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Background: Choosing Wisely is an international movement that stimulates conversations about unnecessary care. The campaign created five recommendations including a statement that less wound care is sometimes better., Aims: The study aims to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care in the Netherlands and the barriers and facilitators to improve this., Design: This is a mixed methods study using a survey and interviews., Methods: The survey was completed by 171 nurses and 71 physicians from November 2017 to February 2018. A total of 17 nurses and 6 physicians were interviewed., Results: Awareness of the five recommendations ranged from 62% to 89% for nurses and 46% to 85% for physicians. However, up to 15% of the nurses and 28% of physicians were aware but did not adhere to the recommendations. Barriers to adhering were a lack of knowledge, the work environment and perceptions of patients' preferences. Repeated attention, cost-consciousness and an open culture facilitated the implementation., Conclusion: Although most nurses and physicians were aware of the recommendations, not all adhered to them. Increasing awareness is not enough for successful implementation. A tailored approach that removes the barriers is necessary, such as increasing knowledge about wounds and changing the work environment., (© 2023 The Authors. International Journal of Nursing Practice published by John Wiley & Sons Australia, Ltd.)

Background: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections in intubated and mechanically ventilated patients. Endotracheal tubes (ETTs) appear to be an independent risk factor for VAP. Silver-coated ETTs slowly release silver cations. It is these silver ions that appear to have a strong antimicrobial effect. Because of this antimicrobial effect of silver, silver-coated ETTs could be an effective intervention to prevent VAP in people who require mechanical ventilation for 24 hours or longer., Objectives: Our primary objective was to investigate whether silver-coated ETTs are effective in reducing the risk of VAP and hospital mortality in comparison with standard non-coated ETTs in people who require mechanical ventilation for 24 hours or longer. Our secondary objective was to ascertain whether silver-coated ETTs are effective in reducing the following clinical outcomes: device-related adverse events, duration of intubation, length of hospital and intensive care unit (ICU) stay, costs, and time to VAP onset., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014 Issue 10, MEDLINE, EMBASE, EBSCO CINAHL, and reference lists of trials. We contacted corresponding authors for additional information and unpublished studies. We did not impose any restrictions on the basis of date of publication or language. The date of the last search was October 2014., Selection Criteria: We included all randomized controlled trials (RCTs) and quasi-randomized trials that evaluated the effects of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs with standard non-coated ETTs or with other antimicrobial-coated ETTs in critically ill people who required mechanical ventilation for 24 hours or longer. We also included studies that evaluated the cost-effectiveness of silver-coated ETTs or a combination of silver with any antimicrobial-coated ETTs., Data Collection and Analysis: Two review authors (GT, HV) independently extracted the data and summarized study details from all included studies using the specially designed data extraction form. We used standard methodological procedures expected by The Cochrane Collaboration. We performed meta-analysis for outcomes when possible., Main Results: We found three eligible randomized controlled trials, with a total of 2081 participants. One of the three included studies did not mention the amount of participants and presented no outcome data. The 'Risk of bias' assessment indicated that there was a high risk of detection bias owing to lack of blinding of outcomes assessors, but we assessed all other domains to be at low risk of bias. Trial design and conduct were generally adequate, with the most common areas of weakness in blinding. The majority of participants were included in centres across North America. The mean age of participants ranged from 61 to 64 years, and the mean duration of intubation was between 3.2 and 7.7 days. One trial comparing silver-coated ETTs versus non-coated ETTs showed a statistically significant decrease in VAP in favour of the silver-coated ETT (1 RCT, 1509 participants; 4.8% versus 7.5%, risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.96; number needed to treat for an additional beneficial outcome (NNTB) = 37; low-quality evidence). The risk of VAP within 10 days of intubation was significantly lower with the silver-coated ETTs compared with non-coated ETTs (1 RCT, 1509 participants; 3.5% versus 6.7%, RR 0.51, 95% CI 0.31 to 0.82; NNTB = 32; low-quality evidence). Silver-coated ETT was associated with delayed time to VAP occurrence compared with non-coated ETT (1 RCT, 1509 participants; hazard ratio 0.55, 95% CI 0.37 to 0.84). The confidence intervals for the results of the following outcomes did not exclude potentially important differences with either treatment. There were no statistically significant differences between groups in hospital mortality (1 RCT, 1509 participants; 30.4% versus 26.6%, RR 1.09, 95% CI 0.93 to 1.29; low-quality evidence); device-related adverse events (2 RCTs, 2081 participants; RR 0.65, 95% CI 0.37 to 1.16; low-quality evidence); duration of intubation; and length of hospital and ICU stay. We found no clinical studies evaluating the cost-effectiveness of silver-coated ETTs., Authors' Conclusions: This review provides limited evidence that silver-coated ETT reduces the risk of VAP, especially during the first 10 days of mechanical ventilation.

