Research Original Investigation
Compression Therapy for Venous Leg Ulcers
14. Partsch H. The static stiffness index: a simple method to assess the elastic property of compression material in vivo. Dermatol Surg. 2005; 31(6):625-630. 15. Partsch H, Clark M, Bassez S, et al. Measurement of lower leg compression in vivo: recommendations for the performance of measurements of interface pressure and stiffness: consensus statement. Dermatol Surg. 2006;32(2): 224-233. 16. Stolk R, Wegen van der-Franken CP, Neumann HA. A method for measuring the dynamic behavior of medical compression hosiery during walking. Dermatol Surg. 2004;30(5):729-736. 17. Partsch H, Clark M, Mosti G, et al. Classification of compression bandages: practical aspects. Dermatol Surg. 2008;34(5):600-609. 18. Blair SD, Wright DD, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. BMJ. 1988;297(6657): 1159-1161.
training: simple interventions to improve efficacy in compression bandaging. Int Wound J. 2009;6(5): 324-330.
and over 2 days of wear time. Arch Dermatol. 2000;136(7):857-863.
21. Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages. Dermatol Surg. 1999;25(9):695-700.
27. Mosti G, Mattaliano V, Partsch H. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux. Phlebology. 2008;23(6): 287-294.
22. Partsch H, Damstra RJ, Mosti G. Dose finding for an optimal compression pressure to reduce chronic edema of the extremities. Int Angiol. 2011; 30(6):527-533.
28. Mayrovitz HN, Sims N. Effects of ankle-to-knee external pressures on skin blood perfusion under and distal to compression. Adv Skin Wound Care. 2003;16(4):198-202.
23. Milic DJ, Zivic SS, Bogdanovic DC, et al. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg. 2010;51(3): 655-661.
29. Mayrovitz HN, Delgado M, Smith J. Compression bandaging effects on lower extremity peripheral and sub-bandage skin blood perfusion. Ostomy Wound Manage. 1998;44(3):56-60, 62, 64.
24. Mosti G, Partsch H. Is low compression pressure able to improve venous pumping function in patients with venous insufficiency? Phlebology. 2010;25(3):145-150.
19. Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg. 2010;51(2):410-416.
25. Damstra RJ, Brouwer ER, Partsch H. Controlled, comparative study of relation between volume changes and interface pressure under short-stretch bandages in leg lymphedema patients. Dermatol Surg. 2008;34(6):773-779.
20. Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and
26. Hafner J, Botonakis I, Burg G. A comparison of multilayer bandage systems during rest, exercise,
30. O’Meara S, Tierney J, Cullum N, et al. Four layer bandage compared with short stretch bandage for venous leg ulcers: systematic review and meta-analysis of randomised controlled trials with data from individual patients. BMJ. 2009;338:b1344. 31. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11(suppl 1):S1-S28.
Invited Commentary PRACTICE GAPS
Compression of Venous Ulcers Standardizing Standard Care Robert S. Kirsner, MD, PhD
Venous leg ulcers (VLUs) are common, affecting upward of 1% of adults and with increasing incidence and prevalence with advancing age. Venous leg ulcers are associated with reduced quality of life and significant health care costs in addition to sustained ambulatory venous pressure (venous hyperRelated article page 730 tension), which most often results from thrombosis and/or valve disease, affecting the superficial, perforator, or deep veins. As a result, calf muscle pump dysfunction ensues, leading to ulcer formation. Standard care with multilayered compression wraps is aimed at reversing these changes, and application of well-delivered compression achieves healing in up to 75% of patients. Applying compression, however, is a challenge. Often viewed by patients and practitioners as cumbersome, uncomfortable, and oppressive, compression interrupts patients’ lives by altering their bathing habits and the clothes and shoes they wear. In this issue of JAMA Dermatology, Zarchi and Jemec1 report that even those with moderate confidence in their ability to apply compression vary substantially in compression application, with less than one-third applying optimal compression, suggesting patients may not be getting the treatment prescribed.2 736
Given that dermatologists often see patients with VLUs, addressing the gap of providing substandard compression is important. The initial barrier toward change is for practitioners to appreciate the importance of compression in healing VLUs. Without optimal compression, substandard care is provided. Practitioners should understand compression systems and recommend the appropriate system. For example, elastic compression (Coban2 [3M] or Profore [Smith and Nephew]) provides compression when patients are either walking or resting and differs from inelastic compression (Unna Boot), which applies compression only when patients are walking (the latter is more desirable in patients with mild arterial insufficiency). Next, it is critical, given the variability in compression applied, that well-trained and experienced personnel apply compression. This need typically causes patients to visit a physician’s office, seek treatment at a wound center, or use home health services once or twice weekly, depending on the amount of exudate. Application of compression by patients or untrained caregivers, such as family members, risks inappropriate provision of care; however, recent work suggests firm compression stockings (30-40 mm Hg) may result in similar outcomes for selected patients.3 Education and training of practitioners, staff, and patients about the importance and application of compression are key.
