***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: OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review OBJECTIVE ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of limb-threatening complications . The aim of this study was to evaluate the role of hyperbaric oxygen in the management of these ulcers . METHOD eighteen diabetic patients with ischaemic , non-healing lower-extremity ulcers were recruited in a double-blind study . Patients were r and omly assigned either to receive 100 % oxygen ( treatment group ) or air ( control group ) , at 2.4 atmospheres of absolute pressure for 90 min daily ( total of 30 treatments ) . RESULTS healing with complete epithelialisation was achieved in five out of eight ulcers in the treatment group compared to one out of eight ulcers in the control group . The median decrease of the wound areas in the treatment group was 100 % and in the control group was 52 % ( p=0.027 ) . Cost-effectiveness analysis has shown that despite the extra cost involved in using hyperbaric oxygen , there was a potential saving in the total cost of treatment for each patient during the study . CONCLUSION hyperbaric oxygen enhanced the healing of ischaemic , non-healing diabetic leg ulcers and may be used as a valuable adjunct to conventional therapy when reconstructive surgery is not possible Diabetic ulcer complications are a leading cause of hospitalization and amputation . Of the 20 million individuals with diabetes , 10–15 % are at risk for developing diabetic ulcers . St and ard therapy involves the use of dressings to protect the wound bed from trauma and to absorb exsu date ; offloading high pressure from the wound bed , e.g. , by prescribing protective footwear ; and wound bed preparation to accelerate endogenous healing and facilitate the effectiveness of topically applied substances . But these measures are often deficient in healing all diabetic ulcers when the patient 's own intrinsic wound-healing system is insufficient . In such patients , skin replacement therapies are second-line treatment options ; however , the effectiveness of skin replacement therapies in treatment of diabetic ulcers is unclear . The objective of this study is to assess their effectiveness using evidence from r and omized trials in diabetic leg and foot ulceration . We search ed the Cochrane Controlled Trials Register ( 1970–2006 ) , MEDLINE ( 1966–2006 ) , EMBASE ( 1980–2006 ) , and CINAHL ( 1982–2006 ) using a combination of text and keywords in addition to a filter for controlled clinical trials . The last up date of search es was performed on 30 September 2007 . We included trials if the allocation of participants was described as r and omized , with participants of any age and in any care setting having diabetic leg or foot ulceration . We included studies that compared the following types of grafts with any other intervention : 1 ) autografts ( pinch , split or full-thickness skin grafts , cultured keratinocytes , or fibroblasts ) , 2 ) allografts ( cultured keratinocytes or fibroblasts ) , 3 ) xerografts , and 4 ) bioengineered skin . Two review ers independently evaluated Diabetic foot ulcers with exposure of tendon , muscle , or bone imply a high probability for deep infections and amputations . Delayed healing times are often described . The aim of this study was to compare the clinical effect and economic cost of cadexomer iodine with st and ard treatment in diabetic feet with cavity ulcers . Patients with deep , exudative foot ulcers were included in a 12-week open , r and omised , comparative study . When ulcers stopped exudating , vaseline gauze was used in both groups until the end of the study . Costs were estimated for dressing material , staff and transportation . Clinical ly relevant improvement was seen in 12 patients treated with cadexomer iodine and in 13 patients treated with st and ard treatment . The average weekly cost was SEK 903 and SEK 1,421 , respectively , of which the major part was costs for staff and transportation related to frequency of dressing changes . Treatment with cadexomer iodine ointment ( Iodosorb ) showed no clinical difference compared to topical treatment consisting of gentamicin solution , streptodornase/streptokinase , or dry saline gauze but was associated with considerably lower weekly treatment costs BACKGROUND Complicated skin and skin-structure infections ( cSSSI ) , including surgical site infections ( SSI ) , cellulitis , and abscesses , have been extensively studied , but controversial issues still exist . CONTROVERSIAL ISSUES The aim of this GISIG ( Gruppo Italiano di Studio sulle Infezioni Gravi ) working group - a panel of multidisciplinary experts - was to define recommendations for the following controversial issues : ( 1 ) What is the efficacy of topical negative pressure wound treatment as compared to st and ard of care in the treatment of severe surgical site infections , i.e. , deep infections , caused by Gram-positive microorganisms ? ( 2 ) Which are the most effective antibiotic therapies in the treatment of cSSSI , including SSI , due to methicillin-resistant staphylococci ? Results are presented and discussed . METHODS A systematic literature search using the MEDLINE , EMBASE , Cochrane Central Register of Controlled Trials , and www . clinical trials.gov data bases of r and omized controlled trials and /or non-r and omized studies was performed . A matrix was created to extract evidence from original studies using the CONSORT method to evaluate r and omized clinical trials and the Newcastle-Ottawa Quality Assessment Scale for case-control studies , longitudinal cohorts , and retrospective studies . The GRADE method was used for grading quality of evidence . An analysis of the studies published between 1990 and 2008 is presented and discussed in detail UNLABELLED In April 2008 , the Medical Advisory Secretariat began an evidence -based review of the literature concerning pressure ulcers . Please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series . PRESSURE ULCER PREVENTION : an evidence based analysis The cost-effectiveness of prevention strategies for pressure ulcers in long-term care homes in Ontario : projections of the Ontario Pressure Ulcer Model ( field evaluation)MANAGEMENT OF CHRONIC