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Journal Scan - 1998

This section features abstracts of articles from professional journals (see invitation, below). Readers are asked to refer to the original source before quoting or making reference elsewhere.

Previous Journal Scan articles are also available:

Use of human albumin in critically ill patients

Cochrane Injuries Group; Human albumin administration in critically ill patients: systematic review of randomised controlled trials. British Medical Journal 1998 Jul 25;317(7153):235-240

Cochrane Injuries Group, Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH.

This systematic review of randomised controlled trials set out to quantify the effect on mortality of administering human albumin or plasma protein fraction during the management of critically ill patients. 30 randomised controlled trials were reviewed, including 1419 randomised patients, comparing the administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. The main outcome measure was mortality from all causes at end of follow up for each trial.

For each patient category, the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death after albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia it was 1.69 (1.07 to 2.67).

Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death.

There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.

Topical anaesthetic and leg ulcer cleansing

Kristofferson A., Lidocaine-prilocaine cream (EMLA Cream) as a topical anaesthetic for the cleansing of leg ulcers. The effect of length of application time. Eur J Dermatol 1998 Jun;8(4):245-247

Pain prevents the effective cleansing of many leg ulcers. Pain relief during debridement has been reported after topical anaesthesia with lidocaine-prilocaine cream (EMLA Cream). The purpose of this study was to assess and compare the pain intensity during debridement after different lengths of application time of lidocaine-prilocaine cream.

Fifty nine patients, stratified for leg ulcer type, were randomised to 10, 20 or 60 minutes treatment with lidocaine-prilocaine cream prior to debridement. The pain was rated by each patient on a 100-mm visual analogue scale (VAS). Pain intensity during debridement decreased significantly with increasing duration of lidocaine-prilocaine cream application (p = 0.001). The median values of the VAS pain scores were 41, 20 and 8 in the 10-, 20- and 60- minute groups respectively. A minimum of 20 minutes application time gives substantial pain relief in the majority of patients.

A novel culturing and grafting system

Villeneuve P, Hafner J, Prenosil JE, et al., A novel culturing and grafting system for the treatment of leg ulcers. Br J Dermatol 1998 May;138(5):849-851

The purpose of this study was to develop and test an efficient culturing and grafting system for the treatment of leg ulcers. The culturing system consisted of a Petriperm culture vessel (20 cm2) aseptically placed in a larger standard Petri dish (60 cm2). Skin cultures were established and cultivated in the Petriperm dish. The cells grew on the bottom of the Petriperm dish, which was made of a gas-permeable 25-micron thick transparent Teflon film.

Grafts were produced simply by cutting the film from the bottom of the Petriperm dish with a scalpel. The system was used to produce subconfluent epidermal autografts which were used to heal a 32 cm2 chronic rheumatoid arthritis leg ulcer. The cultured autografts were transferred cell side down on to the cleaned wound bed without an enzymatic digestion. The grafts consisted of autologous keratinocytes, melanocytes and fibroblasts. Caution was taken not to disturb the wound bed for 7-9 days at which time the Teflon film was removed.

The wound closed 2 weeks after the last grafting and has remained closed for more than a year post-treatment. The culturing and grafting system presented here will make it possible to develop cellular-based therapies that were previously not possible.

Cost effectiveness of leg ulcer clinics

Morrell CJ, Walters SJ, Dixon S, et al  The cost effectiveness of community leg ulcer clinics: a randomised controlled trial. British Medical Journal 1998 May 16;316(7143):1487-1491
School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA.

This randomised controlled trial with one year of follow up set out to establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus conventional care provided by district nurses.

233 patients with venous leg ulcers were recruited from eight community based research clinics in four trusts in Trent and allocated at random to intervention (120) or control (113) group.

The intervention consisted of weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district. Out come measures were to be time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored.

The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status.

