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Biomedical subjects

R G Sibbald

Publications and source records attributed to R G Sibbald.

At least 19 recordsLinked to original sources
PubMed2002

The use of portfolios for assessment of the competence and performance of doctors in practice.

BACKGROUND: The use of portfolios can potentially provide flexibility in the summative assessment of doctors in practice. An assessment system should reflect and reinforce the active and planned professional development goals of individual doctors. This paper discusses some of the issues involved in developing such a system. RESULTS: To provide a complete picture of an individual doctor's practice, we suggest that a portfolio should encompass: (1) evidence covering all three domains of patient care, personal development and context management; (2) evidence that the person continuously undertakes critical assessment of their own performance, identifies and prioritises areas requiring enhanced performance and takes action to improve them as appropriate; (3) evidence that has been generated by assessments that are acceptably reliable, and (4) evidence which, taken in its entirety, is sufficient, valid, current and authentic. We include a suggested outline of the components of such a portfolio and suggest some criteria to determine the effectiveness of learning cycles. Portfolio reliability and validity requires sufficient evidence on which to base a judgement combined with reliable processes. CONCLUSION: Carefully specified portfolios can contribute to a system that ensures all doctors take an active part in identifying and meeting their own learning needs. Such a system, if properly implemented, would have a greatly beneficial impact on continuous quality improvement for the profession in general.

Clinical Competence↗
PubMed2002

Evaluation of a new composite dressing for the management of chronic leg ulcer wounds.

OBJECTIVES: A new composite dressing (Versiva, ConvaTec) combines three technologies: hydrocolloid, hydrofibre and a foam-film layer. This study aimed to assess the safety of the dressing in the management of patients with venous leg ulcers. Clinical performance was also assessed. METHOD: This multicentre, non-randomised, open-label, phase II study assessed the safety (via adverse-effect reporting) and performance, including weartime, absorption, dressing integrity, ease of use and wound progression, of Versiva. Up to 10 dressing changes were assessed within a five-week study period. RESULTS: In 75 dressing changes of 11 ulcers, the mean wear time was approximately five days. No or minimal leakage was observed in 81% of changes. In 93%, the dressing was 'very easy' to remove, with no trauma to surrounding skin. Most changes (77%) were painless. CONCLUSION: Versiva met or exceeded the investigators' expectations for exudate absorption, protection of peri-wound skin and reduction in wound pain and ulcer area. Healing or marked improvement was observed in 82% of leg ulcers within the five-week study. The relatively long wear-time of five days represents a cost-effective advantage for this dressing compared with other available adhesive foams for the management of chronic wounds.

Adult↗
PubMed2001

Best practices for the prevention and treatment of venous leg ulcers.

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.

Humans↗
PubMed2001

Cost-effectiveness of Apligraf in the treatment of venous leg ulcers.

Venous ulcers are the most common chronic wounds of the lower leg. Skin substitutes recently have been introduced to stimulate nonhealing wounds. To conduct an incremental cost-effectiveness analysis, a model was developed to compare the four-layer bandage system, with and without one application of skin substitute, for the outpatient treatment of venous leg ulcers. The model estimated the costs and consequences of treatment with and without the skin substitute application. Two analytic horizons were explored: 3 months and 6 months. Determined by seven physicians, data and assumptions for the 3-month model were based on information from a clinical trial, published studies, and clinical experience. Data for the 6-month model were extrapolated from the shorter model. The model results indicate that over 3 months, the use of the skin substitute provided a benefit of 22 ulcer days averted per patient at an incremental cost of $304 (societal). The incremental cost-effectiveness ratio was $14 per ulcer day averted. Over 6 months, the incremental cost-effectiveness ratio was less than $5 per ulcer-day averted. The skin substitute plus a four-layer bandage was more costly and more effective than the four-layer bandage alone. The skin substitute is increasingly cost-effective over a longer analytic horizon and in a subgroup of patients with ulcers of long duration (greater than 1-year duration at baseline). The results come from a model that is based on a series of estimates and assumptions, and accordingly, confirmation of this finding in a prospective study is encouraged.

Aged↗
PubMed2001

Screening evaluation of an ionized nanocrystalline silver dressing in chronic wound care.

