Introducing the new Chronic Oedema Wet Leg Pathway

Reticence to apply compression therapy has been widely observed in clinical practice, compounded by an absence of evidenced-based pathways for application of prompt compression prior to measuring ankle brachial pressure index (ABPI). Importantly, delaying compression therapy for patients with chronic oedema and lymphorrhoea causes many avoidable complications. In 2017, Lymphoedema Network Wales (LNW) developed an evidenced-based pathway to improve the management of chronic oedema and wet legs (lymphorrhoea) for community nurses. During the past 4 years, the Chronic Oedema Wet Leg Pathway has been presented, published and used internationally, as well as being translated into different languages. It is commonly used in community nursing Teams as an evidenced-based document. However, like all documents and guidelines, when more evidence becomes available, the pathway needs updating. Therefore, this clinical focus article will present the new and enhanced Chronic Oedema Wet Leg Pathway, introducing a new level four compression section, which increases the layers of compression bandaging for patients with venous insufficiency or who are morbidly obese.

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Ankle Brachial Pressure Index and compression application: Review summary

Wound Practice and Research ◽

10.33235/wpr.27.2.74-77 ◽

2019 ◽

Vol 27 (2) ◽

pp. 74-77

Author(s):

Victoria Team ◽

Georgina Gethin ◽

John D Ivory ◽

Kimberley Crawford ◽

Ayoub Bouguettaya ◽

...

Keyword(s):

Content Analysis ◽

Clinical Practice ◽

Venous Insufficiency ◽

Arterial Disease ◽

Leg Ulcers ◽

Current Clinical Practice ◽

Ankle Brachial Pressure Index ◽

Arterial Circulation ◽

Pressure Index ◽

Peripheral Arterial

Venous leg ulcers (VLUs) are a significant complication amongst persons with chronic venous insufficiency (CVI) that frequently follow a cycle of healing and recurrence. Current clinical practice guidelines (CPGs) recommend applying below knee compression to improve VLU healing. Compression could be applied if the Ankle Brachial Pressure Index (ABPI) rules out significant arterial disease, as sufficient peripheral arterial circulation is necessary to ensure safe compression use. We conducted a content analysis of 13 global CPGs on the accuracy of recommendations related to ABPI and compression application. Eight CPGs indicated that compression is recommended when the ABPI is between 0.8 and 1.2 mmHg. However, this review found there is disagreement between 13 global VLU CPGs, with a lack of clarity on whether or not compression is indicated for patients with ABPIs between 0.6 and 0.8 mmHg. Some CPGs recommend reduced compression for treatment of VLUs, while others do not recommend any type of compression at all. This has implications for when it is safe to apply compression, and the inconsistency in evidence indicates that specialist advice may be required at levels beyond the ABPI “safe” range listed above.

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Chronic venous insufficiency: a new concept to understand pathophysiology at the microvascular level - a pilot study

Perfusion ◽

10.1177/0267659118791682 ◽

2018 ◽

Vol 34 (1) ◽

pp. 84-89 ◽

Cited By ~ 3

Author(s):

Omar Mutlak ◽

Mohammed Aslam ◽

Nigel J. Standfield

Keyword(s):

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Tissue Oxygenation ◽

Exercise Group ◽

Ankle Brachial Pressure Index ◽

Duplex Scan ◽

Pressure Index ◽

Group A ◽

Group B ◽

In The Beginning

Objectives: The real mechanism for the development of the later stages of chronic venous insufficiency still remains unclear. Venous hypervolemia and microvascular ischemia have been reported to be the consequences of venous insufficiency. The aim of this study was to investigate the effects of induced venous hypovolemia by dorsiflexion exercise in patients with venous leg ulcers. Methods: Thirty-six participants, all of whom had an ankle brachial pressure index between 0.8 and 1.2 mmHg, were chosen for this study. The participants were divided into two groups: Group A, a non-exercise group and Group B which performed regular exercise in the form of dorsiflexion. The basic assessment, including the history and examination, ankle-brachial pressure index (ABPI), Duplex scan and tcPO2 measurements, was performed on two occasions at the beginning of the trial and after three months. Results: The tcPO2 level was low in the beginning in all the subjects, but the picture was different at the end of the trial. There was a significant increase in the tcPO2 level (p<0.001) in the patients who performed exercise while there was no difference in the measurements (p>0.05) in the non-exercise group. Conclusions: Induced venous hypovolemia through regular evacuation of the peripheral venous system improved tissue oxygenation at skin level. Venous hypervolemia may be the main contributing factor for the development of venous hypoxia and microvascular ischemia.

