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Lower limb oedema is a common condition in clinical practice, frequently affecting the distal lower limbs. Whereas benign causes such as prolonged sitting or standing are typical, oedema can also indicate serious systemic diseases such as cardiac failure, liver disease, or renal impairment. Identifying the cause is crucial to prevent irreversible skin and tissue changes. This clinical review aims to increase the knowledge of advanced clinical practitioners (ACPs) and generalist practitioners, including practice and community nurses, by providing an overview of how to approach patients with lower limb oedema, encompassing history-taking, examinations, investigations, and management plans. The main focus is on lymphoedema, which can be primary or secondary. Primary lymphoedema results from genetic abnormalities, while secondary lymphoedema arises from acquired defects due to factors such as obesity, infections, neoplasms, and trauma. Effective management includes addressing the underlying cause, ensuring proper skin care, recommending appropriate exercises, and the use of compression garments. Referral to a lymphoedema specialist is recommended for patient education on managing and treating the condition when required. Additionally, the article discusses the importance of regular skin inspections, minor injury management, environmental considerations, and the critical role of compression garments in lymphoedema management. This comprehensive approach aims to enhance patient outcomes and provide a thorough strategy for ACPs and generalist practitioners. [ABSTRACT FROM AUTHOR]

The article focuses on a study on the use of compression therapy in the assessment and management of the venous and arterial aetiologies underlying leg ulceration as part of a holistic care plan, which was presented in an expert panel discussion held in October 2023.

Some patients develop breast/chest lymphoedema following breast cancer treatment. Historically this group of patients has been managed in the same way as those with limb lymphoedema, through the application of compression in the form of vests or bras. Some patients reported pain and the feeling of being in a 'strait jacket' and, therefore, abandoned these items for lighter and more comfortable garments without any adverse effects. Reflecting on this insight, the author adapted breast/chest lymphoedema management by suggesting a change to lighter garments to patients who reported improved comfort, with no obvious negative impact on their lymphoedema. Within this article, the author gives a brief explanation of lymphatic mechanisms and factors relating to lymphoedema including signs and symptoms of breast oedema. There will be an exploration of the available treatments for lymphoedema along with treatment plans found to be effective by the author. [ABSTRACT FROM AUTHOR]

Heart failure (HF) and lymphoedema often co-exist, significantly affecting the quality of life and requiring complex management. Heart Failure, characterised by reduced cardiac function, affects around 1 million people in the UK. Lymphoedema, involving lymphatic failure, affects 4 to 29 per 1000 individuals, particularly older adults. Traditionally heart failure management focuses on medication, while lymphoedema relies on compression therapy (CT). The article examines the integration of CT to treat lymphoedema with coexisting HF. Evidence suggests that with careful management and multidisciplinary collaboration, CT can be safely used in stable HF patients to manage lymphoedema, improving overall treatment outcomes and patient wellbeing. This approach requires adherence to guidelines and a holistic, patient-centred care model. Debates about CT for lymphoedema in the presence of HF highlight the need for patient-focused and all-encompassing care. Practitioners must consider the broader context of both conditions and collaborate with colleagues and patients to make informed treatment decisions. [ABSTRACT FROM AUTHOR]

Objective: Multicomponent bandages (MCBs) are recommended by the French Authority for Health (Haute Autorité de Santé) as first-line treatment for venous leg ulcers (VLUs). A first analysis of the data collected from the French administrative healthcare database (Système National des Données de Santé (SNDS)) on 25,255 patients with a VLU supported superiority of MCBs versus short stretch bandages when considering the healing outcomes and costs associated with closure of these wounds. The aim of this study was to assess how beneficial the primary dressing (technology lipido-colloid nano-oligosaccharide factor (TLC NOSF) or control dressing group (CDG)) could be, when used in combination with MCBs in the treatment of VLUs. Method: Data from the SNDS were collected for patients meeting the following inclusion criteria: treatment for a VLU with MCBs and with the same dressing type (TLC-NOSF or CDG) during the whole treatment period. Healing outcomes were documented on the global cohorts and propensity score-matched cohorts. The mean healthcare cost and the ecological impact were calculated for those patients healed within the study period. Results: In total, 12,507 patients met the criteria for treatment with both MCBs and TLC-NOSF dressings (n=1134) versus MCBs and CDG (n=11,373); with 1134 and 2268 patients per group following propensity score matching. Healing outcomes were favourable for the TLC-NOSF group in the global cohort and were enhanced in the propensity score-matched cohorts. At every point of the analysis, the adjusted healing rates were significantly higher in the TLC-NOSF group than in the CDG group (p<0.001). In the propensity score-matched cohorts (n=3402), the healing rate at three months was 52% in the TLC-NOSF group versus 37% in the CDG group (p<0.001). The median healing time was 87 days versus 125.5 days in the TLC-NOSF and CDG groups, respectively (p<0.0001). TLC-NOSF dressings significantly reduced the average treatment cost per healed ulcer (€2099) by 23.7% compared with dressings without TLC-NOSF (€2751) (p<0.001), as well as the resources used. Conclusion: This SNDS analysis confirms, in the largest real-life study performed in VLU management, the superiority of the TLC-NOSF dressings versus those not impregnated with the NOSF compound. Better clinical outcomes associated with cost savings and a positive ecological impact support the combination of MCBs and TLC-NOSF dressings and should be considered as an optimal standard of care for the global management of VLUs. These outcomes reinforce the current positions of the international guidelines on the use of NOSF impregnated dressings (UrgoStart range; Laboratoires Urgo, France) in this pathology. [ABSTRACT FROM AUTHOR]