JAMA Dermatology July 2014 Volume 150, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015
jamadermatology.com
Compression Therapy for Venous Leg Ulcers
Invited Commentary Research
Didactic and hands-on education, such as attending wound sessions at the American Academy of Dermatology (http://www .aad.org) or wound healing meetings (http://www.sawc.org) and learning systematic evaluation and management of VLUs (and other chronic wounds) from evidence-based guidelines for chronic wounds (Wound Healing Society; http://www .woundheal.org), is necessary. Dermatologists can assess their practice of treating VLUs through the newly released performance improvement continuing medical education activity provided by the American Academy of Dermatology. In addition, manufacturers of compression bandages create systems to assist in proper application and educate practitioners on appliARTICLE INFORMATION Author Affiliation: Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida. Corresponding Author: Robert S. Kirsner, MD, PhD, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Rosenstiel Medical Science Building, Room 2023-A, Miami, FL 33136 ([email protected]).
cation, so use of these systems, as opposed to elastic (acetype) wraps, would provide more standardized care. However, direct monitoring of individual patients for adequate compression is not routine. Recently developed real-time subbandage pressure monitors using fiberoptic force sensors might help change that and ensure that all patients receive optimal compression. Finally, assessment of wound improvement through close tracking of wound size reduction by measurements or photographs is needed, and the use of templates for patient care and procedures can be incorporated into electronic medical records, which can serve as a resource to ensure that all elements of evaluation and management are performed. 2. Kirsner RS, Margolis DJ. Stockings before bandages: an option for venous ulcers. Lancet. 2014;383(9920):850-851.
Published Online: May 14, 2014. doi:10.1001/jamadermatol.2014.330. Conflict of Interest Disclosures: None reported. REFERENCES 1. Zarchi K, Jemec GBE. Delivery of compression therapy for venous leg ulcers [published online May 14, 2014]. JAMA Dermatol. doi:10.1001 /jamadermatol.2013.7962.
3. Wang DH, Blenman N, Maunder S, Patton V, Arkwright J. An optical fiber Bragg grating force sensor for monitoring sub-bandage pressure during compression therapy. Opt Express. 2013;21(17): 19799-19807.
