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Chronic Wound Track

Heal Ohio 2008. Chronic Wound Track. Plan. Update / Overview: Mostow Topical Oxygen: Gordillo New treatment(s): Lee Lymphedema: Beinlich and Fruscella Prosthetic venous Valve: Treating Disease not Symptoms: Schmidt. Wound Type. Prevalence. Estimated Annual Direct Cost (USD). Venous.

jennifer-jenkins
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Chronic Wound Track

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  1. Heal Ohio 2008 Chronic Wound Track

  2. Plan • Update / Overview: Mostow • Topical Oxygen: Gordillo • New treatment(s): Lee • Lymphedema: Beinlich and Fruscella • Prosthetic venous Valve: Treating Disease not Symptoms: Schmidt

  3. Wound Type Prevalence Estimated Annual Direct Cost (USD) Venous 2.5 million1,2 $Many billions3 Diabetic 882,0004,5 >$6 billion6 Pressure 10-18% (acute care)Up to 28% (extended care)7 • $Many billions8 • Dr visits: $520/pt8 • Hospital: $16,000/pt8 Extent of the Problem Pt=patient 1Philips T, et al. J Am Acad Dermatol. 1994;31:49-53.2Brem H, et al. Am J Surg. 2004;188(1A Suppl): 1-8.3Based on estimated prevalence of 2.5 million and actual mean direct cost of $9685/person : Olin et al. Vasc Med. 1999;4:1-7.4Based on 14.7 million diabetics: CDC, 2005, 6% of whom expected to develop ulcers over 3 years: 5Ramsey SD, et al. Diabetes Care. 1999;22(3):382-87.6Direct costs of treating non-infected diabetic foot ulcers; Gordois A, et al. Diabetes Care. 2003;26:1790-5.7Cuddigan J, et al. for the National Pressure Ulcer Adv Panel. Adv Skin Wound Care. 2001;14:209-15.8Costs in 1996 and 1998, Kumar RN, et al. Adv Skin Wound Care. 2004;17(3):143-9.

  4. Needs debridement Undermining Infection Co-morbidities

  5. Evaluate with EBM criteria

  6. Facts • Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence. • John Adams, second president

  7. EBM "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients," -David L. Sackett, MD, professor of medicine at Oxford University

  8. EBM problems • “Tools” are tough to put into practice • Limited help in the many “gray areas” of medicine (when there just isn’t good evidence…yet) • Even with internet resources, translation to individual patients not always straightforward • Clinical judgement • Patient preferences.

  9. EBM problems • Evidence presentation issues • Relative risks • Absolute risks • EX: RR 0.5 for outcome (50% decreased risk) vs. 8/1000 vs. 4/1000 • Presentation of data can affect physician interpretation & practice patterns

  10. EBM concerns • Litigation misuse of EBM • Managed care misuse of EBM • “Evidence” versus “I know my patients are getting better with what I’m doing” • Clinical judgment vs self-delusion • Autonomy issues

  11. EBM Answers • Nothing wrong with evidence • Evidence just tells you what happens under certain circumstances • Doc still has to translate how that pertains to your patient’s circumstances…your patient may differ in important ways

  12. Question • Is pentoxifylline (Trental) of any benefit for patients with venous leg ulcers? • Methylxanthine • Increased filterability of RBCs • Suppressed synthesis of TNF-alpha from lipopolysaccharide (LPS)-stimulated human monocytes in cell cultures and in vivo

  13. Question  Resource • “Prefiltered” evidence-based medicine resources • Best Evidence ($85, CD…ACP) • www.acponline.org/catalog/electronic/best_evidence.htm • ACP Journal Club • www.acponline.org/journals/acpjc/jcmenu.htm • Effective Clinical Practice (ACP online journal) • www.acponline.org/journals/ecp/index.html • Cochrane Library ($225 full / Abstracts free) • www.updateusa.com/cochrane/cochrane-frame.htm • Clinical Evidence (BMJ publication) • www.evidence.org

  14. “Prefiltered” resources • Updated • Methodologically sound studies • Clinically important studies • Easy to search

  15. Cochrane Review • http://www.cochrane.org • Skin group • Abstracts available free! • Full reviews in your library….

  16. General medical questions • Textbooks may be better • Uptodate • www.uptodate.com ($495) • Scientific American Medicine • www.samed.com ($245 w/ print / $159 online only) • Medline

  17. Textbooks • emedicine (www.emedicine.com) • Electronic Text of Dermatology (www.telemedicine.org) • Habif’s Clinical Dermatology • (at www.medscape.com)

  18. Pentoxifylline & VLUs • Randomized, double blind placebo controlled trial of pentoxifylline in the treatment of venous leg ulcers • BMJ. 1999;319:875-878. Dale JJ, et al. • Pentoxifylline 400mg tid as adjunct to standard compression therapy • 200 patients randomized

  19. Pentoxifylline & VLUs • Outcome: healing by 24 weeks P < 0.05; trend noted at week 8-10 and continued Cochrane Database of Systematic Reviews April 2007 Trental as adjunct to compression tx: 12 trials, 864 participants RR healing 1.41 (95% CI 1.19-1.66)

  20. Pentoxifylline & VLUs • Twelve trials involving 864 participants were included. • Combining 11 trials that compared pentoxifylline with placebo or no treatment (with or without compression) demonstrated that pentoxifylline is more effective than placebo in terms of complete ulcer healing or significant improvement (RR 1.70, 95% CI 1.30 to 2.24).

  21. Pentoxifylline & VLUs • Pentoxifylline plus compression is more effective than placebo plus compression (RR 1.56, 95% CI 1.14 to 2.13). • Pentoxifylline in the absence of compression appears to be more effective than placebo or no treatment (RR 2.25, 95% CI 1.49 to 3.39).

  22. Compression for VLUs • Established as very important for wound healing • Cochrane review: 22 trials • Compression better than no compression and elastic better than non-elastic • Check the pulse (or ABI > 0.8 with good waveforms) • Make sure it’s tolerable and used!

  23. Unna boot vs. other “wraps” • Unna’s boot: zinc oxide paste & gauze • Multi-layer compression dressing advantages (more continuous pressure)

  24. Compression for prevention! • Studies lacking • Prevention is often difficult “sell” • Memory issues? Telling the future? • See Stumbling on Happiness (Dan Gilbert)

  25. Learning • Even while men teach, they learn. • Seneca, statesman

  26. Creative Minds • Creative minds have always been known to survive any kind of bad training • Psychoanalyst Anna Freud, quoted in The Buffalo News

  27. Truth • Believe in those who are seeking the truth; doubt those who find it • French author Andre Gude, quoted in The Pittsburgh Post-Gazette

  28. Einstein discovers that time is actually money.

  29. Chronic Wound Track • Update / Overview: Mostow • Topical Oxygen: Gordillo • New treatment(s): Lee • Lymphedema: Beinlich and Fruscella • Prosthetic venous Valve: Treating Disease not Symptoms: Schmidt

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