Susan O'Meara

Interventions for preventing obesity in childhood. A systematic review

Background The prevalence of obesity and overweight is increasing worldwide. Obesity in children impacts on their health in both short‐ and long‐term. Obesity prevention strategies are poorly understood.

Four layer bandage compared with short stretch bandage for venous leg ulcers: systematic review and meta-analysis of randomised controlled trials with data from individual patients.

Objective To compare the effectiveness of two types of compression treatment (four layer bandage and short stretch bandage) in people with venous leg ulceration. Design Systematic review and meta-analysis of patient level data. Data sources Electronic databases (the Cochrane Central Register of Controlled Trials, the Cochrane Wounds Group Specialised Register, Medline, Embase, CINAHL, and National Research Register) and reference lists of retrieved articles searched to identify relevant trials and primary investigators. Primary investigators of eligible trials were invited to contribute raw data for re-analysis. Review methods Randomised controlled trials of four layer bandage compared with short stretch bandage in people with venous leg ulceration were eligible for inclusion. The primary outcome for the meta-analysis was time to healing. Cox proportional hazards models were run to compare the methods in terms of time to healing with adjustment for independent predictors of healing. Secondary outcomes included incidence and number of adverse events per patient. Results Seven eligible trials were identified (887 patients), and patient level data were retrieved for five (797 patients, 90% of known randomised patients). The four layer bandage was associated with significantly shorter time to healing: hazard ratio (95% confidence interval) from multifactorial model based on five trials was 1.31 (1.09 to 1.58), P=0.005. Larger ulcer area at baseline, more chronic ulceration, and previous ulceration were all independent predictors of delayed healing. Data from two trials showed no evidence of a difference in adverse event profiles between the two bandage types. Conclusions Venous leg ulcers in patients treated with four layer bandages heal faster, on average, than those of people treated with the short stretch bandage. Benefits were consistent across patients with differing prognostic profiles.

Systematic review of antimicrobial treatments for diabetic foot ulcers

Background  Foot ulcers in diabetes are associated with increased mortality, illness and reduced quality of life. Ulcer infection impairs healing and antimicrobial interventions may cure infection, aid healing and reduce amputation rates.

The prevention and treatment of childhood obesity

The effectiveness of interventions used in the prevention and treatment of childhood obesity published in a recent issue of Effective Heath Care is reviewed.

A systematic review of the clinical effectiveness of orlistat used for the management of obesity

The aim of this paper is to assess the clinical effectiveness of orlistat used for the management of obesity. Nineteen electronic databases were searched for randomized controlled trials evaluating the effectiveness of orlistat for weight loss or maintenance of weight loss in overweight or obese patients. Each included trial was assessed for methodological quality. Statistical pooling was performed when trials were considered to be sufficiently similar. Twenty‐three trials were eligible for inclusion. Placebo‐controlled trials recruiting patients with uncomplicated obesity reported statistically significant differences in favour of orlistat for weight loss and changes in obesity‐related risk factors at all time points. Trials in obese patients with defined risk factors at baseline showed similar results, however, smaller effect sizes were observed in patients with type 2 diabetes. The effectiveness of orlistat relative to other anti‐obesity drugs is currently unclear. When orlistat was added to simvastatin, this proved to be more effective for weight loss than either drug used individually. Orlistat use is associated with a higher incidence of gastrointestinal adverse events compared with placebo. In conclusion, orlistat is more effective than placebo in promoting weight loss, maintenance of weight loss, and improving cardiovascular risk factor profiles. Baseline parameters of patients seen in clinical practice should be taken into account when considering treatment.

Systematic review and mixed treatment comparison: dressings to heal diabetic foot ulcers

Aims/hypothesisFoot ulcers in people with diabetes are a common and serious global health issue. Dressings form a key part of ulcer treatment. Existing systematic reviews are limited by the lack of head-to-head comparisons of alternative dressings in a field where there are several different dressing options. We aimed to determine the relative effects of alternative wound dressings on the healing of diabetic foot ulcers.MethodsThis study was a systematic review involving Bayesian mixed treatment comparison. We included randomised controlled trials evaluating the effects on diabetic foot ulcer healing of one or more wound dressings. There were no restrictions based on language or publication status.ResultsFifteen eligible studies, evaluating nine dressing types, were included. Ten direct treatment comparisons were made. Whilst there was increased healing associated with hydrogel and foam dressings compared with basic wound contact materials, these findings were based on data from small studies at unclear or high risk of bias. The mixed treatment comparison suggested that hydrocolloid-matrix dressings were associated with higher odds of ulcer healing than all other dressing types; there was a high degree of uncertainty around these estimates, which were deemed to be of very low quality.Conclusions/interpretationThese findings summarise all available trial evidence regarding the use of dressings to heal diabetic foot ulcers. More expensive dressings may offer no advantages in terms of healing than cheaper basic dressings. In addition, evidence pointing to a difference in favour of ‘advanced’ dressing types over basic wound contact materials is of low or very low quality.

