Management of chronic pressure ulcers: an evidence-based analysis.
PDF (14M)
Journal: 2012/October - Ontario Health Technology Assessment Series
ISSN: 1915-7398
PUBMED: 23074533
Abstract:
In April 2008, the Medical Advisory Secretariat began an evidence-based review of the literature concerning pressure ulcers.Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series.PRESSURE ULCER PREVENTION: an evidence based analysisThe cost-effectiveness of prevention strategies for pressure ulcers in long-term care homes in Ontario: projections of the Ontario Pressure Ulcer Model (field evaluation)MANAGEMENT OF CHRONIC PRESSURE ULCERS: an evidence-based analysis
OBJECTIVE
The Medical Advisory Secretariat (MAS) conducted a systematic review on interventions used to treat pressure ulcers in order to answer the following questions: Do currently available interventions for the treatment of pressure ulcers increase the healing rate of pressure ulcers compared with standard care, a placebo, or other similar interventions?Within each category of intervention, which one is most effective in promoting the healing of existing pressure ulcers?
BACKGROUND
A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in conjunction with shear and/or friction. Many areas of the body, especially the sacrum and the heel, are prone to the development of pressure ulcers. People with impaired mobility (e.g., stroke or spinal cord injury patients) are most vulnerable to pressure ulcers. Other factors that predispose people to pressure ulcer formation are poor nutrition, poor sensation, urinary and fecal incontinence, and poor overall physical and mental health. The prevalence of pressure ulcers in Ontario has been estimated to range from a median of 22.1% in community settings to a median of 29.9% in nonacute care facilities. Pressure ulcers have been shown to increase the risk of mortality among geriatric patients by as much as 400%, to increase the frequency and duration of hospitalization, and to decrease the quality of life of affected patients. The cost of treating pressure ulcers has been estimated at approximately $9,000 (Cdn) per patient per month in the community setting. Considering the high prevalence of pressure ulcers in the Ontario health care system, the total cost of treating pressure ulcers is substantial.
METHODS
Wounds normally heal in 3 phases (inflammatory phase, a proliferative phase of new tissue and matrix formation, and a remodelling phase). However, pressure ulcers often fail to progress past the inflammatory stage. Current practice for treating pressure ulcers includes treating the underlying causes, debridement to remove necrotic tissues and contaminated tissues, dressings to provide a moist wound environment and to manage exudates, devices and frequent turning of patients to provide pressure relief, topical applications of biologic agents, and nutritional support to correct nutritional deficiencies. A variety of adjunctive physical therapies are also in use.
METHODS
Health technology assessment databases and medical databases were searched from 1996 (Medline), 1980 (EMBASE), and 1982 (CINAHL) systematically up to March 2008 to identify randomized controlled trials (RCTs) on the following treatments of pressure ulcers: cleansing, debridement, dressings, biological therapies, pressure-relieving devices, physical therapies, nutritional therapies, and multidisciplinary wound care teams. Full literature search strategies are reported in appendix 1. English-language studies in previous systematic reviews and studies published since the last systematic review were included if they had more than 10 subjects, were randomized, and provided objective outcome measures on the healing of pressure ulcers. In the absence of RCTs, studies of the highest level of evidence available were included. Studies on wounds other than pressure ulcers and on surgical treatment of pressure ulcers were excluded. A total of 18 systematic reviews, 104 RCTs, and 4 observational studies were included in this review. Data were extracted from studies using standardized forms. The quality of individual studies was assessed based on adequacy of randomization, concealment of treatment allocation, comparability of groups, blinded assessment, and intention-to-treat analysis. Meta-analysis to estimate the relative risk (RR) or weighted mean difference (WMD) for measures of healing was performed when appropriate. A descriptive synthesis was provided where pooled analysis was not appropriate or not feasible. The quality of the overall evidence on each intervention was assessed using the grading of recommendations assessment, development, and evaluation (GRADE) criteria.
RESULTS
Findings from the analysis of the included studies are summarized below: CLEANSING: There is no good trial evidence to support the use of any particular wound cleansing solution or technique for pressure ulcers. DEBRIDEMENT: There was no evidence that debridement using collagenase, dextranomer, cadexomer iodine, or maggots significantly improved complete healing compared with placebo.There were no statistically significant differences between enzymatic or mechanical debridement agents with the following exceptions:Papain urea resulted in better debridement than collagenase.Calcium alginate resulted in a greater reduction in ulcer size compared to dextranomer.Adding streptokinase/streptodornase to hydrogel resulted in faster debridement.Maggot debridement resulted in more complete debridement than conventional treatment.There is limited evidence on the healing effects of debridement devices. DRESSINGS: Hydrocolloid dressing was associated with almost three-times more complete healing compared with saline gauze. There is evidence that hydrogel and hydropolymer may be associated with 50% to 70% more complete healing of pressure ulcers than hydrocolloid dressing.No statistically significant differences in complete healing were detected among other modern dressings.There is evidence that polyurethane foam dressings and hydrocellular dressings are more absorbent and easier to remove than hydrocolloid dressings in ulcers with moderate to high exudates.In deeper ulcers (stage III and IV), the use of alginate with hydrocolloid resulted in significantly greater reduction in the size of the ulcers compared to hydrocolloid alone.Studies on sustained silver-releasing dressing demonstrated a tendency for reducing the risk of infection and promoting faster healing, but the sample sizes were too small for statistical analysis or for drawing conclusions. BIOLOGICAL THERAPIES: The efficacy of platelet-derived growth factors (PDGFs), fibroblast growth factor, and granulocyte-macrophage colony stimulating factor in improving complete healing of chronic pressure ulcers has not been established.Presently only Regranex, a recombinant PDGF, has been approved by Health Canada and only for treatment of diabetic ulcers in the lower extremities.A March 2008 US Food and Drug Administration (FDA) communication reported increased deaths from cancers in people given three or more prescriptions for Regranex.Limited low-quality evidence on skin matrix and engineered skin equivalent suggests a potential role for these products in healing refractory advanced chronic pressure ulcers, but the evidence is insufficient to draw a conclusion. ADJUNCTIVE PHYSICAL THERAPY: There is evidence that electrical stimulation may result in a significantly greater reduction in the surface area and more complete healing of stage II to IV ulcers compared with sham therapy. No conclusion on the efficacy of electrotherapy can be drawn because of significant statistical heterogeneity, small sample sizes, and methodological flaws.The efficacy of other adjunctive physical therapies [electromagnetic therapy, low-level laser (LLL) therapy, ultrasound therapy, ultraviolet light therapy, and negative pressure therapy] in improving complete closure of pressure ulcers has not been established. NUTRITION THERAPY: Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect complete healing but resulted in a 2-fold improvement in Pressure Ulcer Scale for Healing (PUSH) score compared with placebo.Supplementation with 200 mg of zinc three times per day did not have any significant impact on the healing of pressure ulcers compared with a placebo.Supplementation of 500 mg ascorbic acid twice daily was associated with a significantly greater decrease in the size of the ulcer compared with a placebo but did not have any significant impact on healing when compared with supplementation of 10 mg ascorbic acid three times daily.A very high protein tube feeding (25% of energy as protein) resulted in a greater reduction in ulcer area in institutionalized tube-fed patients compared with a high protein tube feeding (16% of energy as protein).Multinutrient supplements that contain zinc, arginine, and vitamin C were associated with a greater reduction in the area of the ulcers compared with standard hospital diet or to a standard supplement without zinc, arginine, or vitamin C.Firm conclusions cannot be drawn because of methodological flaws and small sample sizes. MULTIDISCIPLINARY WOUND CARE TEAMS: The only RCT suggests that multidisciplinary wound care teams may significantly improve healing in the acute care setting in 8 weeks and may significantly shorten the length of hospitalization. However, since only an abstract is available, study biases cannot be assessed and no conclusions can be drawn on the quality of this evidence.
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Ont Health Technol Assess Ser 9(3): 1-203
PMID: 23074533

Management of Chronic Pressure Ulcers

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About the Ontario Health Technology Assessment Series

To conduct its comprehensive analyses, MAS systematically reviews available scientific literature, collaborates with partners across relevant government branches, and consults with clinical and other external experts and manufacturers, and solicits any necessary advice to gather information. The MAS makes every effort to ensure that all relevant research, nationally and internationally, is included in the systematic literature reviews conducted.

The information gathered is the foundation of the evidence to determine if a technology is effective and safe for use in a particular clinical population or setting. Information is collected to understand how a new technology fits within current practice and treatment alternatives. Details of the technology’s diffusion into current practice and input from practicing medical experts and industry add important information to the review of the provision and delivery of the health technology in Ontario. Information concerning the health benefits; economic and human resources; and ethical, regulatory, social and legal issues relating to the technology assist policy makers to make timely and relevant decisions to optimize patient outcomes.

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Disclaimer

This evidence-based analysis was prepared by the Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care, for the Ontario Health Technology Advisory Committee and developed from analysis, interpretation, and comparison of scientific research and/or technology assessments conducted by other organizations. It also incorporates, when available, Ontario data, and information provided by experts and applicants to the Medical Advisory Secretariat to inform the analysis. While every effort has been made to reflect all scientific research available, this document may not fully do so. Additionally, other relevant scientific findings may have been reported since completion of the review. This evidence-based analysis is current to the date of publication. This analysis may be superseded by an updated publication on the same topic. Please check the Medical Advisory Secretariat Website for a list of all evidence-based analyses: http://www.health.gov.on.ca/ohtas.

Presented to the Ontario Health Technology Advisory Committee in October 2008
Presented to the Ontario Health Technology Advisory Committee in October 2008
Copyright © 2009, The Medical Advisory Secretariat

Executive Summary

In April 2008, the Medical Advisory Secretariat began an evidence-based review of the literature concerning pressure ulcers.

Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series.

  1. Pressure ulcer prevention: an evidence based analysis

  2. The cost-effectiveness of prevention strategies for pressure ulcers in long-term care homes in Ontario: projections of the Ontario Pressure Ulcer Model (field evaluation)

  3. Management of chronic pressure ulcers: an evidence-based analysis

Objective

The Medical Advisory Secretariat (MAS) conducted a systematic review on interventions used to treat pressure ulcers in order to answer the following questions:

  • Do currently available interventions for the treatment of pressure ulcers increase the healing rate of pressure ulcers compared with standard care, a placebo, or other similar interventions?

  • Within each category of intervention, which one is most effective in promoting the healing of existing pressure ulcers?

Background

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in conjunction with shear and/or friction. Many areas of the body, especially the sacrum and the heel, are prone to the development of pressure ulcers. People with impaired mobility (e.g., stroke or spinal cord injury patients) are most vulnerable to pressure ulcers. Other factors that predispose people to pressure ulcer formation are poor nutrition, poor sensation, urinary and fecal incontinence, and poor overall physical and mental health.

The prevalence of pressure ulcers in Ontario has been estimated to range from a median of 22.1% in community settings to a median of 29.9% in nonacute care facilities. Pressure ulcers have been shown to increase the risk of mortality among geriatric patients by as much as 400%, to increase the frequency and duration of hospitalization, and to decrease the quality of life of affected patients. The cost of treating pressure ulcers has been estimated at approximately $9,000 (Cdn) per patient per month in the community setting. Considering the high prevalence of pressure ulcers in the Ontario health care system, the total cost of treating pressure ulcers is substantial.

Technology

Wounds normally heal in 3 phases (inflammatory phase, a proliferative phase of new tissue and matrix formation, and a remodelling phase). However, pressure ulcers often fail to progress past the inflammatory stage. Current practice for treating pressure ulcers includes treating the underlying causes, debridement to remove necrotic tissues and contaminated tissues, dressings to provide a moist wound environment and to manage exudates, devices and frequent turning of patients to provide pressure relief, topical applications of biologic agents, and nutritional support to correct nutritional deficiencies. A variety of adjunctive physical therapies are also in use.

Method

Health technology assessment databases and medical databases were searched from 1996 (Medline), 1980 (EMBASE), and 1982 (CINAHL) systematically up to March 2008 to identify randomized controlled trials (RCTs) on the following treatments of pressure ulcers: cleansing, debridement, dressings, biological therapies, pressure-relieving devices, physical therapies, nutritional therapies, and multidisciplinary wound care teams. Full literature search strategies are reported in appendix 1. English-language studies in previous systematic reviews and studies published since the last systematic review were included if they had more than 10 subjects, were randomized, and provided objective outcome measures on the healing of pressure ulcers. In the absence of RCTs, studies of the highest level of evidence available were included. Studies on wounds other than pressure ulcers and on surgical treatment of pressure ulcers were excluded. A total of 18 systematic reviews, 104 RCTs, and 4 observational studies were included in this review.

Data were extracted from studies using standardized forms. The quality of individual studies was assessed based on adequacy of randomization, concealment of treatment allocation, comparability of groups, blinded assessment, and intention-to-treat analysis. Meta-analysis to estimate the relative risk (RR) or weighted mean difference (WMD) for measures of healing was performed when appropriate. A descriptive synthesis was provided where pooled analysis was not appropriate or not feasible. The quality of the overall evidence on each intervention was assessed using the grading of recommendations assessment, development, and evaluation (GRADE) criteria.

Findings

Findings from the analysis of the included studies are summarized below:

Cleansing

  • There is no good trial evidence to support the use of any particular wound cleansing solution or technique for pressure ulcers.

