occlusive chlorhexidine-impregnated dressings provide an opportunity to test simple, safe, and low-cost interventions that may reduce drain bacterial colonization and SSI after breast surgery.


Assuntos
Bandagens/estatística & dados numéricos , Neoplasias da Mama/cirurgia , Clorexidina/uso terapêutico , Drenagem/métodos , Mastectomia/efeitos adversos , Cuidados Pós-Operatórios , Infecção da Ferida Cirúrgica/prevenção & controle , Anti-Infecciosos Locais/uso terapêutico , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/patologia
6.
Adv Skin Wound Care ; 32(7): 1-5, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31232840

RESUMO

OBJECTIVE: To evaluate the effect of different dressing methods on the wound healing process after pilonidal sinus surgery. METHODS: In this clinical trial, 60 patients undergoing pilonidal sinus surgery were randomly assigned to one of three groups. In the first group, hydrogel or alginate and hydrocolloid compounds were used as a standard occlusive dressing method. A modified dressing method was used for the second group, in which transparent hydrocolloid films were replaced by Vaseline gauze. The third group was treated using gauze swabs soaked in normal saline. The length and depth of the studied wounds were recorded once a week for a month. During dressing changes, patient pain was recorded using an 11-point numeric rating scale. The collected data were analyzed by descriptive and inferential statistical methods. RESULTS: There was a significant reduction in wound length after 2 weeks in all three groups (P < .05), and the pain experienced by the first and second groups was significantly lower than the third group. However, the modified method used for the second group was associated with a lower cost. CONCLUSIONS: Considering the beneficial results of using modern dressings for wound healing and reducing the severity of associated pain, providers may want to consider using modified wound dressings after pilonidal sinus surgery. Study authors recommend that providers receive training on how to use these products.


Assuntos
Curativos Hidrocoloides/estatística & dados numéricos , Curativos Biológicos/estatística & dados numéricos , Curativos Oclusivos/estatística & dados numéricos , Seio Pilonidal/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Cicatrização/fisiologia , Adulto , Bandagens/economia , Bandagens/estatística & dados numéricos , Curativos Hidrocoloides/economia , Curativos Biológicos/economia , Análise Custo-Benefício , Feminino , Humanos , Irã (Geográfico) , Masculino , Curativos Oclusivos/economia , Seio Pilonidal/diagnóstico , Cuidados Pós-Operatórios/métodos , Medição de Risco , Resultado do Tratamento , Adulto Jovem
7.
J Clin Nurs ; 28(15-16): 2724-2731, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31002211

RESUMO

AIM: To evaluate the clinical application of moist wound dressings in wound care for patients with the tracheostomy. BACKGROUND: Tracheostomy patients may suffer from many complications. Moist dressings have been proposed to lower complication rates for patients with the tracheostomy. DESIGN: A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist-guided meta-analysis of randomised and controlled clinical trials. METHOD: In this meta-analysis, two reviewers independently searched PubMed, EMBASE, Cochrane Library, Web of Science, CNKI and Wanfang databases for controlled clinical trials (CCTs) comparing the use of moist dressings and gauze for tracheostomy patients. The reviewers screened studies according to the inclusion criteria and extracted data from published reports independently. The outcome of site infection and pressure ulcer incidence, the frequency of dressing changes and wound closing time were evaluated by random-effects or fixed-effects meta-analysis. RESULTS: After the screening, ten studies including 1,220 participants were eligible for analysis. The result showed that the incidence of site infection and pressure ulcer was significantly reduced in the moist dressings group compared with the gauze group. Moist dressings were also associated with significant reductions in the frequency of dressing changes and wound closing time. These results were assessed as moderate- to low-quality evidence. CONCLUSION: Moist dressings seem to be beneficial to tracheostomy patients, giving a lower incidence of site infection and pressure ulcers as well as shorter wound closing times and lower dressing change frequency. More high-quality trials are needed to support this finding. RELEVANCE TO CLINICAL PRACTICE: The findings offer clinicians an assessment of and evidence for the efficacy of moist dressings, which may be a superior option for patients with a tracheotomy.


