Talk:Medical uses of silver/Archive 7

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zad

this is in reference with you removing a secondary source and adjunct primary sources: ' *.BRD is not a valid excuse for reverting good-faith efforts to improve a page simply because you don't like the changes. Don't invoke BRD as your reason for reverting someone else's work or foredit warring: instead, provide a reason that is based onpolicies, guidelines, orcommon sense.' your reason that perhaps you may summarize better in the future doesn't mean that you have to remove what is valid. It can stay untill the time you or other editors could summarize better. Ryanspir (talk) 17:21, 18 January 2013 (UTC)

Are you sure this is in reference to something I did? I didn't say "BRD"... can you provide a diff of the edit you are talking about? Zad68 17:23, 18 January 2013 (UTC)

Maybe Ryanspir is talking about the EPA bit that both you and I removed, since it adds nothing to the article.Desoto10 (talk) 17:50, 18 January 2013 (UTC)

Hi Ryan, twice now you have restored this edit, which has so far been reverted by two different editors. Here is the edit:

The silver ion (Ag⁺
) is bioactive and in sufficient concentration readily kills bacteria in vitro. Liquid sprays containing nano-silver are effective as a hard-surface disinfectant.

The word "sprays" was removed and the "American Biotech Labs EPA approval" was added. The problem is per Wikipedia policy WP:V. The EPA approval of the American Biotech Labs product named "ASAP-AGX-32" applies only to that particular product. The article content it was added to is making a general statement, a scope which the EPA approval document does not address. Therefore the source cannot be used in the way proposed per WP:V. Zad68 19:15, 18 January 2013 (UTC)

wound dressings

We have, as the first sentence:

In the 1970’s silver sulfadiazine (SSD) cream became the most common delivery system for applying silver onto external burn wounds to control infection, and it became the "gold standard" in topical treatment.

Sources are NCCAM and the Atiyeh paper. NCCAM does not claim anything about the prevalence of SSD and I don't have access to the full text of the other source. Does the Atiyeh paper claim that SSD was the most common deliver system?Desoto10 (talk) 22:01, 19 January 2013 (UTC)

Excerpts from Atiyeh:

Introduction, 3rd paragraph:

The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process [17] and that silver may have serious cytotoxic activity on various host cells [2], [17], [18], [19], [20], [21] and [22]. On the other hand, the beneficial effects of silver on wound biology due to its potent antimicrobial activity have been overlooked in general until recently. The literature is becoming replete with clinical trials purporting to show the benefits of silver therapeutics and silver-release dressings on wound repair and regeneration through its antimicrobial efficacy. Little is published, however, to show how the released silver ion influences the wound bed, or to what extent it is metabolized or deposited in the tissue. Moreover, results of the extensive literature review we conducted failed to reveal any clinical studies regarding the risks and probabilities of wounds in general to become infected, about the effect of silver dressings on already infected wounds, nor about studies comparing the effect of silver or other antiseptic dressings on prevention of wound infection.

From section 2, "Various available silver products may be summarized as follows":

2.1. Colloidal silver solutions—electrically charged
This is the most common delivery system prior to 1960. Charged pure silver particles (3–5 ppm) are held in suspension by small electric currents. Positive ions repel each other thus remain in solution even when applied topically to a wound.

Their conclusions:

6. Conclusion
The only constant with wounds is that they are constantly changing. Practitioners should stay vigilant about the adverse effects of bacteria in wounds and keep in mind the role of infection in producing wound healing failure [27]. However, due to substantial experiences with adverse silver sulfadiazine reactions and side effects, it is appropriate to keep the possibility of a toxic silver effect in burn patients treated with slow sustained release silver-coated newly developed wound dressings in mind [25]. Silver levels in plasma and/or urine should be monitored [25]. The dilemma remains however, in product development to produce an agent and system of delivery which maximizes the lethal effect for bacteria and minimizes the damage to human cells. Ultimately, no matter how sophisticated the delivery system the agent, silver, cannot be expected to make a selective kill [23] even though it has been reported that its toxicity towards bacteria was quite a bit greater than that towards the human cells [91]. It is clear also that the effects of the various silver products available on wound infection and wound healing are variable. Understanding the characteristics of these products and dressings may enable them to be targeted more appropriately according to the specific requirements [92]. A word of caution, however, about extrapolating too directly from laboratory studies to clinical application, nevertheless, based on available evidence it is recommend at present that silver-based products should be avoided if possible as a topical antimicrobial strategy where rapidly proliferating keratinocytes are exposed as in donor sites, superficial partial thickness wounds and undifferentiated cultured keratinocyte applications [23]. The ultimate goal remains the choice of a product with a superior profile of antimicrobial activity over cellular toxicity [75].

Hope this helps. -- Scray (talk) 22:29, 19 January 2013 (UTC)

Thanks, Scray! I am not sure what the conclusions should be now. For sure, the article says that colloidal Ag was the most common dressing antibiotic prior to 1960, but it is not clear where it is said that SSD is now or ever was the most common treatment. The article also seems to conclude that the effects of Ag products are variable. I think that we should, in general, avoid direct quotations from these articles and try to arrive at a consensus about what they are actually concluding.Desoto10 (talk) 00:43, 20 January 2013 (UTC)

Atiyeh, regarding SSD:

2.4. Silver compounds—silver sulfadiazine
Silver sulfadiazine (Flammazine®, Silvadene®) was introduced by Fox [30] in 1970s as an antibacterial agent for topical treatment of burns and wounds. Silver is complexed to propyleneglycol, stearyl alcohol, and isopropyl myrislate and mixed with the antibiotic Sulfadiazine producing a combined formulation made from silver nitrate and sodium sulphadiazine by substituting a silver atom for a hydrogen atom in the sulphadiazine molecule and combining the inhibitory action of the silver with the antibacterial effect of sulphadiazine [9] and [31]. This silver complex acts on the bacterial wall in contradistinction to the silver ions which act on the bacterial energy system. All kinds of combinations of sulpha drugs with silver were tested in vitro, but silver sulphadiazine appeared to be the most effective [32]. A possible explanation of this effectiveness could be the relatively strong bonding of silver sulphadiazine to DNA [9] which differs from that of silver nitrate or other silver salts [9] and [33]. Bacterial resistance to these products does develop. Impaired re-epithelialization has been described. Observed bone marrow toxicity with silver sulfadiazine is primarily due to the propylene glycol component.

