Download a study on honey dressing for diabetic foot ulcer healing

BANGALORE – KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
GIJOSE. T. M
1 year M.Sc (Nursing)
MASTER IN MEDICAL-SURGICAL NURSING
YEAR 2009-2010
St
CAUVERY COLLEGE OF NURSING
# 42/2B, 2C, TERESIAN CIRCLE
SIDDARTHA LAYOUT
MYSORE.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.0
NAME OF THE CANDIDATE
AND ADDRESS
GIJOSE. T. M
1st YEAR M.SC NURSING,
CAUVERY COLLEGE OF NURSING,
MYSORE.
2.0
NAME OF THE INSTITUTION
CAUVERY COLLEGE OF NURSING,
MYSORE.
3.0
COURSE OF THE STUDY
AND SUBJECT
MASTER IN NURSING,
MEDICAL SURGIAL NURSING
4.0
DATE OF ADMISSION TO
COURSE
15. 06. 2009
5.0
TITLE OF THE STUDY
A STUDY ON HONEY DRESSING FOR
DIABETIC FOOT ULCER HEALING
5.1
STATEMENT OF THE
PROBLEM
A STUDY TO DETERMINE THE
EFFECTIVENESS OF HONEY
DRESSING FOR DIABETIC FOOT
ULCER HEALING AMONG PATIENTS
WITH TYPE II DIABETES MELLITUS IN
SELECTED HOSPITAL SETTINGS AT
MYSORE.
6. BRIEF RESUME OF THE INTENDED WORK:
6.1 INTRODUCTION
Diabetes mellitus is recognized to be common in Indians of Asian
subcontinent. In 2005, Vijay Viswanathan, Sharad Pendsey and Arun Bal
reported that currently 25 million Indians have diabetes. The projections indicate
that India will have the largest number of diabetic patients by the year 2025 A.D.
The loss of a limb or foot is one of the most feared complications of diabetes and
yet foot problems remain the commonest reason for diabetic patients to be
hospitalized.1
Bloomgarden ZT in 2004 reported that more than seventy percent
diabetics develop foot ulcers in their lifetime Foot infections spread very quickly
without giving much warning. Minor injuries become ulcerated leading to deep
seated abscess and cellulites. Bone involvement is also very fast. Sore swelling
local warmth redness with or without fever may be the consequences of a mild to
moderate injury.2
Dr Basab Ghosh in 2009 reported Diabetic foot ulcers are common and
estimated to affect 15% of all diabetic individuals during their lifetime. Diabetic
foot ulcers precede almost 85% of amputations. There are two main reasons for
the foot complication. Some diabetic patients develop a diabetic peripheral
neuropathy characterized by loss of sensation in the feet. Such patients have a
high risk of injuries which often go unnoticed. Diabetic patients particularly those
with neuropathy have abnormal pressure points under the feet. In these area, the
skin gets thickened (called callus) which then becomes an ulcer. Chronic
infection in the ulcer ultimately leads to amputation of a toe or the whole foot.
These two groups of patients are considered to have “High Risk Feet”3
Lipsky in 2004 reported the Treatment of diabetic foot ulcer includes
debridement with removal of all necrotic tissue and oral antibiotics (emergency
referral) with removal of necrotic or poorly vascular zed tissue, including infected
bone.- Revascularization if necessary. Metabolic control and treatment of co
morbidity -Optimal diabetes control, if necessary with insulin The ulcer care
includes- Frequent wound debridement, Frequent wound inspection and
absorbent, non-adhesive, non-occlusive dressings.
In 2008 the natural remedies e mail article reported that the current trends
in the community dermatology focusing the ulcer healing by the simple natural
remedies which includes topical application of banana leaf, bee propolis, myrrh
and honey dressings.5
6.2 NEED FOR THE STUDY
Devender Singh in 2006 reported that “India is the diabetic capital of the
world” with its largest share of diabetic persons. Among persons with diabetes
about 15% will experience a foot ulcer in their lifetime, and about 14-24% of them
will require an amputation. In the US, an annual incidence of 2% to 3% and a
prevalence of 4% to 10% have been reported. These figures indicate that a large
percentage of foot ulcers are chronic. 6
Wild S et al in 2004 informed that, The number of people with diabetes
worldwide was estimated at 131 million in 2000 ;
it ulcers is ~ 3%, and the
reported incidence in U.S. and U.K. studies ranges as high as 10% is projected
to increase to 366 million by 2030.7
Singh N, Armstrong DG, Lipsky BA studies in 2005 has indicated that
diabetic patients have up to a 25% lifetime risk of developing a foot ulcer.