Background: Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to reduce MEs have led to only limited improvements., Objectives: To determine the effectiveness of interventions aimed at reducing MEs and related harm in hospitalised children., Search Methods: The Effective Practice and Organisation of Care Group (EPOC) Trials Search Co-ordinator searched the following sources for primary studies: The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), the Economic Evaluation Database (EED) and the Health Technology Assessments (HTA) database; MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Proquest Dissertations & Theses, Web of Science (citation indexes and conference proceedings) and the EPOC Register of Studies. Related reviews were identified by searching the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE). Review authors searched grey literature sources and trial registries. They handsearched selected journals, contacted researchers in the field and scanned reference lists of relevant reviews. They conducted searches in November 2013 and November 2014. They applied neither language nor date limits., Selection Criteria: Randomised controlled trials, controlled before-after studies and interrupted time series investigating interventions to improve medication safety in hospitalised children (≤ 18 years). Participants were healthcare professionals authorised to prescribe, dispense or administer medications. Outcome measures included MEs, (potential) patient harm, resource utilisation and unintended consequences of the interventions., Data Collection and Analysis: Two review authors independently selected studies, extracted data and assessed study quality using the EPOC data collection checklist. We evaluated the risk of bias of included studies and used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the quality of the body of evidence. We described results narratively and presented them using GRADE tables., Main Results: We included seven studies describing five different interventions: participation of a clinical pharmacist in a clinical team (n = 2), introduction of a computerised physician order entry system (n = 2), implementation of a barcode medication administration system (n = 1), use of a structured prescribing form (n = 1) and implementation of a check and control checklist in combination with feedback (n = 1).Clinical and methodological heterogeneity between studies precluded meta-analyses. Although some interventions described in this review show a decrease in MEs, the results are not consistent, and none of the studies resulted in a significant reduction in patient harm. Based on the GRADE approach, the overall quality and strengfh of the evidence are low., Authors' Conclusions: Current evidence on effective interventions to prevent MEs in a paediatric population in hospital is limited. Comparative studies with robust study designs are needed to investigate interventions including components that focus on specific paediatric safety issues.

Background: The use of drug round tabards is a widespread intervention that is implemented to reduce the number of interruptions and medication administration errors (MAEs) by nurses; however, evidence for their effectiveness is scarce., Purpose: Evaluation of the effect of drug round tabards on the frequency and type of interruptions, MAEs, the linearity between interruptions and MAEs, as well as to explore nurses' experiences with the tabards., Study Design: A mixed methods before-after study, with three observation periods on three wards of a Dutch university hospital, combined with personal inquiry and a focus group with nurses., Methods: In one pre-implementation period and two post-implementation periods at 2 weeks and 4 months, interruptions and MAEs were observed during drug rounds. Descriptive statistics and univariable linear regression were used to determine the effects of the tabard, combined with personal inquiry and a focus group to find out experiences with the tabard., Findings: A total of 313 medication administrations were observed. Significant reductions in both interruptions and MAEs were found after implementation of the tabards. In the third period, a decrease of 75% in interruptions and 66% in MAEs was found. Linear regression analysis revealed a model R2 of 10.4%. The implementation topics that emerged can be classified into three themes: personal considerations, patient perceptions, and considerations regarding tabard effectiveness., Conclusions: Our study indicates that this intervention contributes to a reduction in interruptions and MAEs. However, the reduction in MAEs cannot be fully explained by the decrease in interruptions alone; other factors may have also influenced the effect on MAEs. We advocate for further research on complementary interventions that contribute to a further reduction of MAEs., Clinical Relevance: We can conclude that drug round tabards are effective to improve medication safety and are therefore important for the quality of nursing care and the reduction of MAEs., (© 2014 Sigma Theta Tau International.)