I find no statement regarding SSD as "most common" or similar. It does say "gold standard", but as noted elsewhere on this talk page, it's clear that this term is not meant as simple praise. -- Scray (talk) 04:21, 20 January 2013 (UTC)

Restored content before

Few concerns with "In the 1970’s silver sulfadiazine (SSD) cream became the most common delivery system for applying silver onto external burn wounds to control infection, and it became the "gold standard" in topical treatment.'

1. How often something is used says absolutely nothing about if it works or not.
2. The paper in questions states that SSD is not effective. The "gold standard" is historical and questionable at best. And unless someone finds a bunch of high quality references for this for the last 3 years we should not state it.
3. We have higher quality sources that directly refute this "Topical silver has been shown to be efficacious in controlling most pathogenic bacteria, including methicillin-resistant Staphylococcus aureus (MRSA)," and some of the supporting refs seem to be mis interpreted.
4. What is with links like this? http://www.touchemergencymedicine.com/articles/ventilator Please use proper formatting.

Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:30, 20 January 2013 (UTC)

Medical products are not widely used, nor do they become a "gold standard", unless they are found to be effective. To do otherwise can cause patients to die, and result in lawsuits, disbarment and criminal sanctions. Lots of specific studies agree they are effective. The Cochrane reviews did not prove they were not effective, they merely questioned the number and methodologies of the studies reviewed - which is not the same thing. The article now says exactly what the Cochrane volunteers concluded - let the readers actually see what is going on please.

Ditto re MRSA - I have put up RS sources that say its effective - if you have sources that say its not effective then please add them, and let the readers see both opinions. Wdford (talk) 05:17, 20 January 2013 (UTC)

I should have also mentioned that the FDA has approved these products for use, which is unlikely to have happened if they were not considered to be effective, and it also indicates that they are considered to be safe (bearing in mind that very few medications have zero side-effects). Wdford (talk) 06:59, 20 January 2013 (UTC)

Cochrane is the best quality of evidence. And thus we present it prominently. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:11, 20 January 2013 (UTC)

Its still very prominent. However the section is now coherent as well, which always helps the reader. Its silly to start a section by saying a few Cochrane volunteers have squashed the stuff, before you have even explained what the stuff is. It is also important to note that the studies reviewed by Cochrane here are five years old and more. Also, the Cochrane paragraph needs a bit more detail so that readers can see the findings in context - detail which I keep adding and which you keep removing. I don't think you are helping much. I think you are at 3RR by now?Wdford (talk) 08:21, 20 January 2013 (UTC)

Yes and you have just made your forth revert. Why are we starting the section on medical uses with a history? Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:46, 20 January 2013 (UTC)

I am trying to improve the article each time - I am not the one who blindly deletes RS material. At least tell the readers what the section is about before you tell them that Cochrane is inconclusive about it. Wdford (talk) 11:49, 20 January 2013 (UTC)

Concerns

In this edit [2] this content was removed with the comment adding relavent details?

"Endotracheal breathing tubes containing silver have been studied with respect to their effect on ventilator associated pneumonia. While in an unblinded trial found that they may decrease the risk of confirmed pneumonia they had no effect on either total death rate or duration in the intensive care unit or hospital."

This is a 2012 review article published in a well respected pubmed indexed journal and properly formatted? What is up? Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:35, 20 January 2013 (UTC)

I replaced your very vague summary with a more detailed and more helpful summary of the same material. I didn't see this detail in your source, so I used other sources which go into more detail. If your source does actually address silver-coated products then by all means lets add the extra reference. Wdford (talk) 04:57, 20 January 2013 (UTC)

It is not vague but clearly states what is know regarding these tube. Read the ref in question Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:58, 20 January 2013 (UTC)

Well now its even more clear, as well as shown in context. Wdford (talk) 08:15, 20 January 2013 (UTC)

Yes have returned it. The fact that we have a single blinded trial and there is no difference in hospitalization or mortality is key. Hard end points are important when one deals with subjective diagnosis.Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:28, 20 January 2013 (UTC)

References

Reference fixes reverted?

User:Jmh649 has just reverted a series of edits I made to the article fixing references, specifically: fixing broken links, filling-in missing metadata, linking to correct representations of books/articles, and properly normalizing citations. There is no substantive change to the article content from when my edit sequence began, to when it ended: merely correction/improvement of references. I do not understand why this work was reverted without explanatory comment; I will revert the edit and await discussion. Alexbrn ^{talk|contribs|COI} 08:07, 20 January 2013 (UTC)

The current wording is much more coherent than the back-to-front version repeatedly reinstated by Jmh649, its more balanced, its more detailed, its more up to date and its fully RS. Please stop disrupting the article - your determined anti-silver POV is starting to look like an edit war. Wdford (talk) 08:14, 20 January 2013 (UTC)

Ah, I see my reference fixes just got bombed as collateral damage as part of wider settling of content issues among editors here. I have no opinion on that (yet), but please spare the references ;-) Alexbrn ^{talk|contribs|COI} 08:18, 20 January 2013 (UTC)

Yes sorry Alexbrn. The current wording is more reflective of the literature and current scientific consensus. We typically emphasis Cochrane reviews. One of the issues we have is that many people are trying to promote silver containing dressing in an effort to profit. In this edit [3] the above user removed a 2012 review article which found no support for an effort on mortality or length of hospitalization from silver containing ET tube. Instead they wish to emphasis that VAP has high costs and mortality. No one denies that VAP has high costs or high mortality but the evidence show these expensive silver containing tubes neither change mortality overall or change length of hospitalization. The evidence in support also unblinded. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:26, 20 January 2013 (UTC)