Total NHS costs were £878.06 per patient year for the clinic group and £859.34 for the control (P=0.89). In this study, community based leg ulcer clinics with trained nurses using four layer bandaging was more effective than traditional home based treatment, at a very small additional cost.

Honey and wound healing revisited

Oryan A., Zaker S.R., The effects of topical application of honey on cutaneous wound healing in rabbits. Zentralbl Veterinarmed A 1998 Apr;45(3):181-188

Although it has been believed for many centuries that honey can accelerate wound healing, there have only been isolated reports of its use in the healing of burns, ulcers, infected wounds and open wounds. None of these reports developed a model to assess the changes in morphological and biochemical properties due to topical application of honey on cutaneous wounds.

This investigation studied the efficacy of honey in the healing of cutaneous wounds of rabbits, on the basis of histopathological and biochemical changes. Forty healthy White New Zealand rabbits were randomly assigned to four equal groups. Using aseptic surgical technique, a 3cm incision was made on the skin of the left thigh of each rabbit and the wounds of five rabbits in each group were twice daily treated with topical application of 5 ml pure unheated honey. The other half remained as untreated controls. Rabbits were biopsied on days 2, 7, 14 and 21 postoperatively respectively, and biopsies from the lesions of all groups were collected for histopathological studies and from two groups for biomechanical evaluations as well.

Treated lesions showed less oedema, fewer polymorphonuclear and mononuclear cell infiltration, less necrosis, better wound contraction, improved epithelialisation and lower glycosaminoglycan and proteoglycan concentration on days 2 and 7 postoperatively and better tissue organization and consequently an improved tissue ultimate strength and yield strength on days 14 and 21 post-operation.

These findings suggest that honey applied topically on cutaneous wounds accelerates the healing process and appears to have an important property that makes it ideal as a dressing for cutaneous wounds.

Risk assessment scales for decubitus ulcers

Anthony D., Barnes J., Unsworth J., An evaluation of current risk assessment scales for decubitus ulcer in general in-patients and wheelchair users. Clin Rehabil 1998 Apr;12(2):136-142

This experimental study aimed to evaluate the components of two risk assessment scales for decubitus ulcer risk, Waterlow and Braden, and of the Chailey score for the same purpose.

Braden, Chailey scores (wheelchair users) and Waterlow scores (all subjects) were measured in one hundred and fifty wheelchair users from the West Midlands and 9022 patients from a District General Hospital in York, the latter consisting of all admissions to the hospital in a four-month period.

Main outcome measures were the development of a pressure sore, receiver operating characteristic (ROC) curves.

Waterlow outperformed Braden for classification of wheelchair patients with respect to decubitus ulcer. The Chailey score performed randomly in this group. The sensitivity and specificity as seen in ROC curves was different for Waterlow scores for wheelchair users and general patients, the latter being much better classified. Only three items out of 11 in the Waterlow score appeared to have any classification ability in the wheelchair group.

Risk indicators used for general patients are probably poorly suited for wheelchair users. There is a need for large-scale predictive studies of wheelchair users and other groups to allow regression analysis of the subscales of risk indicators. From the provisional data of this study it appears that splitting patients by gender and into full- and part-time wheelchair users classifies almost as well the much more complicated risk assessment tools currently available.

Two-stage management of diabetic foot ulcers

Kumagi S.G., Mahoney C.R., Fitzgibbons T.C. et al., The treatment of diabetic (neuropathic) foot ulcers with two-stage debridement and closure. Foot Ankle Int 1998 Mar;19(3):160-165 This study reviewed a two-stage debridement and closure technique for neuropathic foot ulcers, in 33 patients with 37 wounds, treated between November of 1991 and December of 1995. Patients selected included those with obvious osteomyelitis and those who had failed non-surgical treatment.