Background: An accurate handover of clinical information is of great importance to continuity and safety of care. If clinically relevant information is not shared accurately and in a timely manner it may lead to adverse events, delays in treatment and diagnosis, inappropriate treatment and omission of care. During the last decade the call for interventions to improve handovers has increased. These interventions aim to reduce the risk of miscommunication, misunderstanding and the omission of critical information., Objectives: To determine the effectiveness of interventions designed to improve hospital nursing handover, specifically:to identify which nursing handover style(s) are associated with improved outcomes for patients in the hospital setting and which nursing handover style(s) are associated with improved nursing process outcomes., Search Methods: We searched the following electronic databases for primary studies: Cochrane EPOC Group specialised register (to 19 September 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (to 1 March 2013), MEDLINE (1950 to 1 March 2013) OvidSP, EMBASE (1947 to 1 March 2013) OvidSP, CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1980 to 1 March 2013) EbscoHost and ISI Web of Knowledge (Science Citation Index and Social Sciences Citation Index) (to 9 July 2012). The Database of Abstracts of Reviews (DARE) was searched for related reviews. We screened the reference lists of included studies and relevant reviews. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) http://www.who.int/ictrp/en/ and Current Controlled Trials www.controlled-trials.com/mrct and we conducted a search of grey literature web sites., Selection Criteria: Randomised controlled trials (RCTs or cluster-RCTs) evaluating any nursing handover style between nurses in a hospital setting with the aim of preventing adverse events or optimising the transfer of accurate essential information required for continuity of care, or both., Data Collection and Analysis: Two review authors independently assessed trial quality and extracted data., Main Results: The search identified 2178 citations, 28 of which were considered potentially relevant. After independent review of the full text of these studies, no eligible studies were identified for inclusion in this review due to the absence of studies with a randomised controlled study design., Authors' Conclusions: There was no evidence available to support conclusions about the effectiveness of nursing handover styles for ensuring continuity of information in hospitalised patients because we found no studies that fulfilled the methodological criteria for this review. As a consequence, uncertainty about the most effective practice remains. Research efforts should focus on strengthening the evidence abut the effectiveness of nursing handover styles using well designed, rigorous studies. According to current knowledge, the following guiding principles can be applied when redesigning the nursing handover process: face-to-face communication, structured documentation, patient involvement and use of IT technology to support the process.

Background: Conflicting evidence exists on the effectiveness of routinely measured vital signs on the early detection of increased probability of adverse events., Purpose: To assess the clinical relevance of routinely measured vital signs in medically and surgically hospitalized patients through a systematic review., Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature, and Meta-analysen van diagnostisch onderzoek (in Dutch; MEDION) were searched to January 2013., Study Selection: Prospective studies evaluating routine vital sign measurements of hospitalized patients, in relation to mortality, septic or circulatory shock, intensive care unit admission, bleeding, reoperation, or infection., Data Extraction: Two reviewers independently assessed potential bias and extracted data to calculate likelihood ratios (LRs) and predictive values., Data Synthesis: Fifteen studies were performed in medical (n = 7), surgical (n = 4), or combined patient populations (n = 4; totaling 42,565 participants). Only three studies were relatively free from potential bias. For temperature, the positive LR (LR+) ranged from 0 to 9.88 (median 1.78; n = 9 studies); heart rate 0.82 to 6.79 (median 1.51; n = 5 studies); blood pressure 0.72 to 4.7 (median 2.97; n = 4 studies); oxygen saturation 0.65 to 6.35 (median 1.74; n = 2 studies); and respiratory rate 1.27 to 1.89 (n = 3 studies). Overall, three studies reported area under the Receiver Operator Characteristic (ROC) curve (AUC) data, ranging from 0.59 to 0.76. Two studies reported on combined vital signs, in which one study found an LR+ of 47.0, but in the other the AUC was not influenced., Conclusions: Some discriminative LR+ were found, suggesting the clinical relevance of routine vital sign measurements. However, the subject is poorly studied, and many studies have methodological flaws. Further rigorous research is needed specifically intended to investigate the clinical relevance of routinely measured vital signs., Clinical Relevance: The results of this research are important for clinical nurses to underpin daily routine practices and clinical decision making., (© 2013 Sigma Theta Tau International.)

