Cochrane Database of Systematic Reviews

Hylton Menz · Aug 9, 2006

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Congratulations to Shan Bergin on the recent Cochrane review of silver-based wound dressings, presented at the last Australasian Podiatry Conference:

Silver based wound dressings and topical agents for treating diabetic foot ulcers

For those who aren't familiar with the Cochrane Database, I've also listed the other relevant reviews below. All residents of Australia, New Zealand and the UK can access the full-text reviews for free. For other countries, click here to see how you can access the database.

Patient education for preventing diabetic foot ulceration

Debridement of diabetic foot ulcers

Pressure relieving interventions for preventing and treating diabetic foot ulcers

Oral treatments for fungal infections of the skin of the foot

Topical treatments for fungal infections of the skin and nails of the foot

Interventions for treating hallux valgus (abductovalgus) and bunions

Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults

Interventions for treating plantar heel pain

Topical treatments for cutaneous warts

Surgical treatments for ingrowing toenails

Interventions for the treatment of Morton's neuroma

Braces and orthoses for treating osteoarthritis of the knee

Orthotic devices for treating patellofemoral pain syndrome

Tuckersm · Aug 9, 2006

It is interesting and telling that for most of the reviews that you listed, the concluding statement is "more research needed" especially in Australia where there is limited ARC and NHMRC funding, and very few sucessful grant applications that include podiatrists.

Josh Burns · Aug 9, 2006

Dear All,
Karl Landorf and I also have an upcoming Cochrane review partly funded by the NHMRC in Australia:

Burns J, Landorf KB, Ryan MM, Crosbie J, Ouvrier RA. Interventions for the prevention and treatment of pes cavus. (Protocol) Cochrane Database of Systematic Reviews 2006, Issue 3:

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006154/frame.html

Kind regards

Joshua Burns, PhD, B App Sc (Pod) Hons
NHMRC Australian Clinical Research Fellow
Institute for Neuromuscular Research,
The Children's Hospital at Westmead
The University of Sydney, Australia

Trent Baker · Nov 6, 2006

This is Gold Hylton, nice work.

Trent

Admin2 · Jul 24, 2007

The fungal one has been updated:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001434/frame.html

admin · Dec 31, 2008

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admin · Jan 23, 2009

Hylton Menz said: ↑

Orthotic devices for treating patellofemoral pain syndrome
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They have just withdrawn that one (link), most likely becasue the results of this study makes the review somewhat dated.

NewsBot · Jul 11, 2009

Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections.

Cruciani M, Lipsky BA, Mengoli C, de Lalla F.
Cochrane Database Syst Rev. 2009 Jul 8;(3):CD006810.

BACKGROUND: G-CSF increases the release of neutrophil endothelial progenitor cells from the bone marrow, and improves neutrophil functions, which are often impaired in people with diabetes.

OBJECTIVES: To examine the effects of adjunctive G-CSF compared with placebo or no growth factor added to usual care on rates of infection, cure and wound healing in people with diabetes who have a foot infection.

SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (Searched 16/3/09); the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 1 2009); Ovid MEDLINE (1950 to March Week 1 2009); Ovid EMBASE (1980 to 2009 Week 11); EBSCO CINAHL (1982 to March Week 2 2009); LookSmart's Find Articles (January 1990 to January 2008); conference proceedings and references lists in the included studies.

SELECTION CRITERIA: Randomised controlled trials (RCTs) that evaluated the effect of adding G-CSF to usual care in people with a diabetic foot infection.

DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial eligibility, methodological quality and extracted data. Relative risk (RR), or for continuous outcomes, mean differences (MD), with 95% confidence intervals (CI) were reported. In the case of low or no heterogeneity studies were pooled using a fixed-effect model.

MAIN RESULTS: We identified and included five eligible trials with a total of 167 patients. The investigators administered various G-CSF preparations, at different doses and for different durations of time. Adding G-CSF did not significantly affect the likelihood of resolution of infection or wound healing, but it was associated with a significantly reduced likelihood of lower extremity surgical interventions (RR 0.37; 95 % CI 0.20 to 0.68), including amputation (RR 0.41; 95 % CI 0.18 to 0.95). Moreover, providing G-CSF reduced the duration of hospital stay (MD, -1.40 days; 95 % CI, -2.27 to -0.53 days), but did not significantly affect the duration of systemic antibiotic therapy (MD, -0.27 days; 95 % CI, -1.30 to 0.77 days).