The approach included initial surgical excision of the ulcer with biopsy, bone resection with biopsy, and deep culture. The second-stage procedure 4 to 8 days later included debridement of the wound and delayed closure. Intravenous antibiotic treatment using a central line was given postoperatively in patients with documented osteomyelitis for at least 6 weeks and in patients with infected soft tissues only for about 4 weeks. All patients remained non weight-bearing for 4 weeks; this was felt necessary to prevent separation of the wound edges.

Four wounds in four patients failed to heal, and two of these went on to amputation. Satisfactory healing occurred in 29 of 33 patients and in 33 of 37 wounds.

The authors conclude that two-stage surgical debridement and closure is an acceptable treatment in selected non-healing diabetic (neuropathic) foot ulcers.

Stress and pressure sore formation

Braden B.J., The relationship between stress and pressure sore formation. Ostomy Wound Management1998 Mar;44(3A Suppl):26S-36S

The purpose of this study was to explore the relationship between serum cortisol and pressure sore formation among persons over age 65 who recently relocated to a nursing home. Twenty-six subjects who exhibited risk for pressure sore formation and were free of pressure sores and diagnoses or medications known to affect cortisol were recruited from consecutive admissions to a nursing home.

Morning and evening cortisol levels were assayed the first and second weeks following admission, and subject's skin and risk status were assessed twice weekly for five weeks. Subjects who developed pressure sores had significantly higher cortisol levels than those who did not (p < 0.02), with the greatest differences occurring in the second week (p < 0.002).

The cortisol levels observed in subjects who developed pressure sores may be due to the stress of relocation, but other explanations are also possible. Furthermore, a causal relationship between cortisol and pressure sore development cannot be inferred.

Risk of death following burn injury

Ryan C. M., Schoenfeld D. A., Thorpe W. P., et al Objective estimates of the probability of death from burn injuries. New England Journal of Medicine 1998; 338: 6, 362-366.

Accurate, objective measures of the probability of death following burn injury would, argue the authors, provide a firm base for clinical decisions, while also giving patients and significant others the opportunity to think ahead.

Previous methods, usually related to the surface area involved in the injury, have become obsolete as burn management has developed.

The authors reviewed case records of 1665 patients who had been admitted to two Massachusetts Hospitals following burn injury. Data were gathered in respect of age, sex, admission and discharge dates, length of stay, extent of injury, type of burn, presence of inhalation injury, need for surgery, and mortality. Inhalation injury was considered present if the fire was in an enclosed space, if bronchoscopy on admission found soot below the level of the vocal chords, or if blood carboxyhaemaglobin was elevated on admission. All patients who died following admission with burn injury were included.

Stepwise logistic-regression analysis was performed, enabling models to be proposed: the mortality model was tested prospectively on data for patients admitted during 1995/6. The risk factors for death were age greater than 60, greater than 40% of surface area involved and inhalation injury. The data showed that any one or two of these had a similar effect on mortality, which allowed for a greatly simplified model.

The proposed model may be applied as follows; 'when burn size of more than 40 per cent of body surface area, age greater than 60, and presence of inhalation injury are taken as risk factors, patient mortality is 0.3 per cent with no risk factors, 3 per cent with one risk factor, 33 per cent with two risk factors and approximately 90 per cent with all three risk factors. This rule is applicable to all patients younger than 90.' No other factors were found to be significant predictors of death in this type of injury.

The authors note that their model should be used with clinical judgment. For example, it would be unwise to accept a mortality risk of 3% for a young person with 100% burns, without inhalation injury; quality of life issues also need to be considered in parallel with probability of death.

These reviews © 1998 SMTL: compiled by Andrew Heenan

Previous Journal Scan articles are also available:

An invitation

Readers are invited to submit abstracts to the editor for inclusion in this page. Writing abstracts can be a useful exercise in professional updating, as well as an effective method of achieving first publication while learning about the publishing process. Copyright and all the usual rules apply; please see the Author's Guide for advice on how to submit your work.

All materials copyright © 1992-Feb 2001 by SMTL, March 2001 et seq by SMTL unless otherwise stated.

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