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A cura di Claudia Caula, Angela Libardi, Emilia Lo Palo, Alberto Apostoliinvito lettura

Per la (quasi) totalità degli operatori sanitari, la “cura” delle lesioni cutanee coincide con il “mettere una medicazione”, anzi, meglio se le medicazioni sono due o tre o più, e ancor meglio se sono ‘novità’ appena immesse sul mercato. Eppure, se al posto di un paziente con un’ulcera fossero di fronte ad esempio ad un paziente con polmonite batterica, a nessuno di questi stessi operatori passerebbe per la mente che la “terapia” consista in un mucolitico invece dell’antibiotico regolamentare. Per questo motivo, nel numero di dicembre di Invito alla Lettura vi proponiamo una serie di studi sulle lesioni da pressione e sulle ulcere venose dell’arto inferiore, rivolti al trattamento delle cause del danno tessutale, specifico per eziologia.

 


CITAZIONE SECONDO PUBMED
Yap T, Kennerly S, Horn S, Bergstrom N, Colon-Emeric C. TEAM-UP clinical trial: investigating repositioning intervals for nursing home pressure ulcer/injury prevention. Innov Aging. 2018;2(Suppl 1):567. Published 2018 Nov 11. doi:10.1093/geroni/igy023.2097

Abstract
The universally accepted approach to pressure ulcer/injury (PU) prevention is to minimize pressure exposure through frequent repositioning intervals; however, optimal repositioning intervals have yet to be determined. Current PU prevention protocols recommend repositioning nursing home (NH) residents every 2 hours. Turn Everyone and Move for Ulcer Prevention (TEAM-UP) is a cluster randomized clinical trial (National Institute of Nursing Research/National Institute of Aging R01 NR016001-01A1) investigating whether repositioning intervals times can be safely extended by examining 2, 3, and 4-hour assigned NH-wide intervals and nursing staff compliance with on-time resident repositioning for a 4-week period. Preliminary results are presented for one 3-NH cluster (2, 3, and 4 hour). Each NH used resident activity monitoring technology to determine repositioning interval compliance, and this technology also visually cued nursing staff and scheduled and documented repositioning occurrence; furthermore, standardized protocols for risk assessment (Braden Scale Score > 10) and visco-elastic mattress surface were used. Residents at low, moderate, and high risk for PU development (n=321) with varied levels of medical severity who were repositioned at 2, 3, or 4-hour intervals experienced no PU development in contrast to each NH’s 12-month pre-intervention PU prevalence of 2.7–6.2% for the 2, 3, and 4-hour facilities, respectively. Nursing staff on-time repositioning compliance ranged from 93% to 99% with every 4-hour compliance consistently achieving the highest percentage of on-time repositioning. Focus group results revealed a positive experience. Clinical implications of findings thus far will be discussed along with strategies for addressing barriers to effective resident repositioning.

Perché leggerlo: Questo poster, presentato nel corso di un Congresso, anticipa, come un po’ è di ‘moda’, i risultati preliminari di un RCT che ha tutti i numeri per essere interessante, almeno in base al protocollo registrato a ClinicalTrials.gov. Innanzitutto è uno studio intrapreso grazie a finanziamenti pubblici (National Institute of Nursing Research/National Institute of Aging); dovrebbe coinvolgere un campione decisamente ampio (è previsto infatti l’arruolamento di oltre di 1300 soggetti); ma soprattutto, riguarda un aspetto di notevole rilevanza nell’assistenza delle persone a rischio e/o con lesioni da pressione (LDP) in atto, ossia la frequenza del riposizionamento. Nello specifico, gli autori si pongono l’obiettivo di indagare, ai fini della prevenzione delle LDP, quale sia l’intervallo ottimale (2, 3 o 4 ore) del cambio di postura – intervento effettuato in combinazione con l’uso di un materasso in schiuma viscoelastica ad alta densità. D’altro canto, come è risaputo, utilizzare una superficie di supporto NON elimina la necessità del riposizionamento, ma al massimo incide sull’intervallo del riposizionamento stesso.
Lo studio inoltre prende in considerazione la questione della compliance da parte dello staff infermieristico per le ricadute dal punto di vista pratico (quante ‘evidenze’ restano inapplicate nel quotidiano delle corsie ospedaliere o degli altri servizi???).
Bisognerà comunque attendere la conclusione dello studio e la pubblicazione dei risultati definitivi per avere una conferma o meno di questa anteprima. 


