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1.  Evidence for Clinical Use of Honey in Wound Healing as an Anti-bacterial, Anti-inflammatory Anti-oxidant and Anti-viral Agent: A Review 
To provide an updated review of published literature on the anti-oxidant, anti-bacterial and anti-inflammatory properties of honey.
Evidence Acquisition
CINAHL, BioMed Central, Cochrane Library, Medline and Embase data bases and reference lists were used to find randomized controlled trials and review articles. Randomized controlled trials using honey with a comparator were reviewed, along with published review articles to determine the relative benefits of tropical honey. These methods were undertaken by three reviewers.
Honey has anti-oxidant, anti-bacterial and anti-inflammatory properties. It can be used as a wound dressing to promote rapid and improved healing. These effects are due to honey’s anti-bacterial action, secondary to its high acidity, osmotic effect, anti-oxidant content and hydrogen peroxide content. The use of honey leads to improved wound healing in acute cases, pain relief in burn patients and decreased inflammatory response in such patients. However, it has proven to be ineffective in chronic leg ulcers. Overall, studies have been done in favor of the use of honey in medicine.
Honey has almost equal or slightly superior effects when compared with conventional treatments for acute wounds and superficial partial thickness burns. More randomized controlled trials with significant statistical power comparing different kinds of honey, are required in order to create a strong body of evidence towards definite recommendations for medical use. There is biological plausibility.
PMCID: PMC3941901  PMID: 24624197
Honey; Biological Dressings; Burns; Anti-inflammatory Agents
2.  Modalities for the Assessment of Burn Wound Depth 
Objective: Burn wound depth is a significant determinant of patient treatment and morbidity. While superficial partial-thickness burns generally heal by re-epithelialization with minimal scarring, deeper wounds can form hypertrophic or contracted scars, often requiring surgical excision and grafting to prevent a suboptimal result. In addition, without timely intervention, more superficial burn wounds can convert to deeper wounds. As such, the rapid and accurate assessment of burn wound depth is a priority in treating burn-injured patients. The object of this article is to review current research on modalities useful in the assessment of burn wound depth with emphasis on the relative costs and benefits of each technique. Methods: PubMed and Cochrane computerized databases were used for data retrieval, using the search terms “burns,” “burn wounds,” “burn depth,” “burn depth measurement,” and “burn depth progression.” In addition, bibliographic references from prior reviews of burn depth were reviewed. All peer-reviewed, English-language articles relevant to the topic of burn depth measurement were reviewed, including those focusing on animal and human populations. Where appropriate, conclusions drawn from review articles and expert analyses were included. Results: Although bedside evaluation remains the most common modality of diagnosing the depth of burn wounds, recent technological advances have broadened the scope of depth assessment modalities available to clinicians. Other depth assessment techniques include biopsy and histology, and perfusion measurements techniques such as thermography, vital dyes, indocyanine green video angiography, and laser Doppler techniques. Conclusion: Of the depth assessment modalities currently used in clinical practice, LDI and ICG video angiography offer the best data-supported estimates of accuracy. Until the future of new modalities unfolds, a combination of clinical evaluation and another modality—thermography, biopsy, or, ideally, ICG video angiography or LDI—is advised to best assess the depth of acute burn wounds.
PMCID: PMC1687143  PMID: 16921415
3.  Gelam (Melaleuca spp.) Honey-Based Hydrogel as Burn Wound Dressing 
A novel cross-linked honey hydrogel dressing was developed by incorporating Malaysian honey into hydrogel dressing formulation, cross-linked and sterilized using electron beam irradiation (25 kGy). In this study, the physical properties of the prepared honey hydrogel and its wound healing efficacy on deep partial thickness burn wounds in rats were assessed. Skin samples were taken at 7, 14, 21, and 28 days after burn for histopathological and molecular evaluations. Application of honey hydrogel dressings significantly enhanced (P < 0.05) wound closure and accelerated the rate of re-epithelialization as compared to control hydrogel and OpSite film dressing. A significant decrease in inflammatory response was observed in honey hydrogel treated wounds as early as 7 days after burn (P < 0.05). Semiquantitative analysis using RT-PCR revealed that treatment with honey hydrogel significantly (P < 0.05) suppressed the expression of proinflammatory cytokines (IL-1α, IL-1β, and IL-6). The present study substantiates the potential efficacy of honey hydrogel dressings in accelerating burn wound healing.
PMCID: PMC3175734  PMID: 21941590
4.  Comparison between topical honey and mafenide acetate in treatment of burn wounds 
Histological and clinical studies of wound healing were performed in comparable cases of fresh partial-thickness burns treated with honey dressing or mafenide acetate in two groups of 50 randomly allocated patients. Of the patients with honey-treated wounds, 84% showed satisfactory epithelialization by day 7 and 100% by day 21. In wounds treated with mafenide acetate, epithelialization occurred by day 7 in 72% of cases and in 84% by day 21. Histological evidence of reparative activity was observed in 80% of wounds treated with honey dressing by day 7 with minimal inflammation. Fifty-two per cent of the mafenide acetate treated wounds showed reparative activity with inflammatory changes by day 7. Reparative activity reached 100% by day 21 with the honey dressing and 84% with mafenide acetate. Thus, in honey-dressed wounds, early subsidence of acute inflammatory changes, better control of infection, and quicker wound healing were observed, while in mafenide acetate treated wounds a sustained inflammatory reaction was noted even on epithelialization.