Background: Hyperbaric oxygen therapy (HBOT) is used as a treatment for acute wounds (such as those arising from surgery and trauma). However, the effects of HBOT on wound healing are unclear. , Objectives: To determine the effects of HBOT on the healing of acute surgical and traumatic wounds., Search Methods: We searched the Cochrane Wounds Group Specialised Register (searched 9 August 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12); Ovid MEDLINE (2010 to July Week 5 2013); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, August 08, 2013); Ovid EMBASE (2010 to 2013 Week 31); EBSCO CINAHL (2010 to 8 August 2013)., Selection Criteria: Randomised controlled trials (RCTs) comparing HBOT with other interventions such as dressings, steroids, or sham HOBT or comparisons between alternative HBOT regimens., Data Collection and Analysis: Two review authors conducted selection of trials, risk of bias assessment, data extraction and data synthesis independently. Any disagreements were referred to a third review author. , Main Results: Four trials involving 229 participants were included. The studies were clinically heterogeneous, which precluded a meta-analysis.One trial (48 participants with burn wounds undergoing split skin grafts) compared HBOT with usual care and reported a significantly higher complete graft survival associated with HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to 9.11). A second trial (10 participants in free flap surgery) reported no significant difference between graft survival (no data available). A third trial (36 participants with crush injuries) reported significantly more wounds healed (RR 1.70; 95% CI 1.11 to 2.61), and significantly less tissue necrosis (RR 0.13; 95% CI 0.02 to 0.90) with HBOT compared to sham HBOT. The fourth trial (135 people undergoing flap grafting) reported no significant differences in complete graft survival with HBOT compared with dexamethasone (RR 1.14; 95% CI 0.95 to 1.38) or heparin (RR 1.21; 95% CI 0.99 to 1.49).Many of the predefined secondary outcomes of the review were not reported. All four trials were at unclear or high risk of bias., Authors' Conclusions: There is a lack of high quality, valid research evidence regarding the effects of HBOT on wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of skin grafting and trauma, these trials were at risk of bias. Further evaluation by means of high quality RCTs is needed.

Background: Patients suffering from inoperable chronic critical leg ischaemia (NR-CCLI) face amputation of the leg. Spinal cord stimulation (SCS) has been proposed as a helpful treatment in addition to standard conservative treatment., Objectives: To find evidence for an improvement on limb salvage, pain relief, and the clinical situation using SCS compared to conservative treatment alone., Search Methods: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12)., Selection Criteria: Controlled studies comparing the addition of SCS with any form of conservative treatment to conservative treatment alone in patients with NR-CCLI., Data Collection and Analysis: Both authors independently assessed the quality of the studies and extracted data., Main Results: Six studies comprising nearly 450 patients were included. In general the quality of the studies was good. No study was blinded due to the type of intervention.Limb salvage after 12 months was significantly higher in the SCS group (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; risk difference (RD) -0.11, 95% CI -0.20 to -0.02). Significant pain relief occurred in both treatment groups, but was more prominent in the SCS group where the patients required significantly less analgesics. In the SCS group, significantly more patients reached Fontaine stage II than in the conservative group (RR 4.9, 95% CI 2.0 to 11.9; RD 0.33, 95% CI 0.19 to 0.47). Overall, no significantly different effect on ulcer healing was observed with the two treatments.Complications of SCS treatment consisted of implantation problems (9%, 95% CI 4 to 15%) and changes in stimulation requiring re-intervention (15%, 95% CI 10 to 20%). Infections of the lead or pulse generator pocket occurred less frequently (3%, 95% CI 0 to 6%). Overall risk of complications with additional SCS treatment was 17% (95% CI 12 to 22%), indicating a number needed to harm of 6 (95% CI 5 to 8).Average overall costs (one study) at two years were EUR 36,500 (SCS group) and EUR 28,600 (conservative group). The difference (EUR 7900) was significant (P < 0.009)., Authors' Conclusions: There is evidence to favour SCS over standard conservative treatment alone to improve limb salvage and clinical situations in patients with NR-CCLI. The benefits of SCS must be considered against the possible harm of relatively mild complications and the costs.

