Strategy for the treatment of chronic leg wounds: a new model in Poland.

AIM: The aim of the present study was to implement and evaluate a system of care for patients with chronic leg ulceration (CLU) in Poland. METHODS: All patients within two defined geographical areas in Poland were identified for inclusion in the study. A model of care was developed based on guidelines, including the appropriate education of health professionals treating patients, access to non-invasive methods to determine the ulcer aetiology, compression therapy in those with proven venous ulceration. RESULTS: In total 309 patients were identified with CLU at the start of the study (120 men, 189 women). Both regions had a similar profile of patients having a median (IQR) duration of ulceration of 96 (30-168) months. Most (75.7%) patients were assessed using clinical signs and symptoms alone, with a mean (SD) number of treatments per week at 1.8 (1.9) visits. Two years after implementation, the numbers of patients had reduced to 205 (86 men, 119 women) a reduction of 33%. Post implementation more patients were treated at home (49.3% versus 19.5%) with a corresponding reduction in those seen at health centres (35.6% versus 63.3%). The mean (SD) number of visits was reduced to 1.3 (0.7). During implementation the healing rate at 30 weeks improved from 73.3% to 82.9%, with a corresponding reduction in amputations from 6.3% to 2.1%. While the cost per patient was higher post-implementation, the overall cost of treating patients within the service reduced from €3847 to €2913 per week. CONCLUSION: The development and implementation of an evidence based system of care for patients with CLU in Poland is both clinically and cost effective. This may be used as a model for other regions of Poland.

Implementation of a leg ulcer strategy.

BACKGROUND: The care of patients with leg ulceration has developed over the past 15 years, although there is little information available to determine how these changes have affected clinical and patient defined outcomes. OBJECTIVES: To describe and evaluate the implementation of a leg ulcer strategy. PATIENTS/METHODS: This study used a pre- and postimplementation evaluation within population-based services within the boundaries of community services providing leg ulcer care. Evidence-based leg ulcer services were developed, including standardized assessment using Doppler ultrasound, rationalization of treatment using multilayer elastic high compression, development of referral criteria and acute service support. Complete ulcer healing rates, health-related quality of life and use of health resources were evaluated after 12 weeks in both pre- and postimplementation cycles. RESULTS: A total of 955 patients were evaluated (518 preimplementation, 437 postimplementation). The levels of assessment and treatment were poor prior to the change in practice with just one patient having evidence of correct assessment and 49 (11%) receiving high compression therapy. Postimplementation, this improved to 412 of 437 (94%) having evidence of measurement of the ankle brachial pressure index, and 85% receiving compression. Twelve-week healing rates preimplementation ranged between 9% and 24%, and postimplementation rose from 19% to 39%. Combined overall healing rates improved from 71 of 518 (14%) to 160 of 437 (37%), odds ratio =3.53, P < 0.001. Frequency of treatment visits reduced from a mean (SD) of 24.0 (16.1) over 12 weeks to 13.5 (8.6), P < 0.001. Intervention led to major improvements in health-related quality of life (measured using the Nottingham Health Profile), with significant improvements for energy, pain, sleep and mobility (P < 0.01). CONCLUSIONS: Rationalization of leg ulcer services through a total service change results in improvements in professional practice, better patient outcomes, and efficient use of current resources. This study highlights the importance of a multifaceted approach to improve practice focused on the needs of individual organizational settings.

A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema.

This paper describes a randomized controlled crossover study examining the effects of manual lymphatic drainage (MLD) in 31 women with breast cancer-related lymphoedema. MLD is a type of massage used in combination with skin care, support/compression therapy and exercise in the management of lymphoedema. A modified version of MLD, referred to as simple lymphatic drainage (SLD), is commonly taught as a self-help measure. There has been limited research into the efficacy of MLD and SLD. The study reported here explores the effects of MLD and SLD on a range of outcome measures. The findings demonstrate that MLD significantly reduces excess limb volume (difference, d=71, 95% CI=16-126, P=0.013) and reduced dermal thickness in the upper arm (d=0.15, 95% CI=0.12-0.29, P =0.03). Quality of life, in terms of emotional function (d=7.2, 95% CI=2.3-12.1, P=0.006), dyspnoea (d=-4.6, 95% CI=-9.1 to -0.15, P=0.04) and sleep disturbance (d =-9.2, 95% CI=-17.4 to -1.0, P=0.03), and a number of altered sensations, such as pain and heaviness, were also significantly improved by MLD. The study provides evidence to support the use of MLD in women with breast cancer-related lymphoedema. The limitations of the study are outlined and future areas for study are highlighted.

Guard cell volume and pressure measured concurrently by confocal microscopy and the cell pressure probe.

Guard cell turgor pressures in epidermal peels of broad bean (Vicia faba) were measured and controlled with a pressure probe. At the same time, images of the guard cell were acquired using confocal microscopy. To obtain a clear image of guard cell volume, a fluorescent dye that labels the plasma membrane was added to the solution bathing the epidermal peel. At each pressure, 17 to 20 optical sections (each 2 microm thick) were acquired. Out-of-focus light in these images was removed using blind deconvolution, and volume was estimated using direct linear integration. As pressure was increased from as low as 0.3 MPa to as high as 5.0 MPa, guard cell volume increased in a saturating fashion. The elastic modulus was calculated from these data and was found to range from approximately 2 to 40 MPa. The data allow inference of guard cell osmotic content from stomatal aperture and facilitate accurate mechanistic modeling of epidermal water relations and stomatal functioning.

A community/hospital leg ulcer service.

This paper outlines the implementation of a multidisciplinary integrated community and hospital leg ulcer service in 1993 and its effect on the health outcomes and quality of life of patients living in the area of the Hounslow and Spelthorne Community and Mental Health Trust prior to and following the establishment of the service.