PMCID: PMC3293229  PMID: 22396671
burn wounds; mafenide acetate; Honey
5.  A Comparative Study of the Wound Healing Properties of Moist Exposed Burn Ointment (MEBO) and Silver Sulphadiazine 
Burns expose the deeper tissues of the skin or body to invasive microbes. Topical preparations for treating burn wounds, to be useful, should ideally have antibiotic power and promote healing. Silver compounds have been the mainstay of topical burn treatment for decades. However, most chemical substances retard wound healing. Several natural agents such as honey and moist exposed burn ointment (MEBO) are believed to protect wounds from infection and promote healing without causing any of the adverse effects of purified chemicals. In this study, we compared the wound healing properties of MEBO, a herbal preparation of Chinese origin, with silver sulphadiazine (SSD), a long-standing conventional burn dressing. Ten adult Sprague Dawley rats were divided into two groups. They were housed in separate cages and received partial-thickness burn wounds on their dorsal skin. They were then treated with MEBO and SSD. The wounds were inspected daily until day 8, when all the animals were sacrificed, perfused with normal saline, and had their wounds excised and prepared for histology. It was found that animals in both groups were well preserved. No clinical infections occurred. Wound healing was at an advanced stage by day 8 in all the animals. Clinical and histological examination showed that the two agents gave the animals comparable protection and healing possibilities. It is concluded that MEBO is a suitable and efficacious alternative to conventional silver-based topical therapies for treating partial-thickness burn wounds.
PMCID: PMC3188221  PMID: 21991159
6.  Wound contraction effects and antibacterial properties of Tualang honey on full-thickness burn wounds in rats in comparison to hydrofibre 
Full-thickness burn wounds require excision and skin grafting. Multiple surgical procedures are inevitable in managing moderate to severe full-thickness burns. Wound bed preparations prior to surgery are necessary in order to prevent wound infection and promote wound healing. Honey can be used to treat burn wounds. However, not all the honey is the same. This study aims to evaluate the wound contraction and antibacterial properties of locally-produced Tualang honey on managing full-thickness burn wounds in vivo.
Thirty-six female Sprague Dawley rats were randomly divided into three groups. Under anaesthesia, three full-thickness burn wounds were created on the dorsum of the rats. The full-thickness burn wounds were inoculated with a specific organism (104), namely Pseudomonas aeruginosa (n = 12), Klebsiella pneumoniae (n = 12), or Acinetobacter baumannii (n = 12). The three burn wounds were dressed with Tualang honey, hydrofibre and hydrofibre silver respectively. Swab samples were obtained every 3 days (day 3, 6, 9, 12, 15, 18 and 21) for quantitative and semi-quantitative microbiological analyses. Clinical assessments, including observations concerning the appearance and wound size, were measured at the same time.
There was a rapid 32.26% reduction in wound size by day 6 (p = 0.008) in the Tualang honey-treated wounds, and 49.27% by day 15 (p = 0.005). The wounds remained smaller by day 18 (p < 0.032). Tualang honey-treated rats demonstrated a reduction in bacterial growth in Pseudomonas aeruginosa inoculated wounds (p = 0.005). However, hydrofibre silver and hydrofibre-treated wounds are superior to honey-treated wounds with Acinetobacter baumannii (p = 0.035). There was no statistical significant of antibacterial property in Klebsiella pneumonia inoculated wounds.
Tualang honey has better results with regards to its control of Pseudomonas aeruginosa and its wound contraction effects on full-thickness burn wound in vivo.
PMCID: PMC2941475  PMID: 20815896
7.  Medical Honey for Wound Care—Still the ‘Latest Resort’? 
While the ancient Egyptians and Greeks used honey for wound care, and a broad spectrum of wounds are treated all over the world with natural unprocessed honeys from different sources, Medihoney™ has been one of the first medically certified honeys licensed as a medical product for professional wound care in Europe and Australia. Our experience with medical honey in wound care refers only to this product. In this review, we put our clinical experience into a broader perspective to comment on the use of medical honey in wound care. More prospective randomized studies on a wider range of types of wounds are needed to confirm the safety and efficacy of medical honey in wound care. Nonetheless, the current evidence confirming the antibacterial properties and additional beneficial effects of medical honey on wound healing should encourage other wound care professionals to use CE-certified honey dressings with standardized antibacterial activity, such as Medihoney™ products, as an alternative treatment approach in wounds of different natures.
PMCID: PMC2686636  PMID: 18955301
Medical honey; wound care; MRSA
8.  Evaluations of bacterial contaminated full thickness burn wound healing in Sprague Dawley rats Treated with Tualang honey 
The effect of Tualang honey on wound healing in bacterial contaminated full-thickness burn wounds was evaluated in 36 male Sprague Dawley rats.
Materials and Methods:
The rats were randomly divided into three groups (n = 12/group). Three full-thickness burn wounds were created on each rat. Each group of rats was inoculated with a different organism in the burn wounds: Group A was inoculated with Pseudomonas aeruginosa, Group B was inoculated with Klebsiella pneumoniae and Group C was inoculated with Acinetobacter baumannii. One wound on each rat was dressed with either Tualang honey, Chitosan gel or Hydrofibre silver. Each wound size was measured on day 3, 6, 9, 12, 15, 18 and 21 of the study.