If you are referring to me, then I make no profit from anything, and I think you should AGF. The article needs to be coherent, not just a collection of silver-squashing by an editor with a cost fixation. Like I said, add more references if they are useful, but don't delete the referenced material that currently stands, and stop disordering the material in order to make it incoherent. It can't be that hard, surely? Wdford (talk) 08:30, 20 January 2013 (UTC)

No not referring to you but referring to some of the literature. You seem set on deleting this 2012 review article.Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:34, 20 January 2013 (UTC)

OK fine. What I saw in your 2012 source didn't address silver at all, but maybe there is more in the detailed report that I can't see. So read what currently stands now in that section of the article, and add more if you think your point is not covered sufficiently, but leave the rest alone and let's have a comprehensive section. Why not? Wdford (talk) 08:39, 20 January 2013 (UTC)

Didn't you read the source before you removed it? What do you mean it doesn't address silver at all? Also proper formatting of references would be nice. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:41, 20 January 2013 (UTC)

I looked at the abstract which your link lead to, and it doesn't mention silver specifically. Other secondary sources do address this directly, so I used those instead. I have replaced your preferred source as an extra reference, on the assumption that it does address silver-coated tubes somewhere in the detail that I can't access. Wdford (talk) 12:00, 20 January 2013 (UTC)

Oh, I seem to have stumbled into a dispute. I've been looking the issues and will comment in a new section. Alexbrn ^{talk|contribs|COI} 09:06, 20 January 2013 (UTC)

And to add more – apparently these silver tubes are not actually all that expensive – see [4]. And the Kollef study was not “unblinded”, it was “single-blinded” – see [5]. Seemingly it’s an unacceptable risk when dealing with a potentially fatal injury for the attending physician to not know what s/he is applying to a wound. I’m sure this is not as great as double-blinded, but its better than unblinded. Wdford (talk) 16:40, 20 January 2013 (UTC)

Auto-archival

I propose that this Talk page is set up to be auto-archived by bot. Alexbrn ^{talk|contribs|COI} 09:27, 20 January 2013 (UTC)

Agreed. 31 days is perhaps too long a holding period? Wdford (talk) 18:40, 20 January 2013 (UTC)

Medical uses — dressings

I am looking at this section in the context of the dispute in the sections above. The point at issue seems to be whether three Cochrane studies[6][7][8], and one other systematic review should be included[9], and if so, with what weight.

I (intentionally) have not yet reviewed the content of these pieces, but as a matter of principle WP:MEDRS seems quite clear that systematic reviews are "ideal sources" and should be used in preference to others. Furthermore, "individual primary sources should not be cited or juxtaposed so as to 'debunk' or contradict the conclusions of reliable secondary sources". So it would seem to me that the results of the four reviews mentioned above (where pertinent) should be reported, and front and centre in this section. Their conclusions should not be undermined by lesser sources. In fact if lesser sources contradict the reviews I think they simply should not be used, unless their view is clearly labelled as discredited and/or counter to the medical consensus.

Does anybody dispute that this is the principle we should apply? Alexbrn ^{talk|contribs|COI} 09:54, 20 January 2013 (UTC)

Agree completely and that is what I have been trying to do. Doc James (talk · contribs · email) (if I write on your page reply on mine) 09:59, 20 January 2013 (UTC)

Agree +1. Alexbrn - Thanks for putting up efforts to improve page. @ Dr.James - Your edit version seems more logical. Please (re)update it. Its interesting article n topic for sure. AbhiSuryawanshi (talk) 10:27, 20 January 2013 (UTC)

The Cochrane conclusions are that the "quality" evidence on SSD up to 2009 was insufficient to state a conclusive conclusion, and that more studies are required. No one is arguing about that, and the article states this clearly - much more clearly than in Jmh649's version. However it cannot be ignored that the FDA has approved these products, or that tens of thousands of doctors have used them profusely for the last 40 years - seemingly without any doubts, reservations or backlash. I have moved the Cochrane stuff into the first para, although I can't imagine that any doctor will prescribe any treatment based on which para came first in a wikipedia article. When a Cochrane review says conclusively that "these products have been proven to be no better than placebos" then I will be happy to say as much, but right now the Cochrane jury is still out. Deleting RS material because Cochrane was inconclusive is not balanced or encyclopedic. Wdford (talk) 11:44, 20 January 2013 (UTC)

Okay, Wdford, I think I'm sensing some push-back on the MEDRS principle as I stated it. Some thoughts:

1. While "what doctors have done for 40 years" is pertinent to history, it's not pertinent to an encyclopedic description of current thought/research
2. Similarly, what the FDA has done - while potentially useful - would need to bow to any consensus view from systematic reviews, in my reading of MEDRS.
3. It is in the nature of ineffective medicines that their efficacy is not falsifiable; instead the pattern of research is a series of inconclusive reviews which - after a while - tends to shade in the view of the profession from unproven to disproven. I still have not read the sources in question so I do not know whether SSD is on that path, and if it is, how far down that path it is. Alexbrn ^{talk|contribs|COI} 12:12, 20 January 2013 (UTC)

The FDA is a US regulatory organization not a medical one. It is a legal entity and does not dictate medical practice. How many people use something or how long it has been used says absolutely nothing about if it works or not. This does not belong in this section. Move to a section on prevalence or one on history. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:50, 20 January 2013 (UTC)

To be fair, MEDRS does mention that "Medical and scientific organizations" (in which I include the FDA) can be valuable sources. I don't believe they should be used to contradict the "ideal" sources: systematic reviews. Alexbrn ^{talk|contribs|COI} 14:12, 20 January 2013 (UTC)

I did not remove the FDAs approval. It should however go in the section on society and culture as it is a local political decision rather than a medical one. Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:15, 20 January 2013 (UTC)

Thanks for engaging constructively. Re your points:

1. "What doctors have done for 40 years" – this is a mighty long time to be on the top of the pile in something as volatile as medical science, so clearly the stuff does work, as many sources agree (and even the Cochrane guys did not actually find proof that the stuff does not work.) Seemingly something even better has recently been developed (namely nano-silver dressings) but SSD is still being used, and so should not be banished to a "history" section. This section does not need to be limited to only the cutting edge research;
2. “The FDA must bow to any consensus view from systematic reviews” – agreed in full. However there is no consensus against SSD just yet – the Cochrane reviews bemoaned a lack of evidence, but they did not find conclusive evidence against SSD either. Similarly, while the FDA does not dictate what medical practice the doctor must take, it certainly can block a practice that is considered harmful or ineffective – witness the FDA stance on colloidal silver. FDA approval is not based on flipping a coin, and it is by no means a local political decision, so in the current vacuum the FDA approval still counts for a lot (for now, until conclusive studies persuade the FDA to withdraw its' approval);
3. “It is in the nature of ineffective medicines that their efficacy is not falsifiable” - no, here I disagree somewhat. Maybe for headache pills such a comment would be valid, but an infected wound either clears up or the guy dies. If a high percentage of all wounds treated get worse and the patients die, somebody would surely notice eventually. Science is not limited to reviews – every doctor treating infected wounds develops an expertise, and while some of it surely comes from reading etc, they also learn the hard way if the stuff they read about has been oversold. 40 years is a lot of practical testing time - how many doctors use an antiseptic or how long it has been used speaks volumes about if it works or not.

I think the current wording adequately covers the fact that SSD has been used for a long time and is still being used, that the FDA approved its use (after whatever process the FDA followed at the time), that some Cochrane reviews on studies a few years old did not find satisfactory evidence either way, and that new and better things are finally being developed. I don't think there is anything wrong with that? Wdford (talk) 15:09, 20 January 2013 (UTC)

So, looking at the high-quality sources, and taken all-in-all, a fair summary of them would be that they found no evidence of benefit from the use of SSD? If that is the case, that is what the article must state. I think anything from lesser sources that contradicts, or implies contradiction, of that summary must be removed from the article. In particular anything that implies there is evidence of benefit would be a "debunking" statement, as forbidden by MEDRS; reports of what doctors have done, or what the FDA says, would both fall into that category, I think. Alexbrn ^{talk|contribs|COI} 15:39, 20 January 2013 (UTC)

As I have stated many times already, two Cochrane reviews concluded that the available evidence is not good enough to make a conclusive statement. This has been very thoroughly quoted in the article. If Cochrane had stated that "firm evidence says its useless" then well and good, but that is not the case. Also, those reviews did not consider all the studies that have been done since 2009. This leaves a vacuum, which I have filled with other reliable secondary sources on the topic. Ayiteh et al (the gold standard review) admits that silver is a useful antimicrobial, and Lansdown is also secondary and RS. These therefore do not contravene WP:MEDRS, which warns against using primary research where it contradicts secondary sources. Its a fact that SDD has been widely used for 40 years and was considered better than anything else during that time, and its a fact that the FDA has approved its use. No doctor is going to inappropriately prescribe a dressing for an infected wound based on wikipedia. Wdford (talk) 16:05, 20 January 2013 (UTC)

Gold standard

Currently we state "By 2007 it was regarded as the "gold standard" in topical treatment." based on this literature review [10]

"The gold standard in topical burn treatment is silver sulfadiazine (Ag-SD), a useful antibacterial agent for burn wound treatment. Recent findings, however, indicate that the compound delays the wound-healing process[17] and that silver may have serious cytotoxic activity on various host cells [2], [17], [18], [19], [20],[21] and [22]. On the other hand, the beneficial effects of silver on wound biology due to its potent antimicrobial activity have been overlooked in general until recently. The literature is becoming replete with clinical trials purporting to show the benefits of silver therapeutics and silver-release dressings on wound repair and regeneration through its antimicrobial efficacy. Little is published, however, to show how the released silver ion influences the wound bed, or to what extent it is metabolized or deposited in the tissue. Moreover, results of the extensive literature review we conducted failed to reveal any clinical studies regarding the risks and probabilities of wounds in general to become infected, about the effect of silver dressings on already infected wounds, nor about studies comparing the effect of silver or other antiseptic dressings on prevention of wound infection."

1) I do not think this is a fair summary of the source 2) We have a number of references which specifically do not recommend it in burns [11]

I was fine with stating "It however used to be deemed the "gold standard" in topical treatment." but remember this is expert opinion which is a much lower level of evidence than a systematic review and meta analysis. Doc James (talk · contribs · email) (if I write on your page reply on mine) 10:08, 20 January 2013 (UTC)

Yes, in the context of the following sentence of the abstract, this "gold standard" view is framed as mistaken. The conclusion of the article too is quite equivocal: "It is clear also that the effects of the various silver products available on wound infection and wound healing are variable." Alexbrn ^{talk|contribs|COI} 10:31, 20 January 2013 (UTC)

Exactly so we are more or less using a ref to support the exact thing it does not. Doc James (talk · contribs · email) (if I write on your page reply on mine) 10:42, 20 January 2013 (UTC)

Again, not so. The source clearly says that SSD is the gold standard (as of 2007) - this is a clear statement of fact. The source then mentions that SSD has minor side-effects - which neither Lansdown nor the FDA thought was a show-stopper. The source then lists a range of issues about which they could not find satisfactory info - a common problem on this topic it seems, which Cochrane also experienced. However none of these issues actually suggests that SSD doesn't do its primary job, nor does the source suggest that any other treatment is the new gold standard. As far as the "gold standard" remark is concerned, the source is quoted accurately. Wdford (talk) 12:12, 20 January 2013 (UTC)

Some claim it was the "gold standard" before 2007. The source is not stating that it is the gold standard now and raises issues regarding its effectiveness. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:51, 20 January 2013 (UTC)

Obviously, and the article did state that the comment was made in 2007. However, I have not seen any source stating that anything else has taken its place as the gold standard, either. The source raised several issues, but it didn't claim that SSD is not effective - in fact they called it "a useful antibacterial agent". Wdford (talk) 15:27, 20 January 2013 (UTC)

