https://www.commed.vcu.edu/Chronic_Disease/2012/cochranrvwrschbias.pdf

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

Type 2 diabetes mellitus (T2DM) is an expanding global health problem, closely linked to the epidemic of obesity. Individuals with T2DM are at high risk for both microvascular complications (including retinopathy, nephropathy and neuropathy) and macrovascular complications (such as cardiovascular comorbidities), owing to hyperglycaemia and individual components of the insulin resistance (metabolic) syndrome. Environmental factors (for example, obesity, an unhealthy diet and physical inactivity) and genetic factors contribute to the multiple pathophysiological disturbances that are responsible for impaired glucose homeostasis in T2DM. Insulin resistance and impaired insulin secretion remain the core defects in T2DM, but at least six other pathophysiological abnormalities contribute to the dysregulation of glucose metabolism. The multiple pathogenetic disturbances present in T2DM dictate that multiple antidiabetic agents, used in combination, will be required to maintain normoglycaemia. The treatment must not only be effective and safe but also improve the quality of life. Several novel medications are in development, but the greatest need is for agents that enhance insulin sensitivity, halt the progressive pancreatic β-cell failure that is characteristic of T2DM and prevent or reverse the microvascular complications. For an illustrated summary of this Primer, visit: http://go.nature.com/V2eGfN.

Type 2 diabetes mellitus.

Objectives Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety Search strategy and selection criteria Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation This process resulted in the identification of 79 practices for review The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice Pertinent studies were identified using various bibliographic databases (eg, MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts Data collection and analysis Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature" For most practices, the project team required that the primary outcome consist of a clinical endpoint (ie, some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality This criterion was relaxed for some practices drawn from the non-health care literature The evidence supporting each practice was summarized using a prospectively determined format The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries A separate ranking was developed for research priorities Main results Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery Many patient safety practices drawn primarily from nonmedical fields (eg, use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections Conclusions An evidence-based approach can help identify practices that are likely to improve patient safety Such practices target a diverse array of safety problems Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care

Making health care safer: a critical analysis of patient safety practices.

Significance: Chronic wounds include, but are not limited, to diabetic foot ulcers, venous leg ulcers, and pressure ulcers. They are a challenge to wound care professionals and consume a great deal of healthcare resources around the globe. This review discusses the pathophysiology of complex chronic wounds and the means and modalities currently available to achieve healing in such patients. Recent Advances: Although often difficult to treat, an understanding of the underlying pathophysiology and specific attention toward managing these perturbations can often lead to successful healing. Critical Issues: Overcoming the factors that contribute to delayed healing are key components of a comprehensive approach to wound care and present the primary challenges to the treatment of chronic wounds. When wounds fail to achieve sufficient healing after 4 weeks of standard care, reassessment of underlying pathology and consideration of the need for advanced therapeutic agents should be undertaken. However, selection ...

/pdf/challenges-in-the-treatment-of-chronic-wounds-2jwybcph6f.pdf

Challenges in the Treatment of Chronic Wounds.

The healing process in acute wounds has been extensively studied and the knowledge derived from these studies has often been extrapolated to the care of chronic wounds, on the assumption that nonhealing chronic wounds were simply aberrations of the normal tissue repair process. However, this approach is less than satisfactory, as the chronic wound healing process differs in many important respects from that seen in acute wounds. In chronic wounds, the orderly sequence of events seen in acute wounds becomes disrupted or “stuck” at one or more of the different stages of wound healing. For the normal repair process to resume, the barrier to healing must be identified and removed through application of the correct techniques. It is important, therefore, to understand the molecular events that are involved in the wound healing process in order to select the most appropriate intervention. Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. Experts in wound management consider that wound bed preparation is an important concept with significant potential as an educational tool in wound management.

This article was developed after a meeting of wound healing experts in June 2002 and is intended to provide an overview of the current status, role, and key elements of wound bed preparation. Readers will be able to examine the following issues;

• the current status of wound bed preparation;

• an analysis of the acute and chronic wound environments;

• how wound healing can take place in these environments;

• the role of wound bed preparation in the clinic;

• the clinical and cellular components of the wound bed preparation concept;

• a detailed analysis of the components of wound bed preparation.

(WOUND REP REG 2003;11:1–28)

Wound bed preparation: a systematic approach to wound management.