CITAZIONE SECONDO PUBMED
Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: A network meta-analysis. PLoS One. 2018 Feb 23;13(2):e0192707. doi:10.1371/journal.pone.0192707. PMCID: PMC5825032 PMID: 29474359 

Abstract
BACKGROUND: Pressure ulcers are a prevalent and global issue and support surfaces are widely used for preventing ulceration. However, the diversity of available support surfaces and the lack of direct comparisons in RCTs make decision-making difficult. OBJECTIVES: To determine, using network meta-analysis, the relative effects of different support surfaces in reducing pressure ulcer incidence and comfort and to rank these support surfaces in order of their effectiveness. METHODS: We conducted a systematic review, using a literature search up to November 2016, to identify randomised trials comparing support surfaces for pressure ulcer prevention. Two reviewers independently performed study selection, risk of bias assessment and data extraction. We grouped the support surfaces according to their characteristics and formed evidence networks using these groups. We used network meta-analysis to estimate the relative effects and effectiveness ranking of the groups for the outcomes of pressure ulcer incidence and participant comfort. GRADE was used to assess the certainty of evidence. MAIN RESULTS: We included 65 studies in the review. The network for assessing pressure ulcer incidence comprised evidence of low or very low certainty for most network contrasts. There was moderate-certainty evidence that powered active air surfaces and powered hybrid air surfaces probably reduce pressure ulcer incidence compared with standard hospital surfaces (risk ratios (RR) 0.42, 95% confidence intervals (CI) 0.29 to 0.63; 0.22, 0.07 to 0.66, respectively). The network for comfort suggested that powered active air-surfaces are probably slightly less comfortable than standard hospital mattresses (RR 0.80, 95% CI 0.69 to 0.94; moderate-certainty evidence). CONCLUSIONS: This is the first network meta-analysis of the effects of support surfaces for pressure ulcer prevention. Powered active air-surfaces probably reduce pressure ulcer incidence, but are probably less comfortable than standard hospital surfaces. Most prevention evidence was of low or very low certainty, and more research is required to reduce these uncertainties.

Perché leggerlo: L’utilizzo di una superficie di supporto per la riduzione/ridistribuzione per la pressione, associata al riposizionamento, costituisce uno dei principali interventi per la cura – e, ancora più importante – per la prevenzione delle LDP. E in una di quelle tipiche contraddizioni che caratterizzano il wound care, nonostante tale indiscussa importanza, mancano solide prove di efficacia in grado di orientare i comportamenti degli operatori sanitari. Come infatti sottolineano le conclusioni di questa meta analisi, la maggior parte delle evidenze disponibili sono di qualità da bassa a molto bassa. Merita una segnalazione il fatto che, oltre all’efficacia in sé, i revisori hanno valutato anche il comfort del paziente in rapporto alla superficie utilizzata, un aspetto generalmente ignorato o tutt’al più relegato in secondo piano, ma che invece incide profondamente sulla qualità di vita del paziente così come del caregiver. 


CITAZIONE SECONDO PUBMED
Barber GA, Weller CD, Gibson SJ. Effects and associations of nutrition in patients with venous leg ulcers: A systematic review. J Adv Nurs. 2018 Apr;74(4):774-787. doi: 10.1111/jan.13474. Epub 2017 Nov 9. PMID: 28985441.

