(Final) Practical Application of Evidence Based Practice
Content
Practical Application of Evidence Based Practice (EBP) Module: PP0266 ______________________________________________________________ Title of research : (Review Honey as a topical treatment for wounds
!uthors
:
"ull# !ndrew$ %$
&chool of 'ursin(# )niversity of !uc*land# !uc*land# 'ew +ealand$
Rod(ers# !$
,epartment of Medicine# )niversity of !uc*land# -linical Trials Research )nit (-TR) # !uc*land# 'ew +ealand $
.al*er# '$
-linical Trials Research )nit# )niversity of !uc*land# !uc*land# 'ew +ealand
,ate of pu/lication
:
The -ochrane -olla/oration# 0ssue 1# 2002
Pu/lisher
:
"ohn .iley 3 &ons# 4td$
1
.ord count Introduction
:
5222 words
6vidence %ased Practice (6%P is a/out how to /ase one7s professional practice on the /est availa/le evidence$ Here# Concise Oxford Dictionary (Tenth Edition) defines the term evidence as information indicatin( whether a /elief or proposition is true or valid8 /ase as use somethin( as the foundation for or situate at place as the centre of operations8 professional practice as /elon(in( to a practisin( of a profession$ The term 6%P can /e summari9ed as the practisin( of a profession that relies on the information indicatin( trueness or validity which is the foundation for the practice$ To clarify this# 6%P is a practice that needs supports throu(h clear reasonin(# client7s preference and self:;ud(ement$ &ac*ett et al. (<22= has a more rounded definition on this as he relates the term with the decisions made /y us in everyday life$ The popularity of 6%P has put clients to the onus for the decision ma*in($ !ccordin( to 'ieswiadomy (2002 # the main core of the /usiness is to provide the patients or clients with the /est care /ased on their preferences and clinicians7 e>pertise$ 6%P has proven to /e si(nificantly su/tle in helpin( the clients or patients with the decision ma*in( process$ &ac*et et al$ (<22= seconds on this when he stated that 6%P is the /est approach of evidence to /e used /ecause of its conscientious# e>plicit and ;udicious characteristics$ .hen a researcher is en(a(in( in a research or wor* to see* the /est solution 6%P is considered as a useful scientific in?uiry to /e applied on$ @erlin(er (<2A6 did mention a/out the two types of research$ They are namely /asic research and applied research$ !ccordin( to him# /asic research is implemented when testin( the theory on the latest medical information as applied research often serves the purpose to see* for the immediate solutions throu(h (eneratin( *nowled(e$ Harris (2001 did mention a/out this in ma*in(
2
an accurate decision for the patient care that he thin*s should /e practiced /y healthcare providers$ The scientific in?uiry can /e carried out successfully throu(h the scientific study with appropriate methodolo(y used in the research$ 6vidence for (ood practice can /e easily adopted throu(h the advances in health and social care research and the hu(e information made availa/le throu(h communication technolo(y$ The way how health and social care professionals access# evaluate and ma*e sense of the information that is availa/le to them helps facilitatin( the culture of 6%P$
Background
Ministry of Health Malaysia has put its efforts and commitment to ensure that the healthcare services provided in Malaysia is sustaina/le$ Bor the past few decades# healthcare services in Malaysia have e>panded rapidly and !ssistant Medical Cfficers have constantly revolved around in promotin( health for all# especially in rural areas$ !ssistant Medical Cfficers (!MCs # previously *nown as Medical !ssistants (M! # are one (roup of the essential healthcare providers in the Pu/lic Health Pro(rams in Malaysia$ 6ffective primary healthcare delivery helps to reduce the /urden of disease in the country$ !MCs have contri/uted tremendously to the primary healthcare# especially for the rural population$ The contri/ution is made throu(h their holistic approach in health promotion# disease prevention# curative and reha/ilitative mana(ement$ Hence# this effective healthcare delivery in the early detection helps to reduce the num/er of cases that re?uire secondary health$ To sustain the effective healthcare delivery# !MCs should update their *nowled(e and s*ills in recent advances in clinical mana(ement$
3
!s one of the senior assistant medical official in the state community service# my ;o/ has ran(ed from (overn the people and resources in my department to the Dhands on7 medical routines as performin( medical or sur(ical treatment to the people who turn up with sur(ical wounds or /urns$ 0 have to /e readily prepared to stand out at the frontline when there7s a situation that needs e>tra men power or emer(encies$ 0 shall or /e accounted to perform dressin(s to those who show up with minor acute wounds such as mild to moderate partial thic*ness /urns and sur(ical wounds as well$ &ometimes# there are people who are sufferin( much serious condition wounds or chronic wounds such as ulcers (le( or pressure ulcers # post:sur(ical wounds or traumatic wounds$ %y followin( the Standard Operation Procedures (SOPs in performin( dressin(s# they were ta*in( care accordin(ly$ 0 refer to conventional dressin(s that 0 have *nown /efore such as impre(nated (au9e# saline soa*s or polyurethane film dressin(s in dealin( with mild or moderate partial thic*ness /urns$ 0 have /een advised /y my senior collea(ue to perform dressin( with caution when dealin( with chronic wounds such as le( ulcers# pressure ulcers# and post:sur(ical wounds or traumatic wounds$ 0 shall proceed with the recommended treatments /y usin( saline soa*ed (au9e# antiseptic washes# hydro(el or usual care$ The statistic of the dressin(s performed at my department each month e>ceeded 20 cases (min to E0 cases (ma> with full or complete recovery from the wounds within the recoverin( period of E:<1 wee*s at len(th$ 0 have encountered circumstances where there were insufficient dressin( utensils to perform the wound dressin(s$ The emer(ency:dreadin( situation has left me with no other option /ut to leave out the conventional dressin( to the unconventional dressin( /y usin( honey$ The reason why honey was chosen for dressin( is /ecause 0 have seen my senior collea(ues performed the dressin(s previously that seemed wor*in( well on minor acute and chronic
4