Debridement

  • There was no evidence that debridement using collagenase, dextranomer, cadexomer iodine, or maggots significantly improved complete healing compared with placebo.

  • There were no statistically significant differences between enzymatic or mechanical debridement agents with the following exceptions:

    • Papain urea resulted in better debridement than collagenase.

    • Calcium alginate resulted in a greater reduction in ulcer size compared to dextranomer.

    • Adding streptokinase/streptodornase to hydrogel resulted in faster debridement.

    • Maggot debridement resulted in more complete debridement than conventional treatment.

  • There is limited evidence on the healing effects of debridement devices.

Dressings

Hydrocolloid dressing was associated with almost three-times more complete healing compared with saline gauze.

  • There is evidence that hydrogel and hydropolymer may be associated with 50% to 70% more complete healing of pressure ulcers than hydrocolloid dressing.

  • No statistically significant differences in complete healing were detected among other modern dressings.

  • There is evidence that polyurethane foam dressings and hydrocellular dressings are more absorbent and easier to remove than hydrocolloid dressings in ulcers with moderate to high exudates.

  • In deeper ulcers (stage III and IV), the use of alginate with hydrocolloid resulted in significantly greater reduction in the size of the ulcers compared to hydrocolloid alone.

  • Studies on sustained silver-releasing dressing demonstrated a tendency for reducing the risk of infection and promoting faster healing, but the sample sizes were too small for statistical analysis or for drawing conclusions.

Biological Therapies

  • The efficacy of platelet-derived growth factors (PDGFs), fibroblast growth factor, and granulocyte-macrophage colony stimulating factor in improving complete healing of chronic pressure ulcers has not been established.

  • Presently only Regranex, a recombinant PDGF, has been approved by Health Canada and only for treatment of diabetic ulcers in the lower extremities.

  • A March 2008 US Food and Drug Administration (FDA) communication reported increased deaths from cancers in people given three or more prescriptions for Regranex.

  • Limited low-quality evidence on skin matrix and engineered skin equivalent suggests a potential role for these products in healing refractory advanced chronic pressure ulcers, but the evidence is insufficient to draw a conclusion.

Adjunctive Physical Therapy

  • There is evidence that electrical stimulation may result in a significantly greater reduction in the surface area and more complete healing of stage II to IV ulcers compared with sham therapy. No conclusion on the efficacy of electrotherapy can be drawn because of significant statistical heterogeneity, small sample sizes, and methodological flaws.

  • The efficacy of other adjunctive physical therapies [electromagnetic therapy, low-level laser (LLL) therapy, ultrasound therapy, ultraviolet light therapy, and negative pressure therapy] in improving complete closure of pressure ulcers has not been established.

Nutrition Therapy

  • Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect complete healing but resulted in a 2-fold improvement in Pressure Ulcer Scale for Healing (PUSH) score compared with placebo.

  • Supplementation with 200 mg of zinc three times per day did not have any significant impact on the healing of pressure ulcers compared with a placebo.

  • Supplementation of 500 mg ascorbic acid twice daily was associated with a significantly greater decrease in the size of the ulcer compared with a placebo but did not have any significant impact on healing when compared with supplementation of 10 mg ascorbic acid three times daily.

  • A very high protein tube feeding (25% of energy as protein) resulted in a greater reduction in ulcer area in institutionalized tube-fed patients compared with a high protein tube feeding (16% of energy as protein).

  • Multinutrient supplements that contain zinc, arginine, and vitamin C were associated with a greater reduction in the area of the ulcers compared with standard hospital diet or to a standard supplement without zinc, arginine, or vitamin C.

  • Firm conclusions cannot be drawn because of methodological flaws and small sample sizes.

Multidisciplinary Wound Care Teams

  • The only RCT suggests that multidisciplinary wound care teams may significantly improve healing in the acute care setting in 8 weeks and may significantly shorten the length of hospitalization. However, since only an abstract is available, study biases cannot be assessed and no conclusions can be drawn on the quality of this evidence.

Executive Summary

In April 2008, the Medical Advisory Secretariat began an evidence-based review of the literature concerning pressure ulcers.

Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series.

  1. Pressure ulcer prevention: an evidence based analysis

  2. The cost-effectiveness of prevention strategies for pressure ulcers in long-term care homes in Ontario: projections of the Ontario Pressure Ulcer Model (field evaluation)

  3. Management of chronic pressure ulcers: an evidence-based analysis

Copyright © 2006 American Medical Association. All rights reserved.Reproduced with permission from: Zeller JL, Lynm C, Glass RM. JAMA patient page. Pressure ulcers. JAMA 2006; 296 (8): 1020.Based on 2007 National Pressure Ulcer Advisory Panel Classification System. (1)Adapted from Falabella, 2006. (23)Xakellis: Multivariate analysis: Presence of exudate at baseline <down> healing rates by 2/3. Cox proportional HR: exudate vs. no exudate = 0.34 (P = .009). Saline gauze vs. hydrocolloid, HR = .6 (P = .17)In the Motta et al:study, clinical performance included ease of use, slippage, conformability, patient comfort, and dressing debris remaining in the wound area after dressing removal.Study also included leg ulcers 50/50 (only results on pressure ulcers were included in table).Payne 2001 (81) – Complete healing at 6 weeks.From e-mail communications.Spacial and temporal averaged (SATA) intensity 0.10 W/cm2.NPUAP indicates National Pressure Ulcer Advisory Panel; SATA, spacial and temporal averaged; SCI, spinal cord injury; ;UVC, ultraviolet C.

Appendices

Appendix 1: U.S. National Pressure Ulcer Advisory Panel Staging System (1)

StageDefinitionFurther description
Suspected Deep Tissue InjuryPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared with adjacent tissue.Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Stage IIntact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.The area may be painful, firm, soft, warmer or cooler as compared with adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk)
Stage IIPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Stage IIIFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage IVFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
UnstageableFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body's natural (biological) cover” and should not be removed.
Bruising indicates suspected deep tissue injury

Appendix 2: Summary of Studies on Factors That Predict Healing of Pressure Ulcers*

Jones 2007Bergstrom 2005Kramer 2000Berlowitz 1997
DesignMulticentre retrospective cohort studyMulticentre retrospective cohort studySingle centre retrospective cohort studyMulticentre retrospective cohort study
SettingPressure ulcer care in hospitals, clinics, nursing homes and home care in 3 geographical areas95 Long-term care facilitiesChronic unit of one long-term care facilityLong-term care facilities in the United States
Sample size82882106819
Study period6 months12 weeks4 weeks6 months
Mean age, years78.0Stage II Stage III/IV
79.8 76.0 (P < .002)		66.870.4
Caucasian, %59.3NR65NR
Ulcer, %Stage II 76.5
Stage III 33.3
Stage IV 13.3		Stage II 68
Stage III/IV 32		Stage II 21
Stage III 14
Stage IV 65		Stage II NR
Stage III NR
Stage IV 22.3
Source of dataReview of medical records
Structured form		Review of medical records, Medical Data Set, and other recordsMedical recordsVeterans Affairs Assessment File
Statistical analysis-Chi square, F-tests
-Student t test
-Variance analysis
-Forward and backward conditional multiple regression modelling		2 multiple regression models:
One for stage II ulcers and 1 for stage II/III ulcers		-Correlation analysis
-Forward multiple regression modelling		Bivariate analysis
Multiple logistic regression modelling
Measure of healingComplete healing, %Complete healing, %Decrease in surface area of ulcer, %
Mean = 35.6		Complete healing, %
3 mos6 mos12 weeksOverall54
Stage II27.376.5Stage II37Stage II72
Stage III10.233.3Stage III/IV5Stage III45.2
Stage IV2.613.3Stage IV30.6
Between stages (P < .001)
Performance of multivariate regression modelBackward conditional model Significant (P < .001) Explained 75.8 of the variance of healing Predicted correctly 91.5% of casesModel for stage II ulcers
Explained little of the variance (R = 0.13)		3 predictors explained 25% of the variability in healing
Factors associated with ↑ odds of healingUse of exudate management dressing with no exudateAssociated with greatest ↓ in area of ulcer
Stage II ulcers
-Dementia and agitation without hallucination
-↑ in interval of assessment
-Very large ulcers
-Moist dressing
Stage III/IV ulcers
-Dementia
-Very large pressure ulcers ≥ 12cm
-Receiving sufficient enteral feeding >30kcal/kg
(except high acuity patients)
-Moist dressing		-Lower pressure ulcer stage
-Higher patient weight
-Lower mean body temperature
Together predictors explained 25% of the variability in healing

In a regression analysis of treatment variables, only shorter time on a pressure ulcer-relieving bed predicted healing		-Age >75 years
(OR, 1.5 [95% CI, 1.1–2.0])
-Stage II ulcer vs stage IV
(OR, 5.2 [95% CI, 3.5])
-Rehabilitation services (per number received) (OR, 1.3 [95% CI, 1.1–1.6])
Factors associated with ↓ odds of healing-Medicaid
(OR, 0.18, P = .087)
-Comorbid CVD
(OR, 0.14, P = .063)
-Dressing type change
(OR = 0.50, P = .015)
-Topical antiseptics
-Antibiotic administration
-Pressure relief devices
-No exudate management dressing for moderate or large amount of exudate
-No debridement of wounds with yellow slough		Stage II ulcers
Cleaning with saline or soap
Stage III/IV
Receiving debridement		-High pressure ulcer stage
-Low patient weight
-High patient temperature		-Incontinence
(OR, 0.7 [95% CI, 0.4–1.0])
-Immobility
(OR, 0.3 [95% CI, 0.1–0.5])
CI, confidence interval; NR, not reported; OR, odds ratio

Appendix 3: Search Strategies

Pressure Sores Treatment – Final Search

Search date: August 6, 2007

Databases searched: OVID MEDLINE, MEDLINE In-Process &amp; Other Non-Indexed Citations, CINAHL, EMBASE, Cochrane Library, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to July Week 4 2007>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/dh, dt, rt, rh, su, th [Diet Therapy, Drug Therapy, Radiotherapy, Rehabilitation, Surgery, Therapy] (905)

  2. exp Pressure Ulcer/ or exp Skin Ulcer/ or (decubitus or bedsore$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (12589)

  3. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6443)

  4. 2 or 3 (13597)

  5. exp Nutritional Support/ or exp Dietary Supplements/ or exp Nutrition/ (26310)

  6. Debridement/ or exp Irrigation/ or exp Suction/ or exp Bandages/ or exp Beds/ or exp pressure/ or exp Larva/ (55505)

  7. (Platelet releasate or CT-102).mp. (48)

  8. exp Stem Cells/ (70804)

  9. exp Therapeutics/ (908746)

  10. exp Surgery/ (8437)

  11. exp Skin Transplantation/ or exp Skin, Artificial/ (6047)

  12. exp Treatment Outcome/ (275526)

  13. exp Treatment Failure/ (13032)

  14. exp Hydrotherapy/ or exp Ultrasonic Therapy/ or exp Ultraviolet Therapy/ or exp Electric Stimulation Therapy/ or exp Electromagnetics/ (23802)

  15. wound bed prep$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (66)

  16. exp Transforming Growth Factor beta/ or exp Growth Substances/ or exp Fibroblast Growth Factors/ or exp Platelet-Derived Growth Factor/ or exp Epidermal Growth Factor/ or exp Colony-Stimulating Factors/ (248588)

  17. ((wound$ or ulcer$) adj3 (modulat$ or growth factor$ or stimulating factor$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (603)

  18. or/5-17 (1388534)

  19. 4 and 18 (6644)

  20. 1 or 19 (6987)

  21. limit 20 to (humans and english language and yr=“1996 - 2007”) (5718)

  22. limit 21 to (controlled clinical trial or meta analysis or randomized controlled trial) (555)

  23. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (53354)

  24. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (319845)

  25. exp Double-Blind Method/ or exp Control Groups/ or exp placebos/ or RCT$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (55363)

  26. exp Economics/ (172912)

  27. (cost$ or economic$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (190006)

  28. or/22-27 (614901)

  29. 21 and 28 (1377)

  30. exp Diabetes Mellitus/ (95945)

  31. exp Burns/ (10893)

  32. exp Varicose Ulcer/ (1188)

  33. exp Diabetic Angiopathies/ (12924)

  34. or/30-33 (107894)

  35. 29 not 34 (875)

Database: EMBASE <1980 to 2007 Week 30>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/rt, dm, rh, dt, su, th [Radiotherapy, Disease Management, Rehabilitation, Drug Therapy, Surgery, Therapy] (1088)

  2. exp skin ulcer/ or exp decubitus/ (16832)

  3. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (8942)

  4. (decubitus or bedsore$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (4887)

  5. or/2-4 (19305)

  6. exp nutrition/ or exp diet therapy/ or exp nutritional support/ (779276)

  7. exp diet supplementation/ (25678)

  8. exp LAVAGE/ (26658)

  9. exp SUCTION/ (1566)

  10. exp Bandage/ (1531)

  11. exp “BANDAGES AND DRESSINGS”/ (9345)

  12. exp bed/ (2384)

  13. exp PRESSURE/ (24926)

  14. wound care/ or debridement/ or maggot therapy/ or wound drainage/ or wound dressing/ or wound irrigation/ (17158)

  15. exp Stem Cell/ (41237)

  16. exp Therapy/ (2500403)

  17. exp surgery/ (1328439)

  18. exp Skin Transplantation/ (20591)