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Variation in measurement of ankle-brachial pressure index in routine clinical practice

Journal of Vascular Surgery ◽

10.1016/s0741-5214(96)70025-3 ◽

1996 ◽

Vol 24 (5) ◽

pp. 871-875 ◽

Cited By ~ 37

Author(s):

Charles M. Fisher ◽

Alison Burnett ◽

Virginia Makeham ◽

Jenifer Kidd ◽

Madeleine Glasson ◽

...

Keyword(s):

Clinical Practice ◽

Routine Clinical Practice ◽

Ankle Brachial Pressure Index ◽

Pressure Index

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Emergency management of the paediatric patient with convulsive status epilepticus

Paediatrics & Child Health ◽

10.1093/pch/pxaa127 ◽

2021 ◽

Vol 26 (1) ◽

pp. 50-57

Author(s):

Kyle C McKenzie ◽

Cecil D Hahn ◽

Jeremy N Friedman

Keyword(s):

Clinical Practice ◽

Status Epilepticus ◽

Emergency Management ◽

Treatment Algorithm ◽

Position Statement ◽

Convulsive Status Epilepticus ◽

Pharmacological Management ◽

The Past ◽

New Treatment ◽

New Evidence

Abstract This guideline addresses the emergency management of convulsive status epilepticus (CSE) in children and infants older than 1 month of age. It replaces a previous position statement from 2011, and includes a new treatment algorithm and table of recommended medications based on new evidence and reflecting the evolution of clinical practice over the past several years. This statement emphasizes the importance of timely pharmacological management of CSE, and includes some guidance for diagnostic approach and supportive care.

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Noncompaction Cardiomyopathy—History and Current Knowledge for Clinical Practice

Journal of Clinical Medicine ◽

10.3390/jcm10112457 ◽

2021 ◽

Vol 10 (11) ◽

pp. 2457

Author(s):

Birgit J. Gerecke ◽

Rolf Engberding

Keyword(s):

Clinical Practice ◽

Current Knowledge ◽

Clinical Manifestations ◽

Clinical Patient ◽

Noncompaction Cardiomyopathy ◽

The Past ◽

Wide Range ◽

Morphological Variants ◽

A Current ◽

Healthy Persons

Noncompaction cardiomyopathy (NCCM) has gained increasing attention over the past twenty years, but in daily clinical practice NCCM is still rarely considered. So far, there are no generally accepted diagnostic criteria and some groups even refuse to acknowledge it as a distinct cardiomyopathy, and grade it as a variant of dilated cardiomyopathy or a morphological trait of different conditions. A wide range of morphological variants have been observed even in healthy persons, suggesting that pathologic remodeling and physiologic adaptation have to be differentiated in cases where this spongy myocardial pattern is encountered. Recent studies have uncovered numerous new pathogenetic and pathophysiologic aspects of this elusive cardiomyopathy, but a current summary and evaluation of clinical patient management are still lacking, especially to avoid mis- and overdiagnosis. Addressing this issue, this article provides an up to date overview of the current knowledge in classification, pathogenesis, pathophysiology, epidemiology, clinical manifestations and diagnostic evaluation, including genetic testing, treatment and prognosis of NCCM.

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Arteriovenous fistula cannulation in hemodialysis: A vascular access clinical practice guidelines narrative review

The Journal of Vascular Access ◽

10.1177/11297298211006972 ◽

2021 ◽

pp. 112972982110069

Author(s):

Rui Pinto ◽

Clemente Sousa ◽

Anabela Salgueiro ◽

Isabel Fernandes

Keyword(s):

Clinical Practice ◽

Arteriovenous Fistula ◽

Vascular Access ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Good Evidence ◽