That source clearly states it's antibacterial, but also raises concerns about wound healing and the overall conclusion is mixed. Far from what readers might infer from the "gold standard" sound bite, or a statement regarding antibacterial efficacy separate from the concerns about wound healing. -- Scray (talk) 18:06, 20 January 2013 (UTC)

NPOV

Have added concerns regarding NPOV. Pertains partly to this line "Ventilator-associated pneumonia (VAP) has a very high rate of mortality, and the associated costs are high" While this is true having it here implies that somehow this tube decrease both of these, yet the evidence supports no change in either one. This does not belong here. Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:13, 20 January 2013 (UTC)

Are your concerns article-wide, or specific to that section? (in which case, I'd move the template). Alexbrn ^{talk|contribs|COI} 14:18, 20 January 2013 (UTC)

The other issue is this line "Lansdown noted in 2010 that SSD is the most popular antibiotic for topical application in burn and scald clinics" This says nothing about effectiveness. Vioxx was an exceedingly commonly prescribed medication but this did not mean that it was more effective than ibuprofen or did not cause heart attacks. One must separate marketing and medicine. More primary research has ended the adverse effects section such as this [12] So yes issues with more than one section. Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:23, 20 January 2013 (UTC)

Oh please. I long ago inserted the sentence "although in the studies thusfar undertaken, no benefit was seen on the duration of intubation, the duration of stay in intensive care or the mortality rate". It would be very wrong to delete the sentence that says these products reduce incidences of VAP just to avoid a non-existent "implication". I have also already added back your preferred source for the subject as well, even though I can't access the detailed report where it presumably addresses silver products.

Re the Lansdown comment, I have quoted Lansdown quite accurately here, and he is an RS. However many other sources have indeed stated that SSD is effective - including the "gold standard" team as recently noted by me in another section a few seconds ago. Cochrane thusfar holds a different stance, which has been thoroughly ventilated in the article too. Everything is fully referenced, and I even moved the Cochrane paragraph to the top.

What more do you have issue with please so that we can reach a consensus? Wdford (talk) 15:38, 20 January 2013 (UTC)

I completely agree with Jmh649's first point - the preamble about the severity of VAP is likely to mislead the reader regarding the efficacy of the topic at hand (silver). A link will provide interested readers with info on VAP, but more emphasis on severity would be undue considering what sources say about this. -- Scray (talk) 18:03, 20 January 2013 (UTC)

The sources say exactly what the article says - VAP is very serious, silver-coated tubes significantly reduce infection rates, but studies thusfar have not proven that silver-coated tubes reduce mortality or duration. All accepted fact, from reliable sources. How could anybody be mislead? Wdford (talk) 18:38, 20 January 2013 (UTC)

The problem is WP:SYNTH. The sentence in question highlights the mortality and cost of VAP, and the article is about silver's medical use. Unless sources are provided that show a significant effect on mortality or cost attributable to medical use of silver, the sentence represents synthesis in context. -- Scray (talk) 04:22, 21 January 2013 (UTC)

Agree with Scray. You are building up the disease. And than associated a treatment with it even though there is no evidence that it addresses either aspect of that disease. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:00, 21 January 2013 (UTC)

Wound dressings containing SSD

Could a consensus be formed around the concept that the evidence for the efficacy of SSD-containing wound and burn dressing is "mixed"? It seems as though the reviews fall into three categories: (1)insufficient evidence for efficacy claims, (2) not effective, and (3) effective. If we could agree on which reviews fit into each category, then we could start the section out with the one sentence description, then say that the evidence is mixed, and then give the conclusions of reviews in each category. And please, don't use direct quotes.Desoto10 (talk) 03:23, 21 January 2013 (UTC)

Here are the reviews that I have so far. I got booted out of the Landsdown book so maybe some of you @*.edu types can help out:

Aziz Z, Abu SF, Chong NJ., Systematic Review. 2012 conclude the SSD dressings are no better nor worse than non Ag-containing dressings.

Vermeulen H, van Hattem JM, Storm-Versloot MN, Ubbink DT. Systematic review 2007. conclusion: Insufficient evidence to recommend the use of Ag-containing dressings.

Bergin SM, Wraight P. 2006. Systematic review. Conclusion: No evidence.

Atiyeh BS, Costagliola M, Hayek SN, Dibo SA. 2007. Systematic review. Conclusion: “silver-based products should be avoided if possible as a topical antimicrobial strategy where rapidly proliferating keratinocytes are exposed as in donor sites, superficial partial thickness wounds and undifferentiated cultured keratinocyte applications” emphasis mine. OK, I’m lazy, that is a direct quote.

Wasiak J, Cleland H, Campbell F. 2008. systematic review. Conclusion: the use of Ag-containing dressings needs to be reconsidered due to slow healing.

Lo SF, Hayter M, Chang CJ, Hu WY, Lee LL. 2008. systematic review. Conclusion: This review strengthens the case for the use of silver dressings when managing infected chronic wounds. Sorry, another quote, we can paraphrase later

Chopra. 2007. Review. Conclusion: Some silver-based dressings appear to provide an effective alternative to antibiotics in the management of wound infection.

Potential Chopra COI: “I received an educational grant from Smith and Nephew Research to review the literature and prepare this article.” S and N make Ag containing wound dressings.

Landsdown.

Desoto10 (talk) 04:01, 21 January 2013 (UTC)

Agree that the majority of the evidence does not support the Chopra 2007 review. Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:14, 21 January 2013 (UTC)

That’s probably because we have left out half the evidence. To be balanced the summary must also include all the positives, namely:

1. SSD was the gold standard in topical burn treatment as of 2007 (Atiyeh)
2. SSD is a useful antibacterial agent for burn wound treatment (Atiyeh)
3. The FDA has approved a number of topical preparations of SSD for treatment of second- and third-degree burns
4. Topical silver has been shown to be efficacious in controlling most pathogenic bacteria, including methicillin-resistant Staphylococcus aureus (Lansdown)
5. SSD is particularly effective in treating Pseudomonas aeruginosa (Lansdown)
6. SSD has a relatively low health risk threshold (Lansdown)
7. Some nanocrystalline-silver barrier dressings promote healing and reduce inflammatory wound changes.(Lansdown)
8. Most clinical trials have shown that silver-based dressings demonstrate "commendable levels of antimicrobial action and improved wound healing” (Lansdown)

I am happy to drop Chopra – he doesn’t say anything that isn’t already covered by others.