Assuntos
Bandagens/estatística & dados numéricos , Lesão por Pressão/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Traqueostomia/efeitos adversos , Cicatrização , Bandagens/classificação , Humanos , Incidência , Lesão por Pressão/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecção da Ferida Cirúrgica/epidemiologia
8.
Enferm Clin ; 29(2): 74-82, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30837191

RESUMO

AIM: To determine the impact of advanced practice nurses in chronic wound care in the adequacy of treatments for patients with chronic wounds and the consumption of dressings in the districts where they have been implemented. METHOD: A quasi-experimental pre-poststudy without a control group with 3measurements: pre-implementation in 2015, one year after implementation in 2016, and 2years post-implementation in 2017, in the health districts (HD) where the role of the advanced practice nurse in chronic wound care was piloted in Andalusia. The main variables were trained professionals, consultancies, prevalence of chronic wounds, adequacy of treatments and economic cost in materials for the participating HD. RESULTS: The training of a total of 2,717 health teams with a total of 95,095 teaching hours was achieved. In addition, a total of 3,871 consultancies were performed. The prevalence of patients with injuries in the home care (HC) programme and in care homes diminished significantly, to almost half. The adequacy of the treatments increased to 90% and savings of more than 250,000€ in dressings were achieved in just 2years. CONCLUSION: The prevalence of chronic wounds during the 2years of implementation decreased by almost half. Adequacy of training and consultancy was achieved, rationalising health expenditure and ensuring efficient care for patients with chronic wounds.


Assuntos
Prática Avançada de Enfermagem , Bandagens/estatística & dados numéricos , Ferimentos e Lesões/enfermagem , Doença Crônica , Humanos , Projetos Piloto , Espanha
9.
Clin Orthop Relat Res ; 477(9): 2032-2038, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30811354

RESUMO

BACKGROUND: Prolonged wound drainage after TKA is associated with increased risk of infection. To decrease wound drainage, tissue adhesive has been suggested as an adjunct to wound closure after TKA; however, no studies of which we are aware have investigated the effect of tissue adhesive in a modern fast-track TKA setting. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the effect of wound closure using a high-viscosity tissue adhesive in simultaneous bilateral TKA with respect to (1) postoperative wound drainage, measured as number of dressing changes in the first 72 hours postoperatively; and (2) wound healing assessed using the ASEPSIS score. METHODS: Thirty patients undergoing simultaneous bilateral TKA were included in the study. The left knee was randomized to receive either standard three-layer closure with staples or the same closure supplemented with tissue adhesive with the opposite treatment used on the contralateral knee. One patient underwent a constrained TKA and underwent revision 2 days after the index procedure and was therefore excluded leaving 29 patients (58 knees) for analysis. Sixty-two percent (n = 18) were female. Mean age was 64 years (range, 42-78 years). Mean body mass index was 28 kg/m (range, 21-38 kg/m). Postoperative wound drainage was evaluated as drainage resulting in a dressing change. The wound dressing was changed if it was soaked to the borders of the absorbable dressing at any point. The nurses changing the dressing were blinded to treatment allocation up to the first dressing change. The number of dressing changes during the first 72 hours postoperatively was recorded. The secondary study endpoint was the ASEPSIS score, which is a clinical score assessing wound healing. ASEPSIS score, measured by a nurse not involved in the treatment, was compared between the groups at 3 weeks followup. RESULTS: Knees with tissue adhesive underwent fewer dressing changes (median, 0; interquartile range [IQR], 0-1) compared with the contralateral knee (IQR, 1-2; difference of medians, one dressing change; p = 0.001). A total of 59% of knees in the intervention group did not undergo any dressing changes before discharge, whereas 24% of knees in the control group did not undergo any dressing changes before discharge (p = 0.02). The knees in the intervention group and the control group did not differ with respect to ASEPSIS score at 3 weeks. CONCLUSIONS: Tissue adhesive as an adjunct to standard wound closure after primary TKA reduced the number of dressing changes after surgery, but did not change the appearance or healing of the wound at 3 weeks based on the ASEPSIS scores. Whether the small differences observed here in terms of the number of dressing changes performed will justify the additional costs associated with using this product or whether there are other differences associated with the use of tissue adhesive that may prove important such as patient preferences or longer term differences in wound healing or infection should be studied in the future. LEVEL OF EVIDENCE: Level I, therapeutic study.


Assuntos
Artroplastia do Joelho/métodos , Bandagens/estatística & dados numéricos , Ferida Cirúrgica/terapia , Adesivos Teciduais/uso terapêutico , Técnicas de Fechamento de Ferimentos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Resultado do Tratamento , Cicatrização
10.
BJOG ; 126(5): 628-635, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30066454