  19. exp Artificial Skin/ (405)

  20. exp Treatment Outcome/ (389424)

  21. exp Treatment Failure/ (34266)

  22. exp hydrotherapy/ or exp electrostimulation therapy/ or exp ultrasound therapy/ (78822)

  23. exp phototherapy/ (20784)

  24. exp Electromagnetic Field/ (5101)

  25. exp Patient Positioning/ (6574)

  26. exp Growth Factor/ (180173)

  27. ((wound$ or ulcer$) adj3 (modulat$ or growth factor$ or stimulating factor$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1883)

  28. (Platelet releasate or CT-102).mp. (58)

  29. wound bed prep$.mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (56)

  30. or/6-29 (3941237)

  31. 5 and 30 (13134)

  32. 1 or 31 (13288)

  33. limit 32 to (human and english language and yr=“1996 – 2007”) (7329)

  34. Randomized Controlled Trial/ (121547)

  35. exp Randomization/ (23112)

  36. exp RANDOM SAMPLE/ (692)

  37. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).ti,mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (74484)

  38. Double Blind Procedure/ (64908)

  39. exp Triple Blind Procedure/ (7)

  40. exp Control Group/ (902)

  41. exp PLACEBO/ (101571)

  42. exp ECONOMICS/ (12565)

  43. (cost$ or economic$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (324903)

  44. or/34-43 (599075)

  45. 33 and 44 (1289)

  46. exp Diabetes Mellitus/ (206434)

  47. exp Burn/ (21386)

  48. exp Varicosis/ (15726)

  49. or/46-48 (243034)

  50. 45 not 49 (732)

Database: CINAHL - Cumulative Index to Nursing &amp; Allied Health Literature <1982 to July Week 4 2007>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/dh, dt, rh, su, th [Diet Therapy, Drug Therapy, Rehabilitation, Surgery, Therapy] (1098)

  2. exp skin ulcer/ or exp pressure ulcer/ or (decubitus or bedsore$).mp. [mp=title, subject heading word, abstract, instrumentation] (9542)

  3. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6067)

  4. exp NUTRITION/ (31831)

  5. exp Nutritional Support/ (12258)

  6. exp Dietary Supplements/ (1721)

  7. exp Debridement/ (1363)

  8. exp Irrigation/ (1560)

  9. exp SUCTION/ (1152)

  10. exp “Bandages and Dressings”/ (4922)

  11. exp “Beds and Mattresses”/ (1763)

  12. exp Pressure/ (1842)

  13. exp Patient Positioning/ (3886)

  14. exp Stem Cells/ (1757)

  15. exp Therapeutics/ (346621)

  16. exp Surgery, Operative/ (87954)

  17. exp Skin, Artificial/ (309)

  18. exp Skin Transplantation/ (825)

  19. exp Treatment Outcomes/ (38071)

  20. exp Treatment Failure/ (2064)

  21. electrotherapy/ or hydrotherapy/ or ultrasonic therapy/ or ultraviolet therapy/ (1483)

  22. exp Electromagnetics/ or exp Magnet Therapy/ (1015)

  23. exp Growth Substances/ (5215)

  24. ((wound$ or ulcer$) adj3 (modulat$ or growth factor$ or stimulating factor$)).mp. [mp=title, subject heading word, abstract, instrumentation] (172)

  25. (Platelet releasate or CT-102).mp. (5)

  26. wound bed prep$.mp. [mp=title, subject heading word, abstract, instrumentation] (78)

  27. 2 or 3 (10021)

  28. or/4-26 (440839)

  29. 27 and 28 (6279)

  30. 1 or 29 (6500)

  31. limit 30 to (english and yr=“1996 – 2007”) (5101)

  32. exp Diabetes Mellitus/ (26976)

  33. exp BURNS/ (5684)

  34. exp Venous Ulcer/ (788)

  35. or/32-34 (33319)

  36. 31 not 35 (3103)

  37. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (58616)

  38. RCT.mp. (680)

  39. exp Meta Analysis/ (5479)

  40. exp “Systematic Review”/ (3217)

  41. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (19079)

  42. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (11176)

  43. exp PLACEBOS/ (3668)

  44. exp Economics/ (215909)

  45. (economic$ or cost$).mp. [mp=title, subject heading word, abstract, instrumentation] (54062)

  46. or/37-45 (280064)

  47. 36 and 46 (885)

Final Search Strategy – Pressure Sores 2008 - Cleaning

Search date: March 19, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Wound Healing/ or exp Wound Infection/ (34059)

  3. exp Skin Ulcer/ (12547)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1425)

  6. or/1-5 (45415)

  7. exp Irrigation/ (6280)

  8. exp Hydrotherapy/ (418)

  9. exp Solutions/ (33578)

  10. exp Water/ (65110)

  11. exp Sodium Chloride/ (15190)

  12. exp Anti-Infective Agents, Local/ (52642)

  13. exp acetic acids/ or acetic acid/ (32800)

  14. exp Disinfection/ (3099)

  15. exp Potassium Permanganate/ or exp Gentian Violet/ (943)

  16. exp Surface-Active Agents/ (28536)

  17. exp Castor Oil/ (293)

  18. (detergent$ or whirlpool$ or saline or povidone or iodine or disinfect$ or bath$ or water or hydrotherap$ or hydro-therap$ or lavage or irrigat$ or wash$ or cleans$ or clean$ or aloe vera or gentian violet or eusol or potassium permanganate or benzoyl peroxide or hyrogen peroxide or betadine or silver chloride or vulnopur or decyl glucoside).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346012)

  19. or/7-18 (460724)

  20. 6 and 19 (4023)

  21. limit 20 to (english language and humans and yr=“2003 – 2008”) (1178)

  22. limit 21 to (controlled clinical trial or meta analysis or randomized controlled trial) (219)

  23. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31410)

  24. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59462)

  25. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346069)

  26. exp Double-Blind Method/ (50381)

  27. exp Control Groups/ (533)

  28. exp Placebos/ (8753)

  29. RCT.mp. (2244)

  30. or/22-29 (414777)

  31. 21 and 30 (321)

  32. exp *Burns/ (9607)

  33. *Diabetic Foot/ (2580)

  34. *Ischemia/ (8409)

  35. *Surgical Wound Infection/ (4370)

  36. *Postoperative Complications/ (37461)

  37. *Varicose Ulcer/ (1075)

  38. or/32-37 (62828)

  39. 31 not 38 (182)

Database: EMBASE <1980 to 2008 Week 11>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3882)

  2. exp Skin Ulcer/ (17884)

  3. exp Wound Healing/ or exp Wound Infection/ (50625)

  4. exp Chronic Wound/ (227)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9428)

  6. bedsore$.mp. (154)

  7. or/1-6 (67100)

  8. exp WOUND IRRIGATION/ (605)

  9. exp HYDROTHERAPY/ (1143)

  10. exp “Solution and Solubility”/ (66832)

  11. exp WATER/ (110563)

  12. exp Sodium Chloride/ (52921)

  13. exp Hydrogen Peroxide/ (27914)

  14. exp Topical Antiinfective Agent/ (104248)

  15. exp Acetic Acid/ (16793)

  16. exp DISINFECTION/ (8510)

  17. exp Permanganate Potassium/ (1258)

  18. exp Surfactant/ (79380)

  19. exp Castor Oil/ (1021)

  20. (detergent$ or whirlpool$ or saline or povidone or iodine or disinfect$ or bath$ or water or hydrotherap$ or hydro-therap$ or lavage or irrigat$ or wash$ or cleans$ or clean$ or aloe vera or gentian violet or eusol or potassium permanganate or benzoyl peroxide or hyrogen peroxide or betadine or silver chloride or vulnopur or decyl glucoside).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (612905)

  21. or/8-20 (807447)

  22. 7 and 21 (6982)

  23. limit 22 to (human and english language and yr=“2003 - 2008”) (1703)

  24. Randomized Controlled Trial/ (155511)

  25. exp Randomization/ (25203)

  26. exp RANDOM SAMPLE/ (1011)

  27. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (280926)

  28. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56808)

  29. Double Blind Procedure/ (68576)

  30. exp Triple Blind Procedure/ (8)

  31. exp Control Group/ (1516)

  32. exp PLACEBO/ (111054)

  33. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (402720)

  34. or/24-33 (612781)

  35. 23 and 34 (312)

  36. *Burns/ (12425)

  37. *Diabetic Foot/ (1980)

  38. *Varicosis/ (3636)

  39. *MICROVASCULAR ISCHEMIA/ (47)

  40. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10581)

  41. or/36-40 (28645)

  42. 35 not 41 (256)

Database: CINAHL - Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5153)

  2. exp Wound Healing/ or exp Wound Infection/ (9484)

  3. exp Skin Ulcer/ (10197)

  4. exp Wounds, Chronic/ (826)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6554)

  6. bedsore$.mp. (75)

  7. or/1-6 (18277)

  8. exp IRRIGATION/ (1765)

  9. exp HYDROTHERAPY/ (878)

  10. exp SOLUTIONS/ (3029)

  11. exp WATER/ (1697)

  12. exp Sodium Chloride/ (1161)

  13. exp Hydrogen Peroxide/ (290)

  14. exp ANTIINFECTIVE AGENTS, LOCAL/ (2858)

  15. exp Acetic Acid/ (205)

  16. exp “Sterilization and Disinfection”/ (3167)

  17. exp Surface-Active Agents/ (563)

  18. (detergent$ or whirlpool$ or saline or povidone or iodine or disinfect$ or bath$ or water or hydrotherap$ or hydro-therap$ or lavage or irrigat$ or wash$ or cleans$ or clean$ or aloe vera or gentian violet or eusol or potassium permanganate or benzoyl peroxide or hyrogen peroxide or betadine or silver chloride or vulnopur or decyl glucoside).mp. [mp=title, subject heading word, abstract, instrumentation] (31568)

  19. exp Castor Oil/ (26)

  20. or/8-19 (36072)

  21. 7 and 20 (1331)

  22. limit 21 to (english and yr=“2003 - 2008”) (598)

  23. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69213)

  24. RCT.mp. (872)

  25. exp Meta Analysis/ (6294)

  26. exp “Systematic Review”/ (3554)

  27. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22852)

  28. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13890)

  29. exp PLACEBOS/ (4185)

  30. or/23-29 (90540)

  31. 22 and 30 (130)

Final Search – Pressure Sores 2008 - Debridement

Search date: March 22, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Skin Ulcer/ (12547)

  3. exp Wound Healing/ or exp Wound Infection/ (34059)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1425)

  6. or/1-5 (45415)

  7. exp Debridement/ (4526)

  8. debrid$.mp. (8618)

  9. exp Larva/ (14177)

  10. exp Streptokinase/ (1402)

  11. exp Iodine Compounds/ or exp Hydrogel/ (4077)

  12. (trypsin or varidase or enzym$ or chemical$ or autolytic or collagenase or streptokinase or dextranoma or streptodornase or papain-urea or cadexomer iodine or larva$ or maggot$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (668012)

  13. (polysaccharide$ or dextranomer$ or xerogel).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (20260)

  14. (biosurger$ or bio-surg$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (39)

  15. (hydrocolloid* or granuflex or tegasorb or aquacel or hydrocoll or combiderm or duoderm).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (634)

  16. (fibrinolytic$ or proteolytic or hypochlorite or dakin or iodoflex or iodosorb or debrisan or eusol).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (35932)

  17. (malic acid or benzoid acid or salicylic acid or propylene glycol).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (5193)

  18. (hydrogel$ or intrasite gel$ or intrasitgel$ or sterigel or granugel or nugel or purilon or vigilon).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (4770)

  19. or/7-18 (722998)

  20. 6 and 19 (5341)

  21. limit 20 to (english language and humans and yr=“2003 - 2008”) (1823)

  22. limit 21 to (controlled clinical trial or meta analysis or randomized controlled trial) (169)

  23. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31410)

  24. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59462)

  25. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346069)

  26. exp Double-Blind Method/ (50381)

  27. exp Control Groups/ (533)

  28. exp Placebos/ (8753)

  29. RCT.mp. (2244)

  30. or/22-29 (414778)

  31. 21 and 30 (262)

  32. *Diabetic Foot/ (2580)

  33. *Burns/ (7235)

  34. *Ischemia/ (8409)

  35. *Surgical Wound Infection/ (4370)

  36. *Postoperative Complications/ (37461)

  37. *Varicose Ulcer/ (1075)

  38. or/32-37 (60476)

  39. 31 not 38 (163)

  40. limit 39 to (case reports or comment or letter) (6)

  41. 39 not 40 (157)

Database: EMBASE <1980 to 2008 Week 12> Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3887)

  2. exp Skin Ulcer/ (17909)

  3. exp Wound Healing/ or exp Wound Infection/ (50688)

  4. exp Chronic Wound/ (229)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9444)

  6. bedsore$.mp. (155)

  7. or/1-6 (67188)

  8. exp WOUND IRRIGATION/ (606)

  9. exp HYDROTHERAPY/ (1144)

  10. exp “Solution and Solubility”/ (66942)

  11. exp WATER/ (110696)

  12. exp Sodium Chloride/ (53001)

  13. exp Hydrogen Peroxide/ (27975)

  14. exp Topical Antiinfective Agent/ (104398)

  15. exp Acetic Acid/ (16817)

  16. exp DISINFECTION/ (8516)

  17. exp Permanganate Potassium/ (1260)