8
Reiber GE, Vileikyte L, Boyko EJ, in 1999 have reported once an ulcer
has developed, there is an increased risk of wound progression that may
ultimately lead to amputation; diabetic ulceration has been shown to precede
amputation in up to 85% of cases. 9At least 40% of amputations in diabetic
patients can be prevented with a team approach to wound care.9
Devender Singh in 2006 reported that needing a first amputation is a poor
prognostic sign in diabetic patients; 28% to 51% of these patients require a
second amputation with 5 years. The 5-year mortality rate after lower extremity
amputation ranges from 39% to 68%. The vast majority of diabetic foot
complication resulting in amputation begins with the formation of skin ulcer 6
Bridges RM, Deitch EA reported in 1994 conducted routine annual foot
screening facilitates early interventions to reduce the incidence of the most
common precipitating events including injury and foot-related trauma to the
insensitive foot.9 The key elements of preventive care include: annual
examination of the feet by healthcare providers to determine risk factors for
ulceration, subsequent examination of high risk foot ulcer and dressings of foot
ulcer. The selection of wound dressings is also an important component of
diabetic wound care management. There are a number of available dressing
types to consider in the course of wound care. The easy and simple natural
dressings is the honey dressings.10
Cooper RA, Molan PC in 1999 reported that the topical application of
honey on wound act as a deodorant, an effect attributed to the presence of
glucose, which is metabolized by bacteria in preference to proteinaceous necrotic
tissue, resulting in the production of lactic acid and not the malodorous
compounds generated by protein degradation. In addition, the observed benefits
of honey in infected wounds may be attributed to the high glucose content and
low pH, both of which stimulate macrophages.11
Honey is an inexpensive moist dressing with antibacterial and tissuehealing properties that has shown promise in the medical literature. It can be very
effective in diabetic foot ulcer healing.11
Wisconsin school of medicine ,USA Eddy JJ, Gideonsen MD, Mack GP in
2008, used the topical honey and are currently conducting a randomized
controlled trial of its effectiveness in treating diabetic foot ulcers. In this review,
the authors summarize evidence of honey's effectiveness, its hypothesized
mechanism of action, potential risks and benefits, the types of honey available,
and the nature of its application. Critical aspects of ulcer care are also reviewed.
The study concluded that honey is a low-cost topical therapy with important
potential for healing. 12
From the above reviews and with investigator’s clinical experience, the
wound dressing with honey dressings given various benefits in different types of
wound. So the investigator plans to conduct the study to evaluate the
effectiveness of honey dressings on diabetic foot ulcer healing.
6.3 STATEMENT OF THE PROBLEM
A study to determine the effectiveness of honey dressing for diabetic foot
ulcer healing among the patients with type II Diabetes mellitus in selected
hospital settings at Mysore.
6.4 OBJECTIVES
1. To assess the pre test level of ulcer healing in both experimental
and control group.
2. To evaluate the effectiveness of honey dressing by comparing the
pretest and post test scores in both experimental and control group.
3. To associate the post test level of ulcer healing with selected socio
4. demographic variables in both experimental and control group such
as
5. age, sex, duration of illness, foot ulcer duration, blood glucose
level and
6. type of treatment.
6.5 HYPOTHESES
H1. There is a significant increase in the level of diabetic ulcer healing in
experimental group than in control group.
H2. There is a significant association between experimental group and
control group with demographic variables such as age, sex, duration of
illness, foot ulcer duration, blood glucose level and type of treatment.
6.6. OPERATIONAL DEFINITIONS:
1. EVALUTE: Measure the level of healing of foot ulcer before and after the
intervention.
2. EFFECTIVENESS: Outcome of the intervention measured in terms of stages
of wound healing.
3. HONEY DRESSINGS: Topical application of natural honey on diabetic foot
ulcer.
4. DIABETIC FOOT ULCER: One of the complication of diabetes mellitus in the
foot, due to the pressure exerted on foot leads to neuropathy and vasculopathy
causes wound or ulcer.
.