The successful topical treatment of chronic wounds requires adequate debridement, bacterial balance, and moisture balance. An ionized nanocrystalline silver dressing was evaluated through an uncontrolled, prospective study of a case series of 29 patients with a variety of chronic nonhealing wounds. The four arms of the study included nine patients with foot ulcers, six patients with venous stasis ulcers, two patients with pressure ulcers, and 12 patients with miscellaneous wounds. All wounds were assessed for the usual signs of clinical infection, with most of these parameters being measured and recorded. Microbiologically, bacterial load was determined via quantitative biopsies and semi-quantitative swabs. In general, the results showed a marked clinical improvement for the majority of wounds treated with the dressing. Among improved parameters included decreased exudate and decreased purulence. The quantitative bacterial biopsies did not show any decrease in organism numbers, although the semi-quantitative swabs indicated a decrease in the wound surface bacterial loading. This was indicative of the dressing's ability to reduce surface bacteria and achieve an element of bacterial balance in the superficial dermal compartment. The proposed mechanism of action for this ionized nanocrystalline based dressing is through bacterial and moisture balance within the superficial wound space compartment.

Algorithms↗
PubMed2001

High bacterial load in asymptomatic diabetic patients with neurotrophic ulcers retards wound healing after application of Dermagraft.

Diabetic neuropathic foot ulcers are a major healthcare burden. These chronic wounds always have a bacterial load, and although normal flora is not harmful, increased tissue burden may impede healing before clinical signs of infection are evident. In this study, chronic noninfected diabetic neuropathic foot ulcers (those with adequate blood supply and pressure offloading) were assessed for bacterial burden immediately before the application of a skin substitute. Eight patients with diabetic neuropathic foot ulcers greater than 1 cm2 and free of necrotic tissue had 3-mm tissue biopsies taken from the ulcer base for quantitative bacteriology. Five of the eight patients (75%) had greater or equal to 10(5) colony forming units/gram organisms present despite the absence of clinical signs of infection. Wound healing rates were linked to bacterial load as determined from quantitative biopsy--no growth was associated with a wound healing rate of 0.2 cm per week, 10(5) to 10(6) colony forming units/gram was associated with a healing rate of 0.15 cm per week, and greater than 10(6) colony forming units/gram was associated with 0.05 cm/per week healing rate. High bacterial burden impeded healing both before and after the application of the skin substitute. The authors will change their clinical practice to assess all diabetic neuropathic foot ulcers using quantitative skin biopsies before applying skin substitutes. All patients will be treated with combination antibiotics and repeat biopsies obtained with decreased bacterial burden (< 10(6) colony forming units/gram) prior to using any bioengineered skin substitute or growth factor treatment.

Aged↗
PubMed2000

Preparing the wound bed--debridement, bacterial balance, and moisture balance.

Successful diagnosis and treatment of patients with chronic wounds involve holistic care and a team approach. The integration of the work of an interdisciplinary care team that includes doctors, nurses, and allied health professionals with the patient, family, significant others, and caregivers offers an optimal formula for achieving wound resolution. Such an approach challenges practitioners and everyone participating in wound care to integrate data and information that arise from a number of sources and mitigating factors. In this article, the authors define the changing paradigm that links treatment of the cause and focuses on three components of local wound care: debridement, wound-friendly moist interactive dressings, and bacterial balance. The authors demonstrate that the treatment of chronic wounds can be accomplished through a series of recommendations and rationales based on the literature and their experience. These recommendations lay the groundwork for thorough assessment and evaluation of the wound.

Algorithms↗
PubMed2000

Best practices for the prevention, diagnosis, and treatment of diabetic foot ulcers.

Although the prevention, assessment, and treatment of diabetic foot ulcers has improved in recent years, care is often fragmented and does not always meet best clinical practice. This article incorporates current best clinical practices and expert opinion with available research to arrive at 11 recommendations. These recommendations include adequate vascular supply, infection control, pressure offloading, and an optimal local wound environment. This approach is best accomplished through a multidisciplinary team and revolves around the active participation of the person with diabetes. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to establish and empower a team to provide best clinical practices.

Algorithms↗
PubMed1999

The role of Apligraf in the treatment of venous leg ulcers.

A cultured, allogeneic, bi-layered human skin equivalent has recently become available to help clinicians manage difficult-to-heal venous ulcers. This skin equivalent has an epidermis and dermis similar to human skin. Its living keratinocytes and fibroblasts are from cultured cell banks derived from human neonatal foreskin. Because the skin equivalent is made up of viable human cells, it cannot be terminally sterilized. Safety concerns, which have been addressed, include the risk of possible transmission of infection, immunogenicity, immunological graft rejection, and tumor formation. However, the maternal blood of the neonatal donor and the master cell banks are screened for infectious agents. Additionally, the human skin equivalent is produced under strict aseptic control, with sterility continuously monitored by the Good Manufacturing Processes. This paper reviews the characteristics of this human skin equivalent and provides practice guidelines.