  18. exp Surfactant/ (79483)

  19. exp Castor Oil/ (1022)

  20. (detergent$ or whirlpool$ or saline or povidone or iodine or disinfect$ or bath$ or water or hydrotherap$ or hydro-therap$ or lavage or irrigat$ or wash$ or cleans$ or clean$ or aloe vera or gentian violet or eusol or potassium permanganate or benzoyl peroxide or hyrogen peroxide or betadine or silver chloride or vulnopur or decyl glucoside).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (613582)

  21. or/8-20 (808382)

  22. 7 and 21 (6992)

  23. limit 22 to (human and english language and yr=“2003 - 2008”) (1708)

  24. Randomized Controlled Trial/ (155780)

  25. exp Randomization/ (25236)

  26. exp RANDOM SAMPLE/ (1022)

  27. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (281365)

  28. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56961)

  29. Double Blind Procedure/ (68653)

  30. exp Triple Blind Procedure/ (8)

  31. exp Control Group/ (1545)

  32. exp PLACEBO/ (111315)

  33. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (403354)

  34. or/24-33 (613798)

  35. 23 and 34 (312)

  36. *Burns/ (12430)

  37. *Diabetic Foot/ (1981)

  38. *Varicosis/ (3637)

  39. *MICROVASCULAR ISCHEMIA/ (47)

  40. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10590)

  41. or/36-40 (28661)

  42. 35 not 41 (256)

  43. limit 42 to (editorial or letter or note) (13)

  44. Case Report/ (983221)

  45. 42 not (43 or 44) (235)

Database: CINAHL - Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5153)

  2. exp Skin Ulcer/ (10197)

  3. exp Wounds, Chronic/ (826)

  4. exp Wound Healing/ or exp Wound Infection/ (9484)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6554)

  6. bedsore$.mp. (75)

  7. or/1-6 (18277)

  8. exp DEBRIDEMENT/ (1619)

  9. exp Streptokinase/ (249)

  10. exp Larval Therapy/ (180)

  11. exp Iodine Compounds/ (139)

  12. exp HYDROGEL DRESSINGS/ (269)

  13. debrid$.mp. (2318)

  14. (trypsin or varidase or enzym$ or chemical$ or autolytic or collagenase or streptokinase or dextranoma or streptodornase or papain-urea or cadexomer iodine or larva$ or maggot$).mp. [mp=title, subject heading word, abstract, instrumentation] (20077)

  15. (polysaccharide$ or dextranomer$ or xerogel).mp. [mp=title, subject heading word, abstract, instrumentation] (632)

  16. (hydrocolloid* or granuflex or tegasorb or aquacel or hydrocoll or combiderm or duoderm).mp. [mp=title, subject heading word, abstract, instrumentation] (461)

  17. (biosurger$ or bio-surg$).mp. [mp=title, subject heading word, abstract, instrumentation] (10)

  18. (fibrinolytic$ or proteolytic or hypochlorite or dakin or iodoflex or iodosorb or debrisan or eusol).mp. [mp=title, subject heading word, abstract, instrumentation] (2030)

  19. (malic acid or benzoid acid or salicylic acid or propylene glycol).mp. [mp=title, subject heading word, abstract, instrumentation] (65)

  20. (hydrogel$ or intrasite gel$ or intrasitgel$ or sterigel or granugel or nugel or purilon or vigilon).mp. [mp=title, subject heading word, abstract, instrumentation] (389)

  21. or/8-20 (25090)

  22. 7 and 21 (1766)

  23. limit 22 to (english and yr=“2003 - 2008”) (840)

  24. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69213)

  25. RCT.mp. (872)

  26. exp Meta Analysis/ (6294)

  27. exp “Systematic Review”/ (3554)

  28. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22852)

  29. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13890)

  30. exp PLACEBOS/ (4185)

  31. or/24-30 (90540)

  32. 23 and 31 (100)

  33. *Burns/ (4636)

  34. *Diabetic Foot/ (1954)

  35. *Surgical Wound/ or exp Postoperative Complications/ (17091)

  36. *Ischemia/ (645)

  37. *Venous Ulcer/ (625)

  38. or/33-37 (24822)

  39. 32 not 38 (53)

Final Search – Pressure Sores - Dressings

Search date: March 16, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 1 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3480)

  2. exp Wound Healing/ or exp Wound Infection/ (33963)

  3. exp Skin Ulcer/ (12499)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6897)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1422)

  6. or/1-5 (45284)

  7. exp Bandages/ (6673)

  8. ((gauze$ or dressing$ or bandage$) adj4 (biological or collagen or growth factor$ or hyaluronic acid$ or interleukin$ or stimulat$ factor$ or hydrocolloid$ or hydrogel$ or carboxymethylcellulose or hydropolymer or hydrocellular or alginate or normothermic or film$ or foam$ or antimicrobial$ or silver$ or honey or iodine or chorhexidine or polyurethane or fabric$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1377)

  9. 7 or 8 (6880)

  10. 6 and 9 (3093)

  11. limit 10 to (english language and humans and yr=“2003 - 2008”) (1180)

  12. limit 11 to (controlled clinical trial or meta analysis or randomized controlled trial) (191)

  13. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31320)

  14. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59263)

  15. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (345174)

  16. exp Double-Blind Method/ (50275)

  17. exp Control Groups/ (532)

  18. exp Placebos/ (8713)

  19. RCT.mp. (2232)

  20. or/12-19 (413674)

  21. 11 and 20 (333)

  22. *Burns/ (7225)

  23. *Diabetic Foot/ (2565)

  24. *Varicose Ulcer/ (1073)

  25. *Ischemia/ (8391)

  26. *Postoperative Complications/ or *Surgical Wound Infection/ (41550)

  27. or/22-26 (60362)

  28. 21 not 27 (205)

  29. limit 28 to (case reports or comment or editorial or letter) (24)

  30. 28 not 29 (181)

Database: EMBASE <1980 to 2008 Week 11>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3882)

  2. exp Skin Ulcer/ (17884)

  3. exp Wound Healing/ or exp Wound Infection/ (50625)

  4. exp Chronic Wound/ (227)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9428)

  6. bedsore$.mp. (154)

  7. or/1-6 (67100)

  8. exp “bandages and dressings”/ (9947)

  9. ((gauze$ or dressing$ or bandage$) adj4 (biological or collagen or growth factor$ or hyaluronic acid$ or interleukin$ or stimulat$ factor$ or hydrocolloid$ or hydrogel$ or carboxymethylcellulose or hydropolymer or hydrocellular or alginate or normothermic or film$ or foam$ or antimicrobial$ or silver$ or honey or iodine or chorhexidine or polyurethane or fabric$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1422)

  10. 8 or 9 (10334)

  11. 7 and 10 (3144)

  12. limit 11 to (human and english language and yr=“2003 - 2008”) (1072)

  13. Randomized Controlled Trial/ (155511)

  14. exp Randomization/ (25203)

  15. exp RANDOM SAMPLE/ (1011)

  16. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (280926)

  17. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56808)

  18. Double Blind Procedure/ (68576)

  19. exp Triple Blind Procedure/ (8)

  20. exp Control Group/ (1516)

  21. exp PLACEBO/ (111054)

  22. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (402720)

  23. or/13-22 (612781)

  24. 12 and 23 (247)

  25. *Burn/ (12425)

  26. *Diabetic Foot/ (1980)

  27. *Varicosis/ (3636)

  28. *MICROVASCULAR ISCHEMIA/ (47)

  29. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10581)

  30. or/25-29 (28645)

  31. 24 not 30 (178)

  32. limit 31 to (editorial or letter or note) (16)

  33. Case Report/ (982316)

  34. 31 not (32 or 33) (158)

Database: CINAHL - Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 1 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5128)

  2. exp Skin Ulcer/ (10126)

  3. exp Wounds, Chronic/ (817)

  4. exp Wound Healing/ or exp Wound Infection/ (9366)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6512)

  6. bedsore$.mp. (74)

  7. or/1-6 (18089)

  8. exp “Bandages and Dressings”/ (5335)

  9. ((gauze$ or dressing$ or bandage$) adj4 (biological or collagen or growth factor$ or hyaluronic acid$ or interleukin$ or stimulat$ factor$ or hydrocolloid$ or hydrogel$ or carboxymethylcellulose or hydropolymer or hydrocellular or alginate or normothermic or film$ or foam$ or antimicrobial$ or silver$ or honey or iodine or chorhexidine or polyurethane or fabric$)).mp. [mp=title, subject heading word, abstract, instrumentation] (1568)

  10. 8 or 9 (5419)

  11. 7 and 10 (2689)

  12. limit 11 to (english and yr=“2003 - 2008”) (1124)

  13. *Burns/ (4584)

  14. *Diabetic Foot/ (1931)

  15. *Surgical Wound/ or exp Postoperative Complications/ (16692)

  16. *Ischemia/ (618)

  17. *Venous Ulcer/ (619)

  18. or/13-17 (24318)

  19. 12 not 18 (748)

  20. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (67992)

  21. RCT.mp. (858)

  22. exp Meta Analysis/ (6223)

  23. exp “Systematic Review”/ (3535)

  24. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22492)

  25. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13554)

  26. exp PLACEBOS/ (4145)

  27. or/20-26 (88939)

  28. 19 and 27 (67)

Final Search Strategy – Pressure Sores 2008 - Growth Factors

Search date: March 19, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 1 2008> Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3480)

  2. exp Wound Healing/ or exp Wound Infection/ (33963)

  3. exp Skin Ulcer/ (12499)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6897)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1422)

  6. or/1-5 (45284)

  7. exp “Intercellular Signaling Peptides and Proteins”/ (343648)

  8. exp Growth Substances/ (192006)

  9. ((growth or stimulat$) adj2 (substance$ or factor$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (169667)

  10. interleukin$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (110693)

  11. or/7-10 (555006)

  12. 6 and 11 (5613)

  13. limit 12 to (english language and humans and yr=“2003 - 2008”) (1628)

  14. limit 13 to (controlled clinical trial or meta analysis or randomized controlled trial) (74)

  15. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31320)

  16. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59263)

  17. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (345174)

  18. exp Double-Blind Method/ (50275)

  19. exp Control Groups/ (532)

  20. exp Placebos/ (8713)

  21. RCT.mp. (2232)

  22. or/14-21 (413657)

  23. 13 and 22 (153)

  24. *Burns/ (7225)

  25. *Diabetic Foot/ (2565)

  26. *Varicose Ulcer/ (1073)

  27. *Ischemia/ (8391)

  28. *Postoperative Complications/ (37401)

  29. *Surgical Wound Infection/ (4359)

  30. or/24-29 (60362)

  31. 23 not 30 (107)

  32. limit 31 to (case reports or comment or editorial or letter) (12)

  33. 31 not 32 (95)

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3882)

  2. exp Skin Ulcer/ (17884)

  3. exp Wound Healing/ or exp Wound Infection/ (50625)

  4. exp Chronic Wound/ (227)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9428)

  6. bedsore$.mp. (154)

  7. or/1-6 (67100)

  8. exp Growth Factor/ (192755)

  9. exp Cytokine/ (469215)

  10. ((growth or stimulat$) adj2 (substance$ or factor$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (254180)

  11. or/8-10 (599116)

  12. 7 and 11 (8126)

  13. limit 12 to (human and english language and yr=“2003 - 2008”) (2520)

  14. Randomized Controlled Trial/ (155511)

  15. exp Randomization/ (25203)

  16. exp RANDOM SAMPLE/ (1011)

  17. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (280926)

  18. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56808)

  19. Double Blind Procedure/ (68576)

  20. exp Triple Blind Procedure/ (8)

  21. exp Control Group/ (1516)

  22. exp PLACEBO/ (111054)

  23. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (402720)

  24. or/14-23 (612781)

  25. 13 and 24 (397)

  26. *Burn/ (12425)

  27. *Diabetic Foot/ (1980)

  28. *Varicosis/ (3636)

  29. *MICROVASCULAR ISCHEMIA/ (47)

  30. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10581)

  31. or/26-30 (28645)

  32. 25 not 31 (357)

  33. limit 32 to (editorial or letter or note) (22)

  34. Case Report/ (982316)

  35. 32 not (33 or 34) (331)

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5153)

  2. exp Skin Ulcer/ (10197)

  3. exp Wounds, Chronic/ (826)

  4. exp Wound Healing/ or exp Wound Infection/ (9484)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6554)

  6. bedsore$.mp. (75)

  7. or/1-6 (18277)

  8. exp Cytokines/ (10979)

  9. ((growth or stimulat$) adj2 (substance$ or factor$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6293)

  10. interleukin$.mp. (3631)

  11. or/8-10 (14530)

  12. 7 and 11 (760)

  13. limit 12 to (english and yr=“2003 - 2008”) (404)

  14. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69213)

  15. RCT.mp. (872)

  16. exp Meta Analysis/ (6294)

  17. exp “Systematic Review”/ (3554)

  18. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22852)

  19. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13890)

  20. exp PLACEBOS/ (4185)

  21. or/14-20 (90540)

  22. 13 and 21 (45)

  23. *Burns/ (4636)

  24. *Daibetic Foot/ (0)

  25. *Surgical Wound/ or *Postoperative Complications/ (4754)

  26. *Ischemia/ (645)

  27. *Venous Ulcer/ (625)

  28. or/23-27 (10639)

  29. 22 not 28 (39)