The mean wound size of the Tualang honey-treated wounds was not statistically different than that of the Chitosan gel or Hydrofibre silver-treated wounds when the wounds were compared throughout the entire experiment (P > 0.05). However, comparing the mean wound size on day 21 alone revealed that the Tualang honey-treated wounds were smaller in comparison to that of the Chitosan gel and Hydrofibre silver-treated groups.
This study shows that topical application of Tualang honey on burn wounds contaminated with P. aeruginosa and A. baumannii gave the fastest rate of healing compared with other treatments.
PMCID: PMC3111101  PMID: 21713196
Burn wound; honey; Pseudomonas aeruginosa; Acinetobacter baumannii; wound healing
9.  Honey Dressing Versus Silver Sulfadiazene Dressing for Wound Healing in Burn Patients: A Retrospective Study 
The aim was to evaluate the effect of honey dressing and silver sulfadiazene (SSD) dressing on wound healing in burn patients.
Materials and Methods:
We retrospectively reviewed the records of 108 patients (14–68 years of age), with first and second degree burns of less than 50% of the total body surface area admitted to our institution, over a period of 5 years (2004–2008). Fifty-one patients were treated with honey dressings and 57 with SSD. Time elapsed since burn, site, percentage, degree and depth of burns, results of culture sensitivity at various time intervals, duration of healing, formation of post-treatment hypertrophic scar, and/or contracture were recorded and analyzed.
The average duration of healing was 18.16 and 32.68 days for the honey and SSD group, respectively. Wounds of all patients reporting within 1 h of burns became sterile with the honey dressing in less than 7 days while there was none with SSD. All wounds treated with honey became sterile within 21 days while for SSD-treated wounds, this figure was 36.5%. A complete outcome was seen in 81% of all patients in the “honey group” while in only 37% patients in the “SSD group.”
Honey dressings make the wounds sterile in less time, enhance healing, and have a better outcome in terms of hypertropic scars and postburn contractures, as compared to SSD dressings.
PMCID: PMC3263128  PMID: 22279383
Burns; honey dressing; silver sulfadiazine dressing
10.  A Comparative Study of the Burn Wound Healing Properties of Saline-Soaked Dressing and Silver Sulfadiazine in Rats 
The Indian Journal of Surgery  2010;73(1):24-27.
The purpose of this study was to further investigate that phenomenon and to explore the effect silver sulfadiazine on wound healing. Full-thickness burn wounds were created on the dorsum of Wistar albino rats under anesthesia. The wounds were treated with silver sulfadiazine and saline-soaked dressing for fourteen days, and then observed until healed. Wound surface area was measured each three days. Time to 50% and 90% healing was compared. No clinical infections occurred. Wound half-life and healing times were shortest in the saline-soaked group (P < 0.0001) in full-thickness burns. Wound contraction was delayed by silver sulfadiazine. These data suggest that silver sulfadiazine retard burn wound healing. Infection control without delay of burn wound healing is most appealing and clinical trials are planned.
PMCID: PMC3077182  PMID: 22211033
Silver sulfadiazine; Saline-soaked dressing; Burn wounds care
11.  Review of the Medicinal Effects of Tualang Honey and a Comparison with Manuka Honey 
Tualang honey (TH) is a Malaysian multifloral jungle honey. In recent years, there has been a marked increase in the number of studies published in medical databases regarding its potential health benefits. The honey is produced by the rock bee (Apis dorsata), which builds hives on branches of tall Tualang trees located mainly in the north-western region of Peninsular Malaysia. This review collates the results of the various studies of TH that range from research on tissue culture to randomised control clinical trials. Findings thus far show that, TH has antimicrobial, anti-inflammatory, antioxidant, antimutagenic, antitumor, and antidiabetic properties, in addition to wound-healing attributes. Some of its properties are similar to the well-researched Manuka honey (New Zealand and/or Australian monofloral honey). Distinct differences include higher phenolics, flavonoids, and 5-(hydroxymethyl) furfural (HMF). Compared with Manuka honey, TH is also more effective against some gram-negative bacterial strains in burn wounds.
PMCID: PMC3743976  PMID: 23966819
ailments; antitumor; properties of Tualang honey; Tualang honey; wound healing
12.  A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients 
To compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.
PMCID: PMC2845359  PMID: 20368852
Honey dressing; silver-sulfadiazine dressing; wound healing in burn
13.  Antiseptics and disinfectants for the treatment of bacterial vaginosis: A systematic review 
BMC Infectious Diseases  2012;12:148.
The study objective was to assess the available data on efficacy and tolerability of antiseptics and disinfectants in treating bacterial vaginosis (BV).
A systematic search was conducted by consulting PubMed (1966-2010), CINAHL (1982-2010), IPA (1970-2010), and the Cochrane CENTRAL databases. Clinical trials were searched for by the generic names of all antiseptics and disinfectants listed in the Anatomical Therapeutic Chemical (ATC) Classification System under the code D08A. Clinical trials were considered eligible if the efficacy of antiseptics and disinfectants in the treatment of BV was assessed in comparison to placebo or standard antibiotic treatment with metronidazole or clindamycin and if diagnosis of BV relied on standard criteria such as Amsel’s and Nugent’s criteria.