wounds$ !ccordin( to the authors# acute and chronic wounds are names that no lon(er new to this medical profession /ecause they have already /een used re(ularly in clinical practice with little attention on its definition$ Brom my previous *nowled(e on honey# 0 have read a/out its usa(e in traditional medical systems as food# preservatives for her/al medicines and wound dressin( as well$ &till# there is lac*in( of information in treatin( wounds with honey dressin( in the country$ 0t is /elieved that honey potentially have many practical health uses$ 0t has /een used as an ointment for rashes and /urns in ancient time$ %esides# it is also /elieved that honey helps to soothe sore throats when other medicinal practices were failed$ 0n animal studies it has /een demonstrated histolo(ically honey causes no tissue dama(e$ The effect of honey on animals such as mice# rat# ra//it and pi( was evidenced from the research /y (Cryan# <22A $ 0t showed that honey may accelerate the healin( of the wounded animals$ The dressin( procedure is started with the cleanin( of the wound first# even thou(h many reports have indicated that honey has a cleansin( and de/ridement action on wounds (Molan# <22A $ Here# 0 would li*e to ma*e my critical analysis on this unconventional dressin( of usin( honey in the practice despite of more reports of its effectiveness in clinical practice are pu/lished$ &ome trials have performed with some other unconventional dressin(s such as treatment with /oiled potato peel (&u/rahmanyam# <226/ # treatment with amniotic mem/ranes (&u/rahmanyam# <221 and treatment with honey:plus# a type of un:diluted honey of which has enhanced with vitamins especially acid ascor/ic and lecithin# and P6F (&u/rahmanyam# <226c $ The results from the trials are varia/le with the ris* of /ias presents$ The poor ?uality reports of the trials were seen /ut the findin(s somehow su((est an effect in favour of honey$ !ccordin( to Molan (200< # honey has stood out where conventional modern therapeutic a(ents such as antiseptic and usual care are failin( in treatin( infected wounds$ Many pu/lished reports have mentioned the rapidity of
5
honey in clearin( infection from wounds without any or controlled adverse effects found (Molan# 200< $ GHoney as a topical treatment for woundsH# is the title of the research that 0 am (oin( to appraise in detail and therefore critically analysis on its feasi/ility in medical practice$ !ccordin( to &anto (2000 # the main compositions of su(ar found in honey are (lucose# fructose# sucrose and water$ %esides# there are some other su/stances li*e vitamins# minerals and useful en9ymes traced in honey$ The studies of honey were mostly concentrated on its anti/acterial activity rather than its healin( effect on the wounds may trace (Molan# <222 $ This research team was led /y !ndrew % "ull# alon( with !nthony Rod(ers and 'atalie .al*er from )niversity of !uc*land# !uc*land# 'ew +ealand$ The research is considered as an intervention review on usin( honey as a topical treatment for wounds$ The authors have used different sources of data/ase especially some availa/le advanced electronic searches$ The research was pu/lished in an edited version with no chan(e to conclusions in Issue 4, !!", The Cochrane Colla#oration$ 0t was pu/lished /y $ohn %iley & Sons, 'td$ The reasons why this research paper is chosen are /ecause it (ives a comprehensive review on the overall studies and clinical practice that have ta*en place$ The clinical results of the related topic on honey are collected and reviewed$ .ound healin( is the main endpoint as the selection criteria without any restriction in term of source# date of pu/lication or lan(ua(e$ 0 was convinced with these research outcomes as the data from the eli(i/le were e>tracted and summarised$ The unpu/lished trials have /een searched to provide this research with comprehensive review$ The a/stract helps reader to have /etter an overall understandin( to the research study ('ieswiadomy# 2002 $ Throu(h the a/stract# 0 (ot an overview on the research as the a/stract has clearly summarised the ma;or *ey points
6
of its /ac*(round# /rief o/;ectives# data collection and analysis# main results and author7s conclusion$ Methodology
!s this research paper is primarily reviewin( the interventions it has stated some of the criteria that can /e considered in the studies of this review$ The review has considered types of studies conducted# types of participants to /e involved# types of interventions to /e compared and types of outcome measures$ The authors were usin( a wide ran(e of search methods for the identification of studies$ Throu(h the electronic searches# the electronic data/ase underta*en such as -ochrane .ounds Froup &pecialist Re(ister and The -ochrane -entral Re(ister of -ontrolled Trials (-6'TR!4 were searched for relevant studies$ 0 was impressed with the authors7 effort as they had personally made contact with e>perts in the field# real authors of the trials and studies and manufacturers of honey products for wound care to (ive the review with the /est up:to:date information$ &ometimes the authors were facin( insufficient information on the trials /ut they have mana(ed to resolve them /y discussion$ The research has clearly listed the outcomes to /e measured as primary outcomes and secondary outcomes$ Bor the primary outcomes# the authors stated the need for the trials to at least provide one of the data from either the time for the completion of wound healin( or the proportion of the healed wounds participants$ The secondary outcomes consist of the incidence of adverse events# hospital len(th of stay# chan(e o/served in wound si9e# incidence of infection# cost and ?uality of life$ Brom my point of view# the secondary outcomes will only provide the necessary information a/out the healin( of wounds when they are needed$
7
Critical Analysis