Background: Hyperbaric oxygen therapy (HBOT) is used as a treatment for acute wounds (such as those arising from surgery and trauma) however the effects of HBOT on wound healing are unclear. , Objectives: To determine the effects of HBOT on the healing of acute surgical and traumatic wounds., Search Strategy: We searched the Cochrane Wounds Group Specialised Register (25 August 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), Ovid MEDLINE (1950 to August Week 2 2010 ), Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 24, 2010), Ovid EMBASE (1980 to 2010, Week 33) and EBSCO CINAHL (1982 to 20 August 2010)., Selection Criteria: Randomised controlled trials (RCTs) comparing HBOT with other interventions or comparisons between alternative HBOT regimens., Data Collection and Analysis: Two review authors conducted selection of trials, risk of bias assessment, data extraction and data synthesis independently. Any disagreements were referred to a third review author. , Main Results: Three trials involving 219 participants were included. The studies were clinically heterogeneous, therefore a meta-analysis was inappropriate.One trial (48 participants with burn wounds undergoing split skin grafts) compared HBOT with usual care and reported a significantly higher complete graft survival associated with HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to 9.11). A second trial (36 participants with crush injuries) reported significantly more wounds healed with HBOT than with sham HBOT (RR 1.70; 95% CI 1.11 to 2.61) and fewer additional surgical procedures required with HBOT: RR 0.25; 95% CI 0.06 to 1.02 and significantly less tissue necrosis: RR 0.13; 95% CI 0.02 to 0.90). A third trial (135 people undergoing flap grafting) reported no significant differences in complete graft survival with HBOT compared with dexamethasone (RR 1.14; 95% CI 0.95 to 1.38) or heparin (RR 1.21; 95% CI 0.99 to 1.49).Many of the predefined secondary outcomes of the review, including mortality, pain scores, quality of life, patient satisfaction, activities daily living, increase in transcutaneous oxygen pressure (TcpO(2)), amputation, length of hospital stay and costs, were not reported. All three trials were at unclear or high risk of bias., Authors' Conclusions: There is a lack of high quality, valid research evidence regarding the effects of HBOT on wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of skin grafting and trauma these trials were at risk of bias. Further evaluation by means of high quality RCTs is needed.