RESUMO

OBJECTIVE: To evaluate the reduction of surgical site infections by prophylactic incisional negative pressure wound therapy compared with standard postoperative dressings in obese women giving birth by caesarean section. DESIGN: Multicentre randomised controlled trial. SETTING: Five hospitals in Denmark. POPULATION: Obese women (prepregnancy body mass index (BMI) ≥30 kg/m2 ) undergoing elective or emergency caesarean section. METHOD: The participants were randomly assigned to incisional negative pressure wound therapy or a standard dressing after caesarean section and analysed by intention-to-treat. Blinding was not possible due to the nature of the intervention. MAIN OUTCOME MEASURES: The primary outcome was surgical site infection requiring antibiotic treatment within the first 30 days after surgery. Secondary outcomes included wound exudate, dehiscence and health-related quality of life. RESULTS: Incisional negative pressure wound therapy was applied to 432 women and 444 women had a standard dressing. Demographics were similar between groups. Surgical site infection occurred in 20 (4.6%) women treated with incisional negative pressure wound therapy and in 41 (9.2%) women treated with a standard dressing (relative risk 0.50, 95% CI 0.30-0.84; number needed to treat 22; P = 0.007). The effect remained statistically significant when adjusted for BMI and other potential risk factors. Incisional negative pressure wound therapy significantly reduced wound exudate whereas no difference was found for dehiscence and quality of life between the two groups. CONCLUSION: Prophylactic use of incisional negative pressure wound therapy reduced the risk of surgical site infection in obese women giving birth by caesarean section. TWEETABLE ABSTRACT: RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI.


Assuntos
Cesárea/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa/métodos , Obesidade/cirurgia , Complicações na Gravidez/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Bandagens/estatística & dados numéricos , Dinamarca , Feminino , Humanos , Obesidade/complicações , Gravidez , Fatores de Risco , Padrão de Cuidado/estatística & dados numéricos , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento , Cicatrização
11.
Mil Med ; 184(3-4): e290-e296, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30007358

RESUMO

INTRODUCTION: Acute hemorrhage remains the leading cause of death in potentially survivable injuries. The use of topical hemostatic agents has increased over the last two decades with the evolution of damage control surgery. By 2008, the military widely adopted Combat Gauze as the hemostatic dressing of choice for compressible hemorrhage. The goal of this study was to compare the performance of a novel fibrin sealant patch to Combat Gauze in two clinically relevant models of hemorrhage. MATERIALS AND METHODS: Yorkshire swine underwent unilateral femoral artery puncture or a grade V liver laceration with timed free bleeding then received either the fibrin patch or Combat Gauze packing with 3 minutes of standardized pressure. Animals were then resuscitated to maintain a mean arterial pressure of 60 mmHg for 4 hours. Hemostasis, blood loss, resuscitation volume, survival, vessel patency, and hematologic parameters were evaluated. RESULTS: Hemostasis was equivalent in both groups after hepatic and vascular injury. Survival was 80% in the fibrin patch vascular injury group and 100% in all other groups. Hematologic parameters were not significantly different between treatment groups. Femoral artery patency was 80% in both groups after vascular injury. With simulated ambulation after vessel injury, 60% of the Combat Gauze group and 80% of the fibrin patch group remained hemostatic (p > 0.05). In simulated re-exploration with packing removal, all animals rebled after hemostatic product removal. CONCLUSION: There was no significant difference in hemostasis between a novel fibrin patch and Combat Gauze after extremity arterial or hepatic injury. This novel fibrin patch may have a clinical advantage over the Combat Gauze, as it can be left in the body, thereby limiting the potential need for reoperation.


Assuntos
Adesivo Tecidual de Fibrina/normas , Hemorragia/terapia , Animais , Bandagens/normas , Bandagens/estatística & dados numéricos , Modelos Animais de Doenças , Adesivo Tecidual de Fibrina/uso terapêutico , Hemorragia/prevenção & controle , Hemostáticos/normas , Hemostáticos/uso terapêutico , Fígado/lesões , Fígado/cirurgia , Hepatopatias/prevenção & controle , Hepatopatias/terapia , Suínos/lesões , Suínos/cirurgia , Lesões do Sistema Vascular/prevenção & controle , Lesões do Sistema Vascular/terapia
12.
Cochrane Database Syst Rev ; 12: CD012470, 2018 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-30566764