The aim of this review was /ased on the use of honey in acute and chronic wound healin($ The use of honey that confers any /enefit in the healin( of wounds will /e discussed$ !lthou(h only two of the authors were loo*in( into the potential trials of the relevant research /ut they did it independently /y referrin( to their inclusion criteria$ This is to ma*e sure the findin(s achieve neutrality and persistence$ The mutual understandin( is important in the process of the study of trials$ %oth of them mana(ed to resolve their stands throu(h discussion$ The e>traction of data was done and reviewed independently /y the authors for accuracy and persistence$ .hen they encountered with am/i(uity or inade?uate data# additional information was si(ht from the trial authors$ &ometimes# they faced with insufficient of data a/out the included trials$ The authors were una/le to review all the si>ty:one citations /ecause thirty:three of them were found not the trial reports# were animal model studies# honey was not as an intervention# the participant did not have a wound or lac* of interpreta/le data$ 0 would personally su((est that the authors continue their effort to ma*e contact with the trials authors in renderin( data of the trials$ Most of the trials were /ounded with the dissimilarity of the items mentioned in secondary outcomes$ The results from the included trials were collected with their tar(eted population and comparison interventions$ The results to /e reviewed cannot /e treated individually$ The authors com/ined the results from the trials that sufficiently ali*e in terms of population and comparison interventions$ The methodolo(ical ?uality of the trials may /e influenced /y the ris* of /ias as most trials fails to ade?uately report on randomisation$ !ccordin( to &chul9 (<22E # the randomisation and location concealment are *nown as study desi(n elements
8
that reduce the ris* of /ias$ 0n this review# randomisation method and allocation concealment are define respectively the se?uence (eneration of usin( random num/er ta/les# computer random num/er (eneration# coin tossin(# or shufflin( and the allocation that was concealed usin( a randomisation method$ Brom the review# it showed that the trial report still lac*in( of information provided /y the trial authors$ Cther study desi(n elements identified were loss to follow up in which <1 trials were reported# use of intention to treat analysis (0TT # use of /lindin( and /aseline compara/ility for pro(nostic factors showed that /aseline e?uivalence was found to /e present in << trials solely /y one author$ Marshall (200E stated that in each instance the lac* of proportion as the result of the a/sence of e?uivalent (roup in one study may favour the comparison treatment$ The results from the review stated that for minor acute wounds and /urns# the com/ination of trials findin(s was ta*en on usin( a fi>ed effect model$ !s for the chronic wounds# (iven the clinical and methodolo(ical hetero(eneity /etween the trials it was not possi/le to come out with the summary statistic$ 0ncidence of infection was reported durin( the trials$ "ull (200A perceived infection as a positive swa/ result and use of anti/iotic to treat in one trial$ 0t was descri/ed as clinically dia(nosed that re?uires referral of anti/iotics$ Two trials on cost information were reviewed$ 0t showed that the cost per patient for usin( honey was cheaper than hydro(el$ The findin(s also mentioned that the incremental cost effectiveness ratios could /e misleadin( as effectiveness in the review was not esta/lished$ The healin( rates in wounds varied$ &ome authors found that honey had no si(nificant effect on healin( rates (Fethin# 200=8 0n(le# 20068 "ull# 200A $ Marshall (200E did su((est that the healin( rates of honey were si(nificantly slower in favour the comparison treatment$ 0n the discussion of result identification minor acute wounds such as a/rasions and lacerations with honey dressin( were not a/le to /e ;ustified its effect in
9
healin( rates$ The findin(s of honey with respect to the treatment of /urns showed that honey had mi>ed evidence in healin( rates$ Honey was found to delay the healin( in mi>ed depth /urns$ The evidence also showed that honey dressin( performed /etter than /oiled potato dressin(s$ However# it appeared honey may /e as an effect of the comparison treatment delayin( healin($ The use of honey did not si(nificantly decrease infection rates in other types of wounds$ The authors mention that the accurate identification of wound infection is a difficult clinical issue in other types of wounds# particularly chronic wounds$ Cn the other hand# three trials of comparison treatment with silver sulfadia9ine were held and discussed$ 0t showed that treatment with silver sulfadia9ine can only /e used for a limited len(th of time# not the entire treatment period (!--# 200= $ Hetero(eneity was detected in one trial /ut the cause of hetero(eneity was not a/le to /e determined in the trial (&u/rahmanyam# <22< $ This review has ta*en in consideration of a comple> situation with different types of wounds as included trials$ The trials were treated as individuals or /y (roups of similarity in population and intervention$ The outcomes of the trials should /e interpreted with caution as the <2 trials in this review did not consistent with the methodolo(ical ?uality used and the e>istence of moderate to hi(h ris* of /ias may influence the results$ 0 a(reed with the authors on the implications for replica/ility that may persist since the trials were mostly of sin(le author or sin(le centre trials$ 'o recommendations were made in previous review due to the trials were performed /y the same sole researcher$ The findin(s of this review su((ested <2 trials compared with = trials in previous review$ Moore (200< indicated that this review has advanced those in the previous one$ 0n addition# the ?uality of the recent reports is increased$ This review has discussed some of the limitations that may arise$ The authors su((ested the use of survival analysis to analy9e time to event data is more
10
appropriate than the use of mean time to healin($ 0 thin* due to lac* of availa/le trials with the use of survival analysis has restricted the authors to usin( a common metric provided /y the included trials$ ,ifficulties arouse where authors were not a/le to provide sufficient data of their ori(inal pu/lications in the review$ There were some of the trials reports /ein( held retained as no responses or feed/ac* from the authors$ Therefore# the trial results were prohi/ited from incorporatin( into current review$ The presence of si(nificant statistical hetero(eneity mentioned in the two trials su((ests the com/ination would /e a random effects model$ !ccordin( to the protocol# the 0I was used to identify sources of hetero(eneity$ The authors also mentioned a/out the possi/ility of not a/le to evaluate the overall /ias pu/lished$ Here# the author only com/ined the similar trials and re;ected the dissimilar ones$