Abstract
AIMS: To identify the associations and effects of nutritional characteristics and interventions on ulcer outcomes in adult patients with venous leg ulcers. BACKGROUND: Venous leg ulcers are the most prevalent type of lower limb ulcer; however, little evidence exists regarding the relationship between nutritional status and ulcer healing. DESIGN: A systematic search of English language articles was conducted using the Cochrane Collaboration Handbook for Systematic Reviews of Interventions. DATA SOURCES: A search of databases Ovid MEDLINE, EMBASE, Cochrane, CINAHL and Scopus was performed for studies published between January 2004 - May 2017. REVIEW METHODS: Quality of the included studies was assessed using the Cochrane Collaboration's Risk of Bias Assessment tool and the relevant Joanna Briggs Institute quality appraisal checklists. RESULTS: Twenty studies met the inclusion criteria. All participants had Clinical Aetiology Anatomy Pathophysiology classification C5 (healed) or C6 (active) ulcers. Studies were conducted in a range of clinical settings with relatively small sample sizes. The majority of patients were overweight or obese. Increased body mass index was associated with delayed wound healing. Vitamin D, folic acid and flavonoids were associated with some beneficial effects on ulcer healing. Dietary intakes of omega-3 fatty acids, vitamin C and zinc were low for some patients. CONCLUSION: Current evidence suggests that venous leg ulcer patients are more likely to be overweight or obese. However, evidence for weight management improving wound healing is lacking. Micronutrients, including vitamin D and folic acid, may improve wound healing in at-risk patients.

Perché leggerlo: Se per altre tipologie di lesioni cutanee, come ad esempio le LDP, lo stato nutrizionale è da tempo riconosciuto come un elemento determinante per la guarigione delle lesioni stesse e oggetto di raccomandazione da parte delle linee guida tematiche, diverso è il discorso per le ulcere dell’arto inferiore di natura vascolare. In realtà ciò è abbastanza paradossale, come rimarcato da Barber et al che hanno condotto la revisione sistematica con l’intento di colmare questo gap, nelle cui conclusioni troviamo qualche conferma e qualche novità. 


CITAZIONE SECONDO PUBMED
Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Epstein DM, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH; EVRA Trial Investigators. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018 May 31;378(22):2105-2114. doi: 10.1056/NEJMoa1801214. Epub 2018 Apr 24. PMID: 29688123. 

Abstract
BACKGROUND: Venous disease is the most common cause of leg ulceration. Although compression therapy improves venous ulcer healing, it does not treat the underlying causes of venous hypertension. Treatment of superficial venous reflux has been shown to reduce the rate of ulcer recurrence, but the effect of early endovenous ablation of superficial venous reflux on ulcer healing remains unclear. METHODS: In a trial conducted at 20 centers in the United Kingdom, we randomly assigned 450 patients with venous leg ulcers to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group). The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life. RESULTS: Patient and clinical characteristics at baseline were similar in the two treatment groups. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group; more patients had healed ulcers with early intervention (hazard ratio for ulcer healing, 1.38; 95% confidence interval [CI], 1.13 to 1.68; P=0.001). The median time to ulcer healing was 56 days (95% CI, 49 to 66) in the early-intervention group and 82 days (95% CI, 69 to 92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85.6% in the early-intervention group and 76.3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrollment was 306 days (interquartile range, 240 to 328) in the early-intervention group and 278 days (interquartile range, 175 to 324) in the deferred-intervention group (P=0.002). The most common procedural complications of endovenous ablation were pain and deep-vein thrombosis. CONCLUSIONS: Early endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. (Funded by the National Institute for Health Research Health Technology Assessment Program; EVRA Current Controlled Trials number, ISRCTN02335796).

Perché leggerlo: Si tratta di uno studio ben condotto, con un campione rappresentativo (450 pazienti), finanziato dal National Institute for Health Research Health Technology Assessment Program, che indaga gli effetti dell’ablazione precoce del reflusso venoso superficiale associata a terapia compressiva vs sola terapia compressiva su diversi outcomes. Lo ‘sguardo’ dei ricercatori si spinge oltre alla guarigione dell’ulcera venosa in sé, perché, se da una parte la terapia compressiva costituisce la cura dell’ulcera venosa dell’arto inferiore, d’altra parte essa non risolve l’ipertensione venosa, condizione all’origine dell’ulcera, e che ha implicazioni anche in termini di recidiva dell’ulcera stessa – problematiche affatto secondarie, soprattutto per coloro che le vivono, letteralmente, sulla propria pelle.

 

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