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Background

Evidence supports the use of adjustable compression wraps (ACW) in the intensive phase of complex decongestive therapy (CDT), whereas evidence of its use in the maintenance phase of oedema therapy is sparse.

Methods

Randomised controlled non-inferiority trial in the maintenance phase of oedema therapy (CDT phase II) of symmetric lymphostatic oedema of the lower leg. Oedema therapy was performed with ACW and custom-made flat knit compression stockings (FCS) as a reference therapy in parallel over 3 days in n = 30 subjects. The primary outcome was lower leg volume as measured with perometer. Safety of ACW self-application and the patient perspective were secondary outcomes.

Results

ACW is non-inferior to custom-made FCS in CDT phase II of lymphostatic lower leg oedema. The differences of volume effects lie within the apriori defined equivalence interval of ± 50 ml (p = 0.163; 95 %-CI [ − 38.2; + 6.8]). Self-administration of ACW has shown no relevant side effects. ACW are easier to put on and off, while wearing comfort is comparable.

Conclusions

ACW are an alternative therapy option in the maintenance phase of CDT. Self-application seems to be safe, subject to diligent instruction of patients. Patients with difficulties putting on and off compression stockings could benefit from the use of ACW. Patients with pronounced limb volume may need to wear shoes with bigger sizes when wearing ACW. Further research with a longer observation time is to follow.

Aim:

A National Best Practice Statement for the holistic management of venous leg ulcers¹ presents a treatment pathway, originally developed by Atkin and Tickle². The aim was to revise this treatment pathway to reflect new evidence³.

Method:

The treatment pathway was originally developed to reflect published RCT evidence for venous intervention reducing episodes of reoccurrence (ESCHAR trial)⁴ and with leg ulcer hosiery kits as first line as a result of the publication of the VenUS lV study⁵. The treatment pathway has been used since 2016 and needed further updating to reflect the recent evidence investigating the impact of early venous ablation in patients with venous leg ulcers (EVRA)⁶.

Results / Discussion:

In a group of 34 patients with leg ulceration the implementation of this pathway into everyday clinical practice has been shown after 3 months to deliver a number of benefits including increased healing rates, improved documentation and a reduction of nursing visits⁷;

 From 0% to 76% having their leg ulcer diagnosis recorded

 From 34% to 76% having their ABPI recorded

 From 13% to 83% use of compression therapy

 From 7% to 56% healing or signs of healing

 43% reduction in nursing visits

Conclusion:

It is vital to ensure that current research evidence is adopted within frontline services as soon as possible. Formalised evidence-based pathways provide a practical treatment guide and can help reduce unwanted variations, as standardising clinical processes through the use of a pathway is known to optimise the quality of treatments and improve patient satisfaction.

Introduction:

Maceration is the elixation of the skin by prolonged exposure to moisture impeding healing due to failure of skin protection and possible microbial infections. Chronic wounds are often colonized by different kinds of microorganisms, mostly S.aureus and P.aeruginosa. Bacterial load on the wound surface perpetuates an inflammatory environment. It is of interest to elucidate dressing performance by comprehensive in vitro testing including binding capacity for elastase, determination of antibacterial activity, and assessment of fluid handling capability.

Methods:

A hydroactive dressing (HAD) consisting of cellulose/ethyl-sulfonate-cellulose fibres has been investigated. An in vitro maceration model was used to quantify and evaluate fluid uptake, fluid distribution, and shape changes. Binding capacity for elastase was determined over 24h. Determination of antimicrobial activity was performed according to JIS L 1902:2008 against S.aureus and P.aeruginosa.

Results:

HAD exhibited significantly higher fluid uptake than an alginate (AD) or a sodiumcarboxymethylcellulose dressing (SCD). It was shown that it possess a distinctly higher form stability. The SCD already macerated before the dressing was completely soaked while leakage with HAD and AD was only observed after they were completely gelled. HAD is further able to reduce the activity of elastase in vitro. And it exhibited a strong antibacterial activity against S.aureus and a significant antibacterial activity against P.aeruginosa.

Conclusions:

Performance of dressings can be assessed and compared under standard conditions in vitro. Here, HAD is able to reduce elastase activity, inhibit bacterial growth, and possess superior fluid handling capacity compared to AD and SCD.

Introduction

Liam is a 26 year old man who suffered a post trauma DVT when just 18 years old. He has Warfarin therapy and has a history of venous leg ulceration for 8 years. Because of the damage to his primary, deep veins he had developed a collateral venous circulation.

Liam describes having a leg ulcer at a young age as “life changing”. It stopped him playing sport and swimming and it changed how he interacting with friends. Because of his damaged circulation and medication he lived with the constant fear that his leg was going to deteriorate or bleed. Despite this, Liam continued to work full time and support his family.

Method

In the summer of 2018, Liam’s nurse changes his treatment from a combination long-stretch cohesive bandage system, to a cohesive short stretch bandage system. She also implemented a Monofilament fibre biofilm based treatment regime to expedite wound bed preparation and disruption of the biofilm (Morris et al, 2016).