RESUMO

BACKGROUND: Wrist fractures, involving the distal radius, are the most common fractures in children. Most are buckle fractures, which are stable fractures, unlike greenstick and other usually displaced fractures. There is considerable variation in practice, such as the extent of immobilisation for buckle fractures and use of surgery for seriously displaced fractures. OBJECTIVES: To assess the effects (benefits and harms) of interventions for common distal radius fractures in children, including skeletally immature adolescents. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registries and reference lists to May 2018. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating distal radius fractures in children. We sought data on physical function, treatment failure, adverse events, time to return to normal activities (recovery time), wrist pain, and child (and parent) satisfaction. DATA COLLECTION AND ANALYSIS: At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome. MAIN RESULTS: Of the 30 included studies, 21 were RCTs, seven were quasi-RCTs and two did not describe their randomisation method. Overall, 2930 children were recruited. Typically, trials included more male children and reported mean ages between 8 and 10 years. Eight studies recruited buckle fractures, five recruited buckle and other stable fractures, three recruited minimally displaced fractures and 14 recruited displaced fractures, typically requiring closed reduction, typically requiring closed reduction. All studies were at high risk of bias, mainly reflecting lack of blinding. The studies made 14 comparisons. Below we consider five prespecified comparisons:Removable splint versus below-elbow cast for predominantly buckle fractures (6 studies, 695 children)One study (66 children) reported similar Modified Activities Scale for Kids - Performance scores (0 to 100; no disability) at four weeks (median scores: splint 99.04; cast 99.11); low-quality evidence. Thirteen children needed a change or reapplication of device (splint 5/225; cast 8/219; 4 studies); very low-quality evidence. One study (87 children) reported no refractures at six months. One study (50 children) found no between-group difference in pain during treatment; very low-quality evidence. Evidence was absent (recovery time), insufficient (children with minor complications) or contradictory (child or parent satisfaction). Two studies estimated lower healthcare costs for removable splints.Soft or elasticated bandage versus below-elbow cast for buckle or similar fractures (4 studies, 273 children)One study (53 children) reported more children had no or only limited disability at four weeks in the bandage group; very low-quality evidence. Eight children changed device or extended immobilisation for delayed union (bandage 5/90; cast 3/91; 3 studies); very low-quality evidence. Two studies (139 children) reported no serious adverse events at four weeks. Evidence was absent, insufficient or contradictory for recovery time, wrist pain, children with minor complications, and child and parent satisfaction. More bandage-group participants found their treatment convenient (39 children).Removal of casts at home by parents versus at the hospital fracture clinic by clinicians (2 studies, 404 children, mainly buckle fractures)One study (233 children) found full restoration of physical function at four weeks; low-quality evidence. There were five treatment changes (home 4/197; hospital 1/200; 2 studies; very low-quality evidence). One study found no serious adverse effects at six months (288 children). Recovery time and number of children with minor complications were not reported. There was no evidence of a difference in pain at four weeks (233 children); low-quality evidence. One study (80 children) found greater parental satisfaction in the home group; low-quality evidence. One UK study found lower healthcare costs for home removal.Below-elbow versus above-elbow casts for displaced or unstable both-bone fractures (4 studies, 399 children)Short-term physical function data were unavailable but very low-quality evidence indicated less dependency when using below-elbow casts. One study (66 children with minimally displaced both-bone fractures) found little difference in ABILHAND-Kids scores (0 to 42; no problems) (mean scores: below-elbow 40.7; above-elbow 41.8); very low-quality evidence. Overall treatment failure data are unavailable, but nine of the 11 remanipulations or secondary reductions (366 children, 4 studies) were in the above-elbow group; very low-quality evidence. There was no refracture or compartment syndrome at six months (215 children; 2 studies). Recovery time and overall numbers of children with minor complications were not reported. There was little difference in requiring physiotherapy for stiffness (179 children, 2 studies); very low-quality evidence. One study (85 children) found less pain at one week for below-elbow casts; low-quality evidence. One study found treatment with an above-elbow cast cost three times more in Nepal.Surgical fixation with percutaneous wiring and cast immobilisation versus cast immobilisation alone after closed reduction of displaced fractures (5 studies, 323 children)Where reported, above-elbow casts were used. Short-term functional outcome data were unavailable. One study (123 children) reported similar ABILHAND-Kids scores indicating normal physical function at six months (mean scores: surgery 41.9; cast only 41.4); low-quality evidence. There were fewer treatment failures, defined as early or problematic removal of wires or remanipulation for early loss in position, after surgery (surgery 20/124; cast only 41/129; 4 studies; very low-quality evidence). Similarly, there were fewer serious advents after surgery (surgery 28/124; cast only 43/129; 4 studies; very low-quality evidence). Recovery time, wrist pain, and satisfaction were not reported. There was lower referral for physiotherapy for stiffness after surgery (1 study); very low-quality evidence. One USA study found similar treatment costs in both groups. AUTHORS' CONCLUSIONS: Where available, the quality of the RCT-based evidence on interventions for treating wrist fractures in children is low or very low. However, there is reassuring evidence of a full return to previous function with no serious adverse events, including refracture, for correctly-diagnosed buckle fractures, whatever the treatment used. The review findings are consistent with the move away from cast immobilisation for these injuries. High-quality evidence is needed to address key treatment uncertainties; notably, some priority topics are already being tested in ongoing multicentre trials, such as FORCE.