A total of 262 articles were found, of which 15 reports on clinical trials were assessed. Of these, four randomised controlled trials (RCTs) were withheld from analysis. Reasons for exclusion were primarily the lack of standard criteria to diagnose BV or to assess cure, and control treatment not involving placebo or standard antibiotic treatment. Risk of bias for the included studies was assessed with the Cochrane Collaboration’s tool for assessing risk of bias. Three studies showed non-inferiority of chlorhexidine and polyhexamethylene biguanide compared to metronidazole or clindamycin. One RCT found that a single vaginal douche with hydrogen peroxide was slightly, though significantly less effective than a single oral dose of metronidazole.
The use of antiseptics and disinfectants for the treatment of BV has been poorly studied and most studies are somehow methodologically flawed. There is insufficient evidence at present to advocate the use of these agents, although some studies suggest that some antiseptics may have equal efficacy compared to clindamycin or metronidazole. Further study is warranted with special regard to the long-term efficacy and safety of antiseptics and disinfectants for vaginal use.
PMCID: PMC3458956  PMID: 22742642
Bacterial vaginosis; Antiseptics; Disinfectants; Therapy; Systematic review; Chlorhexidine; Polyhexamethylene biguanide; Hydrogen peroxide
14.  Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis 
BMJ : British Medical Journal  2008;336(7649):868-871.
Objective To determine the relative effects of open healing compared with primary closure for pilonidal sinus and optimal closure method (midline v off-midline).
Design Systematic review and meta-analyses of randomised controlled trials.
Data sources Cochrane register of controlled trials, Cochrane Wounds Group specialised trials register, Medline (1950-2007), Embase, and CINAHL bibliographic databases, without language restrictions.
Data extraction Primary outcomes were time (days) to healing, surgical site infection, and recurrence rate. Secondary outcomes were time to return to work, other complications and morbidity, cost, length of hospital stay, and wound healing rate.
Study selection Randomised controlled trials evaluating surgical treatment of pilonidal sinus in patients aged 14 years or more. Data were extracted independently by two reviewers and assessed for quality. Meta-analyses used fixed and random effects models, dichotomous data were reported as relative risks or Peto odds ratios and continuous data are given as mean differences; all with 95% confidence intervals.
Results 18 trials (n=1573) were included. 12 trials compared open healing with primary closure. Time to healing was quicker after primary closure although data were unsuitable for aggregation. Rates of surgical site infection did not differ; recurrence was less likely to occur after open healing (relative risk 0.42, 0.26 to 0.66). 14 patients would require their wound to heal by open healing to prevent one recurrence. Six trials compared surgical closure methods (midline v off-midline). Wounds took longer to heal after midline closure than after off-midline closure (mean difference 5.4 days, 95% confidence interval 2.3 to 8.5), rate of infection was higher (relative risk 4.70, 95% confidence interval 1.93 to 11.45), and risk of recurrence higher (Peto odds ratio 4.95, 95% confidence interval 2.18 to 11.24). Nine patients would need to be treated by an off-midline procedure to prevent one surgical site infection and 11 would need to be treated to prevent one recurrence.
Conclusions Wounds heal more quickly after primary closure than after open healing but at the expense of increased risk of recurrence. Benefits were clearly shown with off-midline closure compared with midline closure. Off-midline closure should become standard management for pilonidal sinus when closure is the desired surgical option.
PMCID: PMC2323096  PMID: 18390914
15.  The Efficacy of Gelam Honey Dressing towards Excisional Wound Healing 
Honey is one of the oldest substances used in wound management. Efficacy of Gelam honey in wound healing was evaluated in this paper. Sprague-Dawley rats were randomly divided into four groups of 24 rats each (untreated group, saline group, Intrasite Gel group, and Gelam honey group) with 2 cm by 2 cm full thickness, excisional wound created on neck area. Wounds were dressed topically according to groups. Rats were sacrificed on days 1, 5, 10, and 15 of treatments. Wounds were then processed for macroscopic and histological observations. Gelam-honey-dressed wounds healed earlier (day 13) than untreated and saline treated groups, as did wounds treated with Intrasite Gel. Honey-treated wounds exhibited less scab and only thin scar formations. Histological features demonstrated positive effects of Gelam honey on the wounds. This paper showed that Gelam honey dressing on excisional wound accelerated the process of wound healing.
PMCID: PMC3320037  PMID: 22536292
16.  Prophylactic antibiotics for burns patients: systematic review and meta-analysis 
Objective To assess the evidence for prophylactic treatment with systemic antibiotics in burns patients.
Design Systematic review and meta-analysis of randomised or quasi-randomised controlled trials recruiting burns inpatients that compared antibiotic prophylaxis (systemic, non-absorbable, or topical) with placebo or no treatment.
Data sources PubMed, Cochrane Library, LILACS, Embase, conference proceedings, and bibliographies. No language, date, or publication status restrictions were imposed.
Review methods Two reviewers independently extracted data. The primary outcome was all cause mortality. Risk or rate ratios with 95% confidence intervals were pooled with a fixed effect model if no heterogeneity was present.