Final Search – Press Sores 2008 – Support Surfaces

March 30, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 3 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3494)

  2. exp Skin Ulcer/ (12566)

  3. exp Wound Healing/ or exp Wound Infection/ (34138)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6933)

  5. bedsore$.mp. (97)

  6. or/1-5 (45241)

  7. Beds/ (1275)

  8. exp “Bedding and Linens”/ (1335)

  9. (pressure adj2 (relief or reliev$ or reduc$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6386)

  10. (sheep?skin$ or sheep skin$ or mattress$ or pillow$ or cushion$ or (support$ adj2 surface) or (support$ adj2 air) or beds or bed or bedding or bolster$ or (foam adj2 wedge$) or (foam adj2 block$) or gelpad$ or gel pad$ or gel-pad$ or gell pad$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (36817)

  11. ((pressure or bedsore$ or wound$ or ulcer$ or sore$) adj2 overlay$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (15)

  12. (pressure-relief or pressure-reduc$ or pressure-reliev$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (2164)

  13. or/7-12 (42829)

  14. 6 and 13 (2009)

  15. limit 14 to (english language and humans and yr=“2003 - 2008”) (745)

  16. limit 15 to (controlled clinical trial or meta analysis or randomized controlled trial) (81)

  17. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31521)

  18. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59631)

  19. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346865)

  20. exp Double-Blind Method/ (50479)

  21. exp Control Groups/ (535)

  22. exp Placebos/ (8762)

  23. RCT.mp. (2250)

  24. or/16-23 (415760)

  25. 15 and 24 (157)

  26. limit 25 to (case reports or comment or editorial or letter) (4)

  27. 25 not 26 (153)

  28. *Burns/ (7238)

  29. *Diabetic Foot/ (2585)

  30. *Varicose Ulcer/ (1076)

  31. *Ischemia/ (8422)

  32. *Postoperative Complications/ or *Surgical Wound Infection/ (41682)

  33. or/28-32 (60558)

  34. 27 not 33 (125)

Database: EMBASE <1980 to 2008 Week 13>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3890)

  2. exp Skin Ulcer/ (17918)

  3. exp Chronic Wound/ (231)

  4. exp Wound Healing/ or exp Wound Infection/ (50734)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9451)

  6. bedsore$.mp. (155)

  7. or/1-6 (67244)

  8. exp position/ (39965)

  9. exp bed/ (2558)

  10. exp Protective Equipment/ (11689)

  11. (pressure adj2 (relief or reliev$ or reduc$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (12215)

  12. (pressure-relief or pressure-reduc$ or pressure-reliev$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3964)

  13. (sheep?skin$ or sheep skin$ or mattress$ or pillow$ or cushion$ or (support$ adj2 surface) or (support$ adj2 air) or beds or bed or bedding or bolster$ or (foam adj2 wedge$) or (foam adj2 block$) or gelpad$ or gel pad$ or gel-pad$ or gell pad$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (57391)

  14. ((pressure or bedsore$ or wound$ or ulcer$ or sore$) adj2 overlay$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (11)

  15. or/8-14 (118266)

  16. 7 and 15 (2582)

  17. limit 16 to (human and english language and yr=“2003 - 2008”) (793)

  18. Randomized Controlled Trial/ (155932)

  19. exp Randomization/ (25259)

  20. exp RANDOM SAMPLE/ (1028)

  21. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (281603)

  22. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (57049)

  23. Double Blind Procedure/ (68699)

  24. exp Triple Blind Procedure/ (8)

  25. exp Control Group/ (1558)

  26. exp PLACEBO/ (111476)

  27. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (403730)

  28. or/18-27 (614387)

  29. 17 and 28 (159)

  30. limit 29 to (editorial or letter or note) (5)

  31. Case Report/ (983732)

  32. 29 not (30 or 31) (152)

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 3 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5163)

  2. exp Skin Ulcer/ (10218)

  3. exp Wound Healing/ or exp Wound Infection/ (9511)

  4. exp Wounds, Chronic/ (832)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6566)

  6. bedsore$.mp. (75)

  7. or/1-6 (18318)

  8. exp Patient Positioning/ (4200)

  9. exp “bedding and linens”/ or exp “beds and mattresses”/ (2265)

  10. (pressure adj2 (relief or reliev$ or reduc$)).mp. [mp=title, subject heading word, abstract, instrumentation] (1462)

  11. (pressure-relief or pressure-reduc$ or pressure-reliev$).mp. [mp=title, subject heading word, abstract, instrumentation] (791)

  12. (sheep?skin$ or sheep skin$ or mattress$ or pillow$ or cushion$ or (support$ adj2 surface) or (support$ adj2 air) or beds or bed or bedding or bolster$ or (foam adj2 wedge$) or (foam adj2 block$) or gelpad$ or gel pad$ or gel-pad$ or gell pad$).mp. [mp=title, subject heading word, abstract, instrumentation] (10655)

  13. ((pressure or bedsore$ or wound$ or ulcer$ or sore$) adj2 overlay$).mp. [mp=title, subject heading word, abstract, instrumentation] (16)

  14. or/8-13 (15368)

  15. 7 and 14 (1908)

  16. limit 15 to (english and yr=“2003 - 2008”) (669)

  17. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69457)

  18. RCT.mp. (874)

  19. exp Meta Analysis/ (6315)

  20. exp “Systematic Review”/ (3577)

  21. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22933)

  22. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13946)

  23. exp PLACEBOS/ (4198)

  24. or/17-23 (90860)

  25. 16 and 24 (88)

  26. *BURNS/ (4653)

  27. *Diabetic Foot/ (1957)

  28. *Venous Ulcer/ (628)

  29. *Ischemia/ (647)

  30. *Surgical Wound/ (145)

  31. *Surgical Wound Infection/ (1459)

  32. *Postoperative Complications/ (4629)

  33. or/26-32 (13984)

  34. 25 not 33 (72)

Final Search Pressure Sores 2008 – Electrical Stimulation

Search date: March 24, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Skin Ulcer/ (12547)

  3. exp Wound Healing/ or exp Wound Infection/ (34059)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1425)

  6. or/1-5 (45415)

  7. exp Electric Stimulation Therapy/ (13139)

  8. (electrostimul$ or electro-stimul$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (833)

  9. tens.mp. (2597)

  10. (electro-therap$ or electrotherap$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (217)

  11. ((electrical or stimulat$ or current or pulse$) adj4 (wound$ or ulcer$ or pressure sore$ or bedsore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (931)

  12. or/7-10 (16001)

  13. 6 and 12 (184)

  14. ((electrical or stimulation) adj4 (wound$ or ulcer$ or pressure sore$ or bedsore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (158)

  15. 13 or 14 (315)

  16. limit 15 to (english language and humans and yr=“2003 - 2008”) (105)

  17. limit 16 to (controlled clinical trial or meta analysis or randomized controlled trial) (11)

  18. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31410)

  19. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59462)

  20. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346069)

  21. exp Double-Blind Method/ (50381)

  22. exp Control Groups/ (533)

  23. exp Placebos/ (8753)

  24. RCT.mp. (2244)

  25. or/17-24 (414757)

  26. 16 and 25 (22)

  27. *Burns/ (7235)

  28. *Ischemia/ (8409)

  29. *Varicose Ulcer/ (1075)

  30. *Diabetic Foot/ (2580)

  31. *Postoperative Complications/ or *Surgical Wound Infection/ (41621)

  32. or/27-31 (60476)

  33. 26 not 32 (16)

Database: EMBASE <1980 to 2008 Week 12>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp DECUBITUS/ (3887)

  2. exp Skin Ulcer/ (17909)

  3. exp Wound Healing/ or exp Wound Infection/ (50688)

  4. exp Chronic Wound/ (229)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9444)

  6. bedsore$.mp. (155)

  7. or/1-6 (67188)

  8. exp Transcutaneous Nerve Stimulation/ (2628)

  9. exp Electrostimulation/ (27469)

  10. exp Electrostimulation Therapy/ (75561)

  11. (electrostimul$ or electro-stimul$ or tens).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (34248)

  12. (electro-therap$ or electrotherap$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (586)

  13. or/8-12 (101146)

  14. 7 and 13 (535)

  15. ((electrical or stimulat$ or current or pulse$) adj4 (wound$ or ulcer$ or pressure sore$ or bedsore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1666)

  16. 14 or 15 (2117)

  17. limit 16 to (human and english language and yr=“2003 - 2008”) (559)

  18. Randomized Controlled Trial/ (155780)

  19. exp Randomization/ (25236)

  20. exp RANDOM SAMPLE/ (1022)

  21. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (281365)

  22. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56961)

  23. Double Blind Procedure/ (68653)

  24. exp Triple Blind Procedure/ (8)

  25. exp Control Group/ (1545)

  26. exp PLACEBO/ (111315)

  27. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (403354)

  28. or/18-27 (613798)

  29. 17 and 28 (105)

  30. *Burns/ (12430)

  31. *Diabetic Foot/ (1981)

  32. *Varicosis/ (3637)

  33. *MICROVASCULAR ISCHEMIA/ (47)

  34. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10590)

  35. or/30-34 (28661)

  36. 29 not 35 (91)

  37. limit 36 to (editorial or letter or note) (5)

  38. Case Report/ (983221) 39 36 not (37 or 38) (85)

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5153)

  2. exp Wounds, Chronic/ (826)

  3. exp Skin Ulcer/ (330)

  4. exp Wound Healing/ or exp Wound Infection/ (9484)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6554)

  6. bedsore*.mp. (75)

  7. or/1-6 (15200)

  8. exp Electrotherapy/ (4396)

  9. (electrostimul$ or electro-stimul$ or tens).mp. [mp=title, subject heading word, abstract, instrumentation] (504)

  10. (electro-therap$ or electrotherap$).mp. [mp=title, subject heading word, abstract, instrumentation] (540)

  11. 8 or 9 or 10 (4588)

  12. 7 and 11 (185)

  13. ((electrical or stimulat$ or current or pulse$) adj4 (wound$ or ulcer$ or pressure sore$ or bedsore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (502)

  14. 12 or 13 (547)

  15. limit 14 to (english and yr=“2003 - 2008”) (236)

  16. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69213)

  17. RCT.mp. (872)

  18. exp Meta Analysis/ (6294)

  19. exp “Systematic Review”/ (3554)

  20. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22852)

  21. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13890)

  22. exp PLACEBOS/ (4185)

  23. or/16-22 (90540)

  24. 15 and 23 (32)

  25. *Burns/ (4636)

  26. *Diabetic Foot/ (1954)

  27. *Surgical Wound/ or exp Postoperative Complications/ (17091)

  28. *Ischemia/ (645)

  29. *Venous Ulcer/ (625)

  30. or/25-29 (24822)

  31. 24 not 30 (18)

Final Search – Pressure Sores - Electromagnetics

Search date: March 24, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Skin Ulcer/ (12547)

  3. exp Wound Healing/ or exp Wound Infection/ (34059)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1425)

  6. or/1-5 (45415)

  7. exp Electromagnetics/ (7920)

  8. (electromagnet$ or electro-magnet$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (10398)

  9. 7 or 8 (10398)

  10. 6 and 9 (105)

  11. limit 10 to (english language and humans and yr=“2003 - 2008”) (25)

Database: EMBASE <1980 to 2008 Week 12>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3887)

  2. exp Skin Ulcer/ (17909)

  3. exp Wound Healing/ or exp Wound Infection/ (50688)

  4. exp Chronic Wound/ (229)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9444)

  6. bedsore$.mp. (155)

  7. or/1-6 (67188)

  8. exp Electromagnetic Field/ (5464)

  9. (electromagnet$ or electro-magnet$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (11265)

  10. 8 or 9 (11265)

  11. 7 and 10 (93)

  12. limit 11 to (human and english language and yr=“2003 - 2008”) (20)

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5153)

  2. exp Skin Ulcer/ (10197)

  3. exp Wounds, Chronic/ (826)

  4. exp Wound Healing/ or exp Wound Infection/ (9484)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6554)

  6. bedsore$.mp. (75)

  7. or/1-6 (18277)

  8. exp Electromagnetics/ (798)

  9. (electro-magnet$ or electromagnet$).mp. [mp=title, subject heading word, abstract, instrumentation] (1089)

  10. 8 or 9 (1089)

  11. 7 and 10 (46)

  12. limit 11 to (english and yr=“2003 - 2008”) (11)

Final Search – Pressure Sores 2008 – Laser Therapy

Search date: March 24, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Skin Ulcer/ (12547)

  3. exp Wound Healing/ or exp Wound Infection/ (34059)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1425)

  6. or/1-5 (45415)

  7. exp Laser Therapy/ (20540)

  8. (laser$ or lllt or biostimulat$ or bio-stimulat$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (72144)

  9. 7 or 8 (72742)

  10. 6 and 9 (1637)

  11. limit 10 to (english language and humans and yr=“2003 - 2008”) (393)

  12. limit 11 to (controlled clinical trial or meta analysis or randomized controlled trial) (65)

  13. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31410)

  14. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59462)

  15. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346069)

  16. exp Double-Blind Method/ (50381)

  17. exp Control Groups/ (533)

  18. exp Placebos/ (8753)

  19. RCT.mp. (2244)

  20. or/12-19 (414769)

  21. 11 and 20 (86)

  22. *corneal surgery, laser/ or *keratectomy, subepithelial, laser-assisted/ (153)

  23. *Burns/ (7235)