Preparation Technique ◽

Patient Centered ◽

The Past ◽

Centered Care

The cannulation of an arteriovenous fistula (AVF) by the hemodialysis (HD) nurse is challenging. Despite it being the focus of extensive research, it is still one of the majors causes of damage making it prone to failure. A considerable number of Clinical Practice Guidelines (CPGs) for the management of vascular access (VA) have been published worldwide over the past two decades. This review aimed to assess all information available in the selected CPG regarding AVF cannulation for HD providing a comprehensive analysis in order to interpret possible future cannulation approaches. A total of seven CPGs were described in a coding table separated in seven subthemes: Initiation of cannulation, preparation, technique, needle selection, surveillance, pain, and education. Our analysis outlines current CPGs for HD VA cannulation with lack of good evidence support for the majority of the recommendations, showing that, there is an urgent need for international collaboration and coordination to ensure relevant and high-quality evidence. Future CPGs must consider recommendations with better grading of evidence aiming patient-centered care and nurse decision models that can potentially represent better AVF cannulation outcomes.

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Neurovascular changes after four-layer compression bandaging in people with chronic venous leg ulcers

Phlebology The Journal of Venous Disease ◽

10.1258/026835507780346123 ◽

2007 ◽

Vol 22 (2) ◽

pp. 49-55 ◽

Cited By ~ 4

Author(s):

R Ogrin ◽

P Darzins ◽

Z Khalil

Keyword(s):

Wound Healing ◽

Wound Repair ◽

Statistical Significance ◽

Sensory Nerve ◽

Compression Therapy ◽

Clinical Problem ◽

Leg Ulcers ◽

Venous Leg Ulcers ◽

Perfusion Measurement ◽

Compression Bandaging

Objectives: Venous leg ulcers represent a major clinical problem, with poor rates of healing. Ideal treatment is compression bandaging. The effect of compression on neurovascular tissues involved in wound repair is unclear. This study aims to assess the effect of four-layer compression therapy (40 mmHg) on neurovascular function and wound healing in people with chronic venous leg ulcers – 15 people (55 years or older) with venous leg ulcers for more than six weeks. Methods: Basal microvascular perfusion measurement (MPM), oxygen tension (tc pO2) measured at sensor temperatures of 39°C and 44°C and sensory nerve function using electrical cutaneous perception thresholds (ECPT) at 5, 250 and 2000 Hz (corresponding to C, A δ and A β fibres) were assessed adjacent to the ulcer site, and at a mirror location on the non-ulcerated limb. Testing was undertaken before and after therapy for 5–12 weeks of four-layer compression bandaging. Results: There was significant improvement in tc pO2 at 44°C and ECPT at 2000 Hz ( P<0.05) compared with pre-intervention. Changes in basal MPM, tc pO2 at 39°C and ECPT at 5 and 250 Hz after compression therapy did not reach statistical significance. Conclusion: Four-layer compression bandaging in people with venous leg ulcers improved some components of neurovascularture in people with chronic venous leg ulcers. Whether this improvement has contributed to wound healing in this study requires further investigation.

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Observed Differences in Diagnostic Test Accuracy between Patient Subgroups: Is It Real or Due to Reference Standard Misclassification?

Clinical Chemistry ◽

10.1373/clinchem.2007.087403 ◽

2007 ◽

Vol 53 (10) ◽

pp. 1725-1729 ◽

Cited By ~ 15

Author(s):

Corné Biesheuvel ◽

Les Irwig ◽

Patrick Bossuyt

Keyword(s):

Clinical Practice ◽

Diagnostic Test ◽

Sensitivity And Specificity ◽

Diagnostic Test Accuracy ◽

Test Accuracy ◽

Reference Standard ◽

Target Condition ◽

Test Sensitivity ◽

The Past ◽

Patient Subgroups

Abstract Before a new test is introduced in clinical practice, its accuracy should be assessed. In the past decade, researchers have put an increased emphasis on exploring differences in test sensitivity and specificity between patient subgroups. If the reference standard is imperfect and the prevalence of the target condition differs among subgroups, apparent differences in test sensitivity and specificity between subgroups may be caused by reference standard misclassification. We provide guidance on how to determine whether observed differences may be explained by reference standard misclassification. Such misclassification may be ascertained by examining how the apparent sensitivity and specificity change with the prevalence of the target condition in the subgroups.

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