July, 2006
Dear Readers,
In the Evidence Corner, Dr. Laura Bolton summarizes results from randomized, controlled trials addressing the effects of preoperative hair removal and also preoperative skin antiseptics on the development of surgical site infections (SSIs). The published systematic reviews on these topics conclude 1) that there is no significant effect of preoperative hair removal using depilatory creams or razors on SSIs compared to no hair removal and 2) preoperative bathing with 4% chlorhexidine solution has no significant effect on postoperative SSIs compared to no bathing. Dr. Bolton challenges us to question what other routine procedures would stand the test of research.
Nomikos et al (Protective and damaging aspects of healing: a review) discuss the biology of successful healing and problems, such as keloids, hypertrophic scars, adhesions, etc., arising from unsuccessful healing. The authors believe that potent activators of the normal healing cascade can be developed based upon a greater understanding of the biology. This, in turn, should lead to improved wound management protocols.
Viswanathan et al (A phase III study to evaluate the safety and efficacy of recombinant human epidermal growth factor [Regen-D 150] in healing diabetic foot ulcers) present the study design and results of a large, multicenter, controlled trial of diabetic foot ulcers treated with epidermal growth factor (EGF) versus placebo. They found that 69% of ulcers treated with EGF healed by 10 weeks, as compared to only 21% of placebo-treated ulcers. The time to healing for EGF-treated wounds was also reduced. The authors advocate the use of EGF “…in chronic wounds, such as diabetic foot ulcers, where healing of the ulcer is a major hindrance.”
It is generally recognized that the diagnosis of infection in chronic wounds is difficult, especially in the chronic venous ulcer, which can display many of the cardinal signs attributed to infection even in the absence of wound infection. Conversely, the venous ulcer may also fail to show clinical signs of infection when it is infected. The article by Serena et al (The lack of reliability of clinical assessment of chronic wound infection: the incidence of biopsy-proven infection in venous leg ulcers) is a very important contribution addressing the dilemma faced in the diagnosis of venous leg ulcer infections. The authors studied 352 venous ulcer patients. Upon admission to the trial, patients were assessed to be free of infection based upon clinical judgment. However, the results of quantitative biopsies revealed 92 (26%) of the 352 patients to have infected wounds (> 105 bacteria/g/tissue). This means that experienced clinicians participating in a clinical trial setting were able to diagnose venous ulcer infection status only 74% of the time. The authors speculate that in a busy clinic or office setting, the ability to diagnose infection status is likely to drop well below 74%. Accurate determination of chronic wound infection is necessary for optimizing wound treatment and outcomes. It is recognized that many sites for wound treatment may lack the availability of quantitative biopsies. Clearly, there is a need for a practical, simple method for assessing infection in chronic wounds. I would recommend a thorough reading of this article for the many interesting points and challenges raised by the authors.
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