  24. *Varicose Ulcer/ (1075)

  25. *Diabetic Foot/ (2580)

  26. *Ischemia/ (8409)

  27. *Postoperative Complications/ or *Surgical Wound Infection/ (41621)

  28. or/22-27 (60612)

  29. 21 not 28 (67)

Database: EMBASE <1980 to 2008 Week 12>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3887)

  2. exp Skin Ulcer/ (17909)

  3. exp Chronic Wound/ (229)

  4. exp Wound Healing/ or exp Wound Infection/ (50688)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9444)

  6. bedsore$.mp. (155)

  7. or/1-6 (67188)

  8. exp Low Level Laser Therapy/ (3056)

  9. exp Laser/ (36300)

  10. (laser$ or lllt or biostim$ or bio-stim$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (102471)

  11. or/8-10 (102471)

  12. 7 and 11 (3025)

  13. limit 12 to (human and english language and yr=“2003 - 2008”) (816)

  14. Randomized Controlled Trial/ (155780)

  15. exp Randomization/ (25236)

  16. exp RANDOM SAMPLE/ (1022)

  17. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (281365)

  18. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56961)

  19. Double Blind Procedure/ (68653)

  20. exp Triple Blind Procedure/ (8)

  21. exp Control Group/ (1545)

  22. exp PLACEBO/ (111315)

  23. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (403354)

  24. or/14-23 (613798)

  25. 13 and 24 (131)

  26. *keratomileusis/ or *laser epithelial keratomileusis/ or *laser prostatectomy/ or *photorefractive keratectomy/ (2493)

  27. *Burns/ (12430)

  28. *Varicosis/ (3637)

  29. *MICROVASCULAR ISCHEMIA/ (47)

  30. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10590)

  31. *Diabetic Foot/ (1981)

  32. or/26-31 (31113)

  33. 25 not 32 (110)

Database: CINAHL - Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 3 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5163)

  2. exp Skin Ulcer/ (10218)

  3. exp Wounds, Chronic/ (832)

  4. exp Wound Healing/ or exp Wound Infection/ (9511)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6566)

  6. bedsore$.mp. (75)

  7. exp Lasers/ (1449)

  8. (laser$ or lllt or biostimulat$ or bio-stimulat$).mp. [mp=title, subject heading word, abstract, instrumentation] (4819)

  9. or/1-6 (18318)

  10. 7 or 8 (4907)

  11. 9 and 10 (223)

  12. limit 11 to (english and yr=“2003 - 2008”) (124)

  13. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69457)

  14. RCT.mp. (874)

  15. exp Meta Analysis/ (6315)

  16. exp “Systematic Review”/ (3577)

  17. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22933)

  18. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13946)

  19. exp PLACEBOS/ (4198)

  20. or/13-19 (90860)

  21. 12 and 20 (26)

Final Search - Pressure Sores 2008 –Ultrasound Therapy

Search date: March 25, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Skin Ulcer/ (12547)

  3. exp Wound Healing/ or exp Wound Infection/ (34059)

  4. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  5. (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1425)

  6. or/1-5 (45415)

  7. exp Ultrasonic Therapy/ (2477)

  8. exp ultrasonography/ (88850)

  9. ultraso$.mp. (111180)

  10. or/7-9 (148047)

  11. 6 and 10 (884)

  12. limit 11 to (english language and humans and yr=“2003 - 2008”) (286)

  13. limit 12 to (controlled clinical trial or meta analysis or randomized controlled trial) (47)

  14. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31410)

  15. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59462)

  16. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346069)

  17. exp Double-Blind Method/ (50381)

  18. exp Control Groups/ (533)

  19. exp Placebos/ (8753)

  20. RCT.mp. (2244)

  21. or/13-20 (414764)

  22. 12 and 21 (59)

  23. *Burns/ (7235)

  24. *Varicose Ulcer/ (1075)

  25. *Diabetic Foot/ (2580)

  26. *Ischemia/ (8409)

  27. *Postoperative Complications/ or *Surgical Wound Infection/ (41621)

  28. or/23-27 (60476)

  29. 22 not 28 (37)

  30. limit 29 to (case reports or comment or editorial or letter) (2)

  31. 29 not 30 (35)

Database: EMBASE <1980 to 2008 Week 12>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3887)

  2. exp Skin Ulcer/ (17909)

  3. exp Wound Healing/ (37834)

  4. exp Wound Infection/ (14264)

  5. exp Chronic Wound/ (229)

  6. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9444)

  7. bedsore*.mp. (155)

  8. or/1-7 (67188)

  9. exp Ultrasound Therapy/ (7582)

  10. exp ULTRASOUND/ (36147)

  11. ultraso$.mp. (159081)

  12. or/9-11 (163633)

  13. 8 and 12 (1064)

  14. limit 13 to (human and english language and yr=“2003 - 2008”) (430)

  15. Randomized Controlled Trial/ (155780)

  16. exp Randomization/ (25236)

  17. exp RANDOM SAMPLE/ (1022)

  18. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (281365)

  19. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56961)

  20. Double Blind Procedure/ (68653)

  21. exp Triple Blind Procedure/ (8)

  22. exp Control Group/ (1545)

  23. exp PLACEBO/ (111315)

  24. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (403354)

  25. or/15-24 (613798)

  26. 14 and 25 (73)

  27. *Burns/ (12430)

  28. *Diabetic Foot/ (1981)

  29. *Varicosis/ (3637)

  30. *MICROVASCULAR ISCHEMIA/ (47)

  31. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10590)

  32. or/27-31 (28661)

  33. 26 not 32 (70)

  34. limit 33 to (editorial or letter or note) (1)

  35. Case Report/ (983221)

  36. 33 not (34 or 35) (68)

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 3 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5163)

  2. exp Skin Ulcer/ (10218)

  3. exp Wounds, Chronic/ (832)

  4. exp Wound Healing/ or exp Wound Infection/ (9511)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6566)

  6. bedsore$.mp. (75)

  7. or/1-6 (18318)

  8. exp Ultrasonic Therapy/ (690)

  9. exp Ultrasonography/ (11547)

  10. ultraso$.mp. (11565)

  11. or/8-10 (16647)

  12. 7 and 11 (255)

  13. limit 12 to (english and yr=“2003 - 2008”) (139)

  14. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69457)

  15. RCT.mp. (874)

  16. exp Meta Analysis/ (6315)

  17. exp “Systematic Review”/ (3577)

  18. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22933)

  19. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13946)

  20. exp PLACEBOS/ (4198)

  21. or/14-20 (90860)

  22. 13 and 21 (29

Final Search – Pressure Sores 2008 – Nutrition

Search date: March 26, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1996 to March Week 2 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (3492)

  2. exp Skin Ulcer/ (12547)

  3. bedsore$.mp. (97)

  4. exp Wound Healing/ or exp Wound Infection/ (34059)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (6921)

  6. or/1-5 (45146)

  7. exp Nutrition Therapy/ or exp Nutrition Phenomena/ or exp Diet/ or exp Food/ or exp Nutrition Assessment/ (365004)

  8. exp Dietary Supplements/ or exp Minerals/ or exp Antioxidants/ (174383)

  9. exp Micronutrients/ (141278)

  10. exp Arginine/ (22951)

  11. (nutrient$ or nutrition$ or enteral or parenteral or vitamin$ or diet$ or zinc or arginine).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (331182)

  12. or/7-11 (654297)

  13. 6 and 12 (2974)

  14. exp Skin Ulcer/dh [Diet Therapy] (27)

  15. exp Pressure Ulcer/dh [Diet Therapy] (16)

  16. 13 or 14 or 15 (2977)

  17. limit 16 to (english language and humans and yr=“2003 - 2008”) (899)

  18. limit 17 to (controlled clinical trial or meta analysis or randomized controlled trial) (105)

  19. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (31410)

  20. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (59462)

  21. exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (346069)

  22. exp Double-Blind Method/ (50381)

  23. exp Control Groups/ (533)

  24. exp Placebos/ (8753)

  25. RCT.mp. (2244)

  26. or/18-25 (414768)

  27. 17 and 26 (179)

  28. *Burns/ (7235)

  29. *Venous Ulcer/ (1075)

  30. *Diabetic Foot/ (2580)

  31. *Ischemia/ (8409)

  32. *Postoperative Complications/ or *Surgical Wound Infection/ (41621)

  33. or/28-32 (60476)

  34. 27 not 33 (128)

Database: EMBASE <1980 to 2008 Week 12>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp DECUBITUS/ (3887)

  2. exp Skin Ulcer/ (17909)

  3. exp Chronic Wound/ (229)

  4. exp Wound Healing/ or exp Wound Infection/ (50688)

  5. ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3776)

  6. bedsore*.mp. (155)

  7. or/1-6 (66870)

  8. exp nutrition/ (824071)

  9. exp Antioxidant/ (40665)

  10. exp Arginine/ (29469)

  11. (nutrient$ or nutrition$ or enteral or parenteral or vitamin$ or diet$ or zinc or arginine).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (588013)

  12. or/8-11 (1068613)

  13. 7 and 12 (5795)

  14. limit 13 to (human and english language and yr=“2003 - 2008”) (2120)

  15. Randomized Controlled Trial/ (155780)

  16. exp Randomization/ (25236)

  17. exp RANDOM SAMPLE/ (1022)

  18. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (281365)

  19. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56961)

  20. Double Blind Procedure/ (68653)

  21. exp Triple Blind Procedure/ (8)

  22. exp Control Group/ (1545)

  23. exp PLACEBO/ (111315)

  24. (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (403354)

  25. or/15-24 (613798)

  26. 14 and 25 (480)

  27. *burns/ (12430)

  28. *Diabetic Foot/ (1981)

  29. *Varicosis/ (3637)

  30. *MICROVASCULAR ISCHEMIA/ (47)

  31. *keratomileusis/ or *laser epithelial keratomileusis/ or *laser prostatectomy/ or *photorefractive keratectomy/ (2493)

  32. *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10590)

  33. or/27-32 (31113)

  34. 26 not 33 (432)

***************************

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to March Week 3 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5163)

  2. exp Skin Ulcer/ (10218)

  3. exp Wounds, Chronic/ (832)

  4. exp Wound Healing/ or exp Wound Infection/ (9511)

  5. ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6566)

  6. bedsore$.mp. (75)

  7. or/1-6 (18318)

  8. exp Diet Therapy/ (7022)

  9. exp NUTRITION/ (35506)

  10. exp Nutritional Support/ (13136)

  11. exp “food and beverages”/ (34182)

  12. exp Nutritional Assessment/ (5654)

  13. exp Arginine/ (572)

  14. (nutrient$ or nutrition$ or enteral or parenteral or vitamin$ or diet$ or zinc or protein$ or arginine).mp. [mp=title, subject heading word, abstract, instrumentation] (92476)

  15. or/8-14 (110901)

  16. 7 and 15 (1604)

  17. exp Pressure Ulcer/dh [Diet Therapy] (52)

  18. 16 or 17 (1615)

  19. limit 18 to (english and yr=“2003 - 2008”) (754)

  20. random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (69457)

  21. RCT.mp. (874)

  22. exp Meta Analysis/ (6315)

  23. exp “Systematic Review”/ (3577)

  24. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22933)

  25. exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (13946)

  26. exp PLACEBOS/ (4198)

  27. or/20-26 (90860)

  28. 19 and 27 (95)

  29. *burns/ (4653)

  30. *Diabetic Foot/ (1957)

  31. *Varicose Ulcer/ (628)

  32. *ISCHEMIA/ (647)

  33. *Surgical Wound Infection/ (1459)

  34. *Postoperative Complications/ (4629)

  35. *Surgical Wound/ (145)

  36. *Keratectomy, Laser/ (3)

  37. or/29-36 (13987)

  38. 28 not 37 (66)

Final Search – Pressure Ulcers – Patient Care Teams

Search date: March 10, 2008

Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Library, CINAHL, INAHTA/CRD

Database: Ovid MEDLINE(R) <1950 to February Week 4 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (7365)

  2. ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (9219)

  3. bedsore$.mp. (275)

  4. or/1-3 (9287)

  5. exp Patient Care Team/ or exp Combined Modality Therapy/ (179245)

  6. exp Delivery of Health Care, Integrated/ or exp “Continuity of Patient Care”/ (14412)

  7. exp Interdisciplinary Communication/ (3093)

  8. exp Interprofessional Relations/ (37746)

  9. (team$ or multi-facet$ or multifacet$ or multifactor$ or multidisciplin$ or multicomponent$ or multi-factor$ or multi-disciplin$ or multi-component$ or interdisciplin$ or inter-disciplin$ or collaborat$ or cooperat$ or co-operat$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (265601)

  10. ((wound$ or pressure sore$ or pressure ulcer$ or bedsore$ or bed sore$) adj3 (centre$ or team$ or program$ or clinic or clinics)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (335)

  11. exp Cooperative Behavior/ (12997)

  12. or/5-11 (436527)

  13. 4 and 12 (690)

  14. limit 13 to (english language and humans) (561)

  15. exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (34815)

  16. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (68160)

  17. 14 and (15 or 16) (32)

  18. 14 (561)

  19. limit 18 to (case reports or comment or editorial or letter or “review”) (190)

  20. 18 not 19 (371)

  21. 17 or 20 (384)

Database: EMBASE <1980 to 2008 Week 09>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Decubitus/ (3874)

