Compliance with NICE guidelines when commissioning varicose vein procedures.

BACKGROUND: Varicose veins impair quality of life and can lead to chronic leg ulcers. National Institute for Health and Care Excellence (NICE) guidelines (CG168) set out evidence-based standards for patient management. In England, Clinical Commissioning Groups (CCGs) fund NHS care within their locality. The objective of this study was to evaluate CCGs' commissioning policies and compare them with CG168. METHODS: Searches were made for the published policies of all 206 English CCGs. They were reviewed for compliance with NICE guidelines and the associated quality standard. Areas of disagreement were analysed for themes. RESULTS: Some 203 CCGs (98·5 per cent) had a published policy and 190 (93·6 per cent) of these were published after publication of CG168. Only 73 of the policies (36·0 per cent) were compliant with CG168. Treatment was restricted on the basis of clinical disease severity in 119 CCGs (58·6 per cent); 29 (14·3 per cent) stipulated delay of treatment using a 'trial' of conservative treatment; 22 (10·8 per cent) used lifestyle-related factors such as BMI and smoking status to ration treatment. Treatment was commissioned for uncomplicated symptomatic varicose veins in 87 CCGs (42·9 per cent), but some applied additional rationing mechanisms; 109 CCGs (53·7 per cent) would treat oedema, 183 (90·1 per cent) would treat skin and soft tissue damage, 202 (99·5 per cent) healed ulceration, and all would allow active ulcers to be treated. DISCUSSION: The majority of CCGs in England have commissioning policies that contradict NICE guidelines. Rationing strategies include disease severity, delay and patient lifestyle-related factors, creating unwarranted geographical variation for varicose vein treatment, disregarding the NHS Constitution for England, and perhaps leading to an increase in costly treatment of chronic complications in the long term.

Quality of life in patients with intermittent claudication.

BACKGROUND: Intermittent claudication (IC) is a common condition that causes pain in the lower limbs when walking and has been shown to severely impact the quality of life (QoL) of patients. The QoL is therefore often regarded as an important measure in clinical trials investigating intermittent claudication. To date, no consensus exits on the type of life questionnaire to be used. This review aims to examine the QoL questionnaires used in trials investigating peripheral arterial disease (PAD). MATERIAL AND METHODS: A systematic review of randomised clinical trials including a primary analysis of QoL via questionnaire was performed. Trials involving patients with diagnosed PAD were included (either clinically or by questionnaire). Any trial which had QoL as the primary outcome data was included with no limit being placed on the type of questionnaire used. RESULTS: The search yielded a total of 1845 articles of which 31 were deemed appropriate for inclusion in the review. In total, 14 different QoL questionnaires were used across 31 studies. Of the questionnaires 24.06% were missing at least one domain when reported in the results of the study. Mean standard deviation varied widely based on the domain reported, particularly within the SF36. DISCUSSION: Despite previous recommendations for Europewide standardisation of quality of life assessment, to date no such tool exists. This review demonstrated that a number of different questionnaires remain in use, that their completion is often inadequate and that further evidence-based guidelines on QoL assessment are required to guide future research.

Dialkylcarbamoyl chloride (DACC)-coated dressings in the management and prevention of wound infection: a systematic review.

OBJECTIVE: Dialkylcarbomoyl chloride (DACC)-coated dressings (Leukomed Sorbact and Cutimed Sorbact) irreversibly bind bacteria at the wound surface that are then removed when the dressing is changed. They are a recent addition to the wound care professional's armamentarium and have been used in a variety of acute and chronic wounds. This systematic review aims to assess the evidence supporting the use of DACC-coated dressings in the clinical environment. METHOD: We included all reports of the clinical use of DACC-coated dressings in relation to wound infection. Medline, Embase, CENTRAL and CINAHL databases were searched to September 2016 for studies evaluating the role of DACC-coated dressings in preventing or managing wound infections. RESULTS: We identified 17 studies with a total of 3408 patients which were included in this review. The DACC-coating was suggested to reduce postoperative surgical site infection rates and result in chronic wounds that subjectively looked cleaner and had less bacterial load on microbiological assessments. CONCLUSION: Existing evidence for DACC-coated dressings in managing chronic wounds or as a surgical site infection (SSI) prophylaxis is limited but encouraging with evidence in support of DACC-coated dressings preventing and treating infection without adverse effects.

B cell antigen receptor cross-linking triggers rapid protein kinase C independent activation of p21ras1.

Membrane Ig (mIg) functions in binding and internalization of Ag for subsequent processing and presentation to T cells, as well as in transmembrane transduction of signals that lead to cell activation, proliferation, and differentiation. Tyrosine kinase activation and subsequent phosphatidylinositol hydrolysis and Ca2+ mobilization are clearly important intermediary events in receptor-mediated B cell activation. However, many details of the cellular signal transduction pathways utilized by this receptor are not resolved. Recent studies that demonstrated co-capping of mIg and the proto-oncoprotein p21ras suggested that this low m.w. GTP-binding protein may function in mIg-mediated signal transduction. p21ras has been implicated in some but not all protein tyrosine kinase/phospholipase C involving signaling pathways. To explore the potential role of p21ras in B cell Ag receptor-mediated signaling, we assessed the effect of Ag receptor ligation on the proportion of p21ras in the active GTP-bound state. We present evidence that p21ras is activated by mIgM and mIgG cross-linking by anti-receptor antibodies as well as by Ag. Depending upon the stimulus employed, this response is detectable within 1 min and occurs with similar kinetics as inductive protein tyrosine phosphorylation and Ca2+ mobilization. Ag dose dependence of this response is similar to that of inductive protein tyrosine phosphorylation. In these cells p21ras is also activated by PMA suggesting that p21ras activation after receptor cross-linking may be mediated by an effector molecule that functions downstream from protein kinase C (PKC). However, the kinetics of p21ras activation after mIg cross-linking are inconsistent with the possibility that PKC functions as the sole mediator of p21ras activation in this system. Finally, under conditions in which the PKC inhibitor calphostin C blocks PMA-induced p21ras activation, it does not inhibit Ag-induced p21ras activation. These data suggest that PKC effector mechanisms play a negligible role in p21ras activation during mIg-mediated signaling.