***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Approximately 10%–15 % of people with diabetes develop at least one foot ulcer during their lifetime . Treatment of diabetic foot ulcers ( DFUs ) represents a significant economic burden . Enzymatic debridement with clostridial collagenase ointment ( CCO ) can be used to remove necrotic tissue from wounds . This study examined the impact of CCO as an effective adjunct therapy to serial sharp debridement ( SSD ) and assessed the cost-effectiveness of CCO compared with st and ard DFU treatments over 1 year . Methods Adults 18 years or older with a diagnosis of type 1 or type 2 diabetes who had a neuropathic DFU were enrolled in a 12-week , r and omized , open-label trial . Patients were r and omly assigned to either treatment with CCO + SSD or to investigator-selected supportive care + SSD ( Control ) . A 3-state Markov model with a 1-week cycle length was developed using wound-closure rates from the trial to estimate the number of healed-wound weeks and the expected DFU cost per patient . The 3 states included unhealed , healed , and death . Results were extrapolated to 1 year to estimate the number of healed-wound weeks per treatment and the average cost to achieve epithelialization . The perspective of the analysis was that of the payer , specifically , the third party payer . Results The study sample included 55 patients ( 28 in CCO group ; 27 Control ) . The majority were men ( 74.5 % ) with a mean age of 57.9 years  . Projected healing rates were greater for the CCO + SSD group compared to Control ( 89 % vs. 80 % , respectively ) . The expected number of epithelialized weeks accumulated over 1 year was 25 % greater in the CCO + SSD group than for Control ( 35 vs. 28 weeks , respectively ) . Over a 1-year time horizon , the expected cost per DFU was greater in the Control group than the CCO group ( $ 2,376 vs. $ 2,099 , respectively ) . The estimated cost per ulcer-free week was 40 % higher for Control ( $ 85/closed-wound week ) than for CCO + SSD ( $ 61/closed-wound week ) . Conclusions CCO + SSD therapy is a cost-effective method of debridement in the management of patients with DFUs , providing better outcomes at a lower cost . Further high quality trials are needed to confirm this finding . Trial registration This study was registered at Clinical Trials.gov as NCT01408277 BACKGROUND Despite significant advances , the treatment of  diabetic foot ulcers ( DFUs ) remains a major therapeutic challenge for clinicians , surgeons , and other health care professionals . There is an urgent need for new strategies with clinical ly effective interventions to treat DFUs to reduce the burden of care in an efficient and cost-effective way . OBJECTIVE This r and omized trial evaluated and compared the clinical effectiveness , tolerability , and costs of clostridial collagenase ointment ( CCO ) debridement to that of debridement using saline moistened gauze ( SMG ) and selective sharp debridement for the treatment of DFUs . METHODS R and omized , controlled , parallel group , multicenter , open-label , 12-week study of 48 patients with neuropathic DFUs r and omized to 4 weeks of treatment with either CCO or SMG after baseline surgical debridement . The primary end point was the condition of the ulcer bed at the end of treatment as measured using a st and ardized wound assessment tool . Secondary end points were the percentage of reduction in wound area and therapeutic response rates . Adverse events were monitored for the tolerability analysis . In addition , a comparative cost-effectiveness analysis was performed from the perspective of the Centers for Medicare and Medicaid Services as a payer . RESULTS Both the CCO and SMG groups had significantly improved wound assessment scores after 4 weeks of treatment ( CCO , -2.5 , P = 0.007 ; SMG , -3.4 , P = 0.006 ) . Only CCO treatment result ed in a statistically significant decrease from baseline in the mean wound area at the end of treatment ( P = 0.0164 ) and at the end of follow-up ( P = 0.012 ) . In addition , the CCO group exhibited a significantly better response rate at the end of follow-up compared with the SMG group ( 0.92 vs 0.75 , P < 0.05 ) . Reported adverse events were similar between the 2 treatment groups . None of the reported adverse events were considered to be related to treatment . The economic analysis indicated that the direct mean costs per responder in the physician office setting of care were $ 832 