Dressings and topical agents for preventing pressure ulcers (Review)

Background: Pressure ulcers, which are localised injury to the skin, or underlying tissue or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful and impact negatively on the individual's quality of life. The cost implications of pressure ulcer treatment are considerable, compounding the challenges in providing cost effective, efficient health services. Efforts to prevent the development of pressure ulcers have focused on nutritional support, pressure redistributing devices, turning regimes and the application of various topical agents and dressings designed to maintain healthy skin, relieve pressure and prevent shearing forces. Although products aimed at preventing pressure ulcers are widely used, it remains unclear which, if any, of these approaches are effective in preventing the development of pressure ulcers. Objectives: To evaluate the effects of dressings and topical agents on the prevention of pressure ulcers, in people of any age without existing pressure ulcers, but considered to be at risk of developing a pressure ulcer, in any healthcare setting. Search methods: In February 2013 we searched the following electronic databases to identify reports of relevant randomised clinical trials (RCTs): the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Database of Abstracts of Reviews of Effects (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. Selection criteria: We included RCTs evaluating the use of dressings, topical agents, or topical agents with dressings, compared with a different dressing, topical agent, or combined topical agent and dressing, or no intervention or standard care, with the aim of preventing the development of a pressure ulcer. Data collection and analysis: We assessed trials for their appropriateness for inclusion and for their risk of bias. This was done by two review authors working independently, using pre-determined inclusion and quality criteria. Main results: Five trials (940 participants) of unclear or high risk of bias compared a topical agent with a placebo. Four of these trials randomised by individual and one by cluster. When results from the five trials were combined, the risk ratio (RR) was 0.78 (95% CI 0.47 to 1.31; P value 0.35) indicating no overall beneficial effect of the topical agents. When the cluster randomised trial was omitted from the analysis, use of topical agents reduced the pressure ulcer incidence by 36%; RR 0.64 (95% CI 0.49 to 0.83; P value 0.0008). Four trials (561 participants), all of which were of high or unclear risk of bias, showed that dressings applied over bony prominences reduced pressure ulcer incidence; RR 0.21 (95% CI 0.09 to 0.51; P value 0.0006). Authors' conclusions: There is insufficient evidence from RCTs to support or refute the use of topical agents applied over bony prominences to prevent pressure ulcers. Although the incidence of pressure ulcers was reduced when dressings were used to protect the skin, results were compromised by the low quality of the included trials. These trials contained substantial risk of bias and clinical heterogeneity (variations in populations and interventions); consequently, results should be interpreted as inconclusive. Further well designed trials addressing important clinical, quality of life and economic outcomes are justified, based on the incidence of the problem and the high costs associated with pressure ulcer management

A Clinical Support App for routine wound management: reducing practice variation, improving clinician confidence and increasing formulary compliance

Abstract: Wounds continue to be of a global concern. Therefore, a more focussed, evidence‐based approach to wound assessment and management is required. The WOUND COMPASS™ Clinical Support App (CSA) is designed to support the health care professional with wound assessment and management at the point of care. This real‐world pilot study aimed to determine the utility of the CSA during routine wound management, in multiple care settings. A non‐interventional, real‐world pilot programme of the CSA was conducted at four sites. Patients received routine wound management. The CSA was programmed to replicate the site's formulary for evidence‐based wound management. Anonymised pre‐ and post‐pilot clinician opinion surveys on useability and impact of the CSA were collected and reported. Wound Specialists (n = 7 [100%]) and Non‐Wound Specialists (NWS) (n = 58 [82%]) indicated that competence and confidence in wound assessment were enhanced with use of the CSA (100%; 82%). Furthermore, practice variation was reduced because of a greater compliance to their local formulary (n = 7 [100%]; 79% [54%]). This real‐world pilot shows the positive impact of the CSA, and the improvements that can be potentially realised via reduction in practice variation, improvement in NWSs confidence when managing wounds and increased formulary compliance. Key Messages: Evidence based wound care is required to reduce practice variation. The WOUND COMPASS Clinical Support App (CSA) supports wound assessment and guides appropriate selection of wound products from the facilities product formulary, at the point of care. Wound Specialist and Non‐Wound Specialists indicated both competence and confidence in wound assessments were enhanced with the use of CSA. CSA enabled reduction in practice variation due to greater compliance to the facilities product formulary

RasGRP1 opposes proliferative EGFR–SOS1–Ras signals and restricts intestinal epithelial cell growth

The character of EGFR signals can influence cell fate but mechanistic insights into intestinal EGFR-Ras signalling are limited. Here we show that two distinct Ras nucleotide exchange factors, RasGRP1 and SOS1, lie downstream of EGFR but act in functional opposition. RasGRP1 is expressed in intestinal crypts where it restricts epithelial growth. High RasGRP1 expression in colorectal cancer (CRC) patient samples correlates with a better clinical outcome. Biochemically, we find that RasGRP1 creates a negative feedback loop that limits proliferative EGFR–SOS1–Ras signals in CRC cells. Genetic Rasgrp1 depletion from mice with either an activating mutation in KRas or with aberrant Wnt signalling due to a mutation in Apc resulted in both cases in exacerbated Ras–ERK signalling and cell proliferation. The unexpected opposing cell biological effects of EGFR–RasGRP1 and EGFR–SOS1 signals in the same cell shed light on the intricacy of EGFR-Ras signalling in normal epithelium and carcinoma