Assuntos
Bandagens/estatística & dados numéricos , Fixação de Fratura/métodos , Fraturas do Rádio/terapia , Contenções/estatística & dados numéricos , Adolescente , Criança , Feminino , Fixação de Fratura/efeitos adversos , Consolidação da Fratura , Humanos , Imobilização/métodos , Imobilização/estatística & dados numéricos , Masculino , Medição da Dor , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Falha de Tratamento , Traumatismos do Punho
13.
Cochrane Database Syst Rev ; 10: CD010318, 2018 10 17.
Artigo em Inglês | MEDLINE | ID: mdl-30328611

RESUMO

BACKGROUND: Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. People with DM are prone to developing foot ulcers and, if these do not heal, they may also undergo foot amputation surgery resulting in postoperative wounds. Negative pressure wound therapy (NPWT) is a technology that is currently used widely in wound care. NPWT involves the application of a wound dressing attached to a vacuum suction machine. A carefully controlled negative pressure (or vacuum) sucks wound and tissue fluid away from the treated area into a canister. A clear and current overview of current evidence is required to facilitate decision-making regarding its use. OBJECTIVES: To assess the effects of negative pressure wound therapy compared with standard care or other therapies in the treatment of foot wounds in people with DM in any care setting. SEARCH METHODS: In January 2018, for this first update of this review, 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, 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. We identified six additional studies for inclusion in the review. SELECTION CRITERIA: Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any brand of NPWT in the treatment of foot wounds in people with DM, irrespective of date or language of publication. Particular effort was made to identify unpublished studies. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. We presented and analysed data separately for foot ulcers and postoperative wounds. MAIN RESULTS: Eleven RCTs (972 participants) met the inclusion criteria. Study sample sizes ranged from 15 to 341 participants. One study had three arms, which were all included in the review. The remaining 10 studies had two arms. Two studies focused on postamputation wounds and all other studies included foot ulcers in people with DM. Ten studies compared NPWT with dressings; and one study compared NPWT delivered at 75 mmHg with NPWT delivered at 125 mmHg. Our primary outcome measures were the number of wounds healed and time to wound healing.NPWT compared with dressings for postoperative woundsTwo studies (292 participants) compared NPWT with moist wound dressings in postoperative wounds (postamputation wounds). Only one study specified a follow-up time, which was 16 weeks. This study (162 participants) reported an increased number of healed wounds in the NPWT group compared with the dressings group (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.03 to 2.01; low-certainty evidence, downgraded for risk of bias and imprecision). This study also reported that median time to healing was 21 days shorter with NPWT compared with moist dressings (hazard ratio (HR) calculated by review authors 1.91, 95% CI 1.21 to 2.99; low-certainty evidence, downgraded for risk of bias and imprecision). Data from the two studies suggest that it is uncertain whether there is a difference between groups in amputation risk (RR 0.38, 95% CI 0.14 to 1.02; 292 participants; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision).NPWT compared with dressings for foot ulcersThere were eight studies (640 participants) in this analysis and follow-up times varied between studies. Six studies (513 participants) reported the proportion of wounds healed and data could be pooled for five studies. Pooled data (486 participants) suggest that NPWT may increase the number of healed wounds compared with dressings (RR 1.40, 95% CI 1.14 to 1.72; I² = 0%; low-certainty evidence, downgraded once for risk of bias and once for imprecision). Three studies assessed time to healing, but only one study reported usable data. This study reported that NPWT reduced the time to healing compared with dressings (hazard ratio (HR) calculated by review authors 1.82, 95% CI 1.27 to 2.60; 341 participants; low-certainty evidence, downgraded once for risk of bias and once for imprecision).Data from three studies (441 participants) suggest that people allocated to NPWT may be at reduced risk of amputation compared with people allocated to dressings (RR 0.33, 95% CI 0.15 to 0.70; I² = 0%; low-certainty evidence; downgraded once for risk of bias and once for imprecision).Low-pressure compared with high-pressure NPWT for foot ulcersOne study (40 participants) compared NPWT 75 mmHg and NPWT 125 mmHg. Follow-up time was four weeks. There were no data on primary outcomes. There was no clear difference in the number of wounds closed or covered with surgery between groups (RR 0.83, 95% CI 0.47 to 1.47; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision) and adverse events (RR 1.50, 95% CI 0.28 to 8.04; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision). AUTHORS' CONCLUSIONS: There is low-certainty evidence to suggest that NPWT, when compared with wound dressings, may increase the proportion of wounds healed and reduce the time to healing for postoperative foot wounds and ulcers of the foot in people with DM. For the comparisons of different pressures of NPWT for treating foot ulcers in people with DM, it is uncertain whether there is a difference in the number of wounds closed or covered with surgery, and adverse events. None of the included studies provided evidence on time to closure or coverage surgery, health-related quality of life or cost-effectiveness. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making regarding the use of NPWT to treat foot wounds in people with DM.