The article should also avoid negative synthesis, whereby some editors are trying to down-play the positives by combining sentences inappropriately. Specifically the article needs to differentiate between the primary purposes of silver-dressings, i.e. defeating bacterial infections, and other issues such as delayed wound healing. It’s well known that silver dressings delay wound healing by a few days, but that doesn’t mean it isn’t doing its primary job of killing bacteria. All antibiotics and antiseptics have side-effects – they are poisons, after all. Wdford (talk) 07:20, 21 January 2013 (UTC)

Cochrane reviews are the best quality of evidence. It takes a little time before their conclusions filter out into the rest of the literature reviews. Systematic reviews are a better quality of evidence than literature reviews. Doc James (talk · contribs · email) (if I write on your page reply on mine) 08:06, 21 January 2013 (UTC)

Agree. Only the systematic reviews should be used; other articles/books not. Alexbrn ^{talk|contribs|COI} 10:35, 21 January 2013 (UTC)

That's not what WP:MEDRS says. What is up with this POV?

WP:MEDRS says that "areas of uncertainty in medicine should be illustrated with reliable secondary sources describing the varying viewpoints". A Cochrane consensus of "insufficient evidence" certainly counts as an uncertainty, especially when other reliable sources have more confident stances. You can't just delete the viewpoints that you don't like.

Just as the Cochrane reviews take time to reach the literature, so the latest studies take time to reach Cochrane reviews. The two reviews you are depending on only covered up to 2009, so there are several years of later studies that had not yet "filtered through" into those reviews.

The US FDA is responsible for, inter alia, “protecting the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products, medical devices, our nation’s food supply, cosmetics, dietary supplements, and products that give off radiation”. [13] A medical product which is FDA approved must therefore by definition be safe and effective. NOTE to non-Americans - its not just a local political decision.

Just for interest, here are two more recent secondary sources that reach favourable conclusions - “Conclusion - Research indicates nanocrystalline silver dressing is an effective antimicrobial for treating wounds especially burns and chronic wounds.” At [14] or [15] “Other studies suggest Acticoat has fewer adverse effects and reduces healing times. Its ease of application and low frequency of change makes it an ideal dressing in burn wounds.” At [16] Wdford (talk) 10:44, 21 January 2013 (UTC)

These "Two more recent reviews" are from 2006, how is this more recent than a 2009 Cochrane review? I am simply confused. Doc James (talk · contribs · email) (if I write on your page reply on mine) 10:58, 21 January 2013 (UTC)

Sigh. Here are two additional recent reviews. Wdford (talk) 11:47, 21 January 2013 (UTC)

We have six systematic reviews: secondary sources of the highest quality. If they report the situation is uncertain, that is what WP must neutrally relay. In that case we should not be using lesser sources to paint a differing/contrary picture which implies there is certainty.

BTW, talking of POV, at the moment while the systematic reviews are carefully reported with in-text attributions, Wikipedia is stating as fact and in its own voice "Nanocrystalline silver barrier dressings promote healing and reduce inflammatory wound changes" (etc). This is concerning. 10:59, 21 January 2013 (UTC)

Which of course the best avaliable evidence does not support. Which is why we have the NPOV tag. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:02, 21 January 2013 (UTC)

Sentence which states nothing about treatment

This sentence "In particular, silver is being used with alginate, a naturally occurring biopolymer derived from seaweed, in a range of products designed to prevent infections as part of wound management procedures, particularly applicable to burns" is carefully worded to say nothing. It states that these products are designed to prevent infection which of course does not mean they do prevent infection. This is marketing speak and thus I am removing. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:22, 21 January 2013 (UTC)

Now I have gone and read the reference in question and it does not support the content to which it is attached [17]. Can whoever added it please added the direct quote that supports the above. Have reworded until that time. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:30, 21 January 2013 (UTC)

This ref does not support the content with which it is associated

We have "Topical silver has been shown to be efficacious in controlling most pathogenic bacteria, including methicillin-resistant Staphylococcus aureus" But the only thing this ref says is "topical silver has gained popularity once again, principally in the management of open wounds. This has been largely due to the spread of methicillin-resistantStaphylococcus aureus and the resultant reduction in first-line antibiotic prescribing"[18]

I do not see how this supports the text in question and therefore have removed. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:38, 21 January 2013 (UTC)

The other ref does not really support either. It states "silver has acquired a worldwide acceptance as a broad specrtum antibiotic. Laboratory and clinical studies have shown it to be safe in long term use and efficacious in controlling most pathogenic bacteria, fungi, and parasitic infections including MRSA". But this does not say topic silver antibiotics are effective and does not even mention silver dressings. Doc James (talk · contribs · email) (if I write on your page reply on mine) 11:43, 21 January 2013 (UTC)

"Efficacious" is very similar in meaning to "effective". see [19]Wdford (talk) 12:08, 21 January 2013 (UTC)

The question is in what form? It does not state "Topical silver" That is one of my concerns. Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:09, 21 January 2013 (UTC)

This textbook

This textbook "silver in healthcare" is not a "widely recognised standard textbooks" [20] and thus in my opinion should not be used to refute the conclusions of more recent (or even less recent) systematic review articles.Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:11, 21 January 2013 (UTC)

Correct. As you may have noticed, I have removed those uses of it. Alexbrn ^{talk|contribs|COI} 12:19, 21 January 2013 (UTC)

american biotech

Zad, you have entered into edit war. You have accused of making a promotion. However when i asked you for a quote, you didn't provide one and instead changed your reasoning. Accusing a fellow editor without a reason is absence of agf. When you have entered an edit war, you further lost some part of my respect for you. I suggest you to retract. This is also your second act of disruptive editing the first one being removing a secondary source. And, you are wrong in essence too. The epa approval indicates that cs can be used for hard surface disinfection. The other source there is invalid and maybe a dummy. I suggest you to urgently redo. Ryanspir (talk) 19:59, 18 January 2013 (UTC)