Background: Silver-containing treatments are popular and used in wound treatments to combat a broad spectrum of pathogens, but evidence of their effectiveness in preventing wound infection or promoting healing is lacking., Objectives: To establish the effects of silver-containing wound dressings and topical agents in preventing wound infection and healing of wounds., Search Strategy: We searched the Cochrane Wounds Group Specialised Register (6 May 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) (2009 Issue 2); Ovid MEDLINE (1950 to April Week 4 2009); Ovid EMBASE (1980 to 2009 Week 18); EBSCO CINAHL (1982 to April Week 4 2009) and Digital Dissertations (to May 2009) for relevant trials. We contacted manufacturers and distributors., Selection Criteria: Randomised controlled trials (RCTs) comparing silver-containing wound dressings and topical agents with silver-containing and non silver-containing comparators on uninfected wounds., Data Collection and Analysis: Two authors independently selected trials, assessed risk of bias, and extracted data., Main Results: We identified 26 RCTs (2066 patients). Heterogeneity of treatments and outcomes precluded meta-analysis. We grouped results according to wound type, and silver preparation.BurnsThirteen trials compared topical silver (in a variety of formulations - including silver sulphadiazine (SSD) cream) with non-silver dressings. One trial showed fewer infections with silver nitrate when compared with a non-silver dressing, but three trials showed significantly more infection with SSD than with the non-silver dressing.Six trials compared SSD cream with silver-containing dressings. One showed significantly fewer infections with the silver-containing dressing (Hydron AgSD) compared with SSD, the remaining five found no evidence of a difference.One trial compared two silver-containing dressings, and showed a significantly lower infection rate with silver-coated gauze (Acticoat(R)) than with silver nitrate gauze.Other woundsSix trials compared SSD/silver-containing dressings with non-silver dressings (nine dressings in total). Most comparisons (seven) found no significant differences in infection rates; one trial in a variety of wounds exhibited significantly fewer infections with SSD/hydrocolloid, but another, in acute wounds, found significantly more infections with SSD. Only one comparison showed a significant reduction in healing time associated with a silver-containing hydrofibre dressing in diabetic foot ulcers., Authors' Conclusions: There is insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection; some poor quality evidence for SSD suggests the opposite.

Background: Chronic wounds mainly affect the elderly and those with multiple health problems. Despite the use of modern dressings, some of these wounds take a long time to heal, fail to heal, or recur, causing significant pain and discomfort to the person and cost to health services. Topical negative pressure (TNP) is used to promote healing of surgical wounds by using suction to drain excess fluid from wounds., Objectives: To assess the effects of TNP on chronic wound healing., Search Strategy: For this second update of this review we searched the Cochrane Wounds Group Specialised Register (December 2007), The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4, 2007, Ovid MEDLINE - 1950 to November Week 2 2007, Ovid EMBASE - 1982 to 2007 Week 50 and Ovid CINAHL - 1980 to December Week 1 2007. In addition, we contacted authors, companies, manufacturers, and distributors to identify relevant trials and information., Selection Criteria: All randomised controlled trials which evaluated the effects of TNP on people with chronic wounds., Data Collection and Analysis: Selection of the trials, quality assessment, data abstraction, and data synthesis were done by two authors independently. Disagreements were solved by discussion., Main Results: Two trials were included in the original review. A further five trials were included in this second update resulting in a total of seven trials involving 205 participants. The seven trials compared TNP with five different comparator treatments. Four trials compared TNP with gauze soaked in either 0.9% saline or Ringer's solution. The other three trials compared TNP with hydrocolloid gel plus gauze, a treatment package comprising papain-urea topical treatment, and cadexomer iodine or hydrocolloid, hydrogels, alginate and foam. These data do not show that TNP significantly increases the healing rate of chronic wounds compared with comparators. Data on secondary outcomes such as infection rate, quality of life, oedema, hospitalisation and bacterial load were not reported., Authors' Conclusions: Trials comparing TNP with alternative treatments for chronic wounds have methodological flaws and data do demonstrate a beneficial effect of TNP on wound healing however more, better quality research is needed.

