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'Working within the NHS is a covenant, something precious welded to professionalism and excellence; many are bound to it by means of ideology and belief: it is for them an article of faith' - heady stuff yet it somehow speaks volumes as to why NHS workers keep going in spite of all the day to day difficulties. Perhaps not surprisingly the quote can be found in an article on a survey on NPfIT (Harwood J [2007] NPfIT branded expensive and unsuccessful. Health Director. 5: 2 (July); 26 - 27).
An occasional series of interesting articles from journals you might not normally read. This month a little something on skin complaints and diabetes from Diabetes Care - Pavlovic M et al (2007) The Prevalence of Cutaneous Manifestations in Young Patients With Type 1 Diabetes. Diabetes Care 2007; 30: 1964-7. The study aimed to assess the prevalence of skin disorders in children and adolescents with type 1 diabetes. 212 patients with diabetes and 196 matched controls were examined. 142 (68%) had at least one skin disorder, compared with 52 (26.5%) of controls. Diabetes-associated lesions were found in 81 (38%). Acquired ichthyosis, rubeosis faciei, diabetic hand, and necrobiosis lipoidica were seen in 22 vs. 3%, 7.1 vs. 0%, 2.3 vs. 0%, and 2.3 vs. 0% of type 1 diabetic and control subjects, respectively. The prevalence of fungal infections in patients and control subjects was 4.7% and 1.5%, respectively. Xerosis was found in 22% but only 3% of controls. Cutaneous manifestations are common in patients with type 1 diabetes, some developing early on in the course of the disease which the authors conclude justifies the early inclusion of a dermatologist in their management.
There was a trailer piece in the Daily Telegraph on 27th September by Boris Johnson and it was also covered by The Times on Septemeber 30th(www.timesonline.co.uk/tol/news/uk/article2558222.ece). If you would like to get involved, make a contribution or find out more contact Hadyn Parry hadynparry@tiscali.co.uk
The British Lymphology Society and Lymphoedema Support Network are conducting an audit of the treatment of skin infections in people with lymphoedema. It is a survey for patients to complete, so download and copy the form from the link and get encouraging! http://www.thebls.com/alert.php?alert_id=2
A new latex-free examination glove has been approved on prescription. Made of a unique synthetic formulation, Vitrex gloves are free of latex, powder, chemical accelerators and protein. Conforming to EN455, Vitrex are an ideal low risk solution for wound-care in the community Vitrex non-sterile gloves are available in small, medium and large, presented in boxes of 25 pairs. For more information contact Richardson Healthcare on 08700 111126.
Telemedicine revolution rolls on A FREE 3 month trail is now available. For more information please see the website www.CooperMedical.co.uk or email robin@coopermedical.co.uk
Snappy nom n'est ce pas - non! Well despite the naff nomenclature you might care to check out this site from the Care Services Improvement Partnership (www.csed.csip.org.uk) who apparently 'work collaboratively with all councils throughout England supporting them to achieve sustainable efficiency improvements in adult social care' - have a look at 'Transforming Community Equipment and Wheelchair Services' and for the big picture thing 'Community Equipment: A vision for the future' but I would suggest you look at the 'Summary of Outline Model' first, here is a radical but interesting little taster:- 'What is the model? The model is a retail solution and proposes that state bodies issue users and carers where there is an assessed need with a 'prescription' that can be exchanged for free equipment at an approved/accredited retailer. The model also proposes encouraging the development of new Independent Needs Assessors who can assess an individual to determine not only what equipment may help, but who can also provide other skills e.g. additional therapeutic intervention or other supportive services and advice. What will the 'prescription' entitle users to? The 'prescription' will enable users and their carers to obtain the equipment that they are currently entitled to receive and they will not have to pay for that equipment. It is proposed that users and their carers will receive equipment from a national catalogue - a catalogue with details of nationally agreed products and prices. If they would prefer equipment not on the national catalogue, they can 'top up' the 'prescription'. This means that the 'prescription' could form the state contribution to the cost of purchasing the equipment the individual feels they would prefer to have.'
Mining for Gold See 'Prescriptions Dispensed in the Community Statistics for 1996 to 2006: England' Table 9 Number, net ingredient cost (NIC) and average NIC per prescription item by British National Formulary chapters, 2005 and 2006 - http://www.ic.nhs.uk/webfiles/publications/PrescDispensed%2096to06/Bulletin%20220807%20version%20for%202006.pdf In England the number of dressings and appliance prescriptions went up 10.6% between 2005 - 2006, from 19.6 - 21.7 million prescriptions. The net ingredient cost (This is the basic price of a drug, i.e. the price listed in the national Drug Tariff or in standard price lists. It standardises cost throughout prescribing nationally, and allows comparisons of data from different sources) rose 8.4% from £436 - 472.8 million, although on a per prescription basis the net ingredient cost fell by 1.9%. So more less expensive prescriptions then; good or bad, debate the issues on your exam paper!