6.7. ASSUMPTION:
a. Natural remedies can be easily availed by the person.
b. Honey dressing promotes wound healing.
c. Honey has effect to heal chronic wounds.
d. Honey is stimulating macrophages activity.
e. Honey available in the low cost
6.8. DELIMITATION:
1. The sample size is limited to 60 patients
2. Prescribed data collection period is only 4 to 6 wks.
6.9. CONCEPTUAL FRAME WORK:
The Ludwig Open system model will be adopted as a conceptual
framework for this study. The Components are input, throughput and
output. The input describes the sample characteristics and existing health
condition. Through put describes the intervention. The output refers to the
outcome of the intervention.
6.10. REVIEW OF LITERATURE:
The review of literature is defined as a broad, comprehensive in
depth, systematic and critical review of scholarly publications, unpublished
scholarly print materials, audio visual materials and personal
communications.
The review of literature will be discussed based on the following
headings
1. Studies related to diabetic foot ulcer.
2. Studies related to honey dressings and wound healing.
1. Studies related to diabetic foot ulcer
According to the Marcus M. Riedhammer, M.D geisinger medical center
reported in 2009 that “Foot ulcers can be painful and can lead to further
infections and even limb amputation if they are not monitored or treated
correctly.” Diabetes can cause nerve damage, which lessens a diabetic’s ability
to feel when an injury develops, and it can adversely affect circulation and the
body’s ability to help wounds heal or fight off infection. “Because of these issues,
diabetics are particularly susceptible to developing foot ulcers,” suggested
checking and washing feet daily and wearing shoes that fit correctly to avoid
developing these ulcers. Rest and limiting pressure to the ulcer is very important,
apart from taking prescribed antibiotics in the case of an infection. The workshop
concluded: “Foot ulcers may seem like a minor issue, but they can pose a
serious threat to your health. By checking your feet every day, being aware of the
risks.13
In the pharma express, Amrita Diabetic Foot Conference 2009 reported
that 40.9 million diabetic patients and 81.8 million feet to be taken care of, India
is a country where 40,000 lower extremity amputations occur per year. According
to experts, even though this is still a grossly underestimated figure, the horrifying
figures recommend an urgent reality check not just on the part of awareness
about the newer treatments modalities in the area of diabetic foot management
for the Indian doctors but also an increased awareness among the masses.
Ulcers pose and consulting a doctor upon the first sign of a wound developing,
the risks and side effects of foot ulcers can be minimized. The three-day
conference dealt with a various issues pertaining to diabetic foot management,
including the newer therapies, drugs and put a new light on the overall
management of the diabetic foot.14
In 2006 the collective experience of treating patients with neuropathic
diabetic foot ulcers in four major diabetic foot programs in the United States and
Europe was analyzed by Brem H, Sheehan P and Rosenberg H J et al. Results
shows that the following protocol was developed for patients with diabetic foot
ulcers: (1) establishment of good communication among the patient, the wound
healing team, and the primary medical doctor; (2) comprehensive, protocoldriven care of the entire patient, including hemoglobin A1c, microalbuminuria,
and cholesterol as well as early treatment of retinopathy, nephropathy, and
cardiac disease; (3) weekly objective measurement of the wound with digital
photography, planimetry, and documentation of the wound-healing process using
the Wound Electronic Medical Record, if available; (4) objective evaluation of
blood flow in the lower extremities (e.g., noninvasive flow studies); (5)
debridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic
antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8)
maintenance of a moist wound bed; (9) use of growth factor and/or cellular
therapy if the wound is not healing after 3 weeks with this protocol; and (10)
consideration of the use of vacuum-assisted therapy in complex wounds. The
study concluded that in diabetic foot ulcers, availability of the above modalities, in
combination with early recognition and comprehensive treatment, ensures rapid
healing, minimizes morbidity and mortality rates, and eliminates toe and limb
amputations in the absence of ischemia and osteomyelitis.15
2. Studies related to honey dressings and wound healing
Shukrimi A in 2008, conducted a prospective study to compare the effect
of honey dressing for Wagner's grade-II diabetic foot ulcers with controlled
dressing group (povidone iodine followed by normal saline). Surgical
debridement and appropriate antibiotics were prescribed in all patients. There
were 30 patients age between 31 to 65-years-old (mean of 52.1 years). The
mean healing time in the standard dressing group was 15.4 days (range 9-36
days) compared to 14.4 days (range 7-26 days) in the honey group (p < 0.005).
In conclusion, ulcer healing was not significantly different in both study groups.