Results 17 trials were included. Trials that assessed systemic antibiotic prophylaxis given for 4-14 days after admission showed a significant reduction in all cause mortality (risk ratio 0.54, 95% confidence interval 0.34 to 0.87, five trials). The corresponding number needed to treat was 8 (5 to 33), with a control event rate of 26%. Perioperative non-absorbable or topical antibiotics alone did not significantly affect mortality. There was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. Staphylococcus aureus infection or colonisation was reduced with anti-staphylococcal antibiotics. In three trials, resistance to the antibiotic used for prophylaxis significantly increased (rate ratio 2.84, 1.38 to 5.83). The overall methodological quality of the trials was poor.
Conclusions Prophylaxis with systemic antibiotics has a beneficial effect in burns patients, but the methodological quality of the data is weak. As such prophylaxis is currently not recommended for patients with severe burns other than perioperatively, there is a need for randomised controlled trials to assess its use.
PMCID: PMC2822136  PMID: 20156911
17.  Collagen-based wound dressings for the treatment of diabetes-related foot ulcers: a systematic review 
Diabetic foot ulcers are a major source of morbidity, limb loss, and mortality. A prolonged inflammatory response, extracellular matrix degradation irregularities, and increased bacteria presence have all been hypothesized as major contributing factors in the delayed healing of diabetic wounds. Collagen components such as fibroblast and keratinocytes are fundamental to the process of wound healing and skin formation. Wound dressings that contain collagen products create a biological scaffold matrix that supports the regulation of extracellular components and promotes wound healing.
A systematic review of studies reporting collagen wound dressings used in the treatment of Diabetic foot ulcers was conducted. Comprehensive searches were run in Ovid MEDLINE, PubMed, EMBASE, and ISI Web of Science to capture citations pertaining to the use of collagen wound dressings in the treatment of diabetic foot ulcers. The searches were limited to human studies reported in English.
Using our search strategy, 26 papers were discussed, and included 13 randomized designs, twelve prospective cohorts, and one retrospective cohort, representing 2386 patients with diabetic foot ulcers. Our design was not a formal meta-analysis. In those studies where complete epithelialization, 58% of collagen-treated wounds completely healed (weighted mean 67%). Only 23% of studies reported control group healing with 29% healing (weighted mean 11%) described for controls.
Collagen-based wound dressings can be an effective tool in the healing of diabetic foot wounds. The current studies show an overall increase in healing rates despite limitations in study designs. This study suggests that future works focus on biofilms and extracellular regulation, and include high risk patients.
PMCID: PMC3555551  PMID: 23357897
bio films; matrix; wound healing; scaffold; dressings
18.  Management of Superficial to Partial-Thickness Wounds 
Journal of Athletic Training  2007;42(3):422-424.
Reference/Citation: Wiechula R. The use of moist wound-healing dressings in the management of split-thickness skin graft donor sites: a systematic review. Int J Nurs Pract. 2003; 9:S9–S17.
Clinical Question: Do rates of healing, infection, and pain differ depending on whether nonmoist or moist dressings are used to manage superficial to partial-thickness wounds?
Data Sources: Investigations were identified by CINAHL, MEDLINE, Pre-MEDLINE, Cochrane Library, Current Contents, Health STAR, EMBASE, Expanded Academic Index, and Dissertation Abstracts International searches. The search terms included skin, graft, and donor. Additional searches were performed with reference lists and bibliographies of retrieved studies.
Study Selection: To be included in the review, each study had to fulfill the following criteria: it had to be an intraindividual or prospective randomized controlled trial of human subjects; it had to include patients with postharvest split-thickness skin graft donor sites; it had to evaluate the effectiveness of primary and secondary wound dressings; and it had to have outcome measures that included healing (objective), infection (subjective), and pain (objective).
Data Extraction: Data extraction and study quality assessment procedures were developed specifically for this review based on Cochrane Collaboration, Centre for Reviews and Dissemination, and Joanna Briggs Institute protocols and were performed independently by the author. Details of the procedures were not fully explained. The principal outcome measures were healing (proportion of sites healed within the study period or time to complete healing), rate of infection, and pain scores. The studies were grouped according to broad dressing type (nonmoist and moist) and specific types of moist dressings (hydrocolloids and polyurethane semipermeable transparent films). When comparable, study results were pooled and analyzed with a fixed-effects model. Data within broader dressing categories (nonmoist and moist) were analyzed with a random-effects model. χ 2 analysis was used to determine heterogeneity among the studies. RevMan software (version 4.04; Cochrane Centre, Oxford, UK) was used for statistical analysis.
Main Results: The searches identified 111 studies and 1 integrative review, of which 58 studies met the inclusion and exclusion criteria. Inconsistency and variation in outcome measures and incomplete reporting of results prevented analysis of many studies. Wound healing was measured by days to complete healing (when dressings could be removed without trauma and pain) and wounds healed by day X (removal of dressings at regular intervals). Wound infection was subjectively measured based on clinical signs of infection (edema, heat, pain, or smell). Visual analog scales were used to measure pain levels.