Sorry you feel that way, but honestly my motivation for editing is to develop articles along Wikipedia policy and guideline and not for the approval of other editors. To be clear, the reason for both reverts was the same--the relevant part of the first edit summary was "not a sufficient source for this", the second one explicitly referenced WP:V per your request. The EPA approval source is insufficient for the content it was applied to, as explained above. The other revert you are talking about (I assume this?) was also a WP:V problem, relevant part of my edit summary was: "PMID 18854209 might be useful but needs more careful summary" and I explained further here. The content you added in that edit wasn't fully supported by the one source I mentioned might have been a good source, so, as I mentioned, the content needed to be reworded to summarize that source more carefully. Zad68 20:13, 18 January 2013 (UTC)

And now you amuse me. In your first revert you mentioned promotion being the reason. But in your reply which you have just posted you say it was wp:v. When you are starting jumping from one policy to another you have to make a self check, why are you actually doing this? To give you a bit of history, wpford posted this context and provided the epa link. Someone has replaced his reference. What you have done is removed the original reference and left the one which is incorrect one, which is without a link, which not about nano silver and not talking about sprays. The epa link is in fact correlates with wp:v because the approved product belongs to nanosilver category. Ryanspir (talk) 20:47, 18 January 2013 (UTC)

"wpford posted this context and provided the epa link" In actual fact, Ryanspir suggested the edit and provided the EPA links. wpford, trying to reach some kind of consensus put the information in the article. The current ref is titled something like Silver as a disinfectant and seems on target. I am sure that a better ref could be found, but let us use research papers, not regulatory documents.Desoto10 (talk) 22:14, 18 January 2013 (UTC)

I agree that I provided the info. I disagree that research papers should be used over regulatory documents. Both of them can be used, and FDA and EPA doesn't write regulatory documents which are not backed up by approved research. In this sense, regulatory papers carry even more weight, because they show that the research upon which they are based has been approved by the experts working at these respective authorities. The current reference has no link and is not on topic either. The reference shall be replaced to the original EPA approval. Ryanspir (talk) 11:05, 23 January 2013 (UTC)

Cautery

Just wondering, but why is there no mention of silver nitrate's application in cautery such as when it's used to treat recurrent epistaxis (nosebleeds)? TylerDurden8823 (talk) 07:07, 20 January 2013 (UTC)

Does silver nitrate count as silver? Alexbrn ^{talk|contribs|COI} 07:22, 20 January 2013 (UTC)

Yes, and it would be good to add. It must be mentioned in a review somewhere.Desoto10 (talk) 07:24, 20 January 2013 (UTC)

Silver nitrate is mentioned already in the Antiseptic section. Should we create a new section for this cautery item? Wdford (talk) 08:10, 20 January 2013 (UTC)

Well, I'm not sure if it merits a section, I'll leave that up to you, but I think its application in nosebleeds deserves some discussion.TylerDurden8823 (talk) 15:16, 23 January 2013 (UTC)

TGA

"Given the associated safety risks, the TGA concluded "efforts should be made to curb the illegal availability of colloidal silver products, which is a significant public health issue."[53]" I've removed this quote because in isolation its misleading and false. Colloidal silver is not illegal in Australia now, and never has been. What the TGA meant was that that they were concerned about the illegal advertising of medical claims for colloidal silver. Thats an entirely different matter which you can explain in detail if you wish, but the to imply that CS itself was illegal is simply untrue regardless of whether its referenced or not. — Preceding unsigned comment added by 119.12.139.52 (talk) 23:10, 20 January 2013 (UTC)

There is no mention that I could see in the source of "ingestion" of CS, just CS with therapeutic claims. I believe that this would include wound dressings containing CS, but not SSD.Desoto10 (talk) 02:38, 21 January 2013 (UTC)

It's possible, since perhaps in Australia there is no approved CS for wound dressings. So they don't need to separate external and internal uses in their statements, unlike in US. Ryanspir (talk) 12:26, 23 January 2013 (UTC)

WP:MEDRS

Per WP:MEDRS we should be using sources from the last 3 to 5 years. Thus I will remove old stuff before 2008 per this consensus.Doc James (talk · contribs · email) (if I write on your page reply on mine) 12:02, 21 January 2013 (UTC)

I agree.Ryanspir (talk) 10:58, 23 January 2013 (UTC)

Antiseptic uses

I have fixed this paragraph to: Silver compounds are used in external preparations as antiseptics, including both silver nitrate and silver proteinate, which can be used in dilute solution as eyedrops to prevent conjunctivitis in newborn babies. Silver nitrate is also sometimes used in dermatology in solid stick form as a caustic ("lunar caustic") to treat certain skin conditions, such as corns and warts.[10] Liquid sprays containing silver may be used as a hard-surface disinfectant.[24]. Silver nanoparticles may promote would healing .[25] Silver is also used in bone prostheses, reconstructive orthopedic surgery and cardiac devices.[26] Isn't it looks ok? Ryanspir (talk) 11:42, 23 January 2013 (UTC)

Lets edit this article per wiki policies.