Background: Poor access to lymphoedema specialists and communication between them and patients prevents appropriate lymphoedema management. Therefore, development and dissemination of remote systems is necessary to improve care in rural areas with limited medical personnel or access to medical coordination. Aims: The authors evaluated the elements required for providing patient education on conservative therapy for lymphoedema, to determine the feasibility of remote management. Methods: The study involved connecting a health professional in a local clinic (point A) treating a patient with lymphoedema, who was present alongside the clinician, with a specialist certified lymphoedema therapist (CLT) located remotely in a university (point B). Findings: The CLT was able to greet, interview and provide guidance to the patient on conservative therapy. Direct contact with the patient was not possible, which limited visualisation, palpation, leg circumference measurement, and lymphatic drainage management. Conclusion: The findings suggest that remote a lymphoedema management approach involving conservative therapy benefits both patients and health professionals, particularly in rural regions. Future studies are needed to confirm the effectiveness of this approach to confirm adequate treatment. [ABSTRACT FROM AUTHOR]

Many of the approaches for managing lymphoedema are straightforward and easily accessible, allowing individuals to take considerable charge of their care. As a result, nurses can play a vital role in lymphoedema treatment by equipping patients with crucial knowledge and offering practical assistance to foster self-management. Francesca Ramadan elaborates upon the aspects of patient education that the community nurse must promote and support to enable individuals with lymphoedema to take back control. [ABSTRACT FROM AUTHOR]

Optimal management of breast cancer-related lymphoedema (BCRL), a common and debilitating complication of surgery and radiotherapy, depends on early detection, personalised risk assessment and proactive intervention. For instance, a recent review advises healthcare professionals to reframe the narrative about the daily-living skin trauma risks away from 'what to avoid' to 'what to do'. Another review recommends daily, or nearly daily, exercise at home to reduce lymphoedema severity. However, several questions await full answers. There is, for instance, no consensus regarding the most appropriate surgical technique for preventing BCRL. This feature summarises some recent papers updating healthcare professionals about BCRL. [ABSTRACT FROM AUTHOR]

Lymphoedema effects approximately 200 000 people in UK. It is a chronic condition without a cure but there is much that can be done to ease and manage these complications. This article looks at the eight most common complications, providing advise on how to manage them, derived from the literature and the author's own experience. It also presents advise on how nurses can promote self-management of these complications, promoting patients' self-care. [ABSTRACT FROM AUTHOR]

Toe and foot swelling can manifest as lymphoedema or chronic oedema but can also be a complication of the treatment of these conditions. In this article, the authors discuss the assessment and treatment options for toe and foot swelling, highlighting the importance of prevention in the first instance. [ABSTRACT FROM AUTHOR]

This article will focus on the integration of tissue viability and lymphoedema services to improve outcomes for patients with leg ulceration. It will highlight why there is a need for lymphoedema specialist knowledge within the care of patients with leg ulceration and how the services are closely aligned. Lymphoedema can adversely affect wound healing and the article will provide case studies that highlight how developing a hybrid tissue viability and lymphoedema clinician or integration of the specialists can provide effective patient-centred care at reduced cost. The article offers potential strategies and suggestions on how to address inequalities in care and how to improve service provision. [ABSTRACT FROM AUTHOR]

This systematic literature review was carried out by a final-year nursing student in response to clinical experience, and to understand the rationale and evidence around managing venous ulcers. In the student's clinical experience, the two most commonly used treatment methods were forms of compression hosiery and compression bandaging. The CINAHL, Science Direct, Cochrane Library, Internurse and MEDLINE databases were searched for literature published over the period 2003–2023. From the resulting five papers, five key themes were identified: types of compression systems used and the rationale for decision-making; clinical effectiveness; the impact on patient experience and quality of life; pain levels following application of compression systems; and cost effectiveness. Conclusion: Management and prevention of venous ulceration is complex. The decisions should be made in partnership with the patient and will be influenced by context. Overall, compression hosiery was identified as the more favourable system. [ABSTRACT FROM AUTHOR]

This case study describes the successful management of a patient with primary lymphoedema, who was experiencing lymphorrhoea and epidermolysis, using a multidisciplinary approach. The patient had Klippel–Trenaunay syndrome. The multidisciplinary team, in an outpatient clinic in Japan, included a certified lymphoedema therapist, plastic surgeons, and a wound, ostomy and continence nurse. The team performed complex physical therapy and lymphaticovenular anastomosis, which promoted the resolution of the lymphorrhoea. This resulted in improvements in skin condition, the prevention of recurrent cellulitis, and no increase in limb circumferences during the 1-year follow-up period. This report highlights the importance of a multidisciplinary approach to lymphoedema management, including lymphorrhoea control that fitted in with the patient's daily life. It is hoped that this article will contribute to the improvement of the quality of life of patients with lymphoedema. [ABSTRACT FROM AUTHOR]

The article provides information on lymphatic insufficiency and stiff compression in venous leg ulceration.

Background: There is no clear guidance or comprehensive comparative evidence to help clinicians select between adjustable wraps for compression therapy. However, adjustable wraps could be compared with three metrics used for compression bandages: variation in pressure, stiffness and elasticity. Aims: To determine whether easywrap (Haddenham Healthcare) had lower standard deviation (SD) in lying pressure, greater static stiffness index (SSI) and/or a greater mean elongation ratio than six other adjustable wraps. Methods: In this preliminary exploratory study, seven adjustable wraps were tested in vivo 20 times each (140 tests in total), on 20 people (with a variable number of readings per participant), to give the SD in lying pressure and mean SSI. The same wraps were tested in vitro five times each to give the mean elongation ratio. Findings: Of all seven adjustable wraps, easywrap had the second lowest SD in lying pressure at 5.9 mmHg, compared with 8.9 mmHg overall; the highest mean SSI at 13.2 mmHg, compared with 9.5 mmHg overall; and the highest mean elongation ratio at 137.0%, compared with 107.1% overall. Conclusions: These metrics suggest that easywrap has clinical advantages over other adjustable wraps. A lower variation in lying pressure suggests more consistent application of pressures within intended therapeutic levels. Higher SSI indicates greater resistance to stretching, which is linked to improved venous function and oedema reduction. Higher elongation ratio demonstrates greater tensile strength, which should maintain therapeutic pressure for longer without readjustment. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines aim to consolidate and incorporate the latest evidence and opinion to improve patient outcomes and reduce variations in practice. Aims and methods: This article will examine the evolution of clinical guidelines and recommendations in leg ulcer assessment and management, from the seminal Royal College of Nursing clinical guideline (1998) to the current Leg Ulcer Recommendations from the National Wound Care Strategy Program (2023). The evolving definitions of leg ulcers will be discussed, as well as the multidisciplinary approach needed to manage the underlying aetiology of this condition. Findings and conclusion: A national appetite for improving leg ulcer assessment and treatment, is being informed by clinical guidelines and recommendations. The cornerstones of assessment and management remain constant, although some fundamental elements around ankle brachial pressure index ranges, historically used to aid diagnosis of leg ulcer aetiology, have been omitted in the recent recommendations. [ABSTRACT FROM AUTHOR]