Honey dressing is a safe alternative dressing for Wagner grade-II diabetic foot
ulcers.16
In Italy ,the study conducted byBeretta G, Artali R, Caneva E,et al
in2009, wound-healing properties of honey are well established and it has been
suggested that, among its pharmaco-active constituents, kynurenic acid (KA)
exerts antinociceptive action on injured tissue by antagonizing NMDA at
peripheral GABA receptors. The aim of this study was to investigate the
quantitative profile of kynurenic acid and of two recently identified, structurally
related derivatives, 3-pyrrolidinyl-kynurenic acid (3-PKA) and its gamma-lactamic
derivative (gamma-LACT-3-PKA), by examining their mass spectrometric
behavior, in honeys from different botanical sources. Small amounts of kynurenic
acid were found in honeydew, sunflower, multifloral, almond and eucalyptus
honeys, in the range of 23.1-143 mg/kg, suggesting contamination with chestnut
honey. Total phenol content (TPC) was in the range from 194.9 to 1636.3
mg(GAE)/kg and total antiradical activity (TAA) from 61 to 940 mg/(GAE)/kg),
depending on the botanical origin. Principal component analysis (PCA) was then
done on these data. The three different clusters depicted: (i) antinociceptive
activity from kynurenic acid and/or its derivatives, typical of chestnut honey; (ii)
antioxidant/radical scavenging activity by antioxidants responsible for the
antiinflammatory action (dark honeys); (iii) peroxide-dependent antibacterial
activity due to H (2)O(2) production by glucose oxidase in honey. The Principle
component analysis findings provide useful indications for the dermatologist for
the treatment of topical diseases, and the profiling of kynurenic acid and its
derivatives may shed light on new aspects of the kynurenine pathway involved in
tryptophan metabolism.17
The study conducted by Stephen-Haynes J in 2004 on Honey has been used for
its healing properties for centuries and has been used to dress wounds with
favorable results. The emergence of antibiotic resistance and growing interest in
"natural" or "complementary" therapies has led to an interest in honey dressings.
Much of the research to date has been related to honey's antibacterial properties.
However, the healing properties claimed for honey also include stimulating new
tissue growth, moist wound healing, fluid handling and promoting
epithelialization. Until recently, honey had not been developed as a wound
management product and was not a certified pharmaceutical device. Activon
Tulle is a sterile, non-adherent dressing impregnated with Leptospermum
scoparium hone. The claimed properties of honey dressings would make this a
valuable addition to the dressing currently available in the primary care setting.
An evaluation was undertaken involving 20 patients with a variety of wounds. A
conclusion is drawn that while further research is needed, medical grade honey
does appear to be a valuable addition to the wound management formulary. 18
The study conducted on by.Lay-flurrie K in 2008 use of honey in wound
management. This is largely due to the growing clinical problem of antibioticresistant bacteria and the combined difficulties for the practitioner in managing
chronic wound types, such as burns, leg ulcers or surgical wounds, which may
become infected, for example, with methicillin-resistant Staphylococcus aureus
or Pseudomonas. The associated costs of treating such wounds are escalating
as a result. While the use of honey as a wound dressing has been recognized, at
least since Egyptian times circa 2000 BC, it is only more recently, due to the
development and licensing of modern honey wound dressings, that such
dressings have become more widely available and used in wound management.
This article focuses on the use of honey in the treatment of infected wounds and
burns. It will examine the effects of honey at the wound bed and its clinical
applications, along with the current dressings available. Also discussed are the
practical considerations, if, like any wound dressing, honey is to be used safely,
appropriately and for the benefit of the patient.19
Jull AB, Rodgers A and Walker N in 2008, New Zealand the evidence
based study conducted by to determine whether honey increases the rate of
healing in acute wounds (burns, lacerations and other traumatic wounds) and
chronic wounds (venous ulcers, arterial ulcers, diabetic ulcers, pressure ulcers,
infected surgical wounds). We searched the Cochrane Wounds Group
Specialised Register (May 2008), CENTRAL (May 2008) and several other
electronic databases (May 2008). Bibliographies were searched and
manufacturers of dressing products were contacted for unpublished trials.
Randomised and quasi randomised trials that evaluated honey as a treatment for
any sort of acute or chronic wound were sought. There was no restriction in
terms of source, date of publication or language. Wound healing was the primary
endpoint. Data from eligible trials were extracted and summarized using a data
extraction sheet by one author and independently verified by a second author.