Among the broad categories of nonmoist (sterile gauze, fine mesh gauze, Xerofoam [Tyco Healthcare Group LP, Mansfield, MA]) and moist (DuoDERM hydrocolloid [ConvaTec, Princeton, NJ], Tegaderm transparent film [3M Health Care, St Paul, MN], Opsite transparent film [Smith & Nephew, London, UK]) dressings, the outcomes of healing, infection, and pain were analyzed. In 6 studies, the findings significantly favored moist dressings, compared with nonmoist dressings, for days to complete healing (weighted mean difference [WMD] = −3.97, 95% confidence interval [CI] = −5.91, −2.02). In 9 studies, wounds healed by day X (day 7, 8, 9, 10, or 12) were analyzed. The results were varied and inconclusive because of a small number of trials and subjects. Among 10 studies, no significant difference was noted in infection rates between nonmoist and moist dressings (odds ratio [OR] = 0.41, 95% CI = 0.14, 1.18). Three studies using visual analog scales for the outcome of pain were converted into a uniform scale of 1 to 10 (10 representing most painful). The findings significantly favored moist dressings over nonmoist dressings (WMD = −1.75, 95% CI = −2.94, −0.56).
Among nonmoist and specific types of moist dressings, a subset analysis was performed to examine the outcomes of healing, infection, and pain. For days to complete healing, 2 investigations significantly favored hydrocolloid dressings over nonmoist dressings (WMD = −2.19, 95% CI = −2.89, −1.49). Additionally, in 2 studies, hydrocolloid dressings were significantly favored over other moist dressings (semiocclusive hydrocolloid and transparent film) for days to complete healing (WMD = −1.45, 95% CI = −2.17, −0.74). In 3 studies, the data significantly favored polyurethane semipermeable transparent film dressings over nonmoist dressings for days to complete healing (WMD = −2.82, 95% CI = −3.58, −2.07). For infection rates, 4 studies significantly favored hydrocolloid dressings over nonmoist dressings (OR = 0.21, 95% CI = 0.07, 0.65). In 4 other studies, polyurethane semipermeable transparent film dressings were significantly favored over nonmoist dressings with regard to infection rates (OR = 0.28, 95% CI = 0.09, 0.91). For the outcome of pain, varied outcome measures and insufficient data prevented analysis among specific types of moist dressings.
Conclusions: Moist dressings decreased the days to complete healing and pain scores when compared with nonmoist dressings. Among the broad categories of nonmoist and moist dressings, no differences were found in infection rates. The data on specific types of moist dressings revealed that days to complete healing were decreased with hydrocolloid dressings compared with nonmoist and other moist dressings. Hydrocolloid dressings also decreased infection rates compared with nonmoist dressings. Polyurethane semipermeable transparent film dressings also decreased days to complete healing and infection rates compared with nonmoist dressings. Overall, the data indicated that hydrocolloid dressings are more effective than nonmoist dressings in terms of rates of healing, infection, and pain in the management of superficial to partial-thickness wounds. The variations in outcome measures among the included studies should be considered in interpreting these findings.
PMCID: PMC1978464  PMID: 18059999
moist dressings; abrasions
19.  Effects of Three Types of Japanese Honey on Full-Thickness Wound in Mice 
Although many previous studies reported that honey promotes wound healing, no study has examined the effects of Japanese honey. The aim of this study was to investigate the effects of three types of Japanese honey, Acacia, Buckwheat flour, and Chinese milk vetch honey, on wound healing in comparison with hydrocolloid dressing. Circular full-thickness skin wounds were produced on male mice. Japanese honey or hydrocolloid dressing was applied daily to the mice for 14 days. The ratio of wound area for the hydrocolloid dressing group increased initially in the inflammatory and early proliferative phases and then decreased rapidly to heal with scarring. However, the ratios of wound area for the Japanese honey groups decreased in the inflammatory phase, increased in the proliferative phase, and decreased in the proliferative phase, and some wounds were not completely covered with new epithelium. These findings indicate that using Japanese honey alone has limited benefit, but since it reduces wound size in the inflammatory phase, it is possible to apply a combined treatment in which Japanese honey is applied only in the inflammatory phase, followed by hydrocolloid dressing from the proliferative phase, which would effectively contract the wound.
PMCID: PMC3563239  PMID: 23401714
20.  Antimicrobial Effect of Bee Honey in Comparison to Antibiotics on Organisms Isolated From Infected Burns 
Despite recent advances in antimicrobial chemotherapy and burn wound management, infection continues to be an important problem in burns. Honey is the most famous rediscovered remedy that is used to treat infected wounds and promote healing. The present study aims to evaluate the antimicrobial effect of bee honey on organisms isolated from infected burns in comparison to the antibiotics used in treatment of burn infection, and to evaluate the effects produced when bee honey is added to antibiotic discs. Thirty patients with burn infection were selected for this study. The collected specimens were cultured on blood agar plates. The isolated colonies were identified by different methods. The isolated organisms were inoculated onto Müller-Hinton agar. Each agar plate was divided by a marker pen into two halves - in one half the antibiotic discs were plated while on the opposite side each antibiotic disc, immersed in honey, was plated opposite to the same antibiotic disc. At the centre of the agar, a sterile filter paper disc immersed in honey was applied. The most frequently isolated organism was Pseudomonas aeruginosa, representing 53.3% of the isolates. The mean inhibition zones (in mm) produced by honey (18.2 ± 2.5 mm) when applied to isolated gram-negative bacteria were significantly higher than amoxicillin/clavulinic acid, sulbactam/ampicillin, and ceftriaxone (p1 = 0.005 for each). When honey was added to the antibiotic discs there was highly significant increased sensitivity of isolated gram-negative bacteria compared with each of the antibiotic discs alone and with honey alone. The susceptibility of isolated staphylococci revealed the synergistic effect of added honey to the antibiotic discs tested. The antimicrobial effect of honey (18.7 ± 2.2 mm) was significantly higher than antibiotics - ciprofloxacin, sulbactam/ampicillin, ceftriaxone, and vancomycin (p1 ≤ 0.05 for each). After the addition of honey to the tested antibiotic discs there were highly significant increased inhibition zones of antibiotic mixed with honey compared with antibiotic alone - ciprofloxacin, vancomycin, and methicillin (p3 ≤ 0.001 for each). Also, the increase was significant compared with antibiotics alone - imipenem, amoxicillin/clavulinic acid, and ceftriaxone (p3 ≤ 0.05). In conclusion, honey had more inhibitory effect (85.7%) on isolated gram-negative bacteria (Pseudomonas aeruginosa, Enterobacter spp., Klebsiella) than commonly used antibiotics, while it had an inhibitory effect on all methicillin-resistant Staphylococcus aureus (100%) compared with antibiotics used. A synergistic effect of honey was observed when it was added to antibiotics for gram-negative bacteria and also for coagulase-positive staphylococci.