Results

There was a dramatic reduction in leg oedema and improvement in leg shape almost immediately the new bandage system was started. Things continued to improve over the following months. Liam reported that the cohesive short stretch bandage system made “his leg feels much more comfortable with less ridging and less slippage”. His leg shape was much better, and it was easier to wear socks and shoes. Liam said that nobody noticed he had a bandage on.

In December 2018, after 8 years of ulceration, Liam’s venous leg ulcer healed.

Conclusion

This case study demonstrates how learning and implementing new knowledge, technology and skills can translate into improved patient outcomes. By sharing Liam’s story we can really understand the devastating effect a leg ulcer can have, especially on a teenager and young adult.

Liam now has a bespoke plan for the prevention of future venous leg ulcers which will include higher compression during working periods when he will be on his feet for long periods. This is achieved by using short stretch wrap systems to encourage continued self-care and ownership of his long term condition.

Introduction

This national, multicentre patient evaluation examines the enhancements that have recently been made to a superabsorbent dressing* and how this product improvement** has led to enhanced performance and improved patient related outcomes. The enhancements are a wider border and more ergonomic shape and a new structure to the superabsorbent polymer which increases absorbency.

Method

The recently developed and improved superabsorbent wound dressing was evaluated in six clinical sites on 27 patients with wounds requiring management of exudate of varying levels.

Results

The mean age of the patients who participated was 70 years and the main wound type was leg ulcer. At the start of the evaluation the surrounding skin was mostly reported to be macerated and/or red and excoriated. Exudate levels were light in 4 cases, moderate in 12 cases and heavy in 11 cases. The improved superabsorbent was used on its own as a primary dressing in only 5 cases and in combination with another primary dressing in 15 cases (7 did not answer the question). A topical antimicrobial was combined with the new superabsorbent in 60% of cases and a contact layer in 20% of cases. It was used under full or reduced compression in 21 cases. In most cases the improved superabsorbent replaced either another superabsorbent or absorbent dressing. The frequency of dressing changes varied from daily to weekly prior to the evaluation with 7 clinicians stating that the new and improved superabsorbent had reduced the frequency of dressing changes. The others either did not comment on this, or did not see a change. Other parameters were rated as good and very good and are outlined in Table 1.

Discussion

Although the improved superabsorbent dressing includes a very effective wound contact layer, 20% of cases used the product in combination with another contact layer. Use with another contact layer would not be recommended as this is not necessary and increases costs. Superabsorbent dressings are designed for the management of medium to high levels of exudate and should not be considered in low exudate.

Conclusion

The new and improved superabsorbent wound dressing demonstrated clear advantages for clinicians managing exudate. The patient shown in Figure 1 - 3 is still being managed with the improved product as this is the only dressing he doesn’t react to.

BACKGROUND

The pressure exerted by a compression device on a part of the body corresponds to the dosage of the compression therapy. Therefore, the pressure course under compression materials should be investigated in different clinical situations.

MATERIAL AND METHODS

Pressure measurements were carried out under different compression materials in lying, standing and walking positions within the framework of training, self-experimentation and in patients with venous leg ulcers.

RESULTS

The results showed that the pressure varied considerably depending on the material used, the firmness of application, the local configuration (body position) and the time interval between applications. A loss of pressure occurred under each compression therapy, especially under inelastic short-stretch material, mainly due to movement and edema reduction. This pressure loss is decisive for the timing of dressing changes and a reason for the good tolerance of high-pressure levels in mobile patients.

CONCLUSION

Low pressures are particularly suitable for edema reduction. Hemodynamic effects require higher pressures (60-80 mmHg). For this purpose, inelastic materials are preferred which enable lower pressures when lying down (40-60 mmHg). As compression bandages are too loosely applied by many users, pressure indicators on bandages or adaptive bandages with templates are helpful to apply the material with the correct pressure. As a consequence of these findings it is postulated that, at least in studies comparing different compression media, pressure measurements should be carried out in the future, whereby the measuring point and body position should be documented.

Background and study aims

Endoscopic negative pressure therapy (ENPT) is used to close transmural defects in the rectum and esophagus. Very few reports have described

ENPT to manage duodenal defects. This study was designed to demonstrate ENPT in a population of 11 patients with transmural duodenal leakages.

Patients and methods

The method of ENPT was adapted for duodenal use. Open-pore polyurethane-foam or a thin, open-pore double-layered film was wrapped around the distal end of a gastroduodenal tube. First, this open-pore element was placed on the inner wound in the duodenum with endoscopy. Second, continuous negative pressure of –125mmHg was applied with an electronic pump. Drains were changed after 2 to 7 days.

Results

Eleven patients were treated with duodenal leaks. Eight defects occurred after operative closure of perforated duodenal ulcers, papillectomy or stricturoplasty, one anastomotic leakage after Billroth – 1 distal gastric resection, one iatrogenic perforation in endoscopic retrograde cholangiopancreatography, and one by a surgical drain. Median duration of therapy was 11 days (range 7 – 24 days). Complete healing of defects was achieved in all patients.

Conclusion

ENPT is an innovative endoscopic alternative for treatment of transmural duodenal defects.