The results shows that 19 trials (n=2554) were identified that met the inclusion
criteria. In acute wounds, three trials evaluated the effect of honey in acute
lacerations, abrasions or minor surgical wounds and nine trials evaluated the
effect the honey in burns. In chronic wounds two trials evaluated the effect of
honey in venous leg ulcers and one trial in pressure ulcers, infected postoperative wounds, and Fournier's gangrene respectively. Two trials recruited
people with mixed groups of chronic or acute wounds. The poor quality of most of
the trial reports means the results should be interpreted with caution, except in
venous leg ulcers. In acute wounds, honey may reduce time to healing compared
with some conventional dressings in partial thickness burns (WMD -4.68 days,
95%CI -4.28 to -5.09 days). All the included burns trials have originated from a
single centre, which may have impact on replicability. In chronic wounds, honey
in addition to compression bandaging does not significantly increase healing in
venous leg ulcers (RR 1.15, 95%CI 0.96 to 1.38). There is insufficient evidence
to determine the effect of honey compared with other treatments for burns or in
other acute or chronic wound types. Honey may improve healing times in mild to
moderate superficial and partial thickness burns compared with some
conventional dressings. Honey dressings as an adjuvant to compression do not
significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence
to guide clinical practice in other areas.20
In 2008 Guildford Surrey, UK. the study conducted by Visavadia BG,
Honeysett J, and Danford MH an Manuka honey dressing: An effective
treatment for chronic wound infections.The battle against methicillin-resistant
Staphylococcus aureus (MRSA) wound infection is becoming more difficult as
drug resistance is widespread and the incidence of MRSA in the community
increases. Manuka honey dressing has long been available as a non-antibiotic
treatment in the management of chronic wound infections. We have been using
honey-impregnated dressings successfully in our wound care clinic and on the
maxillofacial ward for over a year.21
7. MATERIALS AND METHODS OF STUDY
7.1. SIGNIFICANCE OF STUDY
The purpose of the study is to assess the effectiveness of honey dressing
for diabetic foot ulcer healing among patients with type II diabetes mellitus.
7.2. SOURCE OF DATA
Patients those who are admitted in the selected Hospitals at Mysore
7.3. RESEARCH DESIGN
The research design adopted for the study was quasi experimental (two
group pre test and post test design) with manipulation, control group and
randomization
Experimental
group
Control group
O1
X
O2
O1
------
O2
O1 - Pretest level of ulcer.
O2 - Posttest level of ulcer.
X - Intervention-honey dressings.
7.4. METHOD OF DATA COLLECTION
Observation checklist for assessing stages of wound healing.
7.5. SAMPLING PROCEDURE
7.5.1. SAMPLING CRITERIA
Inclusion criteria
1. The patient with type II diabetes mellitus and having diabetic foot
ulcer
2. Patients who are admitted in medical wards
3. Those who are willing to participate in the study
Exclusion criteria
1. Those who have type I diabetes mellitus
2. Patient with severe gangrenous foot ulcer
3. Patient with diabetic coma and diabetic keto- acidosis
7.5.2. POPULATION
Patients who are admitted in selected hospital settings at Mysore.
7.5.3 SAMPLES
Patients those who are fulfilling the sampling criteria.
7.5.4. SAMPLE SIZE
Sample comprises of 60 patients .Thirty for experimental group and thirty
for control group.
7.5.5. SAMPLING TECHNIQUE
Non Probability – Purposive sampling.
7.5.6. SETTING
The study will be conducted in Government Hospital, Mysore.
7.5.7. PILOT STUDY
Pilot study is planned with the 10% of sample size.
7.6. VARIABLES
Independent variable
Honey dressing is an independent variable.
Dependent variables
Diabetic foot ulcer healing is a dependent variable.
7.7. PLAN FOR DATA ANALYSIS
The data analysis will be done by descriptive statistics and inferential
statistics. The descriptive statistics are the percentage, mean, and
standard deviation and inferential statistics are independent‘t’ test and chi
square test.
7.8. PROJECTED OUTCOME:
The findings of the study would reveal:
1. The existing level ulcer healing in the diabetic foot
2. The effectiveness of honey dressing in promoting the diabetic foot ulcer
healing foot.
3. The study will motivate the health personnel to use natural remedies in
wound care.
