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The latest evidence for practice

Una Adderley
Specialist Nurse
Team Leader

Choice picks from the research journals,
with some choice comment …

Are silver dressings under compression effective for treating venous leg ulcers?

Leg ulceration affects a significant proportion of the elderly population. Although it can occur due to venous insufficiency, arterial insufficiency, unusual aetiologies (such as malignancy) or a mixture of causes, the most common cause is venous insufficiency. There is robust evidence to support the use of compression therapy for venous leg ulceration which is uncomplicated by significant arterial disease.

This multi-centre, randomized, controlled trial sought to establish whether the use of silver impregnated dressings under appropriate compression led to improved healing rates or reduced costs in patients with venous leg ulcers. 213 patients who had had a venous leg ulcer for at least six weeks were randomly allocated to one of two groups.  Patients who had insulin controlled diabetes mellitus, who were receiving antibiotic treatment or who were sensitive to silver were not included. The ulcers of the first group were treated with low-adherent dressings containing silver. The ulcers of the second group were treated with a low-adherent dressing that did not contain silver. Secondary dressings and compression therapy were applied to both groups and the patients were followed for a year. No difference in terms of complete healing at 12 weeks, time to healing or quality of life was found. There were no cost savings.

A commentary notes that the trial did not report the state of the wound bed before treatment beginning. And that previous studies have found evidence to suggest that dressings containing silver may reduce wound area, malodour, exudate levels, pain and improve quality of life.

Michaels JA, Campbell B, King B et al. Randomized controlled trial and cost effectiveness analysis of silver-donating antimicrobial dressings for venous leg ulcers (VULCAN trial). British Journal of Surgery 2009;96:1147-56.

Lo SF. Evid Based Nurs 2010;13:120-1.

Is it safe to administer infliximab infusions in a community setting?
Infliximab is a drug that is used to treat rheumatoid arthritis, psoriatic arthritis and Crohn's disease.  It is usually administered in a hospital clinic setting due to concerns about possible adverse reactions.  However, it is likely that many patients prefer to receive clinical care closer to home in a primary care setting, if it is appropriate to do so.

This Canadian study used a retrospective chart review to evaluate the number of adverse events following infusion of infliximab for various chronic conditions. The notes of 3161 patients who received 20,976 infusions were examined. The average number of infusions per patient was just over six, the usual dose was 5 mg/kg and over three-quarters of the patients were already on infleximab at the start of the study.

The review found that an adverse event was only documented in 4.2% of all infusions in 18.9% of patients. Nearly 40% of these adverse events happened more than 24 hours after the infusion. There was a slightly higher rate of adverse events in those patients receiving a first ever dose compared to patients who were already on infleximab. There were very few severe reactions of which none required hospital admission. The authors concluded that infleximab appears to be a safe drug to infuse in a community setting. 

A commentary notes that one shortcoming of the study was that the patients who had already had an adverse reaction to infliximab before the study commenced were dropped from the study. A cohort of patients who were all new starters would have given clearer results. The study would be strengthened if it had followed patients for longer to gather data on a larger number of doses per patient.  However, the commentary agrees that the results are encouraging.

Ducharme J, Pelletier C, Zacharias R. The safety of infliximab infusions in the community setting. Can J Gastroenterol 2010;24:307-11.

Yazici Y. Evid Based Nurs 2010;13:107-8.