Developing a new flexible tool for handover.

BACKGROUND: Transferring medical information among professionals and between shifts is a crucial process, allowing continuity of care and safety, especially for complex patients in life-threatening situations. This process, handover, requires focusing on specific, essential medical information while filtering out redundant and unnecessary details. OBJECTIVES: To create and implement a tool for handover that would be flexible enough to meet the unique needs of specific departments. METHODS: We used Plan-Do-Study-Act (PDSA) methodology to prospectively develop, implement, evaluate and reassess a new handover tool in a 900-bed teaching hospital in central Israel. Nurses from 35 departments participated in developing a tool that presents the staff's viewpoint regarding the most critical information needed for handover. RESULTS: A total of 78 nurse managers and 15 doctors (63.7%) completed the questionnaire. Based on exploratory factor analysis, 15 items explained 58.9% of the variance. Four key areas for handover were identified, in addition to basic patient identification: (i) updated clinical status, (ii) medical information, (iii) special clinical treatment and (iv) treatments not yet initiated. Subsequently, a Flexible Handover Structured Tool (FAST) was designed that identifies patients' needs and is flexible for the specific needs of departments. Revisions based on hands-on experience led to high nurse satisfaction with the new tool in most departments. The FAST format was adopted easily during the COVID-19 pandemic. CONCLUSION: Implementing a new handover tool-FAST-was challenging, but rewarding. Using PDSA methodology enabled continuous monitoring, oversight and adaptive corrections for better implementation of this new handover reporting tool.

Preprogrammed oscillations improve lower limb blood flow and walking distance in patients with peripheral arterial disease.

BACKGROUND: Claudication is one of the sequelae of peripheral arterial disease (PAD). To date, no effective treatment has been found for this condition. OBJECTIVES: To investigate a new device to treat PAD. The device administers pre-programmed protocols of oscillations to the foot. METHODS: Fifteen patients aged 40-70 years who suffered from intermittent claudication secondary to PAD were recruited to an open prospective study. Each patient was treated once for 30 minutes. The following parameters were evaluated: pain-free and maximal walking distances, skin blood flux by laser-Doppler, skin temperature, ankle-brachial and toe-brachial indices, transcutaneous oxygen pressure (tcpO2) and transcutaneous carbon dioxide pressure (tcpCO2). Non-parametric signed-rank test was applied for testing differences between baseline assessment and post-treatment assessments for quantitative parameters. RESULTS: Mean pain-free walking distance was 122 +/- 33 m and increased to 277 +/- 67 m, after the treatment session (P = 0.004). Mean maximal walking distance was 213 +/- 37 m and it increased to 603 +/- 77 m (P < 0.001). Foot skin perfusion also improved, as demonstrated by an increase in tcpO2 by 28.6 +/- 4.1 mmHg (P < 0.001), a decrease in tcpCO2 by 2.8 +/- 1.3 (P= 0.032), and up to twofold improvement in blood flux parameters, and an increase in skin temperature by 1.9 +/- 0.5 degrees C (P < 0.001). Ankle-brachial index increased by 0.06 +/- 0.01 (P = 0.003) and toe-brachial index by 0.17 +/- 0.02 (P < 0.001). CONCLUSIONS: Preprogrammed oscillations applied to the foot had a positive effect on microcirculation, tissue oxygenation and CO2 clearance; they had a smaller though significant effect on arterial blood pressure indices, and the change in the arterial-brachial index correlated with the change in the pain-free walking distance.

[Is there a role for asymptomatic carotid artery stenosis screening?].

Screening for asymptomatic carotid artery stenosis (CAS) is highly controversial Many surgeons routinely screen their patients for carotid disease prior to major operations, yet the benefit of such practice was never demonstrated. The treatment of symptomatic patients has not changed much during the last twenty years, since the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET). However, in contrast, the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST) failed to get the same acceptance among the multidisciplinary group treating CAS.The prevalence of asymptomatic 60-99% carotid artery stenosis among the general population is about 1%. Neither ACAS nor ACST showed that stenosis severity was associated with increasing stroke risk. The 'realpolitik' is that mass interventions in asymptomatic patients will probably only ever prevent about 1% of all strokes. This is even truer regarding patients scheduLed for major operation, in which the incidence of stroke is less than 1%. Moreover the current evidence in the literature suggests that the best medicaL treatment (BMT) results in 0.5% strokes per year, better than resuLts which can be offered by surgery. According to the current evidence, it seems that asymptomatic carotid artery screening should be discontinued, since it is a major waste of resources.

[Secondary lymphedema--the importance of a multidisciplinary team approach].