Systematic review of methods to diagnose infection in foot ulcers in diabetes

Aim  To undertake a systematic review of the diagnostic performance of clinical examination, sample acquisition and sample analysis in infected foot ulcers in diabetes.

Patient acceptability of larval therapy for leg ulcer treatment: a randomised survey to inform the sample size calculation of a randomised trial

BackgroundA trial was commissioned to evaluate the effectiveness of larval therapy to debride and heal sloughy and necrotic venous leg ulcers. Larval therapy in the trial was to be delivered in either loose or bagged form. Researchers were concerned that resistance to larval therapy may threaten the feasibility of the trial. Additionally there was concern that the use of larval therapy may require a larger effect size in time to healing than originally proposed by the investigators.MethodsTo formally evaluate patient preferences a survey using two randomly allocated, nurse administered questionnaires was undertaken. Patients were randomised to receive one of the two following questionnaires (i) preferences between loose larvae and standard treatment (hydrogel) or (ii) patient preferences between bagged larvae and standard therapy (hydrogel). The study was undertaken in a Vascular Clinic, in an Outpatients Department of a large teaching hospital in the North of England. The sample consisted of 35 people aged 18 years and above with at least one leg ulcer of venous or mixed (venous and arterial) aetiology.ResultsApproximately 25% of participants would not consider the use of larval therapy as an acceptable treatment option for leg ulcers, regardless of the method of containment.For the patients that would consider the use of larval therapy, different preferences in healing times required to use the therapy were observed depending upon the method of containment. The median response of those participants questioned about bagged larvae found that they would be willing to use this therapy even if they were equally able to achieve healing with the use of hydrogel by 20 weeks. For those participants questioned about the use of loose larvae complete healing would have to have taken place over 17 weeks for them to choose larvae as their preferred option rather than hydrogel. This difference was not significant (p = 0.075).ConclusionWe found no evidence of widespread resistance to the utilisation of larval therapy from patients regardless of the method of larval therapy containment. These methods have the potential to inform sample size calculations where there are concerns of patient acceptability.

A systematic review of the performance of instruments designed to measure the dimensions of pressure ulcers

The objective was to undertake a systematic review of the performance of wound measurement instruments used for patients with pressure ulcers. Studies of any design, evaluating methods for estimating wound diameter, depth, surface area, or volume in patients with pressure ulcers were included. Eligible evaluations had to report intra‐ or inter‐rater reliability, accuracy, agreement, or feasibility of methods. Electronic databases and other sources were accessed for study identification. Included studies were critically appraised using a modified checklist for diagnostic test evaluations. Twelve studies were included. Most had methodological problems and/or used inappropriate statistical methods. Reliable methods for measuring pressure ulcer surface area may include: grid tracings from photographs combined with whole plus partial square count; a portable digital pad; and stereophotogrammetry combined with computerized image analysis. The agreement between photographic tracing and direct transparency tracing may be satisfactory (both methods being combined with computerized planimetry). No definitive conclusions could be reached about studies of diameter or depth; this means that there is little evidence to underpin recommendations in clinical guidelines. Evaluations of volume measurement were of poor quality, and there were few data on feasibility. Further primary research is needed to evaluate methods of wound measurement used in clinical practice.

How is research evidence used to support claims made in advertisements for wound care products

AIMS AND OBJECTIVE To investigate the amount, type and accuracy of citations use in support of product related claims from advertisements of wound care products. BACKGROUND Although articles submitted to most medical journals are subjected to peer review, such scrutiny is often not required for the content of advertisements. DESIGN A contents survey of advertisements from two wound care journals (Journal of Wound Care and Ostomy Wound Management) from 2002-2003 and the British Medical Journal, 2002-2003. METHODS Data collected from advertisements included identification of product related claims made and any corresponding citations. Where journal articles were cited to support claims, the articles were obtained. Where data on file were cited, this material was requested. In each case the accuracy of claims in relation to the content of the supporting citation was assessed. RESULTS The use of citations to support product related claims was infrequent in advertisements from wound care journals, where 35% of advertisements containing a product related claim also contained at least one citation, compared with 63% of advertisements from the British Medical Journal. Of citations that were supplied, journal articles were less common in the wound journals (40% vs. 73% in the British Medical Journal) and data on file more common (38% vs. 6% in the British Medical Journal). Where journal articles were obtained, 56% of claims in the wound care journals advertisements were not supported by the cited article, compared with 12% of claims in the British Medical Journal. CONCLUSION The wound journals advertised predominantly medical devices. The use and accuracy of referencing in advertisements from wound care journals was poor. RELEVANCE TO CLINICAL PRACTICE Nurses have increasing responsibilities for the prescribing of both drugs and devices, which must be accompanied by the ability to interpret marketing materials and research evidence critically. Nurse educators must ensure that nurse education generally and nurse prescriber training particularly, builds skills of information retrieval and critical appraisal.