Conclusion
&ome clinical o/servations reported honey rapidly cleared the wound infection (Molan# 200<8 Molan# <22A # reduced the inflammation and swellin($ 0t is /elieved that the antimicro/ial properties of honey prevent micro/ial (rowth in the moist healin( environment$ 0n this review# it shows that honey dressin( do not si(nificantly increase rates of healin( of venous le( ulcers at <2 wee*s when used as an ad;uvant to compression$ 0 a(ree with the authors7 su((estion that survival analysis is more appropriate to event data compared to mean time to healin($ Trials are e>plored whether the use of honey has any relevance to modern wound mana(ement$ %ut the ma;or pro/lem lac*in( all the way has always /een the lac* of hi(h ?uality comparative evidence for /oth conventional and unconventional treatments$
11
Implications for practice and research
0t is ar(ua/ly that whether the honey dressin( should /e practiced in clinical practice$ The authors found that the insufficient evidence in these areas or other areas has led to the uncertainty and varia/le in usin( honey for wound dressin($ Borm the outcomes of the review# it shows that at certain types of wounds such as mild to moderate superficial and partial thic*ness /urns honey may improve healin( times /etter than conventional dressin(s$ 0 would su((est the clinical practitioners to revise their *nowled(e and study on this review /efore they turn for honey$ Jet# the authors recommend that honey dressin( should /e practiced in caution until sufficient evidence of effect is availa/le$ Molan# 200< stated that in present# more research in this area is needed to rectify the therapeutic interventions used in modern wound care$ !lthou(h most of the research were conducted and resulted in the a/sence of data from well controlled clinical trials# it is necessary to draw on clinical e>perience and anecdotal reports (Molan# 200< and yet# clinical decisions should /e made more sensi/le and accepta/le lo(ically$
The recommendations for practice of honey dressin( in research are /ased on the assessment of the included trials$ The authors /elieve that trial should /e held in sin(le condition and there should /e sufficient statistical power to deal with multi aetiolo(ies that may recruited$ 0 would certainly a(ree on this as the /est practice of 6%P is to achieve the /est evidence$ ! primary outcome should /e identified to proceed with the calculation of a sample si9e within the trials$ To achieve (ood results of the trials# effort made to follow up as close as possi/le is hi(hly needed$ The authors did not mention a/out the way they dealt with missin( data from participants who lost to follow up$ 4astly# the
12
authors recommend that reported ;ournals should re?uire that trials are consistent with the -onsolidated &tatement on Reportin( of Trials (!ltman# 200< and re(istered to the trials re(ister to meet the .HC criteria$ Honey is considered /y pu/lic that it is a natural product of which its characteristics that are associated with wound healin( may /e affected /y species of /ee# (eo(raphical location and /otanical ori(in$ 0n addition processin( and stora(e conditions may pose some *nown influence to wound healin($
Reference !$-$-$ (200= !ccident -ompensation -orporation$ (ana)e*ent of #urns and scalds in pri*ary care. E+idence,#ased practice )uideline $ .ellin(ton: !ccident -ompensation -orporation# 200=$ !ltman# ,$F$# &chul9# @$B$# Moher# ,$# 6((er# M$# ,avidoff# B$# 6l/ourne# ,$# et al$ (200< The revised -C'&CRT statement for reportin( randomi9ed trials: e>planation and ela/oration$ -nnals of Internal (edicine 200<8 !"(A :665K 21$ Harris# @$P$ (2001 6vidence %ase Healthcare: In Case -pplication in .ursin) 'eadership & (ana)e*ent$ Thomson ,elmer 4earnin(# 'ew Jor*$ "ull# !$ (200A /oney as -d0u+ant 'e) 1lcer Therapy trial colla#orators $ Randomi9ed clinical trial of honey:impre(nated dressin(s for venous le( ulcers$ 2ritish $ournal of Sur)ery 200A8 #$(2 :<=EKA2$
13
Fethin# F$ (200= (anu3a honey +ersus hydro)el : a prospective# open la/el# multicentre# randomised controlled trial to compare deslou(hin( efficacy and healin( outcomes in venous ulcers$ 1npu#lished PhD thesis !!4$ 0n(le R# 4evin "# Polinder @$ (2006 .ound healin( with honey K a randomised controlled trial$ South -frican (edical $ournal 20068 #% (2 :A5<KE$ @erlin(er# B$ (<2A6 5oundations of #eha+iour research$ Third 6dition$ 'ew Jor*: Holt# Rinehart 3 .inston$ Marshall -# Lueen "# Man;ooran# "$ (200E Honey vs po+idine iodine followin( toenail sur(ery$ %ounds 16 200E8 (< :<0K<A$ Molan# P$-$ (<222 %hy honey is effecti+e as a *edicine$ <$ 0ts use in modern medicine$ 2ee %orld <2228 &':A0K22$ Molan# P$-$ (200< %hy honey is effecti+e as *edicine$ 2$ The scientific e>planation of its effects$ 2ee %orld 200<8 &(:22K10$ Molan# P$-$ (200< Honey as a topical anti/acterial a(ent for treatment of infected wounds$ Moore# C$!$# &mith# 4$!$# -amp/ell# B$# &eers# @$# McLuay# H$"$# Moore# R$!$ (200< &ystematic review of the use of honey as a wound care dressin($ 2(C Co*ple*entary & -lternati+e (edicine 200<8 (2 $
http:MMwww$/iomedcentral$comM<1=2K6AA2M<M2$
'ieswiadomy# R$M$ (2002 5oundations of .ursin) 7esearch$ Bourth 6dition$ Prentice Hall Health# )pper &addle River# 'ew "ersey$
14
Cryan !$# +a*er# &$R$ (<22A 6ffects of topical application of honey on coetaneous wound healin( in ra//its$ $ournal of 8eterinary (edicine Series - <22A8 "$(5 :<A<K5$ &ac*ett# ,$4$# Richardson# .$&$# Rosen/er(# .$ 3 Haynes# R$R$ (<22= 6vidence %ase Medicine and Teach 6vidence %ase Medicine$ -hurchil 4ivin(stone# 6din/ur(h$ &ato# T$# Miyata# F$ (2000 The nutraceutical #enefit# part 000: honey$ .utritional Phar*aceuticals 20008 %:16AK2$ &chul9# @$B$# -halmers# 0$# Hays# R$"$# !ltman# ,$F$ (<22E 6mpirical evidence of /ias$ ,imensions of methodolo(ical ?uality associated with estimates of treatment effects in controlled trials$ $-(- <22E8 ()!: 10AK<2$ &u/rahmanyam# M$ (<22< Topical application of honey in treatment of /urns$ 2ritish $ournal of Sur)ery <22<8 )&(= :12=KA$ &u/rahmanyam# M$ (<221 Honey:impre(nated (au9e versus amniotic mem/rane in the treatment of /urns$ 2urns <2218 ('(1 :55<K555$ &u/rahmanyam# M$ (<226/ Honey dressin( versus /oiled potato peel in the treatment of /urns: a prospective randomi9ed study$ 2urns <2268 (((6 :12<K5$ &u/rahmanyam# M$ (<226c !ddition of antio>idants and polyethylene (lycol 1000 enhances the healin( property of honey in /urns$ -nnals of 2urns and 5ire Disasters <2268 I* (2 :25KE$