PMCID: PMC3188067  PMID: 21991075
21.  A porcine model of full-thickness burn, excision and skin autografting 
Acute burn wounds often require early excision and adequate coverage to prevent further hypothermia, protein and fluid losses, and the risk of infection. Meshed autologous skin grafts are generally regarded as the standard treatment for extensive full-thickness burns. Graft take and rate of wound healing, however, depend on several endogenous factors. This paper describes a standardized reproducible porcine model of burn and skin grafting which can be used to study the effects of topical treatments on graft take and re-epithelialization.
Procedures provide a protocol for successful porcine burn wound experiments with special focus on pre-operative care, anesthesia, burn allocation, excision and grafting, postoperative treatment, dressing application, and specimen collection. Selected outcome measurements include percent area of wound closure by planimetry, wound assessment using a clinical assessment scale, and histological scoring.
The use of this standardized model provides burn researchers with a valuable tool for the comparison of different topical drug treatments and dressing materials in a setting that closely mimics clinical reality.
PMCID: PMC2637517  PMID: 18617332
Burn; Burn excision; Wound healing; Reconstruction; Autograft
22.  Collagen Dressing Versus Conventional Dressings in Burn and Chronic Wounds: A Retrospective Study 
Biological dressings like collagen are impermeable to bacteria, and create the most physiological interface between the wound surface and the environment. Collagen dressings have other advantages over conventional dressings in terms of ease of application and being natural, non-immunogenic, non-pyrogenic, hypo-allergenic, and pain-free. This study aims to compare the efficacy of collagen dressing in treating burn and chronic wounds with that of conventional dressing materials.
Materials and Methods:
The records of 120 patients with chronic wounds of varied aetiologies and with mean age 43.7 years were collected and analyzed. The patients had been treated either with collagen or other conventional dressing materials including silver sulfadiazine, nadifloxacin, povidone iodine, or honey (traditional dressing material). Patients with co-morbidities that could grossly affect the wound healing like uncontrolled diabetes mellitus, chronic liver or renal disease, or major nutritional deprivation were not included. For the purpose of comparison the patients were divided into two groups; ‘Collagen group’ and ‘Conventional group’, each having 60 patients. For assessment the wound characteristics (size, edge, floor, slough, granulation tissue, and wound swab or pus culture sensitivity results) were recorded. With start of treatment, appearance of granulation tissue, completeness of healing, need for skin grafting, and patients’ satisfaction was noted for each patient in both groups.
With two weeks of treatment, 60% of the ‘collagen group’ wounds and only 42% of the ‘conventional group’ wounds were sterile (P=0.03). Healthy granulation tissue appeared earlier over collagen-dressed wounds than over conventionally treated wounds (P=0.03). After eight weeks, 52 (87%) of ‘collagen group’ wounds and 48 (80%) of ‘conventional group’ wounds were >75% healed (P=0.21). Eight patients in the ‘collagen group’ and 12 in the ‘conventional group’ needed partial split-skin grafting (P=0.04). Collagen-treated patients enjoyed early and more subjective mobility.
No significant better results in terms of completeness of healing of burn and chronic wounds between collagen dressing and conventional dressing were found. Collagen dressing, however, may avoid the need of skin grafting, and provides additional advantage of patients’ compliance and comfort.
PMCID: PMC3081477  PMID: 21572675
Burns; chronic wounds; collagen dressing
23.  Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials 
BMJ : British Medical Journal  2001;323(7316):773.
To determine whether a period of starvation (nil by mouth) after gastrointestinal surgery is beneficial in terms of specific outcomes.
Systematic review and meta-analysis of randomised controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery. Three electronic databases (PubMed, Embase, and the Cochrane controlled trials register) were searched, reference lists checked, and letters requesting details of unpublished trials and data sent to pharmaceutical companies and authors of previous trials.
Main outcome measures
Anastomotic dehiscence, infection of any type, wound infection, pneumonia, intra-abdominal abscess, length of hospital stay, and mortality.