  2. ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3767)

  3. exp Decubitus/ (3874)

  4. or/1-3 (5279)

  5. exp Integrated Health Care System/ (189)

  6. exp Interdisciplinary Communication/ (755)

  7. exp Cooperation/ or exp Teamwork/ (12687)

  8. (team$ or multi-facet$ or multifacet$ or multifactor$ or multidisciplin$ or multicomponent$ or multi-factor$ or multi-disciplin$ or multi-component$ or interdisciplin$ or inter-disciplin$ or collaborat$ or cooperat$ or co-operat$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (176388)

  9. ((wound$ or pressure sore$ or pressure ulcer$ or bedsore$ or bed sore$) adj3 (centre$ or team$ or program$ or clinic or clinics)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (214)

  10. or/5-9 (176649)

  11. 4 and 10 (300)

  12. limit 11 to (human and english language) (205)

  13. exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (280024)

  14. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56485)

  15. 12 and (13 or 14) (27)

  16. 12 (205)

  17. limit 16 to (editorial or letter or note or “review”) (70)

  18. 16 not 17 (135)

  19. 15 or 18 (145)

Database: CINAHL – Cumulative Index to Nursing &amp; Allied Health Literature <1982 to February Week 5 2008>

Search Strategy:

--------------------------------------------------------------------------------

  1. exp Pressure Ulcer/ (5100)

  2. ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, subject heading word, abstract, instrumentation] (5799)

  3. bedsore$.mp. (74)

  4. or/1-3 (5814)

  5. exp Multidisciplinary Care Team/ (11467)

  6. exp Combined Modality Therapy/ (6430)

  7. exp Health Care Delivery, Integrated/ (1644)

  8. exp “Continuity of Patient Care”/ (5258)

  9. exp Interprofessional Relations/ (8875)

  10. exp Cooperative Behavior/ (1027)

  11. exp TEAMWORK/ (3186)

  12. (team$ or multi-facet$ or multifacet$ or multifactor$ or multidisciplin$ or multicomponent$ or multi-factor$ or multi-disciplin$ or multi-component$ or interdisciplin$ or inter-disciplin$ or collaborat$ or cooperat$ or co-operat$).mp. [mp=title, subject heading word, abstract, instrumentation] (61923)

  13. ((wound$ or pressure sore$ or pressure ulcer$ or bedsore$ or bed sore$) adj3 (centre$ or team$ or program$ or clinic or clinics)).mp. [mp=title, subject heading word, abstract, instrumentation] (1178)

  14. or/5-13 (79579)

  15. 4 and 14 (691)

  16. limit 15 to english (663)

  17. exp Meta Analysis/ (6147)

  18. exp “Systematic Review”/ (3512)

  19. (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (22063)

  20. or/17-19 (22063)

  21. 16 and 20 (12)

  22. 16 (663)

  23. limit 22 to (editorial or letter or “review”) (56)

  24. 22 not 23 (607)

  25. 21 or 24 (607)

Appendix 4: Quality Assessment of Individual Studies

Debridement

StudyRandomization method statedConcealment of allocation statedInclusion/exclusion criteria statedA priori power calculation reportedBaseline characteristics reportedBlinded outcome assessment statedAttrition reportedITT reported
Lee and Ambus, 1975 (24)××✓×✓×✓×
Parish and Collins, 1979 (25)××✓×✓×No withdrawalNA
Burgos et al., 2000 (small sample) (26)✓×✓×✓✓✓ (High)✓
Muller et al., 2001 (small sample) (27)×××✓Only stage×✓×
Pullen et al, 2002 (28)××✓✓✓✓✓✓
Alvarez et al., 2002 (small sample) (22)✓×✓×✓×✓✓
Agren and Stromberg, 1985 (29)××✓ (Inclusion)×✓✓✓✓
Martin et al, 1996✓*×✓×××××
Nasar and Morley, 1982 (30)××✓××✓✓×
Ljungberg 1998 (31)×No✓×✓□×✓NA
Colin et al., 1996 (32)××××✓×✓✓
Thomas et al., 1993 (33)✓†×✓×✓×✓×
Sayag et al., 1996 (34)✓✓✓✓✓✓✓ (High)✓
Moberg et al., 1983 (35)××✓×✓×✓×
Sherman 2002 (36)× (Non-random)×✓×✓×××
Computer-generated
sealed envelopes
Table of random numbers
Opaque envelops

Dressings

StudyRandomization method statedConcealment of allocation statedInclusion/exclusion criteria statedA priori power calculation reportedBaseline characteristics reportedBlinded outcome assessment statedAttrition reportedITT reported
Xakellis, 1992 (54)××✓×✓×✓×
Aim 1989, (53)××××✓✓✓×
Colwell et al., 1993 (55)××✓× (No description of statistical analysis✓×✓×
Matzen, 1998 (56)××✓×✓×✓✓
Hollisaz et al., 2004 (41)✓✓✓✓✓✓✓✓
Barrois, 1992 (61)××✓×✓ (Limited)×✓×
Kim et al., 1996 (59)××××✓×✓×
Kaya et al., 2005 (63)××××✓×None reported×
Mulder et al., 1993 (57)✓×✓×✓×××
Bale, 1997 (66)✓×✓×✓×✓(High)×
Banks, 1994a (67)××✓×✓×✓×
Banks, 1994b (68)✓×✓×✓×✓×
Thomas, 1997 (44)✓✓✓×✓×××
Honde, 1994 (69)✓×✓×✓×✓✓
Banks, 1996 (77)××✓×✓×✓×
Seeley et al., 1999 (70)✓×✓×✓×✓✓
Belmin, 2002 (72)××✓✓✓✓✓
Meaume et al., 2005 (49)✓×✓×✓×✓
Munter et al., 2006 (50)✓✓✓✓✓×✓
Kloth et al., 2002 (73)✓×✓×✓×✓✓
Price et al., 2000 (75)✓✓✓×✓ (Stage)✓✓✓
Thomas et al., 2005 (52)✓✓✓×✓×✓×
Banks, 1997 (43)✓ (Computer)×✓×✓×✓×
Gunes et al., 2007 (51)✓×✓×✓×××
Graumlich, 2003 (11)✓✓✓✓✓✓✓✓
Subbanna et al., 2007 (40)✓×✓×✓×✓×

Support Surfaces

StudyRandomization method statedConcealment of allocation statedInclusion/exclusion criteria statedA priori power calculation reportedBaseline characteristics reportedBlinded i outcome assessment statedAttrition reported and reason providedITT reported
Devine et al., 1995 (94)✓×Exclusion criteria not reported× (Post hoc)✓✓✓✓
Evans, 2000 (95)✓†✓†✓×✓✓✓✓
Russell, 2000a (96)××✓✓✓✓✓×
Russell, 2003 (97)✓*✓†✓✓✓✓✓?
Nixon et al., 2006 (91)✓✓✓✓✓×✓✓
Allman et al., 1987 (98)✓‡✓†✓✓✓✓
Strauss, 1991 (100)✓*×✓×Inadequate✓✓ (High deaths and dropout)×
Ferrell and Christenson, 1993 (101)× (Blocks of 10)✓†✓✓✓×✓
Mulder et al., 1994 (102)××✓×No demographic info or baseline ulcer data×× (Overall, not by study groups)×
Day et al., 1993 (103)✓†✓†✓×✓×✓×
Groen et al., 1999 (104)××✓✓✓×✓×
Keogh et al., 2001 (105)✓*✓§✓Stated but not described✓× (Patient and researcher)✓✓
Rosenthal et al., 2003 (92)✓§✓§✓✓✓×✓×
Clark et al., 1999 (106)×✓ (Central)✓✓✓×✓×
Ochs et al., 2005 (93)✓ (Retrospective)×××✓×NANA
Computer-generated
sealed envelopes
Table of random numbers
Opaque envelops

Adjunctive Physical Therapy

StudyRandomization method statedConcealment of allocation statedInclusion/exclusion criteria statedA priori power calculation reportedBaseline characteristics reportedBlinded outcome assessment statedAttrition reportedITT reported
Electrical
Adunsky et al., 2005 (112)××✓×✓✓✓✓
Griffin et al., 1991 (110)×✓†✓✓✓×✓×
Wood et al., 1993 (111)×✓†✓×✓✓✓×
Electromagnetic
Comorosan, 1993 (115)
Salsberg, 1995 (116)×✓✓×✓✓✓×
Ritz et al., 2002 (117)××✓×✓✓××
Burke et al., 1998 (20)×✓✓××✓✓×
Laser Therapy
Nussbaum et al., 1994 (123)××××✓✓✓×
Lucas et al., 2000 (119)××✓×✓✓✓×
Lucas et al., 2003 (125)✓×✓✓✓✓✓✓
Taly et al., 2004 (121)✓×✓×✓✓✓✓
Schubert et al., 2001 (124)××Minimal×I✓ (Inadequate)×✓×
Ultrasound Therapy
McDiarmid, 1985 (127)××✓××✓✓×
ter Riet et al., 1995) (128)✓*✓✓✓✓✓✓✓
Nussbaum et al., 1994 (123)××××✓✓✓×
Multidisciplinary teams
Vu et al., 2007 (10)Inadequate†×✓✓✓×✓✓
By random permuted blocks of 6 prepared in advance using a computer program (Stratified by nursing home, vitamin C supplementation, and grade IV ulcers)
Cluster, not truly randomized

Growth Factors

StudyRandomization method statedConcealment of allocation statedInclusion/exclusion criteria statedA priori power calculation reportedBaseline characteristics reportedBlinded outcome assessment statedAttrition reportedITT reported
Mustoe, 1994 (78)××✓✓✓✓✓×
Rees, 1999 (79)××✓×✓××✓
Robson, 2000 (80)××✓×✓✓✓✓
Landi, 2003 (82)✓×✓×✓✓✓×

Nutrition Therapy

StudyRandomization method statedConcealment of allocation statedInclusion/exclusion criteria statedA priori power calculation reportedBaseline characteristics reportedBlinded outcome assessment statedAttrition reportedITT reported
Chernoff, 1990 (142)××✓×✓ (Inadequate)×××
Norris et al., 1971 (137)×✓✓×✓ (Inadequate)×✓×
Taylor et al., 1974 (139)✓×××✓ (Inadequate)×××
Ek et al., 1991 (141)××××✓×✓×
Benati et al, 2001 (143)××××××××
Desneves et al., 2005 (144)✓×✓×✓✓✓✓
Lee et al., 2006 (24)✓✓✓×✓✓✓×
ter Riet, 1995 (140)✓×✓×✓✓××

Appendix 5: Assessment of Quality of Evidence (GRADE)

Quality of Evidence on Debridement

GRADE Quality Assessment*
There was no evidence that debridement using collagenase, dextranomer, or cadexomer iodine significantly improved complete healing compared with placebo.
StudiesDesignQuality of StudiesConsistencyDirectnessOutcome
15 studiesRCTMany limitations†No limitationsNoneImportant
HighLowLowLowLow
RCT, randomized controlled trial.
Most were small and did not have a priori power calculation, intention-to-treat, or concealment of allocation. <50% gave method of randomization or reported blinded assessment.
GRADE Quality Assessment*
Papain urea resulted in better debridement than collagenase. Adding streptokinase/streptodornase to hydrogel resulted in faster debridement.
StudiesDesignQuality of StudiesConsistencyDirectnessOutcome
Alvarez, 2002
Martin, 1996		RCTMany limitations†No limitationsNoneImportant
HighLowLowLowLow
RCT, randomized controlled trial.
No concealment of allocation, no a priori power calculation, no blinded outcome assessment, no intention-to-treat in one of the studies.
GRADE Quality Assessment*
Calcium alginate resulted in a greater reduction in ulcer size compared with dextranomer. Weighted mean difference in ulcer reduction -2.12 (95% CI, -3.50 to -0.74) (cm/week)
StudiesDesignQuality of StudyDirectnessModifying FactorsOutcome
Sayag 1996RCTlimitation†No limitationsNoneImportant
HighModerateModerateModerateModerate
CI, confidence interval; RCT, randomized controlled trial. Consistency is Not applicable with only 1 study
High attrition.
GRADE Quality Assessment*
Maggot debridement resulted in more complete debridement than conventional treatment. Complete debridement at 5 weeks = 80% vs. 52%, P = .021.
StudiesDesignQuality of StudyDirectnessModifying FactorsOutcome
Sherman, 2002Non-randomized Clinical controlled trialSome limitations†No limitationsNoneImportant
LowVery lowVery lowVery lowVery low
Consistency is not applicable with only 1 study
Nonrandomized controlled study, no randomization, no concealment, no blinded outcome assessment, and no intention-to-treat.