The use of compression therapy is known to be effective in the management of patients with venous leg ulceration and is commonly recommended as a first-line treatment. A rare but known complication of compression therapy is pressure damage to the limb, also referred to as bandage damage, which should be categorised as a medical device-related pressure injury. Patients should receive a comprehensive, holistic assessment before any compression therapy is applied. Risk factors for compression therapy injury include peripheral arterial disease, older age, fragile skin, pronounced bony prominences or tendons, calf atrophy, foot drop, neuropathy/absent sensation, limited movement, cognitive impairment and receiving end of life care. Risks can be mitigated through a variety of approaches, and practitioners should be aware that these can change depending on the patient's condition. A community improvement initiative, illustrated with a case study, introduced a clinical pathway that can facilitate the identification and management of patients who are at risk of developing pressure injuries as a result of compression therapy. [ABSTRACT FROM AUTHOR]

Background: This case series follows the relective processes undertaken, when ive slim women presented with reactive oedemas of the forearm and hand, that did not respond to usual therapy. Aim: To raise awareness about Aromatase Inhibitor (AI), Letrozole. Methods: Possible causes, including Cyclin-Dependent Kinase 4 and 6 (CDK4/6) inhibitors, Ribociclib and Axillary Web Syndrome, were explored and reviewed, and potential effective treatment options were then sought. New cases presented, which discounted each theory, until Letrozole was suspected. Results: Inlammatory oedemas were explained by the mechanisms-of-action relating to Aromatase Inhibitor Associated Musculoskeletal Syndrome (AIMSS), the severity of which, especially for slim women with oestrogen deprivation, causes almost 50% of women to cease treatment within 6 months; risking disease reoccurrence. Conclusion: Permissions were gained, a table was collated and sent to referring consultants, requesting risk/beneit analysis of Letrozole with a medication review. If non- responsive, inlammatory oedemas present in clinic, AIs should be considered as a trigger. [ABSTRACT FROM AUTHOR]

Objective: Leg ulcers are common, distressing and painful for patients, and are a significant financial burden to healthcare providers. Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression therapy in the community. However, little is known about the prevalence of leg ulceration and use of compression therapy in acute hospitals. The aim of this study was to explore the published literature on the use of compression therapy for inpatients with leg ulcers in UK National Health Service hospital settings. Method: A literature search was undertaken to identify published papers reporting on inpatient leg ulcer populations and the use of compression therapy in hospitals using the following databases: CINAHL, MEDLINE Complete, Embase and PubMed. Results: The literature review identified 364 articles, of which three met the eligibility criteria. These studies reported on the prevalence of leg ulceration, the number of Doppler assessments conducted for patients and the use of compression therapy. Conclusion: This review confirmed a lack of information on the prevalence of hospital inpatients with leg ulcers, and identified the need to conduct prevalence audits, establish leg ulcer services to streamline inpatient leg ulcer care and provide staff and patient education programmes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the healing outcomes and costs associated with the aetiological management of venous leg ulcers (VLUs) treated with recommended multicomponent bandages (MCBs) and short-stretch bandages (SSBs). Method: This observational study is a retrospective comparative study (Level 2b), based on the French administrative healthcare database (Système National des Données de Santé, SNDS). It includes patients treated from onset with reimbursed MCBs and SSBs for a VLU episode, between July 2018 and September 2020. Although other compression systems, such as long-stretch bandages, are commonly used for the treatment of VLUs, they are not recommended by health authorities in France and thus, were not considered for this study. A binomial regression model was performed to estimate the adjusted relative risk of wound closure rates at three months for each group, based on potential confounding factors including, notably, age, sex, key comorbidities, and wound dressing size. The mean healthcare cost was calculated for patients whose VLUs healed within the study period. Results: The reimbursement data (including prescribed compression systems and nursing care) of the 25,255 selected patients were analysed in the study. There were no significant differences between the MCBs and SSBs groups when considering patient characteristics. The healing rates after three months' treatment, were 42% and 35% (p<0.001) in the MCBs and SSBs groups, respectively. When adjusting the statistical model, the chance of healing at three months was still 12% higher with MCBs compared with SSBs (p<0.0001). The median healing time was estimated at 115 (interquartile range (IQR): 60–253) days in the MCB group versus 137 (IQR: 68–300) days in the SSBs group. The average treatment cost per patient with a healed ulcer was €2875±3647 in the MCB group and €3580±5575) in the SSBs group (p=0.0179), due to lower hospital stay and nursing costs in the MCB group. Differences in wound characteristics between the two groups cannot be totally excluded, due to the limited content of the database in terms of clinical data, but should have been addressed, to some extent, through the study selection criteria and the chosen regression model. Conclusion: In this study, this SNDS analysis seemed to confirm that the healing outcomes achieved in real-life with MCBs were in line with those reported in clinical trials, and superior to SSBs, which reinforces the current position from the guidelines. [ABSTRACT FROM AUTHOR]

The article comments on the impact of public policies and legislation on the U.S. wound care community and patient access to treatment and care in 2023 and outlines wound care advocacy initiatives for 2024 covering cellular and/or tissue-based products, antimicrobial dressings, lymphoedema compression and surgical dressings.