15
!uthors
:
"ull# !ndrew$ %$
&chool of 'ursin(# )niversity of !uc*land# !uc*land# 'ew +ealand$
Rod(ers# !$
,epartment of Medicine# )niversity of !uc*land# -linical Trials Research )nit (-TR) # !uc*land# 'ew +ealand $
.al*er# '$
-linical Trials Research )nit# )niversity of !uc*land# !uc*land# 'ew +ealand
,ate of pu/lication
:
The -ochrane -olla/oration# 0ssue 1# 2002
Pu/lisher
:
"ohn .iley 3 &ons# 4td$
1
.ord count Introduction
:
5222 words
6vidence %ased Practice (6%P is a/out how to /ase one7s professional practice on the /est availa/le evidence$ Here# Concise Oxford Dictionary (Tenth Edition) defines the term evidence as information indicatin( whether a /elief or proposition is true or valid8 /ase as use somethin( as the foundation for or situate at place as the centre of operations8 professional practice as /elon(in( to a practisin( of a profession$ The term 6%P can /e summari9ed as the practisin( of a profession that relies on the information indicatin( trueness or validity which is the foundation for the practice$ To clarify this# 6%P is a practice that needs supports throu(h clear reasonin(# client7s preference and self:;ud(ement$ &ac*ett et al. (<22= has a more rounded definition on this as he relates the term with the decisions made /y us in everyday life$ The popularity of 6%P has put clients to the onus for the decision ma*in($ !ccordin( to 'ieswiadomy (2002 # the main core of the /usiness is to provide the patients or clients with the /est care /ased on their preferences and clinicians7 e>pertise$ 6%P has proven to /e si(nificantly su/tle in helpin( the clients or patients with the decision ma*in( process$ &ac*et et al$ (<22= seconds on this when he stated that 6%P is the /est approach of evidence to /e used /ecause of its conscientious# e>plicit and ;udicious characteristics$ .hen a researcher is en(a(in( in a research or wor* to see* the /est solution 6%P is considered as a useful scientific in?uiry to /e applied on$ @erlin(er (<2A6 did mention a/out the two types of research$ They are namely /asic research and applied research$ !ccordin( to him# /asic research is implemented when testin( the theory on the latest medical information as applied research often serves the purpose to see* for the immediate solutions throu(h (eneratin( *nowled(e$ Harris (2001 did mention a/out this in ma*in(
2
an accurate decision for the patient care that he thin*s should /e practiced /y healthcare providers$ The scientific in?uiry can /e carried out successfully throu(h the scientific study with appropriate methodolo(y used in the research$ 6vidence for (ood practice can /e easily adopted throu(h the advances in health and social care research and the hu(e information made availa/le throu(h communication technolo(y$ The way how health and social care professionals access# evaluate and ma*e sense of the information that is availa/le to them helps facilitatin( the culture of 6%P$
Background
Ministry of Health Malaysia has put its efforts and commitment to ensure that the healthcare services provided in Malaysia is sustaina/le$ Bor the past few decades# healthcare services in Malaysia have e>panded rapidly and !ssistant Medical Cfficers have constantly revolved around in promotin( health for all# especially in rural areas$ !ssistant Medical Cfficers (!MCs # previously *nown as Medical !ssistants (M! # are one (roup of the essential healthcare providers in the Pu/lic Health Pro(rams in Malaysia$ 6ffective primary healthcare delivery helps to reduce the /urden of disease in the country$ !MCs have contri/uted tremendously to the primary healthcare# especially for the rural population$ The contri/ution is made throu(h their holistic approach in health promotion# disease prevention# curative and reha/ilitative mana(ement$ Hence# this effective healthcare delivery in the early detection helps to reduce the num/er of cases that re?uire secondary health$ To sustain the effective healthcare delivery# !MCs should update their *nowled(e and s*ills in recent advances in clinical mana(ement$
3
!s one of the senior assistant medical official in the state community service# my ;o/ has ran(ed from (overn the people and resources in my department to the Dhands on7 medical routines as performin( medical or sur(ical treatment to the people who turn up with sur(ical wounds or /urns$ 0 have to /e readily prepared to stand out at the frontline when there7s a situation that needs e>tra men power or emer(encies$ 0 shall or /e accounted to perform dressin(s to those who show up with minor acute wounds such as mild to moderate partial thic*ness /urns and sur(ical wounds as well$ &ometimes# there are people who are sufferin( much serious condition wounds or chronic wounds such as ulcers (le( or pressure ulcers # post:sur(ical wounds or traumatic wounds$ %y followin( the Standard Operation Procedures (SOPs in performin( dressin(s# they were ta*in( care accordin(ly$ 0 refer to conventional dressin(s that 0 have *nown /efore such as impre(nated (au9e# saline soa*s or polyurethane film dressin(s in dealin( with mild or moderate partial thic*ness /urns$ 0 have /een advised /y my senior collea(ue to perform dressin( with caution when dealin( with chronic wounds such as le( ulcers# pressure ulcers# and post:sur(ical wounds or traumatic wounds$ 0 shall proceed with the recommended treatments /y usin( saline soa*ed (au9e# antiseptic washes# hydro(el or usual care$ The statistic of the dressin(s performed at my department each month e>ceeded 20 cases (min to E0 cases (ma> with full or complete recovery from the wounds within the recoverin( period of E:<1 wee*s at len(th$ 0 have encountered circumstances where there were insufficient dressin( utensils to perform the wound dressin(s$ The emer(ency:dreadin( situation has left me with no other option /ut to leave out the conventional dressin( to the unconventional dressin( /y usin( honey$ The reason why honey was chosen for dressin( is /ecause 0 have seen my senior collea(ues performed the dressin(s previously that seemed wor*in( well on minor acute and chronic
4
