https://www.jvascsurg.org/article/S0741-5214(14)00851-9/pdf

Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum.

https://openaccess.city.ac.uk/360/2/interventions_to_improve_hand_hygiene_compliance_in_patient_2011.pdf

Interventions to improve hand hygiene compliance in patient care

Objective To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression. 

Design Randomised controlled trial.

Setting Specialist nurse led leg ulcer clinics in three UK vascular centres.

Participants 500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux.

Interventions Compression alone or compression plus saphenous surgery. 

Main outcome measures Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time.

Results Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test).

Conclusion Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time. 

Trial registration Current Controlled Trials ISRCTN07549334.

https://www.bmj.com/content/bmj/335/7610/83.full.pdf

Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial.

Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum Endorsed by the American College of Phlebology and the Union Internationale de Phlébologie

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

The role of superficial venous surgery in the management of venous ulcers: a systematic review.

The Hand Hygiene Liaison Group and Epic Projects (Pratt et al, J Hosp Infect 47[Suppl A], 2001) have asked specifically for further trials of educational interventions to improve hand decontamination compliance and infection control in the hospital setting This study investigates the efficacy of a ‘clean practice protocol’ (CPP), derived from international guidelines, to improve compliance of infection-control practices by surgical teams in a large UK teaching hospital The key infection-control activities were summated to form the CPP presented here An undisclosed infection-control audit of consultant-led ward-rounds from breast, gastrointestinal, vascular, urological, and intensivecare departments was performed The audit results were presented to the surgical teams, after which an education/awareness program was implemented A repeat undisclosed audit was performed 3 months later In both audits, infection-control activities were recorded together with consultation time and any patient infective complications The surgical teams performed as follows in the initial audit: hand decontamination (28% of consultations), correct use of gloves (2%), instrument cleaning (0%), garment contamination (49%), and notes contamination (34%) Introduction of the CPP education program significantly improved hand decontamination to 87% (p < 00001), the correct use of gloves/aprons to 50% (p < 00001), and overall infection-control practice from 63% to 89% (p < 005) The introduction of the CPP significantly improved compliance of hand decontamination, correct usage of gloves and aprons, and overall infection-control in a large teaching hospital The CPP is a highly effective auditing and educational tool that can be readily adapted for use in hospitals globally to monitor and improve infection-control practices

A simple effective clean practice protocol significantly improves hand decontamination and infection control measures in the acute surgical setting.

The majority of fatal pulmonary emboli arise from deep vein thromboses in the lower limb. Pulmonary embolism continues to be a major cause of death in hospitalized patients. The classification, history, epidemiology, pathophysiology and prognosis are disclosed. An overview of the current recommendations for venous thromboembolism in surgical and medical patients and the failure of its application are discussed. The use of adequate thromboprophylaxis in approximately only one-third of patients is a familiar account. Prophylaxis guidelines use risk stratification systems, which lend to confusion by clinicians with the inevitable consequence of failed prophylaxis implementation. The National Institute of Health and Clinical Excellence are due to provide national prophylactic guidelines in May 2007. Simplified guidelines, a national consensus, and continued education of patients and health care professions to maintain compliance, is the solution to thromboprophylaxis.

Introduction to venous thromboembolism and prophylaxis

Introduction: Femoropopliteal and femorodistal bypasses are indicated in the management of severe claudication or critical limb ischaemia. The choice of type of anaesthesia between general anaesthesia (GA) and regional anaesthesia (RA; epidural/spinal) has remained controversial. The study aimed to compare the rates of graft failure, perioperative mortality, and other major complications (including graft failure) associated with GA versus RA for lower limb bypass revascularisation in patients presenting with significant peripheral arterial disease. Methods: All patients who had femoropopliteal and femorodistal bypass at the vascular unit of Colchester Hospital between January 2016 and September 2018 were included. The primary outcome measure was survival, and secondary outcome measures were respiratory, wound, cardiac, and graft failure complications. Technical success was defined as a successful operation with demonstrated graft patency at discharge and up to 30 days of follow-up. Secondary outcome measures included respiratory, wound, and cardiac complications. Statistical analysis included descriptive statistics and tests of association using chi-square for graft failure outcomes and the Mann-Whitney U test for the length of stay. All analyses were done at a 5% level of significance. Results: There were 139 patients identified during the study period who fulfilled the inclusion criteria, of which 127 had complete records. The overall mortality and morbidity in this study were 1.6% and 14.229%, respectively. The proportion of patients who had ischaemic heart disease is almost threefold amongst those who had failed bypass compared to the successful bypass group (33.3% versus 11.9%, p = 0.018). A total of 65 patients received GA and 62 patients underwent RA; there were no significant differences in baseline preoperative comorbidities, postoperative mortality and complications, and length of stay. The majority (84%) of the patients who had RA had combined spinal and epidural (CSE) anaesthesia. The overall mortality and morbidity in this study were 1.6% and 14.2%, respectively. The proportion of patients with graft failure was 14.5% for GA versus 13.8% for RA (p = 0.914); there was no significant difference for conduit type, quality of vein conduit, the prevalence of heart failure and postoperative hypotensive episodes, redo-surgery, and major amputation, and length of stay (GA: 5.0, RA: 6.0, p = 0.854) did not differ significantly between the two groups. The proportion of patients who had ischaemic heart disease is almost threefold amongst those who had failed bypass compared to the successful bypass group (33.3% versus 11.9%, p = 0.018). Conclusion: The mode of anaesthesia, GA or the use of CSE RA in approximately half of the patients, did not influence survival, respiratory, cardiac, wound, graft failure, or length of stay in this study. There was a relationship between the presence of cardiac comorbidity and bypass failure, indicating a need for a standard care protocol to further optimise cardiac perioperative care to improve outcomes.

/pdf/does-the-mode-of-anaesthesia-general-or-regional-affect-1cgjs0nt.pdf

Does the Mode of Anaesthesia (General or Regional) Affect Survival and Complications Following Femoropopliteal and Femorodistal Bypass?

<h2>Abstract</h2> There are many different causes of leg and foot swelling, some are benign and transient, others can be debilitating and progressive. Correct diagnosis and early treatment is crucial as conservative measures are most effective before the condition is allowed to progress. Current waiting times in the UK National Health Service (NHS) after the Covid-19 pandemic are leading to delays in care for people with chronic leg swelling. Delayed or inadequate treatment for these patients can lead to irreversible tissue damage, an episode of cellulitis, and progression to leg ulceration. There is in addition a significant impact on quality of life associated with living with the pain, anxiety, and reduced mobility. The causes of acute and chronic leg and foot swelling are outlined. Diagnosis and treatment of the common causes of leg and foot swelling in the Western adult population are discussed. The mainstay of treatment for most of these conditions relies on physical therapy and graduated elastic compression garments or elastic Velcro wraps as many do not have a cure. 

Swelling of the legs and feet

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