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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. - PowerPoint PPT Presentation

Text of Chronic Wound Track

  • Heal Ohio 2008

  • PlanUpdate / Overview: MostowTopical Oxygen: GordilloNew treatment(s): LeeLymphedema: Beinlich and FruscellaProsthetic venous Valve: Treating Disease not Symptoms: Schmidt

  • Extent of the Problem1Philips 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.

    Pt=patient

  • Needs debridementUnderminingInfectionCo-morbidities

  • Evaluate with EBM criteria

  • FactsFacts 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

  • 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

  • EBM problemsTools are tough to put into practiceLimited help in the many gray areas of medicine (when there just isnt good evidenceyet)Even with internet resources, translation to individual patients not always straightforwardClinical judgementPatient preferences.

  • EBM problemsEvidence presentation issuesRelative risksAbsolute risksEX: RR 0.5 for outcome (50% decreased risk) vs. 8/1000 vs. 4/1000Presentation of data can affect physician interpretation & practice patterns

  • EBM concernsLitigation misuse of EBMManaged care misuse of EBMEvidence versus I know my patients are getting better with what Im doingClinical judgment vs self-delusionAutonomy issues

  • EBM AnswersNothing wrong with evidenceEvidence just tells you what happens under certain circumstancesDoc still has to translate how that pertains to your patients circumstancesyour patient may differ in important ways

  • QuestionIs pentoxifylline (Trental) of any benefit for patients with venous leg ulcers?MethylxanthineIncreased filterability of RBCsSuppressed synthesis of TNF-alpha from lipopolysaccharide (LPS)-stimulated human monocytes in cell cultures and in vivo

  • Question ResourcePrefiltered evidence-based medicine resourcesBest Evidence ($85, CDACP)www.acponline.org/catalog/electronic/best_evidence.htmACP Journal Clubwww.acponline.org/journals/acpjc/jcmenu.htmEffective Clinical Practice (ACP online journal)www.acponline.org/journals/ecp/index.htmlCochrane Library ($225 full / Abstracts free)www.updateusa.com/cochrane/cochrane-frame.htmClinical Evidence (BMJ publication)www.evidence.org

  • Prefiltered resourcesUpdated Methodologically sound studiesClinically important studiesEasy to search

  • Cochrane Reviewhttp://www.cochrane.org Skin groupAbstracts available free!Full reviews in your library.

  • General medical questionsTextbooks may be betterUptodatewww.uptodate.com ($495)Scientific American Medicinewww.samed.com ($245 w/ print / $159 online only)Medline

  • Textbooksemedicine (www.emedicine.com)Electronic Text of Dermatology (www.telemedicine.org)Habifs Clinical Dermatology(at www.medscape.com)

  • Pentoxifylline & VLUsRandomized, double blind placebo controlled trial of pentoxifylline in the treatment of venous leg ulcersBMJ. 1999;319:875-878. Dale JJ, et al. Pentoxifylline 400mg tid as adjunct to standard compression therapy200 patients randomized

  • Pentoxifylline & VLUsOutcome: healing by 24 weeks

    P < 0.05; trend noted at week 8-10 and continuedCochrane Database of Systematic Reviews April 2007Trental as adjunct to compression tx: 12 trials, 864 participantsRR healing 1.41 (95% CI 1.19-1.66)

    PentoxifyllinePlacebo64% healed53% healed

  • Pentoxifylline & VLUsTwelve 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).

  • Pentoxifylline & VLUsPentoxifylline 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).

  • Compression for VLUsEstablished as very important for wound healing Cochrane review: 22 trialsCompression better than no compression and elastic better than non-elasticCheck the pulse (or ABI > 0.8 with good waveforms)Make sure its tolerable and used!

  • Unna boot vs. other wrapsUnnas boot: zinc oxide paste & gauzeMulti-layer compression dressing advantages (more continuous pressure)

  • Compression for prevention!Studies lackingPrevention is often difficult sell Memory issues? Telling the future?See Stumbling on Happiness (Dan Gilbert)

  • LearningEven while men teach, they learn.Seneca, statesman

  • Creative MindsCreative minds have always been known to survive any kind of bad trainingPsychoanalyst Anna Freud, quoted in The Buffalo News

  • TruthBelieve in those who are seeking the truth; doubt those who find itFrench author Andre Gude, quoted in The Pittsburgh Post-Gazette

  • Einstein discovers that time is actually money.

  • Chronic Wound TrackUpdate / Overview: MostowTopical Oxygen: GordilloNew treatment(s): LeeLymphedema: Beinlich and FruscellaProsthetic venous Valve: Treating Disease not Symptoms: Schmidt

    D2-27Jun06*This slide shows the estimated prevalence and annual direct cost of venous, diabetic, and pressure ulcers in the United States. While not well characterized in the literature, the indirect costs of such wounds including impaired quality of life, reduced productivity, etc. would likely add substantially to the overall burden on individuals and society.Although the exact prevalence of venous ulcers in the US is not known, it has been estimated at 2.5 million.1,2 Such ulcers cost many billions of dollars annually based on a study of actual direct costs of $9685 per person.3 [[To presenter: It is unlikely that all 2.5 million undergo treatment.]]The prevalence of diabetic ulcers in the US is approximately 882,000 based on data showing that there are 14.7 million diabetics in the US4 of whom 6% are expected to develop ulcers over a 3-year period.5 The direct cost of treating non-infected diabetic foot ulcers is more than $6 billion annually.6It has been estimated that 10% to 18% of those in acute care and up to 28% of those in extended care develop pressure ulcers.7 A study of Medicaid patients in New Mexico found that physician visits for pressure ulcers cost a mean of $520 per patient annually in 1996 and hospitalization costs were nearly $16,000 per patient annually in 1998.8 This translates into many billions of dollars across the US population.

    1Phillips T, Stanton B, Provan A, et al. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol. 1994;31:49-53.2Brem H, Kirsner RS, Falanga V. Protocol for the successful treatment of venous ulcers. Am J Surg. 2004;188(1A Suppl):1-8.3Olin JW, Beusterien KM, Childs MB, Seavey C, McHugh L, Griffiths RI. Medical costs of treating venous stasis ulcers: evidence from a retrospective cohort study. Vasc Med. 1999;4(1):1-7. 4Centers for Disease Control and Prevention. Data and Trends. National Diabetes Surveillance System. Prevalence of diabetes. Available at: www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm. Accessed February 14, 2006.5Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, Wagner EH. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382-387.6Gordois A, Scuffham P, Shearer A, Oglesby A, Tobian JA. The health care costs of diabetic peripheral neuropathy in the US. Diabetes Care. 2003 Jun;26(6):1790-5. 7Cuddigan J, Berlowitz DR, Ayello EA for the National Pressure Ulcer Advisory Panel. Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care. 2001;14(4):208-15. 8Kumar RN, Gupchup GV, Dodd MA, Shah B, Iskedjian M, Einarson TR, Raisch DW. Direct health care costs of 4 common skin ulcers in New Mexico Medicaid fee-for-service patients. Adv Skin Wound Care. 2004;17(3):143-9. ********

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