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Tariff bandages
Griffiths, E., Williams, K.; Bandages: Indications for use and
Drug Tariff status; British Journal of Nursing 6
(20) 1154-1165, 13 November 1997
Elastic compression stockings
Veraart, J. C. J. M., Pronk, G., Martino Neumann, H. A.; Pressure
differences of elastic compression stockings at the ankle region;
Dermatologic Surgery 23 (10) 935-939, October 1997
Diagnosing necrotizing fasciitis
Brogan, T. V., Nizet, V.; A clinical approach to differentiating
necrotizing fasciitis from simple cellulitis; Infections in
medicine 14 (9): 734-738, September 1997
Effective care for leg ulcers
Baker, S., Fletcher, A., Glanville,J. et al.; Compression therapy
for venous leg ulcers; Effective Health Care Vol 3, No. 4,
August 1997
This article gives an overview of the uses and application of bandages of various types: retention, support, paste and orthopaedic wool. Compression bandaging, however, is the core of the article, with a review of single layer and short stretch products and a more detailed discussion of multi-layer bandaging.
Sadly, this section confines itself to just two multi-layer systems and the bandages used to apply them: the Charing Cross Four-Layer system, and a proprietary four-layer system. Individual components are named but poorly described, no attempt is made to provide a rationale for their use. Indeed, it is not clear why these two systems have been selected.
The introduction to this section "The following are examples of multi-layer bandage systems" is simply begging too many questions:
The article starts as a useful introduction to bandaging and the Drug Tariff, but is weak at the key, controversial area of four layer bandaging.
Griffiths, E., Williams, K.; Bandages: Indications for use and Drug Tariff status; British Journal of Nursing 6 (20) 1154-1165, 13 November 1997
There is concern that venous ulcers tend to recur, even when patients wear their elastic compression stockings. The authors consider that the current basis of design of these stockings might not be appropriate for the irregular shape of the human leg: compression stockings are routinely designed in the laboratory, using a standard, idealised, round leg. The 'Hohenstein leg' is made of wood.
This study, from the Netherlands, sought to examine the pressures at the skin, beneath class II elastic compression stockings (25-35mm Hg), at different places around the ankle at the B level, which they consider to be the key level in this group of patients.
Forty four consecutive patients at a dermatological clinic were asked to participate; all regularly wore class II elastic compression stockings. None of the subjects had oedema or an active ulcer at the time of the study.
Pressure measurements were taken at the moment each patient started to wear a new pair of stockings, of their usual type. Three types of stocking were involved, Eurostar and Eurotex, flat knitted, made to measure stockings, and Eurolux, round knitted made to measure stockings. Initial measurements were taken seated, with legs horizontal, followed by standing measurements. In 10 patients, measurements were repeated at 5,10,15,20,25 and 30 minutes, to investigate hysteresis. Pressures were recorded using an Oxford pressure monitor, Mark II.
The mean of all measurements was 24.7mm Hg; the highest mean pressures were found at the pretibial area, (33.9mm Hg, SD 13.2), the lowest at the medial site (18.3mm Hg, SD 8.6). There was no significant difference between lying and standing pressures, or between different types or brands of stockings. There was also no significant difference over time in the sub-group of 10 patients, implying that overstretch was not an issue.
The medial side at the B level is the site of over 80% of all venous ulcers; it is the lowest point of the muscle pump. And yet the pressure achieved here was just too low for the class of compression stocking.
The authors advocate the use of class III stockings for patients who have had a venous ulcer, to ensure sufficient medial pressure.
Veraart, J. C. J. M., Pronk, G., Martino Neumann, H. A.; Pressure differences of elastic compression stockings at the ankle region; Dermatologic Surgery 23 (10) 935-939, October 1997
Plain film, ultrasound, computed tomography and magnetic resonance imaging are among the radiological techniques that have been used; no studies have attempted to compare radiology with surgical intervention and frozen section biopsy in terms of predictive value or outcome. These techniques all have a place, despite the incidence of both false positive and false negative findings.
This brief article covers the key issues in diagnosing necrotizing fasciitis. Successful treatment depends on the speed of diagnosis. The authors provide help in distinguishing this condition from cellulitis, and offer guidance to clinicians based on published research.
Brogan, T. V., Nizet, V.; A clinical approach to differentiating necrotizing fasciitis from simple cellulitis; Infections in medicine 14 (9): 734-738, September 1997
2. Swartz MN: Cellulitis and subcutaneous tissue infections, in Mandell GL, Bennett JE, Dolin R (eds): Principles and Practice of Infectious Diseases. New York, Churchill Livingstone, 1995, pp 909-929
The lack of clear conclusions reflects as much on the research base as it does on the authors, but there are flaws none the less. The authors have raised the Randomised Clinical Trial to the level of Holy grail; this is a shame; the human cost of leg ulcers will always elude the pure science approach. More seriously, this blind love of one scientific approach has led to the inclusion of studies which the authors themselves describe as 'small', 'very small', 'poor', and 'poorly reported'.
This is a vital first step towards a more rigorous approach to wound management; a few years ago, it would simply not have been possible. But if the authors want to advance the quality of wound management, they need to rise above their arbitrary selection procedure and weed out studies which are simply too small or too poor to be useful. Any statistician could have assisted in this exercise. The authors have also included unpublished work, undermining their claim to academic excellence. The Randomised Controlled Trial is an essential tool in the research process, not a religious icon, and it does not remove the need for peer review.
Baker, S., Fletcher,A., Glanville,J. et al. Compression therapy for venous leg ulcers; Effective Health Care Vol 3, No. 4, August 1997