Secondary lymphedema is the most common type of lymphedema. Malignancy, mainly breast carcinoma, is the main cause of upper extremity lymphedema, while groin dissection, irradiation and trauma are the cause of lower extremity lymphedema. Early recognition of the pathology followed by early referral to a vascular surgeon, leading a multidisciplinary team, who takes care of those patients, can prevent a miserable Life from these patients. Lifelong commitment of the patients, prolonged financial support of the health insurance supplier, as well as team work of the group taking care of the patient, is the only way to help these patients.

[Lymphedema--guidelines for evaluation and treatment].

Lymphedema is the "neglected vascular disease". A lot has been written about arterial and venous pathologies but our knowledge, as physicians, about the pathophysiology on the one hand and about the treatment, on the other hand, is scarce. Lymphedema is subdivided into primary and secondary disease. The primary lymphedema is further subdivided to congenital, praecox and tarda. Conservative treatment is the first line of therapy. Surgery has not been proven as a good solution for this disease, and furthermore, even when operations are being conducted, conservative treatment should be continued on a daily basis. It seems that further research about this "forgotten disease" should be designed in order to improve the treatment of these complicated patients.

Epithelioid hemangioendothelioma as a rare cause of blue toe syndrome.

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

[Prevention is the name of the game].

The review on critical limb ischemia (CLI) by Melamed and his co-authors in this issue of Harefuah focuses on treatment modalities but does not address the important issue of prevention, which, I believe, is the most effective tool in saving limbs. Peripheral arterial occlusion secondary to atherosclerosis (ASO) is common in the western hemisphere. Ten percent of the population between the ages 50-55 years and more than 20% of the population over 70 years of age suffer from some degree of ASO. Three percent of these patients will develop severe forms of ischemia. The problem is even worse amongst diabetic patients, where 1 in 1000 will lose a leg. Most patients with leg pain are treated by the orthopedic surgeon and many of those with minor skin changes are referred to a dermatologist, often without proper vascular evaluation, until the condition deteriorates. The secret of limb preservation is threefold: 1) High level of awareness by the primary medical team 2) Dedicated foot clinics and 3) A multidisciplinary team. A rigid protocol of foot examination, pulse palpation and Doppler evaluation, combined with clinical education regarding proper foot wear, can prevent close to 70% of major limb amputations. These simple, inexpensive and non-invasive modalities enable us to both diagnose arterial disease and follow-up on the treatment. An interdisciplinary team of a diabetes expert, foot orthopedic surgeon, podiatrist and a vascular surgeon can, in most cases, build a treatment plan which will alter the course of the disease at an early stage and prevent the development of CLI. The natural course of CLI without revascularization leads to major limb amputation in 70% of patients within a year or two of diagnosis. When vascular reconstruction is not an option, more conservative measures, such as hyperbaric oxygen therapy (HBO), can also be useful in some patients but over-use and abuse of this modality and other alternative treatments must be avoided. The fact that 30% of those patients do not lose their leg, leads to unsubstantiated claims of limb salvage by unproven methods. A major effort of educating both the medical teams and the patients is required in order to decrease the number of patients who will develop CLI. On the other hand, one must remember that for some patients primary amputation can be the best alternative, offering minimal risk and a reasonable quality of life.

Carotid artery stenting in high risk patients with carotid artery stenosis not eligible for endarterectomy: clinical outcome after 5 years.

BACKGROUND: Carotid artery stenting is used as an alternative to surgical endarterectomy. OBJECTIVES: To determine the outcome of CAS in a retrospective cohort of patients. METHODS: Between July 1999 and March 2003, 56 consecutive patients with carotid artery stenosis who were considered ineligible for surgery were treated (45 males, 11 females, mean age 69). All underwent the procedure prior to the introduction of distal protective devices in Israel. RESULTS: Intraprocedural complications included transient neurological findings in 5 patients (8%), cerebrovascular accident in 2 (3%), hemodynamic changes in 11 (18%), and 4 procedural failures. Post-procedural complications included transient ischemic attack in 3 patients and cardiovascular accident in 6 (10%). At 30 days follow-up, three patients (5%) remained with signs of CVA. Two patients (3%) died during the post-procedural period and 16 (28%) during the 5 year follow-up, one due to recurrent CVA and the remainder to non-neurological causes. Five-year carotid Doppler follow-up was performed in 25 patients (45%), which revealed normal stent flow in 21 (84%), 50-60% restenosis in 3 (12%) and > 70% restenosis in one patient (4%). CONCLUSIONS: This study confirms that stent procedures are beneficial for symptomatic carotid stenosis in patients not eligible for surgery.

Ultrasound-guided foam sclerotherapy in patients with Klippel-Trenaunay syndrome.