Confidence intervals and relative risk The authors found no evidence that a 'particular class of dressing healed more ulcers....Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of dressings.' Perhaps controversially they concluded 'Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.' This conclusion on the face of it could be used as evidence by NHS pharmaceutical advisors in their drive to cut costs by inferring that gauze be used directly on the wound because it is cheap, but then TVNs know that causes pain on removal and would be unethical. Valuable though this meta-analysis is in answering the question the authors set themselves, it does not of course explore the many patient focussed and symptom controlling outcomes on which dressing choice decisions are made in clinical practice. Neither did it specifically address the hard to heal group on which dressing choice may impact significantly in turning around chronicity and as such impact on cost effectiveness in this sub group of VLU patients. However, setting that discussion aside, the authors used confidence intervals to support their conclusion that 'Hydrodcolloids were no more effective than simple low adherent dressings beneath compression (eight trials; relative risk for healing with hydrocolloid 1.0; 95% confidence interval 0.83 to 1.28).' First then relative risk (RR) (also known as relative ratio) shows how many times more or less the individuals with the risk factor are likely to get the disease relative to those who do not have the risk factor (Dorak 2007), though in this study it was used to describe if the hydrocolloids were more or less likely to produce faster healing than control products. An 'RR' of 5 for example would suggest that the likelihood of faster healing with a hydrocolloid would be 5 times higher than with the standard dressing. The higher above 1.0 the better, so in our example a figure of 1.02 is so low for the hydrocolloid as to be equal in all practical terms to the standard dressing. Confidence intervals give another view on the 1.02. They show how much store you can put in or confidence you can have that the headline figure is representative of the truth. A 95% confidence interval says that if the experiments were repeated again and again 95% of the data would fall between the range (the range in the paper was 0.83 - 1.28) and would contain the true parameter value (Everitt 2003), which in the study paper was 1.02. The narrower the intervals the better as the parameter value is then closely related to the majority (95%) of the data used to produce it. Confidence intervals assume that random sampling has been used in the study/studies (and this was part of the inclusion criteria for the example study), however, clinical judgment is necessary to supplement statistical analysis on non-random sample study conclusions when generalising to individuals not studied (Munro, 2005). References Dorak M (2007) Common concepts in statistics http://www.dorak.info/mtd/glosstat.html(accessed 1.10.07) Everitt B (2003) Medical statistics from A to Z. Cambridge: Cambridge University Press Munro, B. (2005) Statistical Methods for Healthcare Research (5th Edn.). Philadelphia: Lippincott Williams and Wilkins Palfreyman S, Nelson E, Michaels J (2007) Dressings for venous ulcers: systematic review and meta analysis. British Medical Journal. 335: 244-8 doi:10.1136/bmj.39248.634977.AE
Palfreyman S, King B, Walsh B (2007) A review of the treatment for venous ulcers. British Journal of Nursing.16 1; S6-14 Palfreyman S, Nelson E, Michaels J (2007) Dressings for venous ulcers: systematic review and meta analysis. British Medical Journal. 335: 244 - 248 doi:10.1136/bmj.39248.634977.AE Pressure Ulcers Sharp C McLaws M (2005) A discourse on pressure ulcer physiology: the implications of repositioning and staging. World Wide Wounds. http://www.worldwidewounds.com/2005/october/Sharp/Discourse-On-Pressure-Ulcer-Physiology.html Vascular Male S Coull A Murphy-Black T (2007) Preliminary study to investigate the normal range of Ankle Brachial Pressure Index in young adults. Journal of Clinical Nursing. 16: 10; 1878 - 1885 doi: 10.1111/j.1365-2702.2007.01796.x
Volk S, Radu A, Zhang L et al (2007) Stromal progenitor cell therapy corrects the wound-healing defect in the ischemic rabbit ear model of chronic wound repair. Wound Repair and Regeneration (OnlineEarly Articles). Surgical Gray M, Bohacek L et al (2007) Moisture vs pressure: making sense out of perineal wounds. 34: 2; 134-42 Strecker T, Rosch J et al (2007) Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment. Heart Surg Forum. 10: 5; E366-71 Al-Khayat H Al-Khayat H et al (2007) Risk factors for wound complication in pilonidal sinus procedures. J Am Coll Surg.205: 3; 439-44. Epub 2007 Jun 27 Bovanova L, kolarov R, Mitov L (2007) Antimicrobial resistance and the management of anaerobic infections. Expert Rev Anti Infect Ther. 5: 4; 685-701 Owens B, Wenke J (2007) Early wound irrigation improves the ability to remove bacteria. J Bone Joint Surg Am. 89: 8: 1723-6 Vogt K, Uhlyarik M, Torben V, Schroeder (2007) Moist wound healing compared with standard care of treatment of primary closed vascular surgical wounds: A prospective randomized controlled study Wound Repair and Regeneration. 