Assuntos
Amputação , Bandagens , Pé Diabético/cirurgia , Tratamento de Ferimentos com Pressão Negativa/métodos , Cicatrização , Bandagens/estatística & dados numéricos , Desbridamento , Humanos , Tratamento de Ferimentos com Pressão Negativa/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto
14.
J Wound Ostomy Continence Nurs ; 45(5): 432-437, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30086102

RESUMO

PURPOSE: The sacrum is the most common location of pressure injuries (PIs) in bedridden patients. The purpose of this study was to measure the effect of specific pressure preventive devices on sacral skeletal muscle, subcutaneous fat, and skin tissue deformations. SUBJECTS AND SETTING: The sample comprised 3 healthy adults residing in a community setting in Tel Aviv, Israel. DESIGN: Descriptive, comparative design. METHODS: Tissue thickness changes of 3 healthy adults were measured using magnetic resonance imaging (MRI) in weight-bearing sacral skin, subcutaneous fat, and muscle. Changes in tissue thickness were compared under the following conditions: (1) lying supine on a rigid surface (unpadded MRI table), (2) lying on a standard foam mattress, (3) lying on a mattress after application of a prophylactic multilayer dressing, and (4) lying on a standard foam mattress with a prophylactic multilayer dressing and a positioning system. One-way analysis of variance and post hoc Tukey-Kramer multiple pairwise comparisons were used to compare outcomes. RESULTS: The mattress, the prophylactic multilayer dressing, and the turning and positioning device when applied together resulted in significantly lower deformation levels of each of the soft tissue layers (ie, skin, subcutaneous fat, and muscle separately) as well as of the total soft tissue bulk, with respect to the rigid MRI table (P < .05). CONCLUSION: Study findings suggest that a combination of preventive interventions may reduce the risk of developing a sacral PI.


Assuntos
Bandagens/normas , Posicionamento do Paciente/métodos , Região Sacrococcígea/fisiologia , Adulto , Análise de Variância , Bandagens/estatística & dados numéricos , Feminino , Humanos , Israel , Imagem por Ressonância Magnética/métodos , Masculino , Posicionamento do Paciente/instrumentação , Pressão , Lesão por Pressão/prevenção & controle , Região Sacrococcígea/fisiopatologia
15.
Medicine (Baltimore) ; 97(27): e11454, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29979449

RESUMO

BACKGROUND: Diabetic foot management is a challenge for reconstructive surgeons because it combines dramatically decreased circulation and chronic infection. The goal of managing this condition is to maximize viable tissue; however, unsatisfactory results, such as extremity amputation, are unavoidable in some cases. For appropriate management, thorough understanding of diabetic foot and the phased approach to its management is needed. The purpose of this study is to introduce an optimal algorithm for diabetic foot management by analyzing cases >12 years. METHODS: A total of 274 patients with diabetic foot at Hanyang University Guri Hospital from 2005 to 2017 were reviewed. The management process was divided into 5 steps: patient evaluation, wound preparation, improving vascularity, surgery and dressing, and rehabilitation. Patient evaluation included a microbial culture, evaluation of vascularity, and an osteomyelitis assessment. During wound preparation, debridement and negative-pressure wound therapy were performed. Vascularity was improved by radiological intervention or surgical method. Surgery and dressing were performed depending on the indications. Rehabilitation was started after complete wound healing. RESULTS: An infection was confirmed in 213 of 263 patients (81.0%). Of 74 cases in which a vascular study was performed, 83.8% showed arterial occlusion. When surgery was performed with complete eradication of the infection in 155 patients, the rate of revision surgery was 20.6%. The revision rate after surgery with a remnant infection of 66 patients was 40.9% (P = .0003). When surgery was performed after successful revascularization for improving blood flow of 47 patients, the rate of revision surgery was 21.3%. In contrast, the revision rate after surgery with unsuccessful or no revascularization of 174 patients was 28.2% (P = .359). CONCLUSION: Diabetic foot is a debilitating disease arising from multifactorial process. As its management is complex, a comprehensive but accessible treatment algorithm is needed for successful results. For this reason, the appropriate algorithm for diabetic foot management introduced in this study is significant.


Assuntos
Pé Diabético/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Bandagens/estatística & dados numéricos , Desbridamento/métodos , Desbridamento/estatística & dados numéricos , Pé Diabético/diagnóstico , Pé Diabético/reabilitação , Gerenciamento Clínico , Feminino , Pé/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/métodos , Tratamento de Ferimentos com Pressão Negativa/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos
16.
Plast Surg Nurs ; 38(2): 73-75, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29846338

RESUMO

In this study, absorption capacity of the most commonly used types of wound dressings was measured with an objective, quantifiable, and easily reproducible method. The use of objective measurements allowed us to perform an objective comparison of the capacity of the different types of dressings. An experimental study was performed, in which the absorptive capacity of polyurethane foams, alginate, hidrofiber, and hydrocolloid dressings was measured by using a methodology designed by the researchers. Polyurethane foams showed a higher absorption capacity than hidrofibers, alginates, and hydrocolloids when using a similar surface of dressing. A modification of dressing size after saturation was also observed, increasing its size in the case of foams and decreasing or maintaining it in the case of hidrofibers, alginates, and hydrocolloids. The results of this study show a better wound exudate management for polyurethane foams. However, when deciding which dressing to use for a specific wound, absorption capacity is not the only quality that should be taken into account, as other properties should also be considered.