OBJECTIVE To evaluate the effects of two stimulation waveforms on healing rates in patients with diabetes and open ulcers. The hypothesis was that stimulus waveforms with minimal polar characteristics would provide significant healing for this patient sample. RESEARCH DESIGN AND METHODS This was a prospective study that enrolled 80 patients with open ulcers. Patients received stimulation with either an asymmetric biphasic (A) or symmetric biphasic (B) square-wave pulse. Amplitudes were set to activate intact peripheral nerves in the skin. Two other groups received either very low levels of stimulation current (MC), or no electrical stimulation (C). When combined these groups were referred to as the control group. Treatment was carried out daily until the wound healed, the patient withdrew from the study, or the physician changed the overall wound management program. Average healing rates were calculated from weekly measures of the wound perimeter and were used for statistical comparison through a one-way analysis of variance. RESULTS Stimulation with the A protocol significantly increased the healing rate, enhancing healing by nearly 60% over the control rate of healing. Stimulation with the B protocol did not increase the healing rate when compared with control subjects. CONCLUSIONS Electrical stimulation, given daily with a short pulsed, asymmetric biphasic waveform, was effective for enhancement of healing rates for patients with diabetes and open ulcers.

/pdf/effects-of-electrical-stimulation-on-wound-healing-in-4b8p7dttnk.pdf

Effects of Electrical Stimulation on Wound Healing in Patients With Diabetic Ulcers

https://ict.usc.edu/pubs/The%20Potential%20of%20Virtual%20Reality%20and%20Gaming%20to%20Assist%20Successful%20Aging%20with%20Disability.pdf

The Potential of Virtual Reality and Gaming to Assist Successful Aging with Disability

https://www.archives-pmr.org/article/S0003-9993(01)44048-2/pdf

Electromyographic activity of selected trunk muscles during dynamic spine stabilization exercises

Object. The purpose of this study was to describe a novel technology for implantable neuromuscular stimulation to treat complications of paralysis and disuse atrophy, including shoulder subluxation, hand contractures, drop foot, and osteoarthritis. The authors review the results so far of several pilot clinical studies of these muscle stimulation devices. Methods. Miniature wireless stimulators received power and individually addressed command signals from an external radiofrequency transmission coil. One or more implants were injected through a 12-gauge hypodermic insertion tool into muscles or adjacent to motor nerves, where they provided the means to activate the muscles in any desired pattern of intensity and frequency. Randomized controlled studies in small numbers of patients are underway to identify efficacy, acceptability, best methods of practice, and any design changes that may be required to improve the technology. Fifty patients have been enrolled in five studies; 35 patients have undergone implantation of a total of 79 BION1 devices. Comparisons with surface stimulation in patients who have suffered a stroke with shoulder subluxation and hand contractures show similar improvements in objective measures of efficacy but higher comfort levels for stimulation by implants. Conclusions. Injected microstimulators represent a promising new class of technology for the rehabilitation of patients with upper motor neuropathies. As the technology evolves, practitioners may be able to use it to facilitate functional reanimation of paralyzed limbs.

/pdf/the-bion-devices-injectable-interfaces-with-peripheral-37qsn0xkc3.pdf

The BION devices: injectable interfaces with peripheral nerves and muscles.

Neuromuscular electrical stimulation (NMES) can be used to augment range-of-motion, strengthening, and facilitation treatment programs of the muscles surrounding the shoulder. The purposes of this article are 1) to describe the uses of NMES around the shoulder joint as developed through our clinical use and 2) to detail the effects of an NMES program on chronic shoulder subluxation as determined by a clinical study. Because of the complexities of this multiarticular joint, NMES is most useful in the initial phase of the ROM, and stimulated contractions are compromised, relatively, as the humerus moves above the 90-degree horizontal plane. The use of NMES to provide scapular stabilization often entails unwanted alteration of the pressures on the spinal column, occasionally making the treatment program unusable. Electrical stimulation to prevent or correct shoulder subluxation, especially in the neurologically involved patient, provides the therapist with a powerful new treatment technique. In a group of stroke patients, shoulder subluxation was reduced significantly (p less than .05) at the completion of a six-week NMES program. Some of the problems, and possible solutions, unique to the development of electrical stimulation programs for the shoulder muscles are discussed.

Lucinda L. Baker

Papers

Effects of Electrical Stimulation on Wound Healing in Patients With Diabetic Ulcers

The Potential of Virtual Reality and Gaming to Assist Successful Aging with Disability

Electromyographic activity of selected trunk muscles during dynamic spine stabilization exercises

The BION devices: injectable interfaces with peripheral nerves and muscles.

Neuromuscular electrical stimulation of the muscles surrounding the shoulder