BACKGROUND: Klippel-Trenaunay syndrome, a congenital disorder, is characterized by capillary malformation, varicosities and bony or soft tissue hypertrophy. Since there is no cure for this disorder, treatment is directed towards secondary prevention of venous hypertension and preservation of functional integrity of the legs. Elastic stockings are the mainstay of treatment and are indicated in all cases. Surgery is reserved only for a few selected symptomatic patients, however the outcome is unsatisfactory in most cases, with recurrent pain, edema, poor cosmetic result and limb deformity. Ultrasound-guided foam sclerotherapy is a recently introduced minimally invasive ambulatory procedure for the treatment of chronic venous insufficiency. It was recently introduced to treat this disorder. OBJECTIVES: To evaluate the efficacy of USFS in the treatment of patients with Klippel-Trenaunay syndrome. METHODS: Seven patients diagnosed with Klippel-Trenaunay, with massive lower extremity involvement, were treated with USFS between October 2003 and October 2005. Sclerovein (polidocanol, Resinag, Switzerland) 2-4% was used as the sclerosant. The signs, symptoms and overall patient satisfaction were assessed before, during and after the treatment. RESULTS: Patients' mean age was 26 years (range 15-54). The CEAP clinical classification, with ascending severity ranging from 0 (no signs) to 6 (active venous ulcer), was C4 in five patients (71.5%) and C5 and C6 in one patient each. The average number of sessions was 14.5 (range 9-21). No major complications were encountered. All seven patients reported improvement in signs and symptoms. Five of the 7 patients (71%) were very satisfied with the cosmetic result. CONCLUSION: USFS is an effective minimally invasive ambulatory technique, essentially pain-free and with excellent short-term results in patients with Klippel-Trenaunay syndrome (when the deep system is functional). Long-term results and larger study groups are warranted.

Wound Debridement by Continuous Streaming of Proteolytic Enzyme Solutions: Effects on Experimental Chronic Wound Model in Porcin.

Wound debridement for the removal of necrotic tissue is a crucial step in wound management. Enzymatic wound debridement is one example of a method currently used that removes necrotic tissue with proteases and offers selectivity without affecting healthy adjacent tissue. Proteolytic enzymes for wound debndement are commercially available as ointments. The authors previously proposed and demon- strated feasibility on small lab animals-an alternative mode of deliv- ery of proteolytic enzymes for wound debridement with continuous streaming of protease solutions. The present study describes the impact of streaming of papain solut ions, fort ified by the incorporation of hypertonic agents, onto an experimental larger chronic wound model in pigs. Debridement of approximately half of the necrotic tis- sue mass was achieved within 6 to 11 h of streaming of papain solu- tions onto these experimental wounds. No adverse effects or notice- able morphological changes to the wound surface or its immediate surroundings were noted, indicating enzyme selectivity and preference for attacking necrotic tissue. The mechanism of enzymatic attack on the necrotic tissue is also discussed. In the control group, streaming of the basic solution formula (devoid of papain) was performed-no debridement of necrotic tissue was noticed in this case. The results indicate that the streaming delivery mode for enzymatic debridement is a highly effective tool designed to be completed in a few sessions. thus paving the way for extension of its application in clinical trials on humans.

[The effect of standing in the workplace and the development of chronic venous insufficiency].

In the paper published by Shemesh et al. in this issue of Harefuah the authors present a theory according to which mechanical hydrostatic pressure generated by long periods of standing at the workplace is a major etiologic factor in the development of chronic venous insufficiency of the superficial venous system in the legs. Despite their opening remarks, concerning the complexity and controversiality of the etiology of this condition, the authors recommend that doctors and health authorities will take this "fact" into consideration when discussing working conditions and pass appropriate regulations ensuring enforcement. Unfortunately, there is insufficient evidence to support this conclusion. Both varicose veins and working while standing are very common, so it is not surprising to find a high percentage of varicose veins amongst those who work standing up. This, however, does not mean they are directly related. Ambulatory venous pressure while sitting is about 60-80 mm of water, as opposed to 20 mm while walking, and the number is only slightly higher (about 100) while standing. If venous pressure alone was the cause of CVI, we should have found relatively high incidence of CVI amongst workers in sitting positions. Yet, this is not the case. In the normal anatomy, venous valves are absent from the heart to the mid external iliac vein in the majority of the population, leading to high hydrostatic pressure on the first valves in the groin area. Recent work by J. Bergan and his group demonstrated (in laboratory animals) that increased venous pressure will lead to the disappearance of the valve leaflets. This can explain the high frequency of venous reflux amongst young people (13%) and the even higher frequency (35%) found amongst the elderly population. However, despite the high frequency of venous reflux and high venous pressure that are recorded, the majority of patients are asymptomatic. Today it is widely agreed that hydrostatic pressure alone is not enough to create CVI. Muscle pump failure and venous outflow obstruction, are as important contributors as the increased venous pressure. Moreover, new works by Zamboni and his group demonstrate that complicated inflammatory mechanisms play a major role in the etiology of varicose veins. The attempt to blame working conditions (i.e. standing) as an important and significant factor in the development of this complex disease process is far from established. Given the high economic costs (workers' compensations, creating new work environments etc.) that the writers' recommendation will inflict if implemented, one should exercise extreme caution in the interpretation of Dr Shemesh's work.