Background: Topical silver treatments and silver dressings are increasingly used for the local treatment of contaminated or infected wounds, however, there is a lack of clarity regarding the evidence for their effectiveness., Objectives: To evaluate the effects on wound healing of topical silver and silver dressings in the treatment of contaminated and infected acute or chronic wounds., Search Strategy: We sought relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Wounds Group Specialised Register in March 2006 and in MEDLINE, EMBASE, CINAHL, and digital dissertations databases up to September 2006. In addition, we contacted companies, manufacturers and distributors for information to identify relevant trials., Selection Criteria: Randomised controlled trials (RCTs) assessing the effectiveness of topical silver in the treatment of contaminated and infected acute or chronic wounds., Data Collection and Analysis: Eligibility of trials, assessment of trial quality and data extraction were undertaken by two authors independently. Disagreements were referred to a third author., Main Results: Three RCTs were identified, comprising a total of 847 participants. One trial compared silver-containing foam (Contreet) with hydrocellular foam (Allevyn) in patients with leg ulcers. The second trial compared a silver-containing alginate (Silvercel) with an alginate alone (Algosteril). The third trial compared a silver-containing foam dressing (Contreet)) with best local practice in patients with chronic wounds.The data from these trials show that silver-containing foam dressings did not significantly increase complete ulcer healing as compared with standard foam dressings or best local practice after up to four weeks of follow-up, although a greater reduction of ulcer size was observed with the silver-containing foam. The use of antibiotics was assessed in two trials, but no significant differences were found. Data on pain, patient satisfaction, length of hospital stay, and costs were limited and showed no differences. Leakage occurred significantly less frequently in patients with leg ulcers and chronic wounds treated with a silver dressing than with a standard foam dressing or best local practice in one trial., Authors' Conclusions: Only three trials with a short follow-up duration were found. There is insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated chronic wounds.

Background: Patients suffering from inoperable chronic critical leg ischaemia (NR-CCLI), face amputation of the leg. Spinal cord stimulation (SCS) has been proposed as a helpful treatment in addition to standard conservative treatment., Objectives: To find evidence for an improvement of limb salvage, pain relief and clinical situation using SCS compared to conservative treatment alone., Search Strategy: We searched the Cochrane Peripheral Vascular Diseases Group's Specialised Register, (last searched May 2005), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 2, 2005). Additional data were obtained from research institutes., Selection Criteria: Controlled studies comparing additional SCS with any form of conservative treatment in patients with NR-CCLI., Data Collection and Analysis: Both authors independently assessed the quality of the studies and extracted data., Main Results: Six studies comprising nearly 450 patients were included. In general, the quality of the studies was good. None was blinded due to the nature of the intervention. Limb salvage after 12 months was significantly higher in the SCS group (relative risk (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; risk difference (RD) -0.11, 95% CI -0.20 to -0.02). Significant pain relief occurred in both treatment groups, but was more prominent in the SCS group, in which the patients required significantly less analgesics. In the SCS group, significantly more patients reached Fontaine stage II than in the conservative group (RR 4.9, 95% CI 2.0 to 11.9; RD 0.33, 95% CI 0.19 to 0.47). Overall, no significantly different effect on ulcer healing was observed between the two treatments. Complications of SCS treatment consisted of implantation problems (9%, 95% CI 4 to 15%) and changes in stimulation requiring re-intervention (15%, 95% CI 10 to 20%). Infections of the lead or pulse generator pocket occurred less frequently (3%, 95% CI 0 to 6%). The overall risk of complications of additional SCS treatment was 17% (95% CI 12 to 22%), indicating a number needed to harm of 6 (95% CI 5 to 8).A cost comparison was made in only one study. The average overall costs at two years were 36,500 Euros, (SCS group) and 28,600 Euros, (conservative group). The difference (7900 Euros) was significant (P<0.009)., Authors' Conclusions: There is evidence to favour SCS over standard conservative treatment to improve limb salvage and clinical situation in patients with NR-CCLI. The benefits of SCS against the possible harm of relatively mild complications and costs must be considered.