Venous leg ulcers and chronic oedema including lymphoedema are lifelong conditions that cause great distress to sufferers due to psychophysical symptoms. Time and resources spent on managing chronic wounds place an economic burden on healthcare providers, particularly with an anticipated increase in an ageing population and diminishing numbers of those providing long-term care. Resources are further challenged if wounds remain unhealed. The human costs are even greater, with patients often facing a lifetime of discomfort due to low awareness of venous disease, despite epidemiological studies. Possible causes of persistent venous disease may be misdiagnosis, mismanagement, or simply, no management if help is not sought. Therefore, it is important that chronic leg ulcers are managed with clinically effective regimes, reassessment, monitoring and appropriate referrals for adjunct management, alongside patient education. This article provides simple timescaled measurements to ensure timely interventions and appropriate care at each stage. [ABSTRACT FROM AUTHOR]

Background: The complex healing process of venous leg ulcers (VLUs) is widely documented, yet wound healing outcomes continue to challenge community nurses. Compression therapy remains the ‘gold standard’ to improve healing outcomes. However, the complexities surrounding VLUs demand a holistic and unified approach. Advising patients with VLUs to perform exercises is a widely accepted practice based on the known benefits of lower leg mobility reducing venous hypertension. A lack of standardisation surrounding this subject has generated a rise in academic interest over the past decade, particularly in the benefit of a prescribed exercise intervention (PEI) as an adjunct to compression for VLU patients. Aim: This review explored the use of an unsupervised PEI as an adjunct to improve VLU healing in housebound patients wearing compression therapy. The aim was to determine if a PEI is beneficial to VLU healing alongside compression therapy. Results: The review identified five randomised controlled trials (RCT) between 2009 and 2022. Although the evidence showed some limitations, statistically and clinically significant results were identified for VLU healing outcomes. Conclusion: A PEI designed to engage the calf muscle pump is beneficial to improve VLU healing outcomes, alongside compression therapy, for housebound patients and should be included in the community nursing holistic model of care for VLU management. [ABSTRACT FROM AUTHOR]

The article presents a guide to implementing the wound hygiene protocol of care for leg ulcers, that include assessing the wound, lower limb and whole patient, identifying tissue types on the wound bed, managing the ulcer, cleansing the wound bed and surrounding skin, and debriding non-epithelialising tissue.

More than 1 million people are estimated to have lower limb venous ulceration in the UK. Such wounds are predominantly caused by sustained venous hypertension, as a result of chronic venous insufficiency, often due to venous valve incompetence or an impaired calf muscle pump. Compression therapy is key to venous leg ulcer management and the majority of nurses are aware of the importance of starting patients on compression therapy as early as possible. However, there appears to be a lack of awareness of the importance of venous assessment and that more patients could benefit from endovenous correction of superficial venous incompetence. [ABSTRACT FROM AUTHOR]

Aim: To assess the feasibility using the Control of Compression Bandaging (CCB) score to measure skills development on short-stretch compression therapy during a second-year nursing students' workshop. Design: A quasi-experimental pilot study with one group. Method: All students followed a blended learning unit comprising an e-learning unit on leg ulcers and compression therapy including videos, followed by hands-on workshops where they could exercise how to apply short-stretch compression bandages. Clinical nurse specialists in wound care collected pre- and post-workshop measures. Data collection included feasibility, absolute pressure under compression bandages and the CCB score. Results: Six clinical nurse specialists (CNSs) collected data and 16 students participated in this pilot study. The mean application time was 8.02 minutes (min=2, max=20) pre and 9.25 minutes (min=5, max=17) post workshop. Pressure under compression bandages increased at the forefoot (P=0.01) and the calf muscle base (P=0.03) post workshop. One extreme outlier was observed. In addition, the CCB score increased from 3.57 to 4.47 (P=0.16). Using pressure measuring devices was described as essential by all the CNSs and the CCB score was easy to use. Conclusion: Using the CCB score and pressure measuring devices were feasible during an undergraduate education session. Recruitment procedure and modality of data collection were satisfactory. This score may be a valuable way to assess students' skills in short-stretch compression therapy. If used for formal assessment, a passing score should be defined. [ABSTRACT FROM AUTHOR]

The article provides information on exudate, ways to manage exudate and effects of wound exudate and introduces the 3M exudate pathway and foam decision tools. Topics discussed are process of wound assessment and associated exudate, importance of managing exudate, types and colours of exudate, options for exudate management with interactive dressings like alginates, foams, hydrofibres, super absorbents, or through negative pressure wound therapy and compression therapy.

As an incurable condition, lymphoedema, whether primary or secondary, is a significant burden for patients, impacting every aspect of their lives, ranging from the personal to the professional. While daytime compression is a pillar of lymphoedema management, night-time compression delivery is also gaining credence. Health writer Francesca Ramadan summarises the exploration of this growing phenomenon in the literature, overviewing the benefits and dispelling the myths. [ABSTRACT FROM AUTHOR]