wounds$ !ccordin( to the authors# acute and chronic wounds are names that no lon(er new to this medical profession /ecause they have already /een used re(ularly in clinical practice with little attention on its definition$ Brom my previous *nowled(e on honey# 0 have read a/out its usa(e in traditional medical systems as food# preservatives for her/al medicines and wound dressin( as well$ &till# there is lac*in( of information in treatin( wounds with honey dressin( in the country$ 0t is /elieved that honey potentially have many practical health uses$ 0t has /een used as an ointment for rashes and /urns in ancient time$ %esides# it is also /elieved that honey helps to soothe sore throats when other medicinal practices were failed$ 0n animal studies it has /een demonstrated histolo(ically honey causes no tissue dama(e$ The effect of honey on animals such as mice# rat# ra//it and pi( was evidenced from the research /y (Cryan# <22A $ 0t showed that honey may accelerate the healin( of the wounded animals$ The dressin( procedure is started with the cleanin( of the wound first# even thou(h many reports have indicated that honey has a cleansin( and de/ridement action on wounds (Molan# <22A $ Here# 0 would li*e to ma*e my critical analysis on this unconventional dressin( of usin( honey in the practice despite of more reports of its effectiveness in clinical practice are pu/lished$ &ome trials have performed with some other unconventional dressin(s such as treatment with /oiled potato peel (&u/rahmanyam# <226/ # treatment with amniotic mem/ranes (&u/rahmanyam# <221 and treatment with honey:plus# a type of un:diluted honey of which has enhanced with vitamins especially acid ascor/ic and lecithin# and P6F (&u/rahmanyam# <226c $ The results from the trials are varia/le with the ris* of /ias presents$ The poor ?uality reports of the trials were seen /ut the findin(s somehow su((est an effect in favour of honey$ !ccordin( to Molan (200< # honey has stood out where conventional modern therapeutic a(ents such as antiseptic and usual care are failin( in treatin( infected wounds$ Many pu/lished reports have mentioned the rapidity of
5
honey in clearin( infection from wounds without any or controlled adverse effects found (Molan# 200< $ GHoney as a topical treatment for woundsH# is the title of the research that 0 am (oin( to appraise in detail and therefore critically analysis on its feasi/ility in medical practice$ !ccordin( to &anto (2000 # the main compositions of su(ar found in honey are (lucose# fructose# sucrose and water$ %esides# there are some other su/stances li*e vitamins# minerals and useful en9ymes traced in honey$ The studies of honey were mostly concentrated on its anti/acterial activity rather than its healin( effect on the wounds may trace (Molan# <222 $ This research team was led /y !ndrew % "ull# alon( with !nthony Rod(ers and 'atalie .al*er from )niversity of !uc*land# !uc*land# 'ew +ealand$ The research is considered as an intervention review on usin( honey as a topical treatment for wounds$ The authors have used different sources of data/ase especially some availa/le advanced electronic searches$ The research was pu/lished in an edited version with no chan(e to conclusions in Issue 4, !!", The Cochrane Colla#oration$ 0t was pu/lished /y $ohn %iley & Sons, 'td$ The reasons why this research paper is chosen are /ecause it (ives a comprehensive review on the overall studies and clinical practice that have ta*en place$ The clinical results of the related topic on honey are collected and reviewed$ .ound healin( is the main endpoint as the selection criteria without any restriction in term of source# date of pu/lication or lan(ua(e$ 0 was convinced with these research outcomes as the data from the eli(i/le were e>tracted and summarised$ The unpu/lished trials have /een searched to provide this research with comprehensive review$ The a/stract helps reader to have /etter an overall understandin( to the research study ('ieswiadomy# 2002 $ Throu(h the a/stract# 0 (ot an overview on the research as the a/stract has clearly summarised the ma;or *ey points
6
of its /ac*(round# /rief o/;ectives# data collection and analysis# main results and author7s conclusion$ Methodology
!s this research paper is primarily reviewin( the interventions it has stated some of the criteria that can /e considered in the studies of this review$ The review has considered types of studies conducted# types of participants to /e involved# types of interventions to /e compared and types of outcome measures$ The authors were usin( a wide ran(e of search methods for the identification of studies$ Throu(h the electronic searches# the electronic data/ase underta*en such as -ochrane .ounds Froup &pecialist Re(ister and The -ochrane -entral Re(ister of -ontrolled Trials (-6'TR!4 were searched for relevant studies$ 0 was impressed with the authors7 effort as they had personally made contact with e>perts in the field# real authors of the trials and studies and manufacturers of honey products for wound care to (ive the review with the /est up:to:date information$ &ometimes the authors were facin( insufficient information on the trials /ut they have mana(ed to resolve them /y discussion$ The research has clearly listed the outcomes to /e measured as primary outcomes and secondary outcomes$ Bor the primary outcomes# the authors stated the need for the trials to at least provide one of the data from either the time for the completion of wound healin( or the proportion of the healed wounds participants$ The secondary outcomes consist of the incidence of adverse events# hospital len(th of stay# chan(e o/served in wound si9e# incidence of infection# cost and ?uality of life$ Brom my point of view# the secondary outcomes will only provide the necessary information a/out the healin( of wounds when they are needed$
7
Critical Analysis