Background: Many different wound dressings and topical applications are used to cover surgical wounds healing by secondary intention. It is not known whether these dressings heal wounds at different rates., Objectives: To assess the effectiveness of dressings and topical agents on surgical wounds healing by secondary intention, Search Strategy: We sought relevant trials from the Cochrane Central Register of Controlled Trials, Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, and CINAHL databases in March 2002., Selection Criteria: All randomised controlled trials (RCTs) evaluating the effectiveness of dressings and topical agents for surgical wounds healing by secondary intention., Data Collection and Analysis: Eligibility for inclusion was confirmed by two reviewers who independently judged the methodological quality of the trials according to the Dutch Cochrane Centre list of factors relating to internal and external validity. Two reviewers summarised data from eligible studies using a data extraction sheet, any disagreements were referred to a third reviewer., Main Results: Fourteen reports of 13 RCTs on dressings or topical agents for postoperative wounds healing by secondary intention were identified., Wound Healing: Whilst a single small trial of aloe vera supplementation vs gauze suggests delayed healing with aloe vera, the results of this trial are un interpretable since there was a large differential loss to follow up. A plaster cast applied to an amputation stump accelerated wound healing compared with elastic compression, WMD -25.60 days, 95% CI -49.08 to -2.12 days (1 trial). There were no statistically significant differences in healing for other dressing comparisons (e.g. gauze, foam, alginate; 11 trials). PAIN: Gauze was associated with significantly more pain for patients than other dressings (4 trials). PATIENT SATISFACTION: Patients treated with gauze were less satisfied compared with those receiving alternative dressings (3 trials)., Costs: Gauze is inexpensive but its use is associated with the use of significantly more nursing time than foam (2 trials). LENGTH OF HOSPITAL STAY: Four trials showed no difference in length of hospital stay. One trial found shorter hospital stay in people after amputation when plaster casts were applied compared with elastic compression (WMD -30.10 days; 95% CI -49.82 to -10.38)., Reviewers' Conclusions: We found only small, poor quality trials; the evidence is therefore insufficient to determine whether the choice of dressing or topical agent affects the healing of surgical wounds healing by secondary intention. Foam is best studied as an alternative for gauze and appears to be preferable as to pain reduction, patient satisfaction and nursing time.

Background: Patients suffering from inoperable chronic critical leg ischaemia (NR-CCLI), face amputation of the leg. Spinal cord stimulation (SCS) has been proposed as a helpful treatment in addition to standard conservative treatment., Objectives: To find evidence for an improvement of limb salvage, pain relief and clinical situation by means of SCS over conservative treatment alone., Search Strategy: The reviewers searched the Cochrane Peripheral Vascular Diseases Group Specialised Register, (last searched November 2002), the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 4, 2002). Additional data were obtained from research institutes., Selection Criteria: Controlled studies comparing additional SCS with any form of conservative treatment in patients with NR-CCLI., Data Collection and Analysis: Two reviewers (DU, HV), independently assessed the quality of the studies and extracted the data., Main Results: Six studies comprising nearly 450 patients were included. In general the quality of the studies was good, although none of them was blinded due to the nature of the intervention. Limb salvage after 12 months was significantly higher in the SCS group (RR 0.71, 95%CI: 0.56 to 0.90; RD -0.13, 95%CI: -0.22 to -0.04). Significant pain relief occurred in both treatment groups, but was more prominent in the SCS group, in which the patients required significantly less analgesics. In the SCS group significantly more patients reached Fontaine stage II than in the conservative group (RR 4.9, 95%CI: 2.0 to 11.9; RD 0.33, 95%CI: 0.19 to 0.47). Overall, no significantly different effect on ulcer healing was observed between the two treatments. Complications of SCS treatment consisted of implantation problems (9%; 95%CI: 4 to 15%) and changes in stimulation requiring reintervention, (15%; 95%CI: 10 to 20%). Infections of the lead or pulse generator pocket occurred less frequently (3%; 95%CI: 0 to 6%). The overall risk of complications of additional SCS treatment was 17%, 95%CI: 12 to 22%, indicating a number needed to harm of six (95%CI: 5 to 8).A cost comparison was made in only one study. The average overall costs at two years were 36,500 euros, in the SCS group and 28,600 euros, in the conservative group. The difference (7,900 euros) was significant (p<0.009)., Reviewer's Conclusions: There is evidence to favour SCS over standard conservative treatment to improve limb salvage and clinical situation in patients with NR-CCLI. The benefits of SCS against the possible harm of relatively mild complications, and costs must be considered.