Objective: To assess the clinical outcomes and cost-effectiveness of using two different reduced pressure compression systems in treating newly diagnosed venous leg ulcers (VLUs) in clinical practice, from the perspective of the UK's National Health Service (NHS). Methods: This was a modelling study based on a retrospective cohort analysis of the case records of patients with a newly diagnosed VLU, randomly extracted from The Health Improvement Network (THIN) database, who were initially treated with a two-layer cohesive compression bandage (TLCCB Lite; Coban 2 Lite, 3M, US) or a two-layer compression system (TLCS Reduced; Ktwo Reduced, Urgo, France). No significant differences were detected between the groups. Nevertheless, analysis of covariance (ANCOVA) was performed to enable differences in patients' outcomes between the groups to be adjusted for any heterogeneity in baseline covariates. Clinical outcomes and cost-effectiveness of the alternative compression systems were estimated over 12 months after starting treatment. Results: Time from wound onset to starting compression was a mean of two months. The probability of healing at 12 months was 0.59 in the TLCCB Lite group and 0.53 in the TLCS Reduced group. Patients in the TLCCB Lite group experienced a marginally better health-related quality of life (HRQoL) of 0.02 quality-adjusted life years (QALYs) per patient compared to those in the TLCS Reduced group. The 12-month NHS wound management cost was £3883 per patient treated with TLCCB Lite and £4235 per patient treated with TLCS Reduced. When the analysis was repeated without ANCOVA, the findings from the base case analysis remained unchanged (i.e., use of TLCCB Lite improved outcomes at lower cost). Conclusion: Within the study's limitations, treating newly diagnosed VLUs with TLCCB Lite instead of TLCS Reduced potentially affords a cost-effective use of NHS-funded resources in clinical practice, since it is expected to result in an increased healing rate, better HRQoL and a lower NHS wound management cost. [ABSTRACT FROM AUTHOR]

In the article, the author discusses how community nurses in the United Kingdom (UK) can empower people with lymphoedema based on the concept of patient accountability and empowerment. Also cited are the features of lymphoedema like chronic swelling, pain and heaviness in the tissues, and the focus of treatment like lymphatic drainage, exercise, and skincare.

It is understood that intervention for venous leg ulcer (VLU) management is more successful the sooner compression is applied, yet healing rates of VLUs are falling and recurrence rates increasing. This literature review seeks to explore the factors affecting patient concordance with compression therapy to manage VLU. Of the literature searched, 14 articles were identified and four themes of reasons for non-concordance emerged: education; pain/discomfort; physical limitations; and psychosocial issues. The reasons for non-concordance are vast and complex; district nurses must explore these reasons to help improve the alarming rates of non-concordance. A personalised approach is necessary to meet individual needs. High risks of ulcer recurrence are noted and a greater understanding of the chronic nature of ulceration should be conveyed. Follow-up care and building trust is linked with higher rates of concordance. Further research is needed within district nursing as the majority of venous ulceration is managed within the community. [ABSTRACT FROM AUTHOR]

Objective: Venous leg ulcer (VLU) is a chronic disease and has periods of exacerbation and remission. Various bandage systems—single-layered, double-layered and multiple-layered with elastic and non-elastic components—have been developed. The requirement for sustained pressure brought about the introduction of the four-layer bandage. We studied the bacteriology of VLUs and the effect of four-layer bandages on their healing. Method: Clinical details of all patients, with wound size measurement by gauze piece, wax paper and scale, were recorded. The wounds were initially debrided and photographic records of all patients were maintained. Patients were followed up every week, when the dressings and four-layer bandages were changed. Results: A total of 60 patients were recruited to the study with four patients having bilateral disease and so a total of 64 VLUs were evaluated. Of these, 60 (93.8%) healed completely, one (1.6%) healed partially and three (4.7%) did not heal. After excluding the four VLUs that did not fully heal, 10 (16.7%) had recurrence while 50 (83.3%) had no recurrence in the follow-up period, which lasted for one year. During the first visit (baseline), meticillin-resistant Staphylococcus aureus (MRSA) was isolated in 29 (45.31%) VLUs and Pseudomonas spp. in 20 (31.25%) VLUs. With subsequent dressing, the VLU size decreased and the culture of the VLU was sterile from the third culture onwards in 45 cases. There was a significant correlation (p<0.001) between VLU size and the number of dressings. Conclusion: Compression therapy is the mainstay of treatment of VLU, with rapid healing and improvement in bacteriological profile. Compression in the range of 30–40mmHg is the most effective treatment for uncomplicated VLUs with adequate arterial competency. [ABSTRACT FROM AUTHOR]

Venous leg ulcer treatment is frequently discontinued in hospitals in contravention of national guidance, significantly affecting patient outcomes and increasing NHS costs. Aim: To identify, from the published literature, reasons for variable implementation. Method: Systematic review with narrative synthesis, including full papers in English with empirical qualitative data. Synonyms for venous leg ulcer, compression therapy and secondary care were searched across a range of health-related databases. The Critical Appraisal Skills Programme (CASP) checklist determined study quality, and meta-ethnography was used for data synthesis. Results: 7040 titles and abstracts and 41 full-text papers were screened with four papers selected. Three key themes were generated: educational needs surrounding implementation of compression therapy, patient factors regarding adherence and organisational resources including availability of appropriate equipment and trained staff. Conclusion: Barriers at the ward level were identified. There is a need to better understand why hospitals are not addressing them. [ABSTRACT FROM AUTHOR]

Objective: This audit was designed to identify the need of the population and the clinical activity associated with wounds and the management of lower limb swelling. The exploration focused on lower leg wound management, access to diagnostics and compression therapy across each audit site. The variation across the sites was explored to gather insight into the real-world barriers to providing evidence-based management for leg ulceration. Method: We undertook wound prevalence audits across six diverse community provider sites in England. The audit was undertaken by the local providers, with the inclusion of tissue viability and podiatry leads and key local stakeholders, often local quality leads, primary care leads and nursing directors. Each audit was undertaken with full engagement of local clinicians. Data were collected centrally, and each audit site received their own local analysis and report, with additional analytical support from the local tissue viability lead to ensure the feedback was contextualised for their stakeholders. Analysis was provided by Accelerate CIC Lymphoedema & Leg Ulcer Clinic. Results: A total of 2885 patients were reviewed via an online or a paper audit tool. In total, 2721 patients had one or more active wounds. However, 1350 patients had one or more lower leg wounds, with 164 patients being managed for lower limb swelling or prevention of leg ulceration; bilateral conditions ranged from 11–43% across audit sites. Of the six sites, two included both community and primary care providers, thus generating wound point prevalence data. The remaining four sites audited community nursing and podiatry services only, with two sites collecting data on lower limb wounds only rather than all wounds, generating point prevalence for their services only. Compression usage varied across care locations, with the greatest use being seen in community leg ulcer clinics, where it was >96% for 234 residents. Compression usage was lower in the home with a range of 14–62% among 692 residents. For 263 residents, where the cause of their lower leg wound was unknown, compression usage was very low at 12%. Compression usage decreased with age; for three audit sites this was noteworthy, with 65% of those aged >80 years not in receipt of compression. Compression usage had a direct impact on nursing activity; non-use of compression increased activity by 37%. Conclusion: Through the identification of wound location, this series of wound prevalence audits identified a greater number of patients with lower limb wounds than those recognised and classified as a leg ulcer. Substantial variation in access to diagnostics and compression therapy was observed between audit sites, and also between locations within their boroughs. The factors that reduced access to compression therapy included not classifying the lower leg wound as a leg ulcer, being cared for in the home and increasing age of the patient. Lack of compression usage increased nursing activity. Where there is lack of access to therapeutic intervention, the resultant patient harm is not systematically recognised or documented. [ABSTRACT FROM AUTHOR]