The aim of this review was /ased on the use of honey in acute and chronic wound healin($ The use of honey that confers any /enefit in the healin( of wounds will /e discussed$ !lthou(h only two of the authors were loo*in( into the potential trials of the relevant research /ut they did it independently /y referrin( to their inclusion criteria$ This is to ma*e sure the findin(s achieve neutrality and persistence$ The mutual understandin( is important in the process of the study of trials$ %oth of them mana(ed to resolve their stands throu(h discussion$ The e>traction of data was done and reviewed independently /y the authors for accuracy and persistence$ .hen they encountered with am/i(uity or inade?uate data# additional information was si(ht from the trial authors$ &ometimes# they faced with insufficient of data a/out the included trials$ The authors were una/le to review all the si>ty:one citations /ecause thirty:three of them were found not the trial reports# were animal model studies# honey was not as an intervention# the participant did not have a wound or lac* of interpreta/le data$ 0 would personally su((est that the authors continue their effort to ma*e contact with the trials authors in renderin( data of the trials$ Most of the trials were /ounded with the dissimilarity of the items mentioned in secondary outcomes$ The results from the included trials were collected with their tar(eted population and comparison interventions$ The results to /e reviewed cannot /e treated individually$ The authors com/ined the results from the trials that sufficiently ali*e in terms of population and comparison interventions$ The methodolo(ical ?uality of the trials may /e influenced /y the ris* of /ias as most trials fails to ade?uately report on randomisation$ !ccordin( to &chul9 (<22E # the randomisation and location concealment are *nown as study desi(n elements
8
that reduce the ris* of /ias$ 0n this review# randomisation method and allocation concealment are define respectively the se?uence (eneration of usin( random num/er ta/les# computer random num/er (eneration# coin tossin(# or shufflin( and the allocation that was concealed usin( a randomisation method$ Brom the review# it showed that the trial report still lac*in( of information provided /y the trial authors$ Cther study desi(n elements identified were loss to follow up in which <1 trials were reported# use of intention to treat analysis (0TT # use of /lindin( and /aseline compara/ility for pro(nostic factors showed that /aseline e?uivalence was found to /e present in << trials solely /y one author$ Marshall (200E stated that in each instance the lac* of proportion as the result of the a/sence of e?uivalent (roup in one study may favour the comparison treatment$ The results from the review stated that for minor acute wounds and /urns# the com/ination of trials findin(s was ta*en on usin( a fi>ed effect model$ !s for the chronic wounds# (iven the clinical and methodolo(ical hetero(eneity /etween the trials it was not possi/le to come out with the summary statistic$ 0ncidence of infection was reported durin( the trials$ "ull (200A perceived infection as a positive swa/ result and use of anti/iotic to treat in one trial$ 0t was descri/ed as clinically dia(nosed that re?uires referral of anti/iotics$ Two trials on cost information were reviewed$ 0t showed that the cost per patient for usin( honey was cheaper than hydro(el$ The findin(s also mentioned that the incremental cost effectiveness ratios could /e misleadin( as effectiveness in the review was not esta/lished$ The healin( rates in wounds varied$ &ome authors found that honey had no si(nificant effect on healin( rates (Fethin# 200=8 0n(le# 20068 "ull# 200A $ Marshall (200E did su((est that the healin( rates of honey were si(nificantly slower in favour the comparison treatment$ 0n the discussion of result identification minor acute wounds such as a/rasions and lacerations with honey dressin( were not a/le to /e ;ustified its effect in
9
healin( rates$ The findin(s of honey with respect to the treatment of /urns showed that honey had mi>ed evidence in healin( rates$ Honey was found to delay the healin( in mi>ed depth /urns$ The evidence also showed that honey dressin( performed /etter than /oiled potato dressin(s$ However# it appeared honey may /e as an effect of the comparison treatment delayin( healin($ The use of honey did not si(nificantly decrease infection rates in other types of wounds$ The authors mention that the accurate identification of wound infection is a difficult clinical issue in other types of wounds# particularly chronic wounds$ Cn the other hand# three trials of comparison treatment with silver sulfadia9ine were held and discussed$ 0t showed that treatment with silver sulfadia9ine can only /e used for a limited len(th of time# not the entire treatment period (!--# 200= $ Hetero(eneity was detected in one trial /ut the cause of hetero(eneity was not a/le to /e determined in the trial (&u/rahmanyam# <22< $ This review has ta*en in consideration of a comple> situation with different types of wounds as included trials$ The trials were treated as individuals or /y (roups of similarity in population and intervention$ The outcomes of the trials should /e interpreted with caution as the <2 trials in this review did not consistent with the methodolo(ical ?uality used and the e>istence of moderate to hi(h ris* of /ias may influence the results$ 0 a(reed with the authors on the implications for replica/ility that may persist since the trials were mostly of sin(le author or sin(le centre trials$ 'o recommendations were made in previous review due to the trials were performed /y the same sole researcher$ The findin(s of this review su((ested <2 trials compared with = trials in previous review$ Moore (200< indicated that this review has advanced those in the previous one$ 0n addition# the ?uality of the recent reports is increased$ This review has discussed some of the limitations that may arise$ The authors su((ested the use of survival analysis to analy9e time to event data is more
10
appropriate than the use of mean time to healin($ 0 thin* due to lac* of availa/le trials with the use of survival analysis has restricted the authors to usin( a common metric provided /y the included trials$ ,ifficulties arouse where authors were not a/le to provide sufficient data of their ori(inal pu/lications in the review$ There were some of the trials reports /ein( held retained as no responses or feed/ac* from the authors$ Therefore# the trial results were prohi/ited from incorporatin( into current review$ The presence of si(nificant statistical hetero(eneity mentioned in the two trials su((ests the com/ination would /e a random effects model$ !ccordin( to the protocol# the 0I was used to identify sources of hetero(eneity$ The authors also mentioned a/out the possi/ility of not a/le to evaluate the overall /ias pu/lished$ Here# the author only com/ined the similar trials and re;ected the dissimilar ones$
Conclusion