Eleven studies with 837 patients met the inclusion criteria. In six studies patients in the intervention group were fed directly into the small bowel and in five studies patients were fed orally. Early feeding reduced the risk of any type of infection (relative risk 0.72, 95% confidence interval 0.54 to 0.98, P=0.036) and the mean length of stay in hospital (number of days reduced by 0.84, 0.36 to 1.33, P=0.001). Risk reductions were also seen for anastomotic dehiscence (0.53, 0.26 to 1.08, P=0.080), wound infection, pneumonia, intra-abdominal abscess, and mortality, but these failed to reach significance (P>0.10). The risk of vomiting was increased among patients fed early (1.27, 1.01 to 1.61, P=0.046).
There seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection. Early feeding may be of benefit. An adequately powered trial is required to confirm or refute the benefits seen in small trials.
What is already known on this topicEnteral feeding within 24 hours after gastrointestinal surgery is toleratedTheoretically, early enteral feeding improves tissue healing and reduces septic complications after gastrointestinal surgeryWhat this study addsThere is no benefit in keeping patients “nil by mouth” after gastrointestinal surgerySeptic complications and length of hospital stay were reduced in those patients who received early enteral feedingIn patients who received early enteral feeding there were no significant reductions in incidence of anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscess, and mortality
PMCID: PMC57351  PMID: 11588077
24.  Antibacterial properties of tualang honey and its effect in burn wound management: a comparative study 
The use of honey as a natural product of Apis spp. for burn treatment has been widely applied for centuries. Tualang honey has been reported to have antibacterial properties against various microorganisms, including those from burn-related diagnoses, and is cheaper and easier to be absorbed by Aquacel dressing. The aim of this study is to evaluate the potential antibacterial properties of tualang honey dressing and to determine its effectiveness as a partial thickness burn wound dressing.
In order to quantitate the bioburden of the swabs, pour plates were performed to obtain the colony count (CFU/ml). Swabs obtained from burn wounds were streaked on blood agar and MacConkey agar for bacterial isolation and identification. Later, antibacterial activity of Aquacel-tualang honey, Aquacel-Manuka honey, Aquacel-Ag and Aquacel- plain dressings against bacteria isolated from patients were tested (in-vitro) to see the effectiveness of those dressings by zone of inhibition assays.
Seven organisms were isolated. Four types of Gram-negative bacteria, namely Enterobacter cloacae, Klebsiella pneumoniae, Pseudomonas spp. and Acinetobacter spp., and three Gram-positive bacteria, namely Staphylococcus aureus, coagulase-negative Staphylococcus aureus (CONS) and Streptococcus spp., were isolated. Total bacterial count decreased on day 6 and onwards. In the in-vitro antibacterial study, Aquacel-Ag and Aquacel-Manuka honey dressings gave better zone of inhibition for Gram positive bacteria compared to Aquacel-Tualang honey dressing. However, comparable results were obtained against Gram negative bacteria tested with Aquacel-Manuka honey and Aquacel-Tualang honey dressing.
Tualang honey has a bactericidal as well as bacteriostatic effect. It is useful as a dressing, as it is easier to apply and is less sticky compared to Manuka honey. However, for Gram positive bacteria, tualang honey is not as effective as usual care products such as silver-based dressing or medical grade honey dressing.
PMCID: PMC2908556  PMID: 20576085
25.  The antibacterial properties of Malaysian tualang honey against wound and enteric microorganisms in comparison to manuka honey 
Antibiotic resistance of bacteria is on the rise, thus the discovery of alternative therapeutic agents is urgently needed. Honey possesses therapeutic potential, including wound healing properties and antimicrobial activity. Although the antimicrobial activity of honey has been effectively established against an extensive spectrum of microorganisms, it differs depending on the type of honey. To date, no extensive studies of the antibacterial properties of tualang (Koompassia excelsa) honey on wound and enteric microorganisms have been conducted. The objectives of this study were to conduct such studies and to compare the antibacterial activity of tualang honey with that of manuka honey.
Using a broth dilution method, the antibacterial activity of tualang honey against 13 wound and enteric microorganisms was determined; manuka honey was used as the control. Different concentrations of honey [6.25-25% (w/v)] were tested against each type of microorganism. Briefly, two-fold dilutions of honey solutions were tested to determine the minimum inhibitory concentration (MIC) against each type of microorganism, followed by more assays within a narrower dilution range to obtain more precise MIC values. MICs were determined by both visual inspection and spectrophotometric assay at 620 nm. Minimum bactericidal concentration (MBC) also was determined by culturing on blood agar plates.
By visual inspection, the MICs of tualang honey ranged from 8.75% to 25% compared to manuka honey (8.75-20%). Spectrophotometric readings of at least 95% inhibition yielded MIC values ranging between 10% and 25% for both types of honey. The lowest MBC for tualang honey was 20%, whereas that for manuka honey was 11.25% for the microorganisms tested. The lowest MIC value (8.75%) for both types of honey was against Stenotrophomonas maltophilia. Tualang honey had a lower MIC (11.25%) against Acinetobacter baumannii compared to manuka honey (12.5%).
Tualang honey exhibited variable activities against different microorganisms, but they were within the same range as those for manuka honey. This result suggests that tualang honey could potentially be used as an alternative therapeutic agent against certain microorganisms, particularly A. baumannii and S. maltophilia.
PMCID: PMC2753561  PMID: 19754926

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