AUTHORS' CONCLUSIONS: The available evidence is limited, but suggests that adjunctive G-CSF treatment in people with a diabetic foot infection, including infected ulcers, does not appear to increase the likelihood of resolution of infection or healing of the foot ulcer. However, it does appear to reduce the need for surgical interventions, especially amputations, and the duration of hospitalisation. Clinicians might consider adding G-CSF to the usual treatment of diabetic foot infections, especially in patients with a limb-threatening infection, but it is not clear which patients might benefit.
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NewsBot · Jan 22, 2010

Complex interventions for preventing diabetic foot ulceration.
Dorresteijn JA, Kriegsman DM, Valk GD.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007610.

BACKGROUND: Ulceration of the feet, which can lead to the amputation of feet and legs, is a major problem for people with diabetes mellitus, and can cause substantial economic burden. Single preventive strategies have not been shown to reduce the incidence of foot ulceration to a significant extent. Therefore, in clinical practice, preventive interventions directed at patients, health care providers and/or the structure of health care are often combined (complex interventions).

OBJECTIVES: To assess the effectiveness of complex interventions on the prevention of foot ulcers in people with diabetes mellitus compared with single interventions, usual care or alternative complex interventions. A complex intervention is defined as an integrated care approach, combining two or more prevention strategies on at least two different levels of care: the patient, the healthcare provider and/or the structure of healthcare.

SEARCH STRATEGY: Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register (28/05/09), the Cochrane Central Register of Controlled Trials (CENTRAL, 28 May 2009), Ovid MEDLINE (1950 to May Week 3 2009), Ovid EMBASE (1980 to 2009 Week 21) and EBSCO CINAHL (1982 to May Week 4 2009).

SELECTION CRITERIA: Prospective randomised controlled trials (RCTs) which compared the effectiveness of combinations of preventive strategies, not solely patient education, for the prevention of foot ulcers in people with diabetes mellitus, with single interventions, usual care or alternative complex interventions.

DATA COLLECTION AND ANALYSIS: Two review authors were assigned to independently select studies, to extract study data and to assess risk of bias of included studies, using predefined criteria.

MAIN RESULTS: Only five RCTs met the criteria for inclusion. The study characteristics differed substantially in terms of health care settings, the nature of the interventions studied and outcome measures reported. In three studies that compared the effect of an education centred complex intervention with usual care or written instructions only, little evidence of benefit was found. Two studies compared the effect of more intensive and comprehensive complex interventions with usual care. One of these reported improvement of patients' self care behaviour. In the other study a significant and cost-effective reduction of lower extremity amputations (RR 0.30 (95% CI 0.13 to 0.71)) was achieved. All five included RCTs were at high risk of bias; with hardly any of the predefined quality assessment criteria met.

AUTHORS' CONCLUSIONS: There is no high quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit.
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NewsBot · Jan 22, 2010

Debridement of diabetic foot ulcers.
Edwards J, Stapley S.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD003556.

BACKGROUND: Foot ulceration is thought to affect 15% of people with diabetes at some time in their lives. Debridement is widely regarded as an effective intervention to speed up ulcer healing. The most effective method is unclear.

OBJECTIVES: To assess the effects of debridement interventions on the healing of diabetic foot ulcers.

SEARCH STRATEGY: For this third update we searched the Cochrane Wounds Group Specialised Register (June 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2009, Issue 2; Ovid MEDLINE - 1950 to June Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 25 and Ovid CINAHL - 1982 to June Week 3 2009.

SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating any method of debriding diabetic foot ulcers and measuring complete healing or rate of healing. There was no restriction on articles/trials based on language or publication status.

DATA COLLECTION AND ANALYSIS: Data extraction and assessment of study quality were undertaken by one review author and checked by an Editor of the Wounds Group.

MAIN RESULTS: Six RCTs of debridement were identified: four assessed hydrogels, with an additional study evaluating larval therapy against hydrogel and one evaluated surgical debridement. Pooling the three RCTs which compared hydrogel with gauze or standard care suggested that hydrogels are significantly more effective in healing diabetic foot ulcers (Relative Risk 1.84, 95% Confidence Interval (CI)1.3 to 2.61). Surgical debridement showed no significant benefit over standard treatment. One small trial suggested that larvae resulted in a more than 50% reduction in wound area compared with hydrogel. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in diabetic foot ulcers.

AUTHORS' CONCLUSIONS: There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
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