An example I'm referring to are Zad's actions. He reverts ALL of my edits. Even when I posted the secondary source, he *himself* stated as being good per wp:medrs, peer-reviewed, medline indexed review study of good quality. However, someone posted Quackwatch reference which was revised in the year 2005 and haven't updated since and he is silent. I think this kind of editing is considered disrupting editing. The other thing that some editors are making only negative edits. In such a case I propose to rename the article to: "Absence of legitimate medical uses of silver". Ryanspir (talk) 12:52, 24 January 2013 (UTC)

Quack watch has been deemed to be a suitable ref for alt med claims. The 3-5 years is for areas where their is active research such as silver containing dressing (ie there is lots of secondary sources). With respect to CS there are none. With respect to 10 years there are a couple PMID:15748553 and PMID:17538258

So if we have a reliable secondary source from the last 3-5 years than yes we will remove these older sources. If we do not than we will keep them. Doc James (talk ·contribs · email) (if I write on your page reply on mine) 13:01, 24 January 2013 (UTC)

See WP:NOTVAND. Falsely accusing your fellow editors of vandalism is rather serious and I suggest you retract the accusation. Also first warning for disruptive editing. Quackwatch is not a reliable source, fails RS and MEDRS. Ryanspir (talk) 13:36, 24 January 2013 (UTC)

Ryanspir – this[21] edit caused malformed markup ... and so it was quite right for it to be reverted (as a good faith edit) on the basis that it appeared to be vandalism. The assumption I suppose is that you mis-clicked or something. Alexbrn ^{talk|contribs|COI} 13:39, 24 January 2013 (UTC)

When chunks of text are removed half way through a reference yes this is the "appearance of vandalism". Please be more careful. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:50, 24 January 2013 (UTC)

I suggest you rather urgently to read WP:NOTVAND. Ryanspir (talk) 13:59, 24 January 2013 (UTC)

Okay to clarify. If old content is contradicted by new content than yes we remove the content supported by old sources. In this case [22] no newer sources that refute these older sources have been put forwards. Until someone provides these this text should not be used. It appears that I have been mis interpreted.

In the previous case where I removed old source we had much newer high quality systematize reviews and meta analysis by independent organization of international standing that refuted them. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:48, 24 January 2013 (UTC)

Ryan, you say I revert 'all your edits' but if you review the article's history, you'll see that isn't true:

• I've reverted three similar attempts to introduce the EPA certification for one of American Biotech Lab's products as source to support a general statement along the lines of "Liquid containing nano-silver are effective as a hard-surface disinfectant." I have explained the reasons for the revert thoroughly in edit summaries, citing the relevant Wikipedia policies, and, as you've requested, here on this Talk page. You'll see this was covered in sections Talk:Medical_uses_of_silver#american biotech, Talk:Medical_uses_of_silver#zad and Talk:Medical_uses_of_silver#hard surface disinfectant, and there is consensus among myself, Desoto10, Alexbrn and Doc James that the EPA document isn't appropriate for the use suggested in this article. Your further attempts to insert this into the article, such as your restore of the content in this revert with edit summary "Kindly provide a quote from the relevant policy", is disruptive "I didn't hear that" tendentious editing against consensus, and you are requested to stop, perhaps for the last time before sanctions are sought.
• My revert of the edit that added PMID 18854209 was thoroughly explained here: Talk:Medical_uses_of_silver#american biotech and here: Talk:Medical_uses_of_silver#CS effectiveness. I am not sure why you think I am "still working on his representation on that secondary study" as I never said I was going to do so. However, please note that at least one other editor Desoto10 in Talk:Medical_uses_of_silver#A study on Silver Sol expressed doubts about the usefulness of the study due to a conflict of interest in the funding of the study.

Other than those two kinds of edits, you have made lots of other edits I have not reverted.

Zad68 14:24, 24 January 2013 (UTC)

Separation

I'm proposing to separate Nano particles from the current article and create a new article called Nanosilver. 1) It will give us a stable article of medical uses of silver because majority of the debate will be on the nanosilver one. 2) We will be able to address all concerns and reflect all studies on nanosilver and put all relevant warnings there. There are currently many warnings about colloidal silver which are not related to a non-nanosilver. Ryanspir (talk) 13:02, 24 January 2013 (UTC)

The article is way too small to merit a split. Alexbrn ^{talk|contribs|COI} 13:04, 24 January 2013 (UTC)

(edit conflict) I was going to say that. It is not like this article is overly big so I do not see the need. I am seeing maybe 5 reviews on pubmed. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:07, 24 January 2013 (UTC)

Well, it's because Zad is still working on his representation on that secondary study and all adjunct studies. Once Nanosilver will have it's own article all that info can be posted. Also, another very important reason for separation. The wikipedia is created to serve the readers. The people who are googling for "colloidal silver" would like to read that specific information. They may not be interested in ordinary silver creams and such. But the current situation with the research in nanosilver. Ryanspir (talk) 13:20, 24 January 2013 (UTC)

Not sure what you mean. We should give be an accurate view of the whole field. Doc James (talk · contribs · email) (if I write on your page reply on mine)

Per article's name. Nanosilver is a whole field with lots of research going on. Some researchers call it "a new emerging vector in the antimicrobials". Ryanspir (talk) 14:00, 24 January 2013 (UTC)

Agree with Alex and Doc James, far too little quality sourcing covering nanosilver as distinct from silver to justify this. Additionally, the potential for WP:POVFORK problems is very high. Zad68 15:46, 24 January 2013 (UTC)

I agree that there is no need for a split.Desoto10 (talk) 17:29, 24 January 2013 (UTC)

Zad, are you serious? All studies differentiate these two, as well as all regulatory authorities including fda and nccam, and all advisories on this article. Ryanspir (talk) 19:37, 24 January 2013 (UTC)

This is not in response to anything I actually said. Zad68 19:49, 24 January 2013 (UTC)

You have said there are no enough quality sources which are covering nanosilver as distinct from silver. Am i right? Because all the sources on this article covering them distinctly, do you mean that all of them are of no high quality? Or point me to at least three sources on this article which threat them nondistinctly. Ryanspir (talk) 20:19, 24 January 2013 (UTC)

Correct, there's not enough of each to warrant making two separate articles. As I was only one of several editors who brought up this point, and I am having trouble making myself understood to you, perhaps I'll let the other editors explain further. Zad68 20:24, 24 January 2013 (UTC)

You are amusing me with your logic. If you agree that you are the only one who brough this point, why other editors shall explain it? Its your point and please be kind to explain it. Ryanspir (talk) 20:53, 24 January 2013 (UTC)

It'd be really nice if you 1) would not personalize content issues, and 2) would actually make responses that were based on an understanding of what was actually written, as this last response does not. Zad68 20:56, 24 January 2013 (UTC)