Algorithms↗
PubMed1999

The diabetic neuropathic ulcer: an overview.

The leading cause of amputation in patients with diabetes is the nonhealing foot wound and its complications. The effects of peripheral neuropathy, peripheral vascular disease, and infection often combine to facilitate ulcer development that can lead to gangrene and amputation. In many instances, foot ulcers and amputation can be prevented. The literature over the past 5 years has included information on the infrared thermometry in the diagnosis of infection and acute Charcot change. Pressure downloading has been facilitated by computerized foot scanning systems and the use of prefabricated pneumatic walkers as an alternative to the contact cast. Local wound care is enforced by repeated sharp debridement. Nonhealing ulcers can benefit from biologicals: platelet-derived growth factors and a human dermal replacement containing viable fibroblasts. The most successful outcomes are achieved when interdisciplinary teams are formed to provide coordinated care. The goal of this article is to provide healthcare professionals with an overview of the risks of neuropathic foot injury and to offer strategies for prevention, protection, and reduction of recurrences of the diabetic foot ulcer.

Algorithms↗
PubMed1999

Nursing management of chronic wounds: best practices across the continuum of care.

This article highlights the nurse's role within a holistic, interdisciplinary approach to chronic wound management. Best practices for chronic wound care are discussed, drawing on evidence-based science when it is available. The fundamentals of chronic wound care, including cleansing, irrigation, débridement, infection control, and topical treatment are addressed. New devices and technologies are briefly reviewed. Implementing these best practices across the continuum of care will result in greater advances in the management of chronic wounds.

Administration, Topical↗
PubMed1999

Infection in chronic wounds: controversies in diagnosis and treatment.

Chronic wounds all have bacterial contamination, which will not impair healing. Wound contamination must be distinguished from wound colonization and infection. Bacterial infection in wounds depends on the number of organisms present, their virulence, and host resistance. The most important indicators of infection are both local and systemic host characteristics and a holistic assessment of the patient. Several specimen collection and culture techniques are available to measure bacterial burden in the chronic wound. Advantages and disadvantages of each one discussed along with a rational approach to systemic antibiotic therapy. The presence of foreign material such as skin grafts or skin substitutes may lower the bacterial burden that may impair healing from 1.0 x 10(6) colony-forming units to 1.0 x 10(5) or less. The benefits of wound debridement, wound irrigation, and local nonantibiotic modes of treatment have been proven but the use of topical antibiotics and antiseptics requires further assessment. More widespread use of multiple nonantibiotic modalities of treatment for infected chronic wounds and rational antibiotic prescribing should reduce the risk of future antimicrobial resistance such as MRSA.

Anti-Bacterial Agents↗
PubMed1998

Oral famciclovir for the suppression of recurrent genital herpes: a randomized controlled trial. Collaborative Famciclovir Genital Herpes Research Group.

CONTEXT: Recurrent genital herpes simplex virus (HSV) may be treated episodically, but this may not be sufficient for patients with frequent recurrences. OBJECTIVE: To determine the efficacy and safety of famciclovir in the suppression of recurrent genital HSV infection. DESIGN: A randomized, double-blind, placebo-controlled, parallel-group study. SETTING: Thirty university, hospital, or private outpatient referral centers in Canada and Europe. PATIENTS: A total of 455 patients (223 men, 232 women) aged 18 years or older with a history of 6 or more episodes of genital herpes during 12 of the most recent 24 months, in the absence of suppressive therapy, received study medication. INTERVENTION: Oral famciclovir, 125 mg or 250 mg 3 times daily or 250 mg twice daily, or placebo for 52 weeks. MAIN OUTCOME MEASURES: Time to the first recurrence of genital HSV infection; the proportion of patients remaining free of HSV recurrence at 6 months; frequency of adverse events. RESULTS: In an intent-to-treat analysis, famciclovir significantly delayed the time to the first recurrence of genital herpes at all dose regimens (hazard ratios, 2.9-3.3; P<.001); median time to recurrence for famciclovir recipients was 222 to 336 days compared with 47 days for placebo recipients. The proportion of patients remaining free of HSV recurrence was approximately 3 times higher in famciclovir recipients (79%-86%) than in placebo recipients (27%) at 6 months (relative risks, 2.9-3.1; P<.001); efficacy was maintained at 12 months. Famciclovir was well tolerated with an adverse experience profile comparable to placebo. CONCLUSIONS: Oral famciclovir (125 mg or 250 mg 3 times daily or 250 mg twice daily) is an effective, well-tolerated treatment for the suppression of genital HSV infection in patients with frequent recurrences.

2-Aminopurine↗