&ome clinical o/servations reported honey rapidly cleared the wound infection (Molan# 200<8 Molan# <22A # reduced the inflammation and swellin($ 0t is /elieved that the antimicro/ial properties of honey prevent micro/ial (rowth in the moist healin( environment$ 0n this review# it shows that honey dressin( do not si(nificantly increase rates of healin( of venous le( ulcers at <2 wee*s when used as an ad;uvant to compression$ 0 a(ree with the authors7 su((estion that survival analysis is more appropriate to event data compared to mean time to healin($ Trials are e>plored whether the use of honey has any relevance to modern wound mana(ement$ %ut the ma;or pro/lem lac*in( all the way has always /een the lac* of hi(h ?uality comparative evidence for /oth conventional and unconventional treatments$
11
Implications for practice and research
0t is ar(ua/ly that whether the honey dressin( should /e practiced in clinical practice$ The authors found that the insufficient evidence in these areas or other areas has led to the uncertainty and varia/le in usin( honey for wound dressin($ Borm the outcomes of the review# it shows that at certain types of wounds such as mild to moderate superficial and partial thic*ness /urns honey may improve healin( times /etter than conventional dressin(s$ 0 would su((est the clinical practitioners to revise their *nowled(e and study on this review /efore they turn for honey$ Jet# the authors recommend that honey dressin( should /e practiced in caution until sufficient evidence of effect is availa/le$ Molan# 200< stated that in present# more research in this area is needed to rectify the therapeutic interventions used in modern wound care$ !lthou(h most of the research were conducted and resulted in the a/sence of data from well controlled clinical trials# it is necessary to draw on clinical e>perience and anecdotal reports (Molan# 200< and yet# clinical decisions should /e made more sensi/le and accepta/le lo(ically$
The recommendations for practice of honey dressin( in research are /ased on the assessment of the included trials$ The authors /elieve that trial should /e held in sin(le condition and there should /e sufficient statistical power to deal with multi aetiolo(ies that may recruited$ 0 would certainly a(ree on this as the /est practice of 6%P is to achieve the /est evidence$ ! primary outcome should /e identified to proceed with the calculation of a sample si9e within the trials$ To achieve (ood results of the trials# effort made to follow up as close as possi/le is hi(hly needed$ The authors did not mention a/out the way they dealt with missin( data from participants who lost to follow up$ 4astly# the
12
authors recommend that reported ;ournals should re?uire that trials are consistent with the -onsolidated &tatement on Reportin( of Trials (!ltman# 200< and re(istered to the trials re(ister to meet the .HC criteria$ Honey is considered /y pu/lic that it is a natural product of which its characteristics that are associated with wound healin( may /e affected /y species of /ee# (eo(raphical location and /otanical ori(in$ 0n addition processin( and stora(e conditions may pose some *nown influence to wound healin($
Reference !$-$-$ (200= !ccident -ompensation -orporation$ (ana)e*ent of #urns and scalds in pri*ary care. E+idence,#ased practice )uideline $ .ellin(ton: !ccident -ompensation -orporation# 200=$ !ltman# ,$F$# &chul9# @$B$# Moher# ,$# 6((er# M$# ,avidoff# B$# 6l/ourne# ,$# et al$ (200< The revised -C'&CRT statement for reportin( randomi9ed trials: e>planation and ela/oration$ -nnals of Internal (edicine 200<8 !"(A :665K 21$ Harris# @$P$ (2001 6vidence %ase Healthcare: In Case -pplication in .ursin) 'eadership & (ana)e*ent$ Thomson ,elmer 4earnin(# 'ew Jor*$ "ull# !$ (200A /oney as -d0u+ant 'e) 1lcer Therapy trial colla#orators $ Randomi9ed clinical trial of honey:impre(nated dressin(s for venous le( ulcers$ 2ritish $ournal of Sur)ery 200A8 #$(2 :<=EKA2$
13
Fethin# F$ (200= (anu3a honey +ersus hydro)el : a prospective# open la/el# multicentre# randomised controlled trial to compare deslou(hin( efficacy and healin( outcomes in venous ulcers$ 1npu#lished PhD thesis !!4$ 0n(le R# 4evin "# Polinder @$ (2006 .ound healin( with honey K a randomised controlled trial$ South -frican (edical $ournal 20068 #% (2 :A5<KE$ @erlin(er# B$ (<2A6 5oundations of #eha+iour research$ Third 6dition$ 'ew Jor*: Holt# Rinehart 3 .inston$ Marshall -# Lueen "# Man;ooran# "$ (200E Honey vs po+idine iodine followin( toenail sur(ery$ %ounds 16 200E8 (< :<0K<A$ Molan# P$-$ (<222 %hy honey is effecti+e as a *edicine$ <$ 0ts use in modern medicine$ 2ee %orld <2228 &':A0K22$ Molan# P$-$ (200< %hy honey is effecti+e as *edicine$ 2$ The scientific e>planation of its effects$ 2ee %orld 200<8 &(:22K10$ Molan# P$-$ (200< Honey as a topical anti/acterial a(ent for treatment of infected wounds$ Moore# C$!$# &mith# 4$!$# -amp/ell# B$# &eers# @$# McLuay# H$"$# Moore# R$!$ (200< &ystematic review of the use of honey as a wound care dressin($ 2(C Co*ple*entary & -lternati+e (edicine 200<8 (2 $
http:MMwww$/iomedcentral$comM<1=2K6AA2M<M2$
'ieswiadomy# R$M$ (2002 5oundations of .ursin) 7esearch$ Bourth 6dition$ Prentice Hall Health# )pper &addle River# 'ew "ersey$
14
Cryan !$# +a*er# &$R$ (<22A 6ffects of topical application of honey on coetaneous wound healin( in ra//its$ $ournal of 8eterinary (edicine Series - <22A8 "$(5 :<A<K5$ &ac*ett# ,$4$# Richardson# .$&$# Rosen/er(# .$ 3 Haynes# R$R$ (<22= 6vidence %ase Medicine and Teach 6vidence %ase Medicine$ -hurchil 4ivin(stone# 6din/ur(h$ &ato# T$# Miyata# F$ (2000 The nutraceutical #enefit# part 000: honey$ .utritional Phar*aceuticals 20008 %:16AK2$ &chul9# @$B$# -halmers# 0$# Hays# R$"$# !ltman# ,$F$ (<22E 6mpirical evidence of /ias$ ,imensions of methodolo(ical ?uality associated with estimates of treatment effects in controlled trials$ $-(- <22E8 ()!: 10AK<2$ &u/rahmanyam# M$ (<22< Topical application of honey in treatment of /urns$ 2ritish $ournal of Sur)ery <22<8 )&(= :12=KA$ &u/rahmanyam# M$ (<221 Honey:impre(nated (au9e versus amniotic mem/rane in the treatment of /urns$ 2urns <2218 ('(1 :55<K555$ &u/rahmanyam# M$ (<226/ Honey dressin( versus /oiled potato peel in the treatment of /urns: a prospective randomi9ed study$ 2urns <2268 (((6 :12<K5$ &u/rahmanyam# M$ (<226c !ddition of antio>idants and polyethylene (lycol 1000 enhances the healin( property of honey in /urns$ -nnals of 2urns and 5ire Disasters <2268 I* (2 :25KE$
15
