Classification of forefoot plantar pressure distribution in persons with diabetes: a novel perspective for the mechanical management of diabetic foot?

BACKGROUND: The aim of this study was to identify groups of subjects with similar patterns of forefoot loading and verify if specific groups of patients with diabetes could be isolated from non-diabetics. METHODOLOGY/PRINCIPAL FINDINGS: Ninety-seven patients with diabetes and 33 control participants between 45 and 70 years were prospectively recruited in two Belgian Diabetic Foot Clinics. Barefoot plantar pressure measurements were recorded and subsequently analysed using a semi-automatic total mapping technique. Kmeans cluster analysis was applied on relative regional impulses of six forefoot segments in order to pursue a classification for the control group separately, the diabetic group separately and both groups together. Cluster analysis led to identification of three distinct groups when considering only the control group. For the diabetic group, and the computation considering both groups together, four distinct groups were isolated. Compared to the cluster analysis of the control group an additional forefoot loading pattern was identified. This group comprised diabetic feet only. The relevance of the reported clusters was supported by ANOVA statistics indicating significant differences between different regions of interest and different clusters. CONCLUSION/S SIGNIFICANCE: There seems to emerge a new era in diabetic foot medicine which embraces the classification of diabetic patients according to their biomechanical profile. Classification of the plantar pressure distribution has the potential to provide a means to determine mechanical interventions for the prevention and/or treatment of the diabetic foot.

Dogmas and controversies in compression therapy: report of an International Compression Club (ICC) meeting, Brussels, May 2011.

The International Compression Club (ICC) is a partnership between academics, clinicians and industry focused upon understanding the role of compression in the management of different clinical conditions. The ICC meet regularly and from these meetings have produced a series of eight consensus publications upon topics ranging from evidence-based compression to compression trials for arm lymphoedema. All of the current consensus documents can be accessed on the ICC website (http://www.icc-compressionclub.com/index.php). In May 2011, the ICC met in Brussels during the European Wound Management Association (EWMA) annual conference. With almost 50 members in attendance, the day-long ICC meeting challenged a series of dogmas and myths that exist when considering compression therapies. In preparation for a discussion on beliefs surrounding compression, a forum was established on the ICC website where presenters were able to display a summary of their thoughts upon each dogma to be discussed during the meeting. Members of the ICC could then provide comments on each topic thereby widening the discussion to the entire membership of the ICC rather than simply those who were attending the EWMA conference. This article presents an extended report of the issues that were discussed, with each dogma covered in a separate section. The ICC discussed 12 'dogmas' with areas 1 through 7 dedicated to materials and application techniques used to apply compression with the remaining topics (8 through 12) related to the indications for using compression.

Systematic development and validation of a nursing intervention: the case of lifestyle adherence promotion in patients with leg ulcers.

AIMS: To describe and discuss of the added value of systematic development and validation of nursing interventions in nursing care. BACKGROUND: An adherence-promoting intervention for leg ulcer patients was developed in 2008, based on the model of van Meijel. This model requires a systematic development using an analysis of patients' (lived) experiences and professionals' views on (good) care. It employs a cyclical process of trying out, evaluating, revising and reassessing the adapted intervention in patients. The intervention consists of information and counselling sessions carried out by tissue viability nurses and focuses on wearing compression hosiery, practising leg elevation, physical activity and performing leg exercises. DISCUSSION: Exploring patients' and nurses' perspectives during the development of intervention increases the likelihood that the resultant intervention is both feasible and attuned to patients' needs. Various implementation issues were identified during the developmental process. Validation of the intervention through its use in nursing care aids in refining the intervention and in linking the techniques most successful in effecting behavioural change to theoretical constructs. It contributes to the refinement of concepts of behavioural theories by clarifying the processes underlying the intervention's effectiveness. Direct involvement of the researcher in the validation phase has great added value. IMPLICATIONS FOR NURSING: Patient involvement in intervention development is essential, as is the researcher's direct involvement in practical situations in which the intervention is tested. Qualitative (evaluation) approaches are recommended. CONCLUSION: Although the systematic development of nursing interventions is time-consuming, the contribution to the development of nursing practice and nursing science makes it worthwhile.

Creative compression treatment in challenging situations.

There are globally accepted insights and country-specific standards, preferences, and traditions regarding compression therapy. Although there is a wide choice of bandaging and compression materials, the use of these materials must be planned to meet individual patient's temporary needs using the most appropriate technique and optimal timing. Even though indications and contraindications exist for elastic and nonelastic materials and techniques, professionals must use the technical advantages of the several systems for the benefit of the patient. Whatever method is chosen, the effectiveness of compression depends on several technical and personal issues, including the anatomical and functional status of the limb to be treated. Notwithstanding the guidelines for treatment, there will always be situations where either standard or optimal treatment cannot be applied and where clinicians must be creative in the treatment offered. The aim of this article is to reflect on what is possible outside the margins of the normal consensus on compression treatment to stimulate debate.

Classification of compression bandages: practical aspects.

BACKGROUND: Compression bandages appear to be simple medical devices. However, there is a lack of agreement over their classification and confusion over the use of important terms such as elastic, inelastic, and stiffness. OBJECTIVES: The objectives were to propose terms to describe both simple and complex compression bandage systems and to offer classification based on in vivo measurements of subbandage pressure and stiffness. METHODS: A consensus meeting of experts including members from medical professions and from companies producing compression products discussed a proposal that was sent out beforehand and agreed on by the authors after correction. RESULTS: Pressure, layers, components, and elastic properties (P-LA-C-E) are the important characteristics of compression bandages. Based on simple in vivo measurements, pressure ranges and elastic properties of different bandage systems can be described. Descriptions of composite bandages should also report the number of layers of bandage material applied to the leg and the components that have been used to create the final bandage system. CONCLUSION: Future descriptions of compression bandages should include the subbandage pressure range measured in the medial gaiter area, the number of layers, and a specification of the bandage components and of the elastic property (stiffness) of the final bandage.

Measurement of lower leg compression in vivo: recommendations for the performance of measurements of interface pressure and stiffness: consensus statement.

BACKGROUND: Interface pressure and stiffness characterizing the elastic properties of the material are the parameters determining the dosage of compression treatment and should therefore be measured in future clinical trials. OBJECTIVE: To provide some recommendations regarding the use of suitable methods for this indication. METHOD: This article was formulated based on the results of an international consensus meeting between a group of medical experts and representatives from the industry held in January 2005 in Vienna, Austria. RESULTS: Proposals are made concerning methods for measuring the interface pressure and for assessing the stiffness of a compression device in an individual patient. CONCLUSIONS: In vivo measurement of interface pressure is encouraged when clinical and experimental outcomes of compression treatment are to be evaluated.

The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring.

The aim of this study was threefold: (1) Assess the pressure loss of two types of pressure garments that are used in the treatment of hypertrophic scars after burn injury, (2) investigate the influence of two different levels of compression on erythema and thickness of burn scars and (3) examine the association between erythema and thickness. The study was a prospective trial in which 76 burn scars in 60 patients were objectively assessed with the Minolta Chromameter CR-300 for erythema and with the Dermascan C for thickness of the scar over a period of 3 months. Each patient was randomly assigned to a "normal" or "lower" compression class treatment, with respectively mean values of 15 and 10 mmHg pressure after wearing the garment for 1 month. Measurements for both parameters were taken at 0, 1, 2 and 3 months of treatment. Pressure garments with "normal" compression did lose significantly more compression over 1 month (4.82 mmHg) than did the garments from the low compression class (2.57 mmHg). Scars that were treated with garments from a "normal" compression class did score significantly better for thickness compared to the "low" compression class. The difference in thickness was most evident at 1 month. Thereafter no further significant improvement between the two different treatments over time could be obtained. This difference was not found for erythema. Positive correlations could be found between erythema and thickness values at all of the three test points while changes in erythema and thickness only correlated significantly after the first month. The pattern of change of both parameters correlated at a high level of significance after 3 months of treatment. These data suggest that pressure garments that deliver a pressure of at least 15 mmHg pressure tend to accelerate scar maturation and that measurements of the pattern of change of the erythema can be used to predict changes in scar thickness and vice versa.

Efficacy and safety of the freeze-dried cultured human keratinocyte lysate, LyphoDerm 0.9%, in the treatment of hard-to-heal venous leg ulcers.

LyphoDerm (XCELLentis, Belgium) is an end-sterilized, freeze-dried lysate from cultured allogeneic epidermal keratinocytes, formulated into a hydrophilic gel. Its efficacy and safety were evaluated, in combination with standard care (hydrocolloid dressing and compression therapy), in 194 patients suffering from hard-to-heal (lasting more than 6 weeks and not responding to conventional therapy) venous leg ulcers. Two control groups received standard care, with or without vehicle, respectively. Patients had a median age of 67.5 years and the majority were females (61%). The median duration of the ulcer was 43 weeks and in 39% of the subjects it had been present for more than 1 year. Thirty-eight percent of the patients in the standard care + LyphoDerm group had complete ulcer healing within 24 weeks (primary end point) compared to 27% of patients in the standard care + vehicle pooled groups (P = 0.114) in the "as treated" intent-to-treat cohort (37% vs. 27% in the "as randomized intent-to-treat cohort; p = 0.137). In the subgroup of patients with enlarging ulcers, the difference between the two groups was significant (30% vs. 11%; p = 0.024 in the "as treated" intent-to-treat cohort and 31% vs. 9%; p = 0.005 in the "as randomized" intent-to-treat cohort). LyphoDerm was well tolerated and safe, and no differences in the frequency of adverse events were noted between the treatment groups. Although the primary objective of the study was not achieved, the exploratory analysis carried out in patients with enlarging ulcers suggests that LyphoDerm could offer a new prospect for the treatment of patients with venous ulcers that may prove to be a significant adjunct to the overall provision of care.

Reproducibility of repeated measurements on post-burn scars with Dermascan C.

The present study investigated the reproducibility of measurements with the Dermascan C on post-burn scars. Intra- and inter-rater reproducibility and test-retest reliability with a one week time lapse were examined on 40 post-burn scars of 6 volunteering burn patients by means of intra-class- correlation coefficients (ICC) and standard error of measurements (SEM). Results showed good to excellent values for ICC in all the three conditions. On the basis of these results, we concluded that the instrument provides reliable information and can be used in comparative clinical trials that examine therapeutic strategies on healing scars.