Background: Compression therapy is a safe, effective treatment for lower leg conditions such as lymphatic insufficiency and venous hypertension. The most common method of arterial assessment is the calculation of a patient's ankle–brachial pressure index (ABPI). The need for ABPI is highlighted in many best practice statement and local policies. ABPI compares the arterial flow of the arms and the legs, providing a ratio used to determine the presence and severity of peripheral artery disease and assess whether a patient is suitable for compression therapy. Aim: This study critically reviews and analyses findings from contemporary literature with the aim of evaluating the effectiveness of the ABPI screening tool. Method: A structured literature review using a narrative approach was carried out. Results: Four studies were identified for inclusion, which involved medical, nursing and allied health professional staff in primary and secondary care, with a total of 51 patients. Analysis generated eight themes: appropriateness of the ABPI tool; clinician education; referral process; access to appropriate equipment; lack of time to conduct the assessment; competence; associated costs; and role definition. Conclusion: It is important to undertake a holistic assessment of the patient, incorporating ABPI assessment where not contraindicated. Further research to explore patient experience and safety when assessing a patient's suitability for lower limb compression therapy is required. [ABSTRACT FROM AUTHOR]

The prevalence of wounds and comorbidities such as dementia increases with age. Given projected rises in population ageing and growth, the likelihood of encountering an overlap in these conditions in clinical practice has increased. Clinicians provide wound care for patients in a variety of settings, drawing on different evidence-based clinical guidelines. Most research into wound care has excluded patients with dementia. Therefore, the aim of this review is to provide safe strategies and methods of implementation in those patients living with dementia. [ABSTRACT FROM AUTHOR]

Chronic peripheral oedema is a common long-term condition, with conflicting evidence on how it is best managed. It is crucial to establish the cause of the oedema to decide on the most appropriate intervention for its management. If the oedema is not managed, it can lead to unwanted complications for the service user. The District Nurse (DN) is pivotal in the management of patients with long-term conditions, both directly and indirectly. It is important that a multi-disciplinary approach is used, although nurses are now more autonomous due to advances in practice. The present study focuses on leg elevation as a form of intervention in the treatment of chronic peripheral oedema. As with any intervention, there are some risks with leg elevation that must be considered. This should be disseminated and monitored effectively. [ABSTRACT FROM AUTHOR]

This case report discusses the role of a practitioner managing a patient with secondary lymphoedema as part of a self-management regime. The patient was diagnosed with multiple sclerosis and lumbar spinal stenosis. The focus is on compression therapy, which is used as part of complete decongestive therapy to reduce and control lymphoedema. The case report illustrates how a patient-centred plan can help people with lymphoedema and co-morbidities to achieve their personal goals. The evidence behind treatment decisions is considered, and modifications made to the care plan to accommodate the needs of the individual are described. The teaching and rehabilitation role of the practitioner is explored, including strategies used to support patients with long-term conditions. This report also identifies a lack of research-based evidence supporting the management of oedema as a symptom of multiple sclerosis. Further research is needed to inform clinical guidelines which would promote the management of secondary lymphoedema. [ABSTRACT FROM AUTHOR]

Objective: The aim of this case report is to describe the results of complex decongestive therapy (CDT) in a patient with poliomyelitis and bilateral lymphoedema, and to emphasise the effect of CDT on wound healing. Method: A 48-year-old female patient was given CDT for bilateral grade 3 lymphoedema in the lower extremities and a deep wound on the right foot. She had been diagnosed with poliomyelitis sequela and mobilised with a wheelchair for 26 years. The lymphoedema on both legs and the wound on the right foot sole had been present for five years and eight months, respectively. Detailed wound care had been performed previously upon the green, malodorous infected wound, without healing. The patient received skin care education, manual lymphatic drainage, multilayer bandaging and exercises for 4 weeks in a total of 20 sessions. The improvement was assessed by limb volumes prior to and at the end of the treatments. Results: The right and left lower limb volumes were decreased significantly at the end of treatments (3042cm³ (R) and 3165cm³ (L) before versus 2702cm3 (R) and 2401cm3 (L) afterward). The wound size decreased considerably and the green malodorous flow ceased. The patient continued self-massage and self-bandaging after hospital discharge. The control follow-up, one month later, revealed a completely healed wound with maintained volume. Conclusion: In conclusion CDT for a duration of 4 weeks in a female patient with poliomyelitis, bilateral lymphoedema and an infectious hard-to-heal wound, improved both the lymphoedema and wound healing. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy, tolerability and acceptability of a new multicomponent compression system in one bandage for the local treatment of patients with venous leg ulcers (VLUs). Method: This was an international, prospective, non-comparative, clinical trial, conducted in France and Germany. Eligible participants had a VLU with a wound area of 2–20cm2, lasting for a maximum of 24 months. For a period of 6 weeks, patients were treated with a new multicomponent compression system in one bandage which was worn day and night, providing high working pressure and moderate resting pressure (UrgoK1). Clinical assessments, wound measurement and photographs were planned at weeks 1, 2, 4 and 6. The primary endpoint was the relative wound area reduction (RWAR) after 6 weeks of treatment. Secondary endpoints included wound closure rate, oedema resolution, change in patient's health-related quality of life (HRQoL), acceptability, adherence to the compression therapy, local tolerance, and physician's overall satisfaction with the evaluated compression system. Results: A cohort of 52 patients (52% female, mean age 75.4±13.0 years) with VLUs, including oedema in 58% of cases, were recruited from 22 centres. At baseline, 42 patients had already been treated with a different compression system. VLUs had been present for 5.6±4.9 months and had a mean area of 5.7±4.3cm2. After 6 weeks of treatment, a median RWAR of 91% (interquartile range: 39.4; 100.0) was achieved. Wound closure was reported in 35% of patients. A RWAR ≥40% at week 4, predictive of wound healing at 12 weeks, was achieved in 62% of patients. At the final visit, oedema present at baseline was resolved in 57% of patients. Substantial improvements in the HRQoL of the patients were reported with a decrease of the pain/discomfort and anxiety/depression dimensions. Comfort in wearing the evaluated system was reported as 'very good' or 'good' by 79% of patients, resulting in a high patient adherence to compression therapy. Compared to previous compression systems, half of the patients reported more ease in wearing shoes, and greater satisfaction and comfort with this new system. Nine non-serious adverse events related to the device or its procedure occurred in seven patients. At the final visit, the majority of the physicians were 'very satisfied' or 'satisfied' with the new compression system overall. Conclusion: The new multicomponent compression system in one bandage has been shown to promote rapid healing of VLUs, reduce oedema, improve HRQoL and to be well tolerated and accepted. It appears to be a viable alternative to existing compression systems. [ABSTRACT FROM AUTHOR]

Introduction: Compression therapy is important in oedema control in lymphoedema. However, some patients have difficulties starting compression therapy because standard self-care education does not enable them to fully understand lymphoedema and recognise it as their problem. To overcome this, real-time image-sharing education, using a combination of indocyanine green lymphography (ICG) and ultrasonography, may be used to educate patients. In this case study, real-time image-sharing education promoted decision-making and behaviour change in a patient with lower extremity lymphoedema so she would wear elastic stockings. Case: A 51-year-old woman with a BMI of 31.7 kg/m2 and secondary lower extremity lymphoedema following cervical cancer surgery did not adhere to self-care instructions regarding wearing elastic stockings for 5 years. The oedema worsened, her limb circumference increased and she had two episodes of cellulitis within a year. Because the patient had a negative attitude towards elastic stockings, real-time image-sharing education was used to promote recognition of illness using ICG and an understanding of the condition of lymphoedema using ultrasonography. After the images were shared and explained, the patient discussed her recognition and understanding of lymphoedema, then decided to use compression stockings. She continued to wear them for 4 months, and her limb circumference decreased. Conclusion: Real-time image-sharing education using ICG and ultrasonography as self-care support for a lymphoedema patient who would not start compression therapy could result in behavioural changes and the patient starting and continuing to wear elastic stockings. [ABSTRACT FROM AUTHOR]

Objective: Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression in the community. However, little is known about the leg ulcer population and use of compression therapy in the hospital setting, where it is not often part of inpatient care. This study aimed to evaluate the proportion of inpatients with leg ulceration eligible for compression therapy. Method: A point prevalence audit was undertaken using three methods: patient electronic live report; a leg ulcer audit form; and an electronic record search. The following data were retrieved: patient age, sex, primary reason for admission, diabetes, mobility status, history of dementia, Clinical Frailty Scale score and presence of oedema. Ankle-brachial pressure index was measured to determine patients' eligibility for compression therapy. Results: The audit identified 80/931 (8.5%) inpatients as having confirmed, active leg ulceration. A total of 36/80 (45%) inpatients were assessed for eligibility for compression, of whom 25/36 (69.4%) were eligible for full compression, 2/36 (5.6%) reduced compression and 9/36 (25%) were not eligible for compression therapy. Conclusion: The audit demonstrated that a significant proportion of hospital inpatients with leg ulcers were eligible for compression therapy and that this patient population were heterogenous in terms of comorbidity profile, mobility, frailty and dementia, among other factors. Further research is required to explore the most feasible and effective compression options for inpatients with leg ulcers. [ABSTRACT FROM AUTHOR]

Aim: Lymphoedema is associated with dysfunctional lymphatics, tissue fibrosis and inflammatory changes in the skin and local tissue. Ensuring compression supports tissue health is crucial to managing lymphoedema. Providing patients with safe compression which enhances their tissue health is paramount when supporting their 24-hour self-management regimens. This case study explores the use of a new compression garment in two sitting positions in an adult with primary lymphoedema. Method: An 18-year-old female (body mass index 25.2 kg/m2) with Milroy's disease was recruited. She attended two separate 1-hour sessions to evaluate tissue oxygenation (StO2) in chair-sitting and long-sitting (sitting up with a supported back and legs horizontal) positions. Following removal of her usual class 2 (20–30 mmHg) flat-knit compression hosiery, StO2 was recorded for 20 minutes: pre-, during and post the application of an adjustable compression garment (Lohmann & Rauscher) to the right leg. Results: In the long-sitting position, StO2 levels started high at baseline (94.5%), and were relatively maintained both during and post-a short 20-minute intervention (94.1%). In the chair-sitting position, StO2 levels were significantly lower at baseline (52%), showing a 77% increase during the intervention (92%), followed by a small 9% decrease post-intervention (83.7%). Conclusion: This compression garment significantly increased StO2 levels in the chair-sitting position, while maintaining the effects of the patient's compression stockings, in the long-sitting position. Similar to non-lymphoedematous limbs, the patient's normal prescription hosiery maintains StO2. Through implementation of the short intervention sessions, night compression garments may have the potential to improve tissue health in individuals with primary lymphoedema, encouraging self-management and offering a potential night compression solution where the need arises in a 24-hour management plan. [ABSTRACT FROM AUTHOR]