7.9. ETHICAL CONSIDERATION:
Has ethical clearances been obtained from institution or concerned
authority?
Yes.
Whether the ethical committee’s suggestions and opinions will be taken
into consideration?
Yes.
8. LIST OF REFERENCE:
1. Vijay Viswanathan, Sharad Pendsey, Arun Bal. Diabetic Foot in India Diabetic Foot in India
Medicine Update 2005.
2. Bloomgarden ZT. Diabetes complications. Diabetes Care 2004;27: 1506–14.
3. Dr Basab Ghosh , MBBS, MDRC (Chennai), Dip Diab. Consultant Diabetologist, Dr Basab‘S
Diabetes Care, Old Kalibari Road, Krishnanagar, Agartala, Tripura, India. www.google.com 2009.
4. Lipsky BA Medical treatment of diabetic foot infections. Clin Infect Dis 39:S104- S114, 2004 .
5. www.natural/ remedies.com /cached pages updated 2008
6. Devender Singh et al.Diabetic foot: It’s time to share the burden Calicut Medical Journal
2006;4(3):e4
7. Wild S, Roglic G, Green A, Sicree R, King H : Global prevalence of diabetes: estimates for the
year 2000 and projections for 2030. Diabetes Care 2004 27:10471053,
8. Singh N, Armstrong DG, Lipsky BA : Preventing foot ulcers in patients with diabetes.
JAMA,2005 293:217-228,
9. Reiber GE, Vileikyte L, Boyko EJ, : Causal pathways for incident lower extremity ulcers in
patients with diabetes from two settings. Diabetes Care 22:157-162, 1999
10. Bridges RM, Deitch EA . Diabetic foot infections: pathophysiology and treatment. Surg Clin
North Am ,1994 74:537-555,
11. Cooper RA, Molan PC. Honey in wound care. Journal Wound Care 1999; 8: 340.
12. Eddy JJ, Gideonsen MD, Mack GP..Practical considerations of using topical for neuropathic
diabetic foot ulcers: a review. Wisconsin Medical 2008 Jul;107(4):187-90
13. Marcus M. Riedhammer, M.D .Foot ulcers dangerous for diabetics foot by ANI on November
26, 2009
14. Amrita Diabetic Foot Conference 2009'Lack of Awareness about Diabetic Foot Lead to Delay
in Treatment'www.expresshealthcare.in july 2009
15. Brem H, Sheehan P, and Rosenberg HJ et al.Evidence-based protocol for diabetic foot
ulcers. Plast Reconstr Surg. 2006 Jun;117(7 Suppl):193S-209S; discussion 210S-211S.
16. Shukrimi A, Sulaiman AR, Halim AY and Azril A.A comparative study between honey and
povidone iodine as dressing solution for Wagner type II diabetic ulcers. Med J Malaysia. 2008
Mar;63(1):44-6.
17. Beretta G, Artali R, Caneva Eet al.Quinoline alkaloids in honey: analytical (HPLC-DAD-ESIMS, multidimensional diffusion-ordered pectroscopy), theoretical and chemometric studies. J
Pharm Biomed Anal. Oct15;50(3):432-9. Epub 2009 Jun 6.
18. Stephen-Haynes J.Evaluation of a honey-impregnated tulle dressing in primary care. Br J
Community Nurs. 2004 Jun;Suppl:S21-7.
19. Lay-flurrie KHoney in wound care: effects, clinical application and patient benefit. British
Journal of Nursing. 2008 Jun12-25;17(11):S30, S32-6.
20. Jull AB, Rodgers A, Walker N.Honey as a topical treatment for wounds. Cochrane Database
Syst Rev. 2008 Oct 8;(4):CD005083.
21.Visavadia BG, Honeysett J, Danford MH.Manuka honey dressing: An effective treatment for
chronic wound infections. Br J Oral Maxillofac Surg. 2008 Jan;46(1):55-6. Epub 2006 Nov 20.
9. SIGNATURE OF THE CANDIDATE
10. REMARKS OF THE GUIDE
RECOMMENDED AND
FORWARDED
11. NAME AND DESIGNATION OF
(IN BLOCK LETTERS)
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE (IF ANY)
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT
11.6 SIGNATURE
12.1 REMARKS OF THE CHAIRMAN
AND PRINCIPAL
12.2 SIGNATURE
RECOMMENDED AND
FORWARDED