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Journal Scan 1997 This section features abstracts of articles from professional journals (see invitation, below). Readers are asked to refer to the original source before quoting or making reference elsewhere.

See the latest journal scan for recent articles and links to archive articles.


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


Tariff bandages

Community nurses in the UK need up to date knowledge of which bandages are available on NHS prescription (the Drug Tariff) to enable them to select the most appropriate bandage, in terms of both cost and effectiveness.

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


Elastic compression stockings

Elastic stockings are widely used in the management of deep venous insufficiency, particularly after surgery or other interventions, to prevent occurrence or recurrence of leg ulcers.

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.

The Study

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.

Results

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


Diagnosing necrotizing fasciitis

After all the publicity for Killer Bugs from Outer Space, it is refreshing to read a measured, logical overview of diagnostic issues in this rare, but life-threatening condition.

Definitions

Necrotizing fasciitis is usefully defined as 'an infection of the dermal, fascial, and subcutaneous layers of the skin. It is characterised by microbial and leukocytic infiltrates leading to vasculitis, thrombosis, and tissue necrosis',[1] while cellulitis is defined as an acute infection of the skin involving the dermis and subcutaneous tissue, commonly marked by local signs of inflammation, including erythema, oedema, warmth, and tenderness[2]. The authors point out that both are associated with Staphylococcus aureus and group A beta-hemolytic streptococci (GABHS) infection.

Differential diagnosis

The article then reviews clinical findings, before considering laboratory, surgical and radiographic evaluation. Necrotizing fasciitis, it suggests, should be considered as a possible cause of soft tissue pain and swelling, particularly in patients with diabetes, a compromised immune system, abnormal peripheral circulation or those with burns, traumatic or surgical wounds.

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.

Conclusion

Surgical intervention is seen as being a major component of both diagnosis and treatment. Early debridement has been shown to be a useful intervention. Although cytological examination can suggest a diagnosis, the authors argue that a definitive diagnosis can only come from exploration.

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

References

1. Sawin RS, Schaller RT, Tapper D, et al: Early recognition of neonatal abdominal-wall necrotizing fasciitis. Am J Surg 167:481-484, 1994

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


Effective care for leg ulcers

While arguments rage on about the benefits of different approaches to leg ulcer management, clinical research has simply been unable to confirm or deny conflicting claims. This issue of Effective Health Care is devoted to examining the evidence.

Compression

Concentrating on randomised clinical trials, studies of compression therapy are divided into four groups; compression versus no compression, high compression versus low compression, different types of high compression and intermittent pneumatic compression. This section leaves a firm impression that high compression is probably the way forward, but provides no convincing evidence that any particular system is advantageous. In fact, the unstated conclusion seems to be that the standard of research rules out any clear recommendation.

Prevention

Seven studies comparing different interventions for the prevention of recurrence are discussed; no randomised clinical trial could be found to evaluate using compression stockings versus not using them, though one study compared class 2 and class 3 stockings in this role. Studies which examined pharmacological and surgical intervention failed to demonstrate any advantage in the prevention of recurrence.

Diagnosis

This section exposes the level of confusion among experts - let alone those entrusted with day-to-day care - on diagnostic principles in this area. While there appears to be broad consensus that high compression can be dangerous in the presence of significant arterial disease, there is little, if any, agreement on what constitutes significant arterial disease. The issue of staff education is raised, with evidence that highly trained staff can produce more reliable measurement of the ankle:brachial pressure index.

Conclusion

This document is a fascinating review of the scientific evidence available in one important area of wound management. In particular, it shows the paucity of high quality research in an area that adds millions to health care costs - mostly nursing time - and untold misery to millions of people.

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


These reviews © 1997 SMTL: compiled by Andrew Heenan

An invitation

Readers are invited to submit abstracts to the editor for inclusion in this page. Writing abstracts can be a useful exercise in professional updating, as well as an effective method of achieving first publication while learning about the publishing process. Copyright and all the usual rules apply; please see the Author's Guide for advice on how to submit your work.

All materials copyright © 1992-Feb 2001 by SMTL, March 2001 et seq by SMTL unless otherwise stated.

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