Assuntos
Bandagens/normas , Drenagem/instrumentação , Exsudatos e Transudatos , Alginatos/normas , Alginatos/uso terapêutico , Bandagens/estatística & dados numéricos , Curativos Hidrocoloides/normas , Curativos Hidrocoloides/estatística & dados numéricos , Humanos , Poliuretanos/normas , Poliuretanos/uso terapêutico , Cicatrização/fisiologia
17.
Ostomy Wound Manage ; 64(4): 38-43, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29718816

RESUMO

Chronic wounds (ie, wounds that fail to progress through a normal, orderly, timely sequence of repair) continue to pose significant clinical and economic burdens. A prospective, descriptive, 3-week post-marketing surveillance study was conducted across 3 wound care centers in the United States to evaluate the effectiveness of a collagen calcium alginate dressing on chronic wounds in conjunction with standard care (SC) practices (eg, offloading, debridement, compression) to support healing. Eligible participants had to be >18 years of age, have at least 1 chronic wound, and no known sensitivity to collagen. Demographic characteristics were recorded at the screening visit on case report forms. At each visit, wound-related pain was assessed using the Visual Analog Scale along with wound characteristics including size (using digital planimetry), wound exudate (minimal, moderate, heavy), and odor (none, mild). Participants were monitored for adverse events as well as infection based on signs and symptoms in and around the local wound bed, the deeper structures, and the surrounding skin. An intention-to-treat approach was used for all analyses. If an observation was missing, the last observation carried forward principle was used. For wounds that healed, pain and exudate were set to 0 (no pain/exudate) at visit 4. Descriptive, paired t tests and the Wilcoxon signed rank test were used to analyze the data. Of the 31 participants (15 men, 16 women, mean age 66.6 years), most (13, 42%) had a diabetic foot ulcer or venous leg ulcer (10, 32%); median duration of all wounds was 148 days. Thirty (30) patients completed the study. The mean number of comorbidities was 10.6 ± 6.3, and patients used a mean of 9.3 ± 5.64 prescription or over-the-counter medications. For all wounds combined, mean wound area was 4.8 ± 8.38 cm2 at baseline. At week 3, a decrease in wound area of 38.1% was noted (median: 45% ± 42.54; P = .006); 3 wounds healed completely. The change in wound exudate level from visit 1 to visit 4 was statistically significant (P = .006). No adverse events or infections occurred. In this population, the use of etiology-appropriate SC and a collagen calcium alginate dressing resulted in a decrease in wound area after 3 weeks of care. Longer-term studies to confirm these observations and controlled clinical studies to compare the effects of this dressing to other nongauze dressing treatments are needed.


Assuntos
Alginatos/farmacologia , Bandagens/normas , Doença Crônica/terapia , Cicatrização/efeitos dos fármacos , Idoso , Idoso de 80 Anos ou mais , Alginatos/uso terapêutico , Bandagens/estatística & dados numéricos , Doença Crônica/enfermagem , Colágeno/farmacologia , Colágeno/uso terapêutico , Angiopatias Diabéticas/complicações , Angiopatias Diabéticas/fisiopatologia , Feminino , Humanos , Masculino , Marketing de Serviços de Saúde/métodos , Pessoa de Meia-Idade , Vigilância da População/métodos , Estudos Prospectivos , Estados Unidos , Úlcera Varicosa/complicações , Úlcera Varicosa/fisiopatologia , Escala Visual Analógica
18.
J Wound Care ; 27(3): 136-144, 2018 03 02.
Artigo em Inglês | MEDLINE | ID: mdl-29509110

RESUMO

OBJECTIVE: To estimate whether a collagen-containing dressing could potentially afford the UK's National Health Service (NHS) a cost-effective intervention for the management of diabetic foot ulcers (DFUs). METHOD: A decision model depicting the management of a DFU was constructed and populated with a combination of published clinical outcomes, resource use estimates and utilities for DFUs. The model estimated the incremental cost-effectiveness of a collagen-containing dressing plus standard care compared with standard care alone over a period of four months in terms of the incremental cost per quality-adjusted life year (QALY) gained. RESULTS: Treatment of DFUs of >6 months duration with a collagen-containing dressing plus standard care instead of standard care alone is expected to increase the probability of healing from 0.08 to 0.53 by four months and increase health-related quality of life at four months from 0.156 to 0.163 QALYs per patient. Additionally, treatment with a collagen-containing dressing has the potential to reduce management costs by 22% over four months when compared with standard care alone (from £2897 to £2255 per patient). Treatment of new DFUs with a collagen-containing dressing plus standard care instead of standard care alone was also found to improve outcomes for less cost. CONCLUSION: Within the study's limitations, use of a collagen-containing dressing plus standard care instead of standard care alone potentially affords the NHS a cost-effective (dominant) treatment for both non-healing and new DFUs, since it improves outcomes for less cost. Hence, protocols should be established which enable clinicians to effectively introduce collagen-containing dressings into care pathways and monitor response to treatment.