Civilian casualties of terror-related explosions: The impact of vascular trauma on treatment and prognosis.

OBJECTIVES: A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non-terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. RESULTS: Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25-75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals' resources were used-trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). CONCLUSIONS: Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital's resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Surgery of the superficial venous system in elderly patients.

Chronic venous insufficiency, which traditionally has been attributed to failure of the deep venous system, may result from reflux in the superficial venous system. Chronic venous insufficiency is common in elderly patients, but surgical treatment is seldom offered to this patient population. We evaluated the results of superficial venous surgery for the treatment of severe chronic venous insufficiency in a cohort of elderly patients. The authors assessed patients aged 70 years or more with chronic venous insufficiency that had failed conventional conservative treatment. The superficial and deep venous systems were thoroughly investigated by duplex ultrasonography. Associated medical conditions were reevaluated and their treatment optimized. Twenty-eight patients (11 men, 17 women), aged between 70 and 89 years (mean 79), underwent superficial venous surgery. Open ulcers, active dermatitis and recurrent erysipelas were evident in 12, 9 and 7 patients, respectively. Limb swelling and severe pain were present in 25 (89%). The operations were performed under general or regional anesthesia with overnight hospitalization. Surgical treatment consisted of ligation of the points of reflux at the junctions of the superficial and deep systems, as defined by the duplex examination (21 saphenofemoral junctions, 5 saphenopopliteal junctions, 10 perforator veins), and stripping of the long saphenous vein to knee level (15 patients). Postoperative ambulatory treatment was continued until the wounds were completely closed. All ulcers healed completely within 8 weeks. No cardiac, respiratory, or renal complications were encountered. Wound infection at the groin occurred in 1 patient. Cellulitis of the calf area developed in 4 patients. Two ulcers recurred during follow-up of 1 to 5 years (mean 2.5). Surgery of the superficial venous system for treatment of severe chronic venous insufficiency is effective and can be achieved with minimal morbidity in selected elderly patients. The risk/benefit ratio for this procedure has been reduced sufficiently to ensure a major improvement in the quality of life of such patients.

Quality of life and social support following distal arterial bypass in elderly patients.

BACKGROUND: The chronic progressive course of peripheral arterial occlusive disease with its limb-threatening and life-threatening potential is associated with physical, psychological and social distress for elderly patients and their families. OBJECTIVE: To evaluate the influence of infra-inguinal bypass surgery for limb salvage, and social support, on quality of life in elderly patients (over 60 years old). METHODS: Sixty patients aged 60 years and above diagnosed with limb-threatening ischemia were evaluated using the SF-36 generic questionnaire for quality of life, and the MOS-SS questionnaire for social support. Thirty patients (group I) were evaluated in the hospital prior to reconstructive surgery and 30 postoperative patients (group II) were evaluated at home at least 6 months after infra-inguinal bypass operations. Both groups were comparable in terms of age, gender, prevalence of ischemic heart disease, diabetes, and other athero-sclerosis risk factors. RESULTS: All quality of life parameters were higher among patients who underwent limb salvage surgery (group II) as compared to preoperative patients (group I), yet the obtained values were lower than those in the general population. Patients in the surgical intervention group had higher levels of function, lower pain levels, and higher emotional and social well-being and, in addition, were spared limb amputation. The findings also indicate that the social support dimensions (emotional support, receipt of information, affection and positive social interaction), as measured in terms of perceived availability, do not operate as one entity. Different types of social support were more beneficial along different stages of the disease. CONCLUSION: Peripheral arterial occlusive disease causes severe impairment of the quality of life in elderly patients. Arterial reconstructive surgery improves the quality of life though it still remains low compared to the general population. Social support is beneficial in the treatment of these patients, and the social worker in the vascular surgery department has a key role in identifying the various needs of the patients along the path of their chronic illness.

Terror attacks increase the risk of vascular injuries.

OBJECTIVES: Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed. METHODS: A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment. RESULTS: Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries. CONCLUSION: Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.