Graduated compression, using bandaging or compression stockings, is the gold-standard treatment for the management of venous leg ulcers (VLUs) and preventing recurrence. However, achieving the required pressures on different parts of the leg is extremely difficult, even for experienced practitioners. Inappropriately applied compression can result in delayed healing and poor compliance. Graducheck® is a pressure sensor system that ensures that the prescribed level of compression is being applied accurately. This study aimed to determine if two experienced tissue viability nurses (TVNs) could achieve accurate pressures using four commonly used bandage systems, as measured using Graducheck sensor strips. Ideal pressures were not achieved, but in two systems, once the application pressure was adjusted according to the sensor level, ideal compression was achieved. In the remaining two systems, ideal pressures could not be produced, even after adjustments to application. Clinically, the Graducheck system could improve the standard of compression therapy, as real-time feedback ensures that corrections can be made. However, further work is required to determine why ideal pressures were not achieved in two of the tested systems. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to compare the healing outcomes between three types of compression therapy—two-layer bandage (2LB), four-layer bandage (4LB), and compression stockings, and to identify the predictors of venous leg ulcer (VLU) healing Method: A retrospective review of the medical records of patients diagnosed with VLU between 2011 and 2016 in Singapore was conducted. Univariate and multivariate analyses were done between healed and unhealed VLU patients at three and six months, based on potential factors, ranging from demographic profile to comorbidities and treatment-related variables. Results: Data from 377 patients' medical records were analysed. The healing rates with the three types of compression system, 4LB, 2LB and compression stockings, were 22.3%, 34.9% and 8.7% respectively at three months; at six months they were 44.2%, 41.9% and 34.8% respectively. Patients on 2LB reported a significantly higher proportion of healed ulcers at three months (p=0.003) but at six months there was no difference in healing rates between the three types of therapy. At three and six months, the duration of compression therapy was found to be an independent predictor of healing (p<0.001). Conclusion: In this study, the 2LB appeared to show the most favourable healing outcome in the short-term but as VLUs persisted beyond the months, the type of compression system used did not make a difference in the healing outcome. Our findings suggested that, as the duration became more prolonged, VLUs became more resistant to healing despite compression therapy. Therefore, it may be necessary for clinicians to consider adjuvant therapies for hard-to-heal ulcers at an earlier stage. [ABSTRACT FROM AUTHOR]

The completion of a scoping review within the area of compression therapy and heart failure offers an insight into the present literature in this area, alongside offering the ability to connect this existing knowledge to chronic oedema/lymphoedema when both conditions co-exist. The evidence obtained included national agreed guidelines, consensus documents and existing primary/secondary research. The review identified existing evidence that suggests that the application of compression therapy in those with heart failure may be appropriate, but is dependent upon staging and stability. However, this needs to be contextualised against other co-morbidities, such as lymphoedema, which may impact upon the exact compression therapy and level applied. Further research within the area of heart failure in combination with chronic oedema/lymphoedema would expand the existing evidence base. This is set against a need for further consensus guidance to bridge the gap that exists within the literature. [ABSTRACT FROM AUTHOR]

Objective: The aim of this case series was to retrospectively assess the impact on volume control and patients' quality of life (QOL) when a night-time garment was added to their previous compression regimen for a full 24-hour interval compression plan. Method: Patients who had a history of chronic oedema presented to one of two oedema management centres in the US for treatment for oedema exacerbation and/or suboptimal performance of their current garments. Objective data examined were circumferential limb volume (cm3) measurements and QOL measured with the Lymphoedema QOL Tool (LYMQOL-Leg and LYMQOL-Arm). Subjective comments on functional abilities and perception of improvement with a compression plan that comprised a 24-hour interval were documented. Results: All three patients presented in this case series had a reduction in limb volume and improvement in QOL when their daytime regimen of garments was updated and new night-time garments were added. Their subjective comments indicated improvement in activities of daily living and ease of controlling daytime oedema with a 24-hour interval compression plan. Conclusion: This case series illustrates the need for clinicians to create a partnership with the patient to promote concordance and adherence as part of their individual 24-hour interval compression plan. This partnership allows the plan to be uniquely changed and adjusted to allow each patient to feel in control of refreshing their mood, their skin and their garments. [ABSTRACT FROM AUTHOR]

Leg ulcers are painful, distressing and common in the older population. They are costly to treat and put pressure on NHS providers. Compression therapy is the mainstay of treatment of venous leg ulceration. Aim: To explore the service provision for compression therapy for inpatients with leg ulcers in UK hospitals. Methods: An online survey was carried out to explore the service provision in hospital settings. It was distributed to Wounds UK National Conference delegates and to wound care specialist groups using social media. Results: The authors received 101 responses from health professionals in the UK. Of these, 67.3% reported there was no dedicated service for inpatients with leg ulceration and only 32% said compression therapy was provided in their hospitals. Conclusion: This survey confirmed there is a significant shortfall in care provision for patients with leg ulcers in secondary care and highlighted the wide variations in service delivery in hospitals. Further research is needed to understand the reasons for these variations. [ABSTRACT FROM AUTHOR]

Compression, skin care, manual lymph drainage and exercise form the mainstays of treatment of chronic limb oedema. The compression aspect of the regimen is often prescribed and used without conscious concern for the patient's ability for self-adjustment and skin hygiene. This article will focus on the action of compression therapy using a new concept of encouraging patients to apply and reapply an adjustable compression garment or multiple garment types during a 24-hour interval. The benefits of this focus on interval compression therapy on all aspects of care will be explained and case studies presented. [ABSTRACT FROM AUTHOR]