15: 5; 624-627. doi:10.1111/j.1524-475X.2007.00294.x Dermatology Roelofzen J, Aben K et al (2007) Coal tar in dermatology. J Dermatolog Treat. 12: 1-6 [Epub ahead of print] http://www.ncbi.nlm.nih.gov Jones H (2007) Nurse-administered laser in dermatology. Nurs Clin North Am. 42: 3; 393-406 Hirschmann J (2007) Antimicrobial prophylaxis in dermatologic surgery. Cutis. 79: 6; (Suppl):43-51 Debridement Felix A, Blake D, Abromeit N, Bubenheim M et al (2007) The biosurgical wound debridement: Experimental investigation of efficiency and practicability. Wound Repair and Regeneration. 15: 5; 756-761. doi:10.1111/j.1524-475X.2007.00298.x
Exudate Vanscheidt W, Munter K et al (2007) A prospective study on the use of a non-adhesive gelling foam dressing on exuding leg ulcers. J Wound Care 16: 6; 261 - 265 Gray M, Weir D (2007) prevention and treatment of moisture-associated skin damage (maceration) in the periwound skin. J Wound Ostomy Continence Nurs. 34: 2; 153-7 Infection Mulder G, Carvorsi J, Lee D (2007) Polyhexamethylene Biguanide (PHMB): An addendum to current topical antimicrobials. Wounds. 19: 7; 173 - 182 http://www.medscape.com/viewarticle/561512
Telgenhoff D, Lam K, Ramsay S, et al (2007) Influence of papain urea copper chlorophyllin on wound matrix remodeling
Wound Repair and Regeneration (OnlineEarly Articles). doi:10.1111/j.1524-475X.2007.00279.x
Pai P, Bearden D (2007) Antimicrobial dosing in adult obese patients. Pharmacotherapy. 27: 8; 1081-1091. Fong J Wood F (2006) Nanocrystalline silver dressings in wound management: a review. Int J Nanomedicine. 1: 4; 441-9 Bovanova L, kolarov R, Mitov L (2007) Antimicrobial resistance and the management of anaerobic infections. Expert Rev Anti Infect Ther. 5: 4; 685-701 Owens B, Wenke J (2007) Early wound irrigation improves the ability to remove bacteria. J Bone Joint Surg Am. 89: 8: 1723-6. Fungating wounds Langemo D, Anderson J, et al (2007) Managing fungating wounds. 20: 6; 312-4 Scar Syed Basith Amjad, Robert Carachi MD, Michael Edward PhD. Keratinocyte regulation of TGF-? and connective tissue growth factor expression: A role in suppression of scar tissue formation. Wound Repair and Regeneration (OnlineEarly Articles). doi:10.1111/j.1524-475X.2007.00281.x http://www.blackwell-synergy.com/doi/abs/10.1111/j.1524-475X.2007.00281.x Chuangsuwanich A, Gunjittisomram S (2007) The efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids. J Med Assoc Thai. 90: 7; 1363-7 Topical Negative Pressure Jerome D (2007) Advances in negative pressure wound therapy: the VAC instill. J Wound Ostomy Continence Nursing. 34: 2; 191-4 Strecker T, Rosch J et al (2007) Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment. Heart Surg Forum. 10: 5; E366 - E371 Hyperbaric oxygen Huang K, Tsai Y, Hsu R (2007) Hyperbaric oxygen therapy facilitates surgery on complex open elbow injuries: preliminary results. J Shoulder Elbow Surg. 16: 4; 454-60. Epub 2007 May 15 Various Harper J, McQuillan D (2007) Extracellular wound matrices: A novel regenerative tissue matrix (RTM) technology for connective tissue reconstruction. Wounds. 19: 6; 163 - 168 - http://www.medscape.com/viewarticle/561362 Pavlovic M, Milenkovic T et al (2007) The prevalence of cutaneous manifestations in young patients with type 1 diabetes. Diabetes Care 30:1964-1967
Shaw J, Hughes C, Lagan K, Bell P (2007) The clinical effect of topical phenytoin on wound healing: a systematic review. British Journal of Dermatology (OnLineEarly Articles) doi: 10.1111/j.1365-2133.2007.08160.x
Spiekstra S, Breetveld M, Rustemeyer T et al (2007) Wound-healing factors secreted by epidermal keratinocytes and dermal fibroblasts in skin substitutes. Wound Repair and Regeneration (OnlineEarly Articles).
doi:10.1111/j.1524-475X.2007.00280.x Shukla V, Shukla D et al (2007) Evaluation of pH measurement as a method of wound assessment. J Wound Care. 16: 7; 291 - 294. Yasukawa A, Hrui H et al (2007) The effect of low reactive-level laser therapy (LLLT) with helium-neon laser on operative wound healing in a rat model. J Vet Med Sci. 69: 8: 799 - 806 Chandra R, Handorf C et al (2007) Histologic effects of autologous platelet gel in skin flap healing. Arch Facial Plast Surg. 9: 4; 260 - 263 Braund R, Hook S, Medlicott N (2007) The role of topical growth factors in chronic wounds. Curr Drug Deliv.4: 3; 195-204 Bhatia M, Pereira M et al (2007) The Mechanism of Cell Interaction and Response on Decellularized Human Amniotic Membrane: Implications in Wound Healing Wounds. 19: 8; 207 - 217
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Download this newsletter in PDF formatOctober 2007 |
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