Assuntos
Bandagens/economia , Colágeno/economia , Colágeno/uso terapêutico , Pé Diabético/economia , Pé Diabético/terapia , Infecções Bacterianas/prevenção & controle , Bandagens/estatística & dados numéricos , Análise Custo-Benefício , Humanos , Medicina Estatal/economia , Reino Unido , Cicatrização
19.
BMJ Open ; 8(3): e019440, 2018 03 22.
Artigo em Inglês | MEDLINE | ID: mdl-29572395

RESUMO

BACKGROUND: Complex wounds impose a substantial health economic burden worldwide. As wound care is managed across multiple settings by a range of healthcare professionals with varying levels of expertise, the actual care delivered can vary considerably and result in the underuse of evidence-based interventions, the overuse of interventions supported by limited evidence and low value healthcare. OBJECTIVES: To quantify the number, type and management of complex wounds being treated over a two-week period and to explore variations in care by comparing current practices in wound assessment, prevention and treatment. DESIGN: A multiservice cross-sectional survey. SETTING: This survey spanned eight community services within five Northern England NHS Trusts. RESULTS: The point prevalence of complex wounds in this community-based population was 16.4 per 10 000 (95% CI 15.9 to 17.0). Based on data from 3179 patients, antimicrobial dressings were being used as the primary dressing for 36% of patients with complex wounds. Forty per cent of people with leg ulcers either had not received the recommended Doppler-aided Ankle Brachial Pressure Index assessment or it was unclear whether a recording had been taken. Thirty-one per cent of patients whose most severe wound was a venous leg ulcer were not receiving compression therapy, and there was limited use of two-layer compression hosiery. Of patients with a pressure ulcer, 39% were not using a pressure-relieving cushion or mattress. CONCLUSIONS: Marked variations were found in care, underuse of evidence-based practices and overuse of practices that are not supported by robust research evidence. Significant opportunities for delivering better value wound care therefore exist. Efforts should now focus on developing strategies to identify, assess and disinvest from products and practices supported by little or no evidence and enhance the uptake of those that are.


Assuntos
Lesão por Pressão/epidemiologia , Lesão por Pressão/terapia , Úlcera Varicosa/epidemiologia , Úlcera Varicosa/terapia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Bandagens/estatística & dados numéricos , Leitos/estatística & dados numéricos , Criança , Pré-Escolar , Estudos Transversais , Inglaterra/epidemiologia , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Cicatrização , Ferimentos e Lesões/complicações , Adulto Jovem
20.
J Vasc Nurs ; 36(1): 3-7, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29452627

RESUMO

The purpose of this case series was to assess the performance of a concentrated surfactant-based gel (CSG) dressing on 18 patients in the outpatient setting over 4 weeks. Wounds selected were full thickness, had been presented for greater than 4 weeks, and were located on the lower extremities. Patients were given the CSG dressing and instructed on its use. On follow-up clinic visits, the wound was assessed, measurements were obtained, Pressure Ulcer Scale for Healing (PUSH) Tool scores completed, and satisfaction with the dressing was solicited. Individual analysis of each subject's wound was conducted to determine if there was a healing trend over time with a decrease in total PUSH score. Descriptive statistics were used to analyze the results. Eighteen patients participated in this case series involving 9 women and 9 men with a mean age of 66 years (range from 52 to 91). All 18 of the patients had a primary diagnosis of peripheral vascular disease with 7 patients having venous leg ulcers and 11 patients with lower extremity arterial ulcers. The mean Total PUSH score before the CSG dressing was applied was 10.7 (range from 5 to 15) (standard deviation [SD] 3.09) and posttreatment was 8.3 (range from 0 to 14) (SD 4). All 18 patients had a decrease in their pretreatment score from the first clinic visit compared with the posttreatment PUSH Tool score, indicating that the CSG dressing may be an effective dressing in the management of lower extremity wounds.


Assuntos
Bandagens/estatística & dados numéricos , Extremidade Inferior , Tensoativos/uso terapêutico , Úlcera Varicosa/terapia , Cicatrização , Idoso , Feminino , Humanos , Masculino , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA