The moderating effect of social support on the effectiveness of a web-based, computer-tailored physical activity intervention for older adults.

This study aimed to assess the moderating effect of social support on the effectiveness of a web-based, computer-tailored physical activity intervention for older adults. In the Active for Life trial, 243 inactive adults aged 65+ years were randomised into: (1) tailoring + Fitbit (n = 78), (2) tailoring-only (n = 96) or (3) control (n = 69). For the current study, participants were categorised as having higher (n = 146) or lower (n = 97) social support based on the Duke Social Support Index (DSSI_10). Moderate-to-vigorous physical activity (MVPA) was measured through accelerometers at baseline and post-intervention. A linear mixed model analysis demonstrated that among participants with lower social support, the tailoring + Fitbit participants, but not the tailoring only participants increased their MVPA more than the control. Among participants with higher social support, no differences in MVPA changes were observed between groups. Web-based computer-tailored interventions with Fitbit integration may be more effective in older adults with lower levels of social support.

Investigating the relationship between bullying involvement and self-harmful thoughts and behaviour in young people: A systematic review.

BACKGROUND: There is a complex and inconsistent relationship between bullying involvement and self-harmful thoughts and behaviour (SHTB) in young people. This novel systematic review aims to establish key interacting, moderating and mediating variables associated with SHTB in young people involved in bullying. METHODS: The systematic review was registered with PROSPERO: CRD42020192023. A search was conducted (until February 2021) across databases: PubMed/MEDLINE, EMBASE, PsycINFO (Ovid), Cochrane Library, Scopus (Elsevier), Web of Science, ERIC and CINAHL (EBSCOhost). Observational studies containing quantitative primary or secondary data analyses were included in the review, on the basis that they examined interactions, moderators, or mediators between bullying involvement and SHTB in young people. Versions of the Newcastle-Ottawa Scale were used to assess risk of bias in the included studies. RESULTS: A total of 57 studies were included. Overall, 3 studies identified interactions, 25 studies identified moderators and 21 studies identified mediators. 9 studies identified moderator-mediators. The findings were categorised as either self-harmful thoughts or self-harmful behaviours and synthesised under the following themes: socio-demographic; depression; parental; personality/psychological; and social/environmental. LIMITATIONS: This review uncovered significant heterogeneity and a paucity of replicated studies in the field, therefore, tentative conclusions have been drawn. CONCLUSIONS: This comprehensive review highlights the key role of depression as a mediator between traditional/cyber victimisation and SHTB in young people. The moderating effects of gender on mediation models investigating the role of depression suggest the possibility that females involved in bullying may be at increased suicide risk.

Pilot Trial of Neuromuscular Stimulation in Human Subjects with Chronic Venous Disease.

INTRODUCTION: Neuromuscular stimulation (NMES) has been shown to improve peripheral blood flow in healthy people. We investigated the effect of bilateral leg NMES on the symptoms of chronic venous disease. METHODS: Forty subjects were recruited from four groups: healthy, superficial insufficiency, deep insufficiency, and deep obstruction. Haemodynamic venous measurements were taken from the right femoral vein with ultrasound, laser Doppler fluximetry from the left hand and foot. Devices were then worn for 4-6 hours per day, for 6 weeks. Haemodynamic measurements were repeated at week 6. Quality of life questionnaires were taken at week 0, 6 and 8. RESULTS: The mean age was 48.7, BMI 28.6kg/m2, and maximum calf circumference 39.0 cm. Twenty-four subjects were men. NMES increased femoral vein peak velocity, TAMV and volume flow by 55%, 20%, 36% at 20 minutes (all p<0.05), which was enhanced at week 6 (PV and TAMV p<0.05). Mean increases in arm and leg fluximetry were 71% and 194% (both p<0.01). Leg swelling was reduced by mean 252.7 mL (13%, p<0.05) overall; 338.9 mL (16%, p<0.05) in venous disease. For those with venous pathology, scores for disease specific and generic quality of life questionnaires improved. Those with C4-6 disease benefitted the most, with improvements in VDS score of 1, AVVQ of 6, and SF-12 of 10. CONCLUSION: NMES improves venous haemodynamic parameters in chronic venous disease, which is enhanced by regular use. NMES reduces leg oedema, improves blood supply to the skin of the foot, and may positively affect quality of life. CLINICAL TRIALS: This trial was registered with www.clinicaltrials.org.uk (NCT02137499).

Incidence of emergency calls and out-of-hospital cardiac arrest deaths during the COVID-19 pandemic: findings from a cross-sectional study in a UK ambulance service.

BACKGROUND: In response to the COVID-19 pandemic, a national lockdown was introduced on 23 March 2020. In the following weeks, emergency departments in the UK reported a reduction in attendances. We aimed to explore the incidence of emergency calls across North East England, as well as the number of out-of-hospital cardiac arrest (OHCA) deaths. METHODS: Data were collected for all patients who contacted North East Ambulance Service between 4 March 2019-2 June 2019 and 2 March 2020-31 May 2020 suffering stroke, ST elevation myocardial infarction, allergy, asthma, chronic obstructive pulmonary disease, falls, intoxication, seizure, sepsis, acute coronary syndrome and OHCA. RESULTS: There were a reduction in incidence of calls, excluding OHCA, resulting in ambulance activation during the pandemic compared with same period in 2019, 16 743 versus 19 639, respectively (-14.74%). The decline in calls was partially reversed by the end of May 2020. Incidence of OHCA at the time of the national lockdown had increased by 13.79% with a peak increase of 73.56% in the second week in April 2020. OHCA deaths peaked in the first 2 weeks in April 2020, 95.65% and 90.07%, respectively, but by the end May 2020, incidence of OHCA and OHCA deaths had returned to prelockdown levels. CONCLUSION: Incidence of emergency calls were reduced during the pandemic compared with 2019. There was a rise in incidence of OHCA and OHCA deaths during the same period; however, these changes appear transient. Further research is required to understand patient behaviour towards seeking help during the pandemic and the long-term consequences of not doing so.

Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study.

OBJECTIVES: Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. METHODS: A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). 'Good' and 'very good' consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. RESULTS: Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, 'good' and 'very good' consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, 'very good' consensus was achieved for 3/3 statements. CONCLUSIONS: The main findings from this study were that there was 'good' or 'very good' consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

Cyanoacrylate glue embolisation for varicose veins - A novel complication.

BACKGROUND: Non-thermal non-tumescent methods for varicose vein treatment have rapidly gained popularity in recent years due to clinical efficacy comparable to other endovenous methods, but with a superior safety and tolerability profile. Cyanoacrylate is an adhesive that rapidly polymerises during endovenous treatment to cause rapid occlusion of veins and initiate vein fibrosis. METHOD: Cyanoacrylate glue treatment is known to cause complications such as phlebitis, cellulitis and deep vein thrombosis in rare instances. We present the first reported case of cyanoacrylate extravasation with chronic foreign body reaction in a patient nine months after initial treatment. RESULTS: We discuss the aetiology of this complication, its treatment, patient outcome and its significance to both clinicians and patients. CONCLUSION: Cyanoacrylate glue embolisation can, in rare instances, lead to extravasation and chronic foreign body reaction, necessitating surgical intervention. The relative novelty of cyanoacrylate glue embolisation in the treatment of varicose veins requires clinicians to monitor for rare complications during its use in clinical practice. Patients should be aware of the rare risk of glue extravasation and foreign body reaction for fully informed consent prior to treatment.

Intravenous versus oral paracetamol in a UK ambulance service: a case control study.

OBJECTIVES: To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting. METHODS: We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant. RESULTS: 80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups. CONCLUSION: Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.

Management of acute and chronic iliofemoral venous outflow obstruction: a multidisciplinary team consensus.

The aim of this manuscript was to establish a consensus for the management of acute and chronic venous obstruction among specialists in the UK. Specialist physicians representing vascular surgery, interventional radiology and hematology were invited to 3 meetings to discuss management of acute and chronic iliofemoral obstruction. The meetings outlined controversial areas, included a topic-by-topic review; and on completion reached a consensus when greater than 80% agreement was reached on each topic. Physicians from 19 UK hospitals agreed on treatment protocols and highlighted areas that need development. Potential standard treatment algorithms were created. It was decided to establish a national registry of venous patients led by representatives from the treating multidisciplinary teams. Technical improvements have facilitated invasive treatment of patients with acute and chronic venous obstruction; however, the evidence guiding treatment is weak. Treatment should be conducted in centers with multi-disciplinary input; robust, coordinated data collection; and regular outcome analysis to ensure safe and effective treatment and a basis for future evolvement.

Neuromuscular electrical stimulation for the prevention of venous thromboembolism.

Objective Venous thromboembolism, encompassing deep vein thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality, affecting one in 1000 adults per year. Neuromuscular electrical stimulation is the transcutaneous application of electrical impulses to elicit muscle contraction, preventing venous stasis. This review aims to investigate the evidence underlying the use of neuromuscular electrical stimulation in thromboprophylaxis. Methods The Medline and Embase databases were systematically searched, adhering to PRISMA guidelines, for articles relating to electrical stimulation and thromboprophylaxis. Articles were screened according to a priori inclusion and exclusion criteria. Results The search strategy identified 10 randomised controlled trials, which were used in three separate meta-analyses: five trials compared neuromuscular electrical stimulation to control, favouring neuromuscular electrical stimulation (odds ratio of deep vein thrombosis 0.29, 95% confidence interval 0.13-0.65; P = .003); three trials compared neuromuscular electrical stimulation to heparin, favouring heparin (odds ratio of deep vein thrombosis 2.00, 95% confidence interval 1.13-3.52; P = .02); three trials compared neuromuscular electrical stimulation as an adjunct to heparin versus heparin only, demonstrating no significant difference (odds ratio of deep vein thrombosis 0.33, 95% confidence interval 0.10-1.14; P = .08). Conclusion Neuromuscular electrical stimulation significantly reduces the risk of deep vein thrombosis compared to no prophylaxis. It is inferior to heparin in preventing deep vein thrombosis and there is no evidence for its use as an adjunct to heparin.

Deep Venous Reconstruction: A Case Series.

Objectives This study aims to review a case series of deep venous reconstruction procedures performed at one centre by a single consultant. Methods A retrospective review of deep venous reconstruction procedures performed by a single consultant from 1994 to 2013 was carried out and all notes were reviewed for outcomes. A 58-month cumulative patency rate was calculated using Kaplan-Meier survival analysis. Results Nineteen patients underwent deep venous reconstruction procedures including the Palma bypass, May-Husni bypass, femoral vein transposition and axillary vein transplant techniques from 1994 to 2013. Eleven patients were male and eight were female with a mean average age of 45.2 years (range 29-63). Clinical severity of disease ranged from C3 to C6, and 16 patients had a confirmed history of deep vein thrombosis. Cumulative primary patency rate for all reconstructions at 58 months was 89.5%, with two patients occluding and 17 remaining patent at last follow-up. Conclusion Deep venous reconstructions, particularly the Palma and May-Husni procedures, are feasible and can have good outcomes in patients failed by endovascular techniques and other more conservative therapies.

Lymphoedema management with the LymphFlow Advance pneumatic compression pump.

There are many intermittent pneumatic compression devices available for use in the management and adjunct treatment of lymphatic, venous and arterial disease. This article discusses the development of a new advanced pneumatic compression device, the LymphFlow Advance, which can perform focussed treatment on the lymphoedematous area using a variety of different cycles. Case studies with therapist and patient feedback are used to demonstrate the use of the LymphFlow Advance in the lymphoedema clinic, with a discussion of the evidence to underpin recommended treatment regimes.

Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence.

There are excellent guidelines for clinicians to manage venous diseases but few reviews to assess their hemodynamic background. Hemodynamic concepts that evolved in the past have largely remained unchallenged in recent decades, perhaps due to their often complicated nature and in part due to emergence of new diagnostic techniques. Duplex ultrasound scanning and other imaging techniques which evolved in the latter part of the 20th century have dominated investigation. They have greatly improved our understanding of the anatomical patterns of venous reflux and obstruction. However, they do not provide the physiological basis for understanding the hemodynamics of flow, pressure, compliance and resistance. Hemodynamic investigations appear to provide a better correlation with post-treatment clinical outcome and quality of life than ultrasound findings. There is a far better prospect for understanding the complete picture of the patient's disability and response to management by combining ultrasound with hemodynamic studies. Accordingly, at the instigation of Dr Angelo Scuderi, the Union Internationale de Phlebologie (UIP) executive board commissioned a large number of experts to assess all aspects of management for venous disease by evidence-based principles. These included experts from various member societies including the European Venous Forum (EVF), American Venous Forum (AVF), American College of Phlebology (ACP) and Cardiovascular Disease Educational and Research Trust (CDERT). Their aim was to confirm or dispel long-held hemodynamic principles and to provide a comprehensive review of venous hemodynamic concepts underlying the pathophysiology of lower limb venous disorders, their usefulness for investigating patients and the relevant hemodynamic changes associated with various forms of treatment. Chapter 1 is devoted to basic hemodynamic concepts and normal venous physiology. Chapter 2 presents the mechanism and magnitude of hemodynamic changes in acute deep vein thrombosis indicating their pathophysiological and clinical significance. Chapter 3 describes the hemodynamic changes that occur in different classes of chronic venous disease and their relation to the anatomic extent of disease in the macrocirculation and microcirculation. The next four chapters (Chapters 4-7) describe the hemodynamic changes resulting from treatmen by compression using different materials, intermittent compression devices, pharmacological agents and finally surgical or endovenous ablation. Chapter 8 discusses the unique hemodynamic features associated with alternative treatment techniques used by the CHIVA and ASVAL. Chapter 9 describes the hemodynamic effects following treatment to relieve pelvic reflux and obstruction. Finally, Chapter 10 demonstrates that contrary to general belief there is a moderate to good correlation between certain hemodynamic measurements and clinical severity of chronic venous disease. The authors believe that this document will be a timely asset to both clinicians and researchers alike. It is directed towards surgeons and physicians who are anxious to incorporate the conclusions of research into their daily practice. It is also directed to postgraduate trainees, vascular technologists and bioengineers, particularly to help them understand the hemodynamic background to pathophysiology, investigations and treatment of patients with venous disorders. Hopefully it will be a platform for those who would like to embark on new research in the field of venous disease.

Flap Endonuclease 1 Limits Telomere Fragility on the Leading Strand.

The existence of redundant replication and repair systems that ensure genome stability underscores the importance of faithful DNA replication. Nowhere is this complexity more evident than in challenging DNA templates, including highly repetitive or transcribed sequences. Here, we demonstrate that flap endonuclease 1 (FEN1), a canonical lagging strand DNA replication protein, is required for normal, complete leading strand replication at telomeres. We find that the loss of FEN1 nuclease activity, but not DNA repair activities, results in leading strand-specific telomere fragility. Furthermore, we show that FEN1 depletion-induced telomere fragility is increased by RNA polymerase II inhibition and is rescued by ectopic RNase H1 expression. These data suggest that FEN1 limits leading strand-specific telomere fragility by processing RNA:DNA hybrid/flap intermediates that arise from co-directional collisions occurring between the replisome and RNA polymerase. Our data reveal the first molecular mechanism for leading strand-specific telomere fragility and the first known role for FEN1 in leading strand DNA replication. Because FEN1 mutations have been identified in human cancers, our findings raise the possibility that unresolved RNA:DNA hybrid structures contribute to the genomic instability associated with cancer.

DNA2 drives processing and restart of reversed replication forks in human cells.

Accurate processing of stalled or damaged DNA replication forks is paramount to genomic integrity and recent work points to replication fork reversal and restart as a central mechanism to ensuring high-fidelity DNA replication. Here, we identify a novel DNA2- and WRN-dependent mechanism of reversed replication fork processing and restart after prolonged genotoxic stress. The human DNA2 nuclease and WRN ATPase activities functionally interact to degrade reversed replication forks with a 5'-to-3' polarity and promote replication restart, thus preventing aberrant processing of unresolved replication intermediates. Unexpectedly, EXO1, MRE11, and CtIP are not involved in the same mechanism of reversed fork processing, whereas human RECQ1 limits DNA2 activity by preventing extensive nascent strand degradation. RAD51 depletion antagonizes this mechanism, presumably by preventing reversed fork formation. These studies define a new mechanism for maintaining genome integrity tightly controlled by specific nucleolytic activities and central homologous recombination factors.

Inferior vena cava filters for prevention of venous thromboembolism in obese patients undergoing bariatric surgery: a systematic review.

OBJECTIVE: The use of inferior vena cava (IVC) filters for prevention of venous thromboembolism (VTE) in bariatric surgery is a contentious issue. We aim to review the evidence for the use of IVC filters in bariatric surgical patients, describe trends in practice, and discuss challenges in developing evidence-based guidelines. BACKGROUND: The incidence of VTE in modern bariatric procedures with traditional methods of thromboprophylaxis, such as sequential calf compression devices and perioperative low molecular weight heparin, is approximately 2%. METHODS: A systematic review of the literature was conducted according to PRISMA guidelines. We searched Medline up until July 2013 with the terms "bariatric filter" and "gastric bypass filter." Two investigators independently screened search results according to an agreed list of eligibility criteria. RESULTS: Eighteen studies were included. There were no randomized controlled trials. Data from controlled cohort studies suggest that those who undergo IVC filter insertion preoperatively may be at higher risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). A small cohort of patients with multiple risk factors for VTE benefitted from reduced PE-related mortality after preoperative IVC filter insertion. Data from 12 case series reporting VTE outcomes from a total of 497 patients who underwent preoperative IVC filter insertion demonstrated DVT rates of 0% to 20.8% and PE rates ranging from 0% to 6.4%. CONCLUSIONS: Published data reporting the safety and efficacy of IVC filter use in bariatric surgical patients is highly heterogeneous. There is no evidence to suggest that the potential benefits of IVC filters outweigh the significant risks of therapy.

The effect of footplate neuromuscular electrical stimulation on venous and arterial haemodynamics.

OBJECTIVE: This pilot study aims to determine the effect of the Revitive™ footplate neuromuscular electrical stimulation device on venous and arterial haemodynamic changes in healthy individuals. METHOD: The blood flow (cc/min) and time averaged mean velocity (cm/s) of the superficial femoral vein and artery were measured using ultrasound at baseline, 15 min during, and immediately after cessation of the 30 min stimulation cycle. Data were analysed using the Wilcoxon matched-pairs signed rank test. RESULTS: Venous and arterial duplex ultrasound haemodynamic measurements were taken in 10 and 20 healthy volunteers, respectively. Mean age 38.7 (range 21-64), ankle brachial pressure index 0.9-1.0. At 15 min, there was a significant increase in venous median blood flow (88.3 cc/min, p = 0.014) and an increase in time averaged mean velocity (1.13 cm/s, p = 0.065) compared to baseline. Similarly, there was a significant increase in arterial median blood flow (38.7 cc/min, p < 0.0001) and time averaged mean velocity (2.21 cm/s, p = 0.0003) at 15 min compared to baseline. There was no significant difference in venous or arterial measurements compared to baseline after stimulation cessation. CONCLUSIONS: Blood flow and time averaged mean velocity increased during neuromuscular electrical stimulation but returned to baseline once stimulation had stopped. By improving blood flow, neuromuscular electrical stimulation has the ability to enhance venous return, counteract venous stasis and improve limb arterial inflow.

Venous injuries in pediatric trauma: Systematic review of injuries and management.

BACKGROUND: Diagnosis of vascular injury in pediatric trauma is challenging as clinical signs may be masked by physiologic compensation. We aimed to (1) investigate the prevalence of noniatrogenic pediatric venous injuries, (2) discuss options in management of traumatic venous injury, and (3) investigate mortality from venous injury in pediatric trauma. Our objective was to provide the practicing clinician with a summary of the published literature and to develop an evidence-based guide to the diagnosis and management of traumatic venous injuries in children. METHODS: A systematic review of published literature (PubMed) describing noniatrogenic traumatic venous injury in the pediatric population (<17 years) was performed according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] guidelines. Data were retrieved systematically under the following headings: Study Design, Population Demographics (dates of recruitment, mean age, mechanism of injury), Diagnostic Approach, Vessel Injured, Management (operative technique), and Mortality. RESULTS: Thirteen articles were included in this systematic review. In total, 508 noniatrogenic traumatic venous injuries were reported in children between the year 1957 and present day. Mechanisms of injury included blunt trauma from seat belt-related injury and fall from height or penetrating trauma from gunshot and foreign object. Injury to the inferior vena cava was most frequently reported, followed by femoral vein and internal jugular injuries. Primary repair was the most frequently reported technique for surgical repair (38%), followed by ligation (25%) and end-to-end anastomosis (15%). Mortality in pediatric trauma patients who had venous injury was reported as 0% to 67% in published series, highest in the series in which the most frequently reported injury was of the inferior vena cava. CONCLUSION: Traumatic venous injury in the pediatric population is uncommon but may be associated with significant morbidity and mortality. Intra-abdominal venous injuries are associated with high mortality from exsanguination. Early diagnosis and intervention are therefore essential in such cases. LEVEL OF EVIDENCE: Systematic review, level IV.

The Future of Phlebology in Europe.

BACKGROUND: Worldwide superficial and deep venous diseases are common and associated with significant individual and socioeconomic morbidity. Increasing burden of venous disease requires Phlebology to define itself as an independent specialty representing not only patients but the multidisciplinary physicians involved in venous care. METHODS & RESULTS: In this article the scope of venous disease in Europe and subsequent future governance for treatment in the region is discussed. Superficial venous disease is common with 26.9-68.6% of European populations reported to have C2-C6 disease according to the CEAP (Clinical severity, Aetiology, Anatomy and Pathophysiology) scoring system. However, a significant disparity is observed in the treatment of superficial venous disease across Europe. Post thrombotic syndrome (PTS) after deep vein thrombosis (DVT) contributes to the increasing burden of deep venous disease. Aggressive thrombus removal for acute ileofemoral DVT provides a cost-effective 14.4% risk reduction in the development of PTS. Additionally, deep venous lesions requiring endovascular intervention are being increasingly performed to prevent recurrent thrombosis. The European College of Phlebology (ECoP) has been formed to provide a responsible body for the care of the European patient with venous disease. The role of the ECoP includes unifying European member states through standardised guideline production, identification of research strategy and provision of training and accreditation of physicians. CONCLUSION: Creation of a European venous disease specific speciality will provide a patient centred approach through understanding of the impact of disease in the region and delivery of high quality diagnostics and treatment from an appropriately certified Phlebologist.

The calf muscle pump revisited.

BACKGROUND: Chronic venous disease (CVD) defines the spectrum of manifestations of venous disease that originate as a result of ambulatory venous hypertension. Thus far, the role of the calf muscle pump in the development and potentiation of CVD has been overlooked and understated in the clinical setting, with much greater emphasis placed on reflux and obstruction. The aim of this review is to explore the level of significance that calf muscle pump function or dysfunction bears on the development and potentiation of CVD. METHODS: EMBASE and MEDLINE databases were searched with keywords "calf" AND "muscle" AND "pump" AND "venous" AND "insufficiency" AND ("lower limb*" OR "leg*"), screened for cross-sectional and longitudinal studies relating to chronic venous insufficiency, highlighting the role of the calf muscle pump in CVD and the extent to which the calf muscle pump is impaired in these cases. This resulted in the inclusion of 10 studies. RESULTS: Compared with healthy subjects, patients with CVD have a reduced ejection fraction (15.9%; P < .001) and an increased venous filling index (4.66 mL/s; P < .001), indicating impairment in calf muscle pump ejection ability as well as poor venous competence. Calf muscle pump dysfunction is present in 55% of patients with CVD in the literature, but this did not reach significance on meta-analysis. Isotonic exercise programs in patients with active and healed ulcers have been shown to increase calf muscle pump function but not venous competence. DISCUSSION: Calf muscle pump failure is a therapeutic target in the treatment of CVD. Evidence suggests that isotonic exercise treatment may be an effective method of increasing the hemodynamic performance of the calf muscle pump. CONCLUSIONS: This review emphasizes the requirement for more attention to be placed on the treatment of calf muscle pump failure in cases of CVD by use of exercise treatment programs or other methods, which may be of clinical importance in managing symptomatic disease. To establish this in routine clinical practice, these results would need to be replicated in appropriate clinical trials. It would also be logical to look at other modifiable muscle pumps, such as the thigh and foot, and to explore the potential benefit of electrical devices acting on the leg (eg, electrical muscular or neuromuscular stimulation), especially for those patients in whom exercise capacity is limited.