versus $ 1042 for the CCO group versus the SMG group , whereas the direct mean costs per responder in the hospital outpatient department setting were $ 1607 versus $ 1980 . CONCLUSIONS CCO treatment provides equivalent debridement of DFUs similar to SMG while fostering better progress toward healing as measured by decreasing wound area over time and improved response rates at the end of follow-up . In addition , CCO yields a more favorable cost-effectiveness ratio in both the physician office and hospital outpatient department setting s of care . Clinical Trials.gov identifier : NCT01056198 INTRODUCTION The purpose of this study is to determine the cost-effectiveness of collagenase ointment relative to autolysis with a hydrogel dressing when debriding necrotic pressure ulcers in a long-term care setting . METHODS A Markov decision process model with 2 states ( necrotic nonviable wound bed transitioning to a granulated viable wound bed ) was developed using data derived from a prospect i ve , r and omized , 6-week , single-center trial of 27 institutionalized subjects with pressure ulcers that were ≥ 85 % necrotic nonviable tissue .  Direct medical costs from the payer perspective included study treatments , wound treatment supplies , and nursing time . Clinical benefit was measured as " granulation days " and was derived from the time-dependent debridement rates of the alternative products . RESULTS The average cost per patient for 42 days of pressure ulcer care was $ 1,817 in 2012 for the collagenase group and $ 1,611 for the hydrogel group . Days spent with a granulated wound were 3.6 times higher for collagenase ( 23.4 vs 6.5 ) than with the hydrogel . The estimated cost per granulation day was > 3.2 times higher for hydrogel ( $ 249 ) vs collagenase ( $ 78 ) . CONCLUSIONS In this economic analysis based on a r and omized , controlled clinical trial , collagenase ointment result ed in a faster time to complete debridement and was more cost-effective  than hydrogel autolysis for pressure ulcers in a long-term care setting . Even though collagenase ointment has a higher acquisition cost than hydrogel , the clinical benefit offsets the initial cost difference , result ing in lower cost per granulation day to the nursing home over the course of the 42-day analysis UNLABELLED ﻿﻿﻿﻿﻿﻿ The role of maintenance debridement in wound healing has been well described , yet little is known regarding comparative methods and associated outcomes with this process when using collagenase or hydrogel . OBJECTIVE Evaluation of maintenance debridement and wound closure with collagenase compared to hydrogel in institutionalized adults with pressure ulcers from time of necrotic tissue removal up to 84 days from enrollment . METHODS This second phase of a rollover evaluation enrolled only subjects who successfully completed phase 1 ( previously reported ) from time of necrotic tissue debridement . Subjects received daily dressing changes with either hydrogel or collagenase followed by a st and ard semiocclusive dressing to evaluate wound-healing parameters and wound closure from initial enrollment to day 84 . Investigators blinded to r and omization evaluated weekly wound photographs using a digital planimetry software package for wound-healing parameters . Additionally , Pressure Ulcer Scale for Healing ( PUSH ) © Tool and wound bed scores ( WBS ) were monitored . RESULTS Eleven of 13 subjects from the collagenase group entered into phase 2 , with 4 of the 14 subjects from the hydrogel group . One subject from each group was eliminated within the first week of phase 2 . All subjects ( n = 3 ) in the hydrogel group reached complete epithelialization with a mean of 32.6 days . Nine of 10 subjects in the collagenase group reached completed epithelialization with a mean of 45 days . An independent sample s t test showed no statistical significance between the 2 groups ( P = 0.121 ) in days to healing . A Fisher 's exact test performed on the primary endpoint of complete epithelialization also demonstrated no significant difference in outcomes between the groups ( P = 0.99 ) . Mean WBS at the onsetof phase 2 was 13.7 ( range 12 - 16 ) , and the PUSH Tool mean score was 1.0 ( range 0 - 3 ) . In aggregating phase 1 and phase 2 data , a difference in the closure rates at the end of the study , 69 % ( collagenase ) vs 21 % ( hydrogel ) , was statically significant ( P = 0.0213 ) using a Fisher 's exact test . CONCLUSION Facilitating maintenance debridement by either collagenase or hydrogel can be used to complete wound closure when used in conjunction with a vali date d predictive wound-healing tool that closely monitors therapy . This study showed statistical significance in favor of collagenase when evaluating closure rates from the onset of the pressure ulcer . OBJECTIVE A r and omised clinical trial ( n = 42 ) compared the effectiveness of two approaches to debriding chronic leg ulcers :  TenderWet 24 , which is design ed to support the autolytic degradation process , and Iruxol N ( Santyl ) , an enzymatic treatment cl aim ed to enhance the degradation process . METHOD Patients were r and omly assigned to one of the two treatment groups for three weeks . Wounds were evaluated weekly for the amount of eschar/slough , the area of healthy granulation and the re-epithelialised area . RESULTS During days 1 - 14 slough within the groups was reduced by almost 19 % for TenderWet 24 and by 9 % for Iruxol N , followed by an increase of 26 % and 10 % respectively in granulation tissue . These effects were less accentuated during days 7 - 21 . There was a further 11 % improvement in tissue debridement for the TenderWet 24 group and a relapse ( + 9.1 % ) in the Iruxol N group . CONCLUSION Although TenderWet 24 appeared to be more efficient in a few cases , the general efficacy of the two products appeared to be almost the same as no statistically significant superiority of either product was found UNLABELLED ﻿﻿﻿﻿﻿ ﻿Comparisons of collagenase to other methods of debridement , including wet to dry dressings , have been reported in the literature ; however , studies comparing collagenase to hydrogel have not been reported . OBJECTIVE Time to complete necrotic tissue debridement with collagenase compared to hydrogel in institutionalized adults with pressure ulcers . METHODS R and omization occurred after obtaining informed consent to avoid selection bias . Subjects received daily dressing changes with either hydrogel or collagenase followed by a st and ard semi-occlusive dressing to evaluate time to debridement up to Day 42 . Investigators , who were blinded to r and omization , evaluated weekly wound photographs for necrotic tissue debridement and wound healing parameters using a digital planimetry software package . Nonviable tissue was not cross-hatched in either group . RESULTS Twenty-seven nursing home residents were enrolled over a period of 1 year . According to a Student 's t test , there were no significant differences between groups for age , gender , age of wound , or percentage of nonviable tissue at the time of enrollment ( P = .03 ) . Using a Pearson Chi square analysis , the collagenase group was found to have statistical ( P = .003 ) significance in achieving full debridement by Day 42 . CONCLUSION This study showed statistical significance in favor of collagenase when used to debride nonviable tissue in pressure ulcers . Despite recommendations to cross-hatch eschar , statistical significance was still achieved when wounds were not cross-hatched , indicating clinical utility in setting s without clinician availability for the cross-hatching procedure During burn care the wounds must be repeatedly debrided of adherent and loose debris until the decision is made to surgically excise and graft the wound or to await epithelialization . Though native proteolytic enzymes in the skin or those produced by colonizing bacteria can speed eschar separation , the use of exogenous enzymes for wound debridement may accelerate wound cleaning and healing . Collagenase digests native and denatured collagen in necrotic tissue . This multicenter trial of 79 patients with partial-thickness wounds compared the efficacy of collagenase ointment applied with polymyxin B sulfate/bacitracin powder with the efficacy of st and ard topical antimicrobial therapy ( control ) in which silver sulfadiazine cream ( 1 % ) was used to debride paired burn sites . Patients selected for the study had two noncontiguous , partial-thickness , comparably sized , and anatomically similar burn wounds . Ages of patients ranged from 5 to 60 years ( mean 33 years ) . The total body surface area burned ranged from 2 % to 30 % ( mean 13.6 % ) .  Mean burn sizes used for study treatment were 366 cm2 ( 26 to 2310 cm2 ) for col 
    Output:
    
Results support the use of collagenase for enzymatic debridement in pressure ulcers , diabetic foot ulcers and in conjunction with topical antibiotics for burns .