PRESSURE ULCERS : an evidence -based analysis OBJECTIVE The Medical Advisory Secretariat ( MAS ) conducted a systematic review on interventions used to treat pressure ulcers in order to answer the following questions : Do currently available interventions for the treatment of pressure ulcers increase the healing rate of pressure ulcers compared with st and ard care , a placebo , or other similar interventions ? Within each category of intervention , which one is most effective in promoting the healing of existing pressure ulcers ? BACKGROUND A pressure ulcer is a localized injury to the skin and /or underlying tissue usually over a bony prominence , as a result of pressure , or pressure in conjunction with shear and /or friction . Many areas of the body , especially the sacrum and the heel , are prone to the development of pressure ulcers . People with impaired mobility ( e.g. , stroke or spinal cord injury patients ) are most vulnerable to pressure ulcers . Other factors that predispose people to pressure ulcer formation are poor nutrition , poor sensation , urinary and fecal incontinence , and poor overall physical and mental health . The prevalence of  pressure ulcers  in Ontario has been estimated to range from a median of 22.1 % in community setting s to a median of 29.9 % in nonacute care facilities . Pressure ulcers have been shown to increase the risk of mortality among geriatric patients by as much as 400 % , to increase the frequency and duration of hospitalization , and to decrease the quality of life of affected patients . The cost of treating pressure ulcers has been estimated at approximately $ 9,000 ( Cdn ) per patient per month in the community setting . Considering the high prevalence of pressure ulcers in the Ontario health care system , the total cost of treating pressure ulcers is substantial . TECHNOLOGY Wounds normally heal in 3 phases ( inflammatory phase , a proliferative phase of new tissue and matrix formation , and a remodelling phase ) . However , pressure ulcers often fail to progress past the inflammatory stage . Current practice for treating pressure ulcers includes treating the underlying causes , debridement to remove necrotic tissues and contaminated tissues , dressings to provide a moist wound environment and to manage exu date s , devices and frequent turning of patients to provide pressure relief , topical applications of biologic agents , and nutritional support to correct nutritional deficiencies . A variety of adjunctive physical therapies are also in use . METHOD Health technology assessment data bases and medical data bases were search ed from 1996 ( Medline ) , 1980 ( EMBASE ) , and 1982 ( CINAHL ) systematic ally up to March 2008 to identify r and omized controlled trials ( RCTs ) on the following treatments of pressure ulcers :  cleansing , debridement , dressings , biological therapies , pressure-relieving devices , physical therapies , nutritional therapies , and multidisciplinary wound care teams . Full literature search strategies are reported in appendix 1 . English- language studies in previous systematic review s and studies published since the last systematic review were included if they had more than 10 subjects , were r and omized , and provided objective outcome measures on the healing of pressure ulcers . In the absence of RCTs , studies of the highest level of evidence available were included . Studies on wounds other than pressure ulcers and on surgical treatment of pressure ulcers were excluded . A total of 18 systematic review s , 104 RCTs , and 4 observational studies were included in this review . Data were extracted from studies using st and ardized forms . The quality of individual studies was assessed based on adequacy of r and omization , concealment of treatment allocation , comparability of groups , blinded assessment , and intention-to-treat analysis . Meta- analysis to estimate the relative risk ( RR ) or weighted mean difference ( WMD ) for measures of healing was performed when appropriate . A descriptive synthesis was provided where pooled analysis was not appropriate or not feasible . The quality of the overall evidence on each intervention was assessed using the grading of recommendations assessment , development , and evaluation ( GRADE ) criteria . FINDINGS Findings from the analysis of the included studies are summarized below : CLEANSING : There is no good trial evidence to support the use of any particular wound cleansing solution or technique for pressure ulcers . DEBRIDEMENT : There was no evidence that debridement using collagenase , dextranomer , cadexomer iodine , or maggots significantly improved complete healing compared with placebo . There were no statistically significant differences between enzymatic or mechanical debridement agents with the following exceptions : Papain urea result ed in better debridement than collagenase . Calcium alginate result ed in a greater reduction in ulcer size compared to dextranomer . Adding streptokinase/streptodornase to hydrogel result ed in faster debridement . Maggot debridement result ed in more complete debridement than conventional treatment . There is limited evidence on the healing effects of debridement devices . DRESSINGS : Hydrocolloid dressing was associated with almost three-times more complete healing compared with saline gauze . There is evidence that hydrogel and hydropolymer may be associated with 50 % to 70 % more complete healing of pressure ulcers than hydrocolloid dressing . No statistically significant differences in complete healing were detected among other modern dressings . There is evidence that polyurethane foam dressings and hydrocellular dressings are more absorbent and easier to remove than hydrocolloid dressings in ulcers with moderate to high exu date s . In deeper ulcers ( stage III and IV ) , the use of alginate with hydro 
    Output:
    
For surgical wound infections , topical negative pressure and vacuum-assisted closure were promising interventions , but this was based on evidence from moderate to low quality systematic review s. Conclusions Numerous interventions can be utilized for patients with varying types of complex wounds , yet few treatments were consistently effective across all outcomes throughout the literature .