4 Type of Question: Therpy 臨床個案的PICOPatient / ProblemPatient who has Type 2 DM with foot ulcers(foot ulcer or diabetic foot)InterventionHBO OR hyperbaric oxygenationComparisonskin graft or skin transplantationOutcomeenhance the wound healingType of Question: Therpy
6 Best available evidence: （挑選可獲得之最佳研究證據） Citation/s:A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes(2008)Lead author's name :R.J.Hinchliffe, G.D.Valk, J.Apelqvist, D.G.Armstrong, K.Bakker, F.L.Game, A.Hartemann-Heurtier, M.Londahl, P.E.Price, W.H.van Houtum,W. J.Jeffcoate
7 The Study: （研究效度）- 1Prospective and retrospective controlled studies, published in any language, that evaluated interventions for the treatment of chronic foot ulcers in people aged 18 years or older with either type 1 or type 2 diabetes mellitus were considered.Randomized controlled trials (RCTs), case-control studies, prospective and retrospective cohort studies, control before-and-after (CBA) design and interrupted time series (ITS) designs were included.MEDLINE ( ) EMBASE( )The Cochrane database of systematic reviews, and the Cochrane Central Controlled Trials Register (2006)
8 The Study: （研究效度）- 2One reviewer assessed all identified references by title and abstract on the basis of patient group, intervention and outcome.Full paper copies of identified articles were then assessed for eligibility by two independent reviewers (agreement was reached).Each included paper was further assessed by two reviewers, working independently, and information was extracted on study design, patient group, intervention, outcomes, duration of and loss to followup, using standard data extraction sheets.
9 The Study: （研究效度）- 3Each study was scored for methodological quality using designspecific scoring, based on checklists developed by the Dutch Cochrane Center(RCT score:1-9).The SIGN instrument : (1) RCTs and (2) studies with case-control, cohort, CBA or ITS design. Studies were also rated as: ++ (high quality with low risk of bias), + (well conducted with low risk of bias) and – (low quality with higher risk of bias).
10 The Study: （研究效度）- 5 Level of Evidence: 1A(SR of RCTs) HBO therapy 6篇RCT(114 studies identified )Bioengineered skin and skin grafts 6篇RCT(72 papers identified)Level of Evidence: 1A(SR of RCTs)
11 The Study: （研究效度）- 6 本篇文獻的PICO (T) Patient / Problemchronic foot ulcers in people aged 18 years or older with either type 1 or type 2 diabetes MellitusInterventionDressings, Debridement, Bioengineered skin and skin grafts, Electromagnetic, laser and ultrasound, Stem cell therapy, Abnormalities of wound biology and gene therapy, Reduction of tissue oedema, Hyperbaric oxygen, Resection of the chronic wound/surgical proceduresComparisonOutcomeThe healing of chronic ulcer, ulcer area, amputation rateTime3 months – 1 years
12 The Evidence: （研究重要結果）- 1 Topical HBO inclusion of the affected foot into a sealed chamber containing hyperbaric oxygen (HBO)Systemic HBO the patient spending prolonged periods of time in a large HBO chamber
15 The Evidence: （研究重要結果）- 4 Bioengineered skin and skin grafts-1
16 The Evidence: （研究重要結果）- 5 Bioengineered skin and skin grafts-2
17 Comment & Discussion: -1 Systemic HBO may reduce the incidence of major amputation. While further evidence of effectiveness and cost-effectiveness, is required from larger, more robust and blinded studies.The benefit of topically administered HBO is not established.
18 Comment & Discussion: -2 Bioengineered skin products and skin grafts are widely used in some areas, but their benefit has not been clearly established.Many clinicians will reserve the use of these relatively expensive treatments for ulcers that fail to respond to simpler approaches and yet bioengineered skin products have not been evaluated in such populations.
20 Comment & Discussion: -4 回顧以(foot ulcer or diabetic foot) AND (skin graft or skin transplantation) 搜尋出的8篇相關randomized controlled trial文章中，雖大部分支持植皮之療效，但仍有少部份認為無明顯助益（2篇）。(autologous dermal and epidermal grafts versus nonadherent paraffin gauze)The autologous tissue-engineered treatment exhibited improved healing in dorsal ulcers when compared with the current standard dressing. For plantar ulcers, the off-loading cast was presumably paramount and masked or nullified the effects of the autologous wound treatment.
22 Clinical bottom line 臨床決策底線 回到臨床個案情境Clinical bottom line 臨床決策底線對於糖尿病足部潰瘍患者，單純接受高壓氧治療仍可提高傷口復原能力，降低截肢機率證據等級1A, 建議等級B
23 References:1: Belov VV: [Effects of short-term immunosuppression on the engraftment of skin transplants at syndrome of the diabetic foot]. Vestn Khir Im I I Grek. 2007;166(5):32-5.2: Puttirutvong P. Meshed skin graft versus split thickness skin graft in diabetic ulcer coverage. J Med Assoc Thai Jan;87(1):66-72.3: Caravaggi C: HYAFF 11-based autologous dermal and epidermal grafts in the treatment of noninfected diabetic plantar and dorsal foot ulcers: a prospective, multicenter, controlled, randomized clinical trial. Diabetes Care Oct;26(10):2853-64: Hanft JR: Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast-derived dermis. J Foot Ankle Surg Sep-Oct;41(5):291-9.
24 References:5: Veves A: Diabetic Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care Feb;24(2):290-5.6: Chang DW:Can a tissue-engineered skin graft improve healing of lower extremity foot wounds after revascularization? Ann Vasc Surg Jan;14(1):44-9.7: Naughton G:A metabolically active human dermal replacement for the treatment of diabetic foot ulcers. Artif Organs Nov;21(11):8: Sabolinski ML: Cultured skin as a ‘smart material’ for healing wounds: experience in venous ulcers. Biomaterials Feb;17(3):
25 結 論 （標題 Title）Systemic HBO may improve the healing of of DM foot ulcer and reduce the incidence of major amputationUpdate By（下次更新日期）:Oct. 29, 2010