NOTABLE NOTES
Two Important Italian Scientists of the Renaissance and the First Book Ever Devoted to Nevi Filippo Pesapane, MD; Antonella Coggi, MD; Raffaele Gianotti, MD
Gerolamo Cardano (1501-1576) was an important figure in the medical world of the Renaissance: he wrote more than 200 works on medicine, mathematics, physics, philosophy, religion, and music.1 His gambling led him to formulate elementary rules in probability, making him one of the founders of the field. In 1520, he entered the University of Pavia, where he studied medicine. In 1525, Cardano repeatedly applied to the College of Physicians in Milan but was not admitted owing to his combative reputation and illegitimate birth. Eventually, he managed to develop a considerable reputation as a physician, and his services were highly valued at the royal courts. He was the first to describe typhoid fever, and in 1553 he cured the Scottish Archbishop of St Andrews of a disease that had left him speechless and was thought incurable.2 Indeed, Cardano’s popularity and fame were based largely on his books dealing with scientific and philosophical questions, especially De Subtilitate Rerum (“The Subtlety of Things”), a collection of physical experiments and inventions, interspersed with anecdotes. Among his many books on medicine, alchemy, and natural phenomena, he also wrote De Metoscopia (literally:“Abouttheobservationofthefront”).Inthisbookheexplainedhistheory that it should be possible to identify the character of a person looking the appearanceofhisfrontalskin.Healsospeculatesonthemeaningofthenevi.3 Inspired by Cardano’s ideas, Ludovico Settala (1552-1633) wrote the first book ever devoted to nevi (De Naevis) in 1626. According to Set-
jamadermatology.com
tala it was possible to understand the qualities and defects of a person by observing the position of the nevus in his body. After his studies with the Jesuits in Milan and graduation with a medical degree at Pavia, he applied himself to problems of public hygiene. He published De Peste et Pestiferis Affectibus Libri Quinque (“Five Books on the Effects of the Plague and Pestiferous”) in 1622 and Della Preservazione della Peste (“The Preservation of the Plague”) in 1630. Settala is featured in Alessandro Manzoni’s masterpiece Promessi Sposi as an exemplary physician who, because of his foresight and rare knowledge of hygiene, was actually accused of creating and spreading the plague. Author Affiliations: Dermatology Unit, “Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico,” University of Milan, Milan, Italy. Corresponding Author: Filippo Pesapane, MD, Dermatology Unit, “Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico,” Department of Medical-Surgical and Transplantation Physiopathology, University of Milan, Via Pace 9, Milan 20100, Italy ([email protected]). 1. Westfall RS. Girolamo Cardano: The Galileo Project. http://galileo.rice.edu /Catalog/NewFiles/cardano.html. Accessed April 24, 2014. 2. Cardanus G. De Propria Vita Liber (His Own Life). Amsterdam, The Netherlands: Self-published; 1654:136-137. 3. Cardanus G. De Metoscopia Libris Tredecim, et Octingentis Faciei Humanae Eiconibus Complexa. Paris, France: Gabriel Naudé; 1658.
JAMA Dermatology July 2014 Volume 150, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015
737
Compression Therapy for Venous Leg Ulcers
14. Partsch H. The static stiffness index: a simple method to assess the elastic property of compression material in vivo. Dermatol Surg. 2005; 31(6):625-630. 15. Partsch H, Clark M, Bassez S, et al. Measurement of lower leg compression in vivo: recommendations for the performance of measurements of interface pressure and stiffness: consensus statement. Dermatol Surg. 2006;32(2): 224-233. 16. Stolk R, Wegen van der-Franken CP, Neumann HA. A method for measuring the dynamic behavior of medical compression hosiery during walking. Dermatol Surg. 2004;30(5):729-736. 17. Partsch H, Clark M, Mosti G, et al. Classification of compression bandages: practical aspects. Dermatol Surg. 2008;34(5):600-609. 18. Blair SD, Wright DD, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. BMJ. 1988;297(6657): 1159-1161.
training: simple interventions to improve efficacy in compression bandaging. Int Wound J. 2009;6(5): 324-330.
and over 2 days of wear time. Arch Dermatol. 2000;136(7):857-863.
21. Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages. Dermatol Surg. 1999;25(9):695-700.
27. Mosti G, Mattaliano V, Partsch H. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux. Phlebology. 2008;23(6): 287-294.
22. Partsch H, Damstra RJ, Mosti G. Dose finding for an optimal compression pressure to reduce chronic edema of the extremities. Int Angiol. 2011; 30(6):527-533.
28. Mayrovitz HN, Sims N. Effects of ankle-to-knee external pressures on skin blood perfusion under and distal to compression. Adv Skin Wound Care. 2003;16(4):198-202.
23. Milic DJ, Zivic SS, Bogdanovic DC, et al. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg. 2010;51(3): 655-661.
29. Mayrovitz HN, Delgado M, Smith J. Compression bandaging effects on lower extremity peripheral and sub-bandage skin blood perfusion. Ostomy Wound Manage. 1998;44(3):56-60, 62, 64.
24. Mosti G, Partsch H. Is low compression pressure able to improve venous pumping function in patients with venous insufficiency? Phlebology. 2010;25(3):145-150.
19. Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg. 2010;51(2):410-416.
25. Damstra RJ, Brouwer ER, Partsch H. Controlled, comparative study of relation between volume changes and interface pressure under short-stretch bandages in leg lymphedema patients. Dermatol Surg. 2008;34(6):773-779.
20. Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and
26. Hafner J, Botonakis I, Burg G. A comparison of multilayer bandage systems during rest, exercise,
30. O’Meara S, Tierney J, Cullum N, et al. Four layer bandage compared with short stretch bandage for venous leg ulcers: systematic review and meta-analysis of randomised controlled trials with data from individual patients. BMJ. 2009;338:b1344. 31. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11(suppl 1):S1-S28.
Invited Commentary PRACTICE GAPS
Compression of Venous Ulcers Standardizing Standard Care Robert S. Kirsner, MD, PhD
Venous leg ulcers (VLUs) are common, affecting upward of 1% of adults and with increasing incidence and prevalence with advancing age. Venous leg ulcers are associated with reduced quality of life and significant health care costs in addition to sustained ambulatory venous pressure (venous hyperRelated article page 730 tension), which most often results from thrombosis and/or valve disease, affecting the superficial, perforator, or deep veins. As a result, calf muscle pump dysfunction ensues, leading to ulcer formation. Standard care with multilayered compression wraps is aimed at reversing these changes, and application of well-delivered compression achieves healing in up to 75% of patients. Applying compression, however, is a challenge. Often viewed by patients and practitioners as cumbersome, uncomfortable, and oppressive, compression interrupts patients’ lives by altering their bathing habits and the clothes and shoes they wear. In this issue of JAMA Dermatology, Zarchi and Jemec1 report that even those with moderate confidence in their ability to apply compression vary substantially in compression application, with less than one-third applying optimal compression, suggesting patients may not be getting the treatment prescribed.2 736
Given that dermatologists often see patients with VLUs, addressing the gap of providing substandard compression is important. The initial barrier toward change is for practitioners to appreciate the importance of compression in healing VLUs. Without optimal compression, substandard care is provided. Practitioners should understand compression systems and recommend the appropriate system. For example, elastic compression (Coban2 [3M] or Profore [Smith and Nephew]) provides compression when patients are either walking or resting and differs from inelastic compression (Unna Boot), which applies compression only when patients are walking (the latter is more desirable in patients with mild arterial insufficiency). Next, it is critical, given the variability in compression applied, that well-trained and experienced personnel apply compression. This need typically causes patients to visit a physician’s office, seek treatment at a wound center, or use home health services once or twice weekly, depending on the amount of exudate. Application of compression by patients or untrained caregivers, such as family members, risks inappropriate provision of care; however, recent work suggests firm compression stockings (30-40 mm Hg) may result in similar outcomes for selected patients.3 Education and training of practitioners, staff, and patients about the importance and application of compression are key.
JAMA Dermatology July 2014 Volume 150, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015
jamadermatology.com
Compression Therapy for Venous Leg Ulcers
Invited Commentary Research
Didactic and hands-on education, such as attending wound sessions at the American Academy of Dermatology (http://www .aad.org) or wound healing meetings (http://www.sawc.org) and learning systematic evaluation and management of VLUs (and other chronic wounds) from evidence-based guidelines for chronic wounds (Wound Healing Society; http://www .woundheal.org), is necessary. Dermatologists can assess their practice of treating VLUs through the newly released performance improvement continuing medical education activity provided by the American Academy of Dermatology. In addition, manufacturers of compression bandages create systems to assist in proper application and educate practitioners on appliARTICLE INFORMATION Author Affiliation: Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida. Corresponding Author: Robert S. Kirsner, MD, PhD, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Rosenstiel Medical Science Building, Room 2023-A, Miami, FL 33136 ([email protected]).
cation, so use of these systems, as opposed to elastic (acetype) wraps, would provide more standardized care. However, direct monitoring of individual patients for adequate compression is not routine. Recently developed real-time subbandage pressure monitors using fiberoptic force sensors might help change that and ensure that all patients receive optimal compression. Finally, assessment of wound improvement through close tracking of wound size reduction by measurements or photographs is needed, and the use of templates for patient care and procedures can be incorporated into electronic medical records, which can serve as a resource to ensure that all elements of evaluation and management are performed. 2. Kirsner RS, Margolis DJ. Stockings before bandages: an option for venous ulcers. Lancet. 2014;383(9920):850-851.
Published Online: May 14, 2014. doi:10.1001/jamadermatol.2014.330. Conflict of Interest Disclosures: None reported. REFERENCES 1. Zarchi K, Jemec GBE. Delivery of compression therapy for venous leg ulcers [published online May 14, 2014]. JAMA Dermatol. doi:10.1001 /jamadermatol.2013.7962.
3. Wang DH, Blenman N, Maunder S, Patton V, Arkwright J. An optical fiber Bragg grating force sensor for monitoring sub-bandage pressure during compression therapy. Opt Express. 2013;21(17): 19799-19807.
NOTABLE NOTES
Two Important Italian Scientists of the Renaissance and the First Book Ever Devoted to Nevi Filippo Pesapane, MD; Antonella Coggi, MD; Raffaele Gianotti, MD
Gerolamo Cardano (1501-1576) was an important figure in the medical world of the Renaissance: he wrote more than 200 works on medicine, mathematics, physics, philosophy, religion, and music.1 His gambling led him to formulate elementary rules in probability, making him one of the founders of the field. In 1520, he entered the University of Pavia, where he studied medicine. In 1525, Cardano repeatedly applied to the College of Physicians in Milan but was not admitted owing to his combative reputation and illegitimate birth. Eventually, he managed to develop a considerable reputation as a physician, and his services were highly valued at the royal courts. He was the first to describe typhoid fever, and in 1553 he cured the Scottish Archbishop of St Andrews of a disease that had left him speechless and was thought incurable.2 Indeed, Cardano’s popularity and fame were based largely on his books dealing with scientific and philosophical questions, especially De Subtilitate Rerum (“The Subtlety of Things”), a collection of physical experiments and inventions, interspersed with anecdotes. Among his many books on medicine, alchemy, and natural phenomena, he also wrote De Metoscopia (literally:“Abouttheobservationofthefront”).Inthisbookheexplainedhistheory that it should be possible to identify the character of a person looking the appearanceofhisfrontalskin.Healsospeculatesonthemeaningofthenevi.3 Inspired by Cardano’s ideas, Ludovico Settala (1552-1633) wrote the first book ever devoted to nevi (De Naevis) in 1626. According to Set-
jamadermatology.com
tala it was possible to understand the qualities and defects of a person by observing the position of the nevus in his body. After his studies with the Jesuits in Milan and graduation with a medical degree at Pavia, he applied himself to problems of public hygiene. He published De Peste et Pestiferis Affectibus Libri Quinque (“Five Books on the Effects of the Plague and Pestiferous”) in 1622 and Della Preservazione della Peste (“The Preservation of the Plague”) in 1630. Settala is featured in Alessandro Manzoni’s masterpiece Promessi Sposi as an exemplary physician who, because of his foresight and rare knowledge of hygiene, was actually accused of creating and spreading the plague. Author Affiliations: Dermatology Unit, “Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico,” University of Milan, Milan, Italy. Corresponding Author: Filippo Pesapane, MD, Dermatology Unit, “Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico,” Department of Medical-Surgical and Transplantation Physiopathology, University of Milan, Via Pace 9, Milan 20100, Italy ([email protected]). 1. Westfall RS. Girolamo Cardano: The Galileo Project. http://galileo.rice.edu /Catalog/NewFiles/cardano.html. Accessed April 24, 2014. 2. Cardanus G. De Propria Vita Liber (His Own Life). Amsterdam, The Netherlands: Self-published; 1654:136-137. 3. Cardanus G. De Metoscopia Libris Tredecim, et Octingentis Faciei Humanae Eiconibus Complexa. Paris, France: Gabriel Naudé; 1658.
JAMA Dermatology July 2014 Volume 150, Number 7
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/28/2015
737