Quality of Evidence on Dressings

GRADE Quality Assessment*
Ulcer (>Stage II) treated with hydrocolloid dressing for 5-12 weeks had a higher proportion of complete healing compared with those treated with saline gauze dressing (RR, 2.91 [95% CI, 1.52-5.57]).
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Aim, 1989
Colwell, 1993
Matzen, 1999
Hollisaz, 2004		RCTsMany limitations†NoNo limitationRR >2Important
N = 127 vs. 119HighLowLowLowModerateModerate
CI, confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small sample; no a priori sample calculation; method of randomization not stated; and no blinded outcome assessment.
GRADE Quality Assessment*
Ulcers (Stage ll-lII) treated with hydrogel dressing had a higher proportion of complete healing compared with those treated with hydrocolloid dressing (RR, 1.71 [95% CI, 1.05-2.79])
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Darkovich, 1990
Motta, 1999		RCTsMany limitations†No limitationNo limitationNoneImportant
N = 67 vs. 72HighLowLowLowLowLow
CI, confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small samples, no a priori sample calculation, method of randomization not stated, concealment of allocation not stated, attrition not reported, no blinded outcome assessment, and no intention-to-treat analysis.
GRADE Quality Assessment*
Ulcers (Stage II-III) treated with hydropolymer dressing had a higher proportion of complete healing compared with those treated with hydrocolloid dressing (RR, 1.53 [95% CI, 1.05-2.22]).
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Thomas, 1997
Honde, 1994		RCTsMany limitations†No limitationNo limitationNoneImportant
N = 129 vs 138HighLowLowLowLowLow
CI, confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small samples, no a priori sample calculation, method of randomization not stated, concealment of allocation not stated, attrition not reported, no blinded outcome assessment, and no intention-to-treat analysis
GRADE Quality Assessment*
There were no significant differences in complete healing of ulcers (Stage lll-IV) treated with normothermic or radiant heat dressing compared with those treated with other advanced dressings.
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Price, 2000
Whitney, 2001
Kloth, 2002
Thomas, 2005		RCTsSome limitationsNo limitationNo limitationNoneImportant
N = 75 vs. 77HighModerateModerateModerateModerateModerate
RCT, randomized controlled trial.

Quality of Evidence on Growth Factors

GRADE Quality Assessment*
No significant difference in complete healing in pressure ulcers treated with platelet derived growth factor, fibroblast growth factors, or granulocyte macrophage colony-stimulating factor compared with pressure ulcers treated with placebo.
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Mustoe, 1994
Rees, 1999
Payne, 2001
Landi, 2003		RCTsSome limitations†Some limitations‡No limitationNoneImportant
N = 75 vs. 77HighModerateLowLowLowLow
RCT, randomized controlled trial.
Small sample, method of randomization not stated, and no priori sample size calculation. Uncertainty due to small study size and methodological flaws.
One study showed a different trend in complete healing compared with the other 3 studies.

Quality of Evidence on Electrotherapy

GRADE Quality Assessment*
The adjunct use of electrotherapy significantly improved complete healing compared with sham therapy when a fixed effects model was used but there was significant heterogeneity (RR, 4.48 [95% CI, 1.91-10.51], P = .0006, I = 70.1%). The RR became insignificant when a random effects model was used. There was no significant difference when a random effects model was used (RR, 3.08 [95% CI, 0.58-16.41], P= .19, I = 70.1%)
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Griffin, 1991
Wood, 1993
Adunsky, 2005		RCTsSome limitations†Some inconsistencyNo limitationNoneImportant
N = 86 vs. 68HighModerateLowLowLowLow
CI refers to confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small sample size, no method of randomization, no concealment of allocation, and no a priori power calculation.
GRADE Quality Assessment*
The adjunct use of electrotherapy was associated with significantly greater reduction in the size of pressure ulcers.
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Gentzkow, 1991
Griffin, 1991
Wood, 1993		RCTsManylimitations†NoinconsistencyNo limitationNoneImportant
N = 41 vs. 28HighModerateModerateModerateModerateModerate
RCT refers to randomized controlled trial.
Small sample size, no method of randomization, no concealment of allocation, and no a priori power calculation.

Quality of Evidence on Electromagnetic Therapy

GRADE Quality Assessment*
The adjunct use of electromagnetic therapy did not significantly improve complete healing compared with sham therapy (RR, 3.43 [95% CI, 0.35-33.61], P = .29).
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Comorosan, 1993
Salsberg, 1995
Ritz, 2002		RCTsMany limitations†No inconsistencyNo limitationNoneImportant
N = 41 vs. 28HighLowLowLowLowLow
CI refers to confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small samples, no method of randomization, no concealment of allocation, no a priori power calculation, and no intention-to-treat analysis. One study did not provide patient or ulcer characteristics and had imbalanced sample sizes.

Quality of Evidence on Low-Level Laser Therapy

GRADE Quality Assessment*
The adjunct use of low level laser therapy did not significantly improve the complete healing of pressure ulcers compared with standard therapy or sham therapy (RR, 1.17 [95% CI, 0.85-1.63], P = .33).
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Nussbaum, 1994
Lucas, 2000
Lucas, 2003
Taly, 2004		RCTsSome limitations†Some inconsistency‡No limitationNoneImportant
N = 85 vs. 86HighmoderateLowLowLowLow
CI refers to confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small sample, no concealment of allocation, and no a priori power calculation.
One study had a different trend.

Quality of Evidence on Ultrasound Therapy

GRADE Quality Assessment*
The adjunct use of ultrasound therapy did not significantly improve complete healing of pressure ulcers compared with sham therapy (RR, 0.97 [95% CI, 0.65-1.45], P = .89)
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
McDiarmid, 1985†
ter Riet, 1995		RCTsSome limitations†No inconsistencyNo limitationNoneImportant
N = 66 vs. 62HighModerateModerateModerateModerateModerate
CI refers to confidence interval; RCT, randomized controlled trial; RR, relative risk.
Small samples. One study had no description of method of randomization, no concealment of allocation, and no a priori sample calculation.
GRADE Quality Assessment*
The adjunct use of ultrasound therapy in conjunction with ultraviolet therapy did not significantly improve complete healing compared with standard therapy or low-level laser therapy.
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
Nussbaum, 1994RCTMany limitations†No limitationNoneImportant
N = 6 vs. 6HighLowLowLowLow
RCT refers to randomized controlled trial; Consistency is not applicable with 1 study
No method of randomization or concealment, no inclusion/exclusion criteria, no a priori power calculation, and no intention-to-treat.

Quality of Evidence on Negative Pressure Therapy

GRADE Quality Assessment*
The adjunct use of negative pressure therapy did not significantly improve complete healing compared with standard therapy including a debridement gel.
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
Ford, 2002RCTMany limitations†No limitationNoneImportant
N =20 vs. 15HighLowLowLowLow
RCT refers to randomized controlled trial; Consistency is not applicable with 1 study
Very small sample, no method of randomization, no concealment of allocation, no inclusion/exclusion criteria, and no apriori power calculation.

Quality of Evidence on Nutrition Support Therapy

GRADE Quality Assessment*
Supplementation with 15 grams of hydrolyzed protein 3 times daily did not improve complete healing of pressure ulcers but was associated with a 2-fold improvement in PUSH score compared with placebo.
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
Lee, 2006RCTsSome limitations†No limitationNoneImportant
N = 89HighModerateLowLowLow
RCT refers to randomized controlled trial; PUSH, pressure ulcer scale for healing; Consistency is not applicable with 1 study
GRADE Quality Assessment*
Supplementation with 500 mg ascorbic acid twice daily for 1 month was associated with significantly greater reduction in the size of ulcers compared with placebo.
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
Taylor, 1974RCTMany limitations†No limitationNoneImportant
N = 20HighLowLowLowLow
RCT refers to randomized controlled trial; Consistency is not applicable with 1 study
No concealment of allocation, no inclusion/exclusion criteria, no a priori power calculation, inadequate baseline information, no report on attrition, and no intention-to-treat.
GRADE Quality Assessment*
Supplementation with 200 mg Zinc (as zinc sulphate) did not significantly improve the healing of pressure ulcers compared with placebo.
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Norris 1971
Brewer 1967		RCTSome limitations†Some inconsistencyNo limitationNoneImportant
N = 31HighModerateLowLowLowLow
RCT refers to randomized controlled trial.
No method of randomization, a priori power calculation, inadequate baseline information, no blinded assessment, no intention-to-treat.
GRADE Quality Assessment*
Supplementation with 500 mg ascorbic acid twice daily for 12 weeks did not significantly improve the absolute or relative reduction in the surface area or volume of ulcers compared with supplementation with 10 mg ascorbic acid twice daily.
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
ter Riet, 1995RCTSome limitationsNo limitationNoneImportant
N = 88HighModerateLowLowLow
RCT refers to randomized controlled trial; consistency not applicable with 1 study
GRADE Quality Assessment*
A very high protein feeding (25% of energy as protein) resulted in a greater reduction in the area of ulcers in institutionalized tube-fed patients compared with a lower protein feeding (16% of the energy as protein).
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
Chernoff, 1990RCTMany limitations†No limitationNoneImportant
N = 12HighLowLowLowLow
RCT, randomized controlled trial; Consistency is not applicable with only 1 study
No method of randomization, concealment of allocation, a priori power calculation, inadequate baseline information, no blinded outcome assessment, no report on attrition, and no intention-to-treat.
GRADE Quality Assessment*
A multinutrient supplemental feeding containing 1600 kJ, 16 g protein, and vitamins and minerals did not significantly improve the complete healing of pressure ulcers compared with standard diet alone.
StudiesDesignQuality of StudiesDirectnessModifying FactorsOutcome
Ek, 1991RCTsMany limitations†No limitationNoneImportant
N = 150HighLowLowLowLow
RCT, randomized controlled trial; Consistency is not applicable with only 1 study.
No method of randomization, concealment of allocation, no inclusion/exclusion criteria, no a priori power calculation, no blinded outcome assessment, and no intention-to-treat.
GRADE Quality Assessment*
A high protein high energy multinutrient supplemental feeding with added arginine, zinc, and vitamins was associated with a greater decrease in the size of the ulcer and improvement in ulcer scores compared with a similar feeding without added arginine, zinc and vitamin C or compared with a standard diet alone.
StudiesDesignQuality of StudiesConsistencyDirectnessModifying FactorsOutcome
Benati, 2001
Desneves, 2005		RCTsMany limitations†No inconsistencyNo limitationNoneImportant
N = 31HighLowLowLowLowLow
RCT, randomized controlled trial.
One study had better quality than the other did. No method of randomization in one study, no blinded outcome assessment in one study, and no intention-to-treat in one study. No method of concealment of allocation no a priori power calculation in either study,.
Appendices

Notes

Suggested Citation

This report should be cited as follows:

Medical Advisory Secretariat. Management of chronic pressure ulcers: an evidence-based analysis. Ontario Health Technology Assessment Series 2009;9(3).

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The Medical Advisory Secretariat (MAS) is part of the Ontario Ministry of Health and Long-Term Care. The mandate of MAS is to provide evidence-based policy advice on the coordinated uptake of health services and new health technologies in Ontario to the Ministry of Health and Long-Term Care and to the healthcare system. The aim is to ensure that residents of Ontario have access to the best available new health technologies that will improve patient outcomes.

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This evidence-based analysis was prepared by the Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care, for the Ontario Health Technology Advisory Committee and developed from analysis, interpretation, and comparison of scientific research and/or technology assessments conducted by other organizations. It also incorporates, when available, Ontario data, and information provided by experts and applicants to the Medical Advisory Secretariat to inform the analysis. While every effort has been made to reflect all scientific research available, this document may not fully do so. Additionally, other relevant scientific findings may have been reported since completion of the review. This evidence-based analysis is current to the date of publication. This analysis may be superseded by an updated publication on the same topic. Please check the Medical Advisory Secretariat Website for a list of all evidence-based analyses: http://www.health.gov.on.ca/ohtas.

Abbreviations

AH
Amorphous hydrogel
AHRQ
Agency for Healthcare Research and Quality
Al
Aluminum
AP
Alternating pressure
As
Arsenide
BFGF
Basic fibroblast growth factor
BID
Twice daily
C
Collagenase
CI
Confidence interval
D
Dextranomer paste
DDCT
Decubitus direct current treatment
DIME
Debridement, infection control, moist wound environment, and edge effect
DNAase
Deoxyribonuclease
FDA
Food and Drug Administration
FGF
Fibroblast growth factor
GA
Gallium
GM-CSF
Granulo macrophage-colony stimulating factor
GRADE
Grading of Recommendation Assessment, Development, and Evaluation
He
Helium
HINF
High Intensity Fund
HR
Hazard ratio
kJ
Kilojoule
LAL
Low-air-loss
LLL
Low-level laser
LOS
Length of stay
LP
Low pressure
LTC
Long-term care
MCSF
Macrophage-colony stimulating factor
MD
Medical doctor
Ug
Microgram
mg
Milligram
mL
Millilitre
MVP
Moisture vapour permeable
NA
Not applicable
NCNT
Noncontact normothermic therapy
NE
Neon
NGF
Nerve growth factor
NPUAP
National Pressure Ulcer Advisory Panel
NPWT
Negative pressure wound therapy
NS
Not statistically significant
OR
Odds ratio
PBO
Placebo
PDGF
Platelet-derived growth factor
PMN
Polymorphonuclear neutrophils
PSST
Pressure Sore Status Tool
PT
Physical therapist
PUSH
Pressure Ulcer Scale for Healing
RCN
Royal College of Nurses
RCT
Randomized controlled trial
RD
Registered dietician
rhPDGF
Recombinant human platelet-derived growth factor
RN
Registered nurse
RR
Relative risk
RR
Relative risk
SATA
Spacial and temporal averaged
SCI
Spinal cord injury
SD
Standard deviation
TGF
Transforming growth factor
Tx
Treatment
UCV
Ultraviolet C
us/uvc
Ultrasound/ultraviolet C
VA
Veterans Administration
VAC
Vacuum-assisted closure
WMD
Weighted mean difference
Notes

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