Performance of endovenous foam sclerotherapy in the USA for the treatment of venous disorders: ACP/SVM/AVF/SIR quality improvement guidelines

Objective

This report summarizes the findings of the consensus panel based on the results of the comprehensive questionnaire of US American College of Phlebology annual congress attendees and results of the systematic meta-analysis of the literature and provides quality improvement guidelines for the use of endovenous foam sclerotherapy (EFS) for the treatment of venous disorders, as well as identifies areas of needed research.

Methods

Based on the above data, quality improvement guidelines were developed and reviewed by the ten US consensus panel members and approved by their respective societies.

Results

EFS is effective for the treatment of truncal and tributary varicose veins, both as primary treatment and for treatment of recurrence. It may improve the signs and symptoms associated with varicose veins including pain and swelling. EFS is contraindicated in patients who have experienced an allergic reaction to previous treatment with foam or liquid sclerosant, and in patients with acute venous thrombosis events secondary to EFS.

Conclusion

These guidelines for the use of EFS in the treatment of venous disorders provide an initial framework for the safe and efficacious use of this therapy, and the impetus to promote the evaluation of the questions remaining regarding the use of EFS through well-designed randomized and cohort studies.

Efficacy and safety of endovenous foam sclerotherapy: meta-analysis for treatment of venous disorders

Aim

Endovenous foam sclerotherapy (EFS) is used widely throughout the USA for the treatment of venous disorders. The purpose of the quantitative meta-analysis was to systematically and comprehensively evaluate the literature to provide accurate estimates of safety and efficacy outcomes for this procedure.

Methods

A comprehensive electronic search of published literature in several databases was performed using a wide variety of MESH headings. In addition, meeting abstracts and bibliographies of selected references were reviewed for eligible papers. Two reviewers abstracted selected treatment-related data.

Results

Of 684 identified manuscripts and abstracts reviewed, 104 papers were abstracted and analysed. More than 50% were published between 2004 and 2008. EFS was found to be effective with similar vein occlusion rates to laser therapy, but less effective than surgery. In addition, major adverse effects were rare.

Conclusions

EFS is a safe and effective therapy for the treatment of venous disorders.

Exploring the Ethics of Observational Research: The Case of an HIV Study in Tanzania

BACKGROUND

Observational studies have generally been viewed as incurring minimal risk to participants, resulting in fewer ethical obligations for investigators than intervention studies. In 2004, the lead author (AN) carried out an observational study measuring sexual behavior and the prevalence of HIV, syphilis, and herpes simplex virus type 2 (HSV-2), among Tanzanian agricultural plantation residents (results reported elsewhere). This article uses an ethical lens to consider the consequences of the observational study and explore what, if any, effects it had on participants and their community.

METHODS

Using a case study approach, we critically examine three core principles of research ethics-respect for persons/autonomy; beneficence/nonmaleficence; and distributive justice-as manifested in the 2004 observational study. We base our findings on three sources: discussions with plantation residents following presentations of observational research findings; in-depth interviews with key informants; and researcher observations.

RESULTS

The observational research team was found to have ensured confidentiality and noncoercive recruitment. Ironically, maintenance of confidentiality and voluntary participation led some participants to doubt study results. Receiving HIV test results was important for participants and contributed to changing community norms about HIV testing.

CONCLUSIONS

Observational studies may act like de facto intervention studies and thus incur obligations similar to those of intervention studies. We found that ensuring respect for persons may have compromised the principles of beneficence and distributive justice. While in theory these three ethical principles have equal moral force, in practice, researchers may have to prioritize one over the others. Careful community engagement is necessary to promote well-considered ethical decisions.

Performance of endovenous foam sclerotherapy in the USA

Purpose

To assess practice patterns of endovenous foam sclerotherapy (EFS) use in the USA.

Methods

A multidisciplinary panel of US experts was convened and developed a questionnaire to assess use of EFS. US attendees at the American College of Phlebology 2009 Annual Congress were asked to complete the questionnaire.

Results

Of 776 questionnaires distributed, 239 were completed (31%). The majority of respondents (87%) reported using EFS for the treatment of venous disorders. Foam sclerotherapy was used by a wide variety of specialists in every region of the USA. The most common indication was sclerosis of recurrent truncal or tributary veins of the leg. There was variation among practitioners in the indications for use, pre- and postprocedural evaluation and procedure methodology.

Conclusions

The results of this questionnaire show widespread usage of EFS and are important in the development of national quality improvement guidelines for the performance of EFS.

Abortion stigma: a reconceptualization of constituents, causes, and consequences

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.

Heritability of mortality in response to a natural pancreas disease (SPDV) challenge in Atlantic salmon, Salmo salar L., post-smolts on a West of Ireland sea site

Pancreas disease (PD) is an economically important disease of European farmed Atlantic salmon. It can cause significant losses because of morbidity, mortality and reduced production. The disease is caused by an alphavirus, known as salmon PD virus (SPDV) or salmonid alphavirus subtype 1 in Ireland. To examine whether it is possible to improve the natural resistance of Atlantic salmon to SPDV by selective breeding, 6000 genotyped, tagged, pedigreed fish from 150 full-sib families were exposed to a natural challenge during 2005 in a sea cage on a commercial salmon farm in the West of Ireland. Histopathological and serological examination was performed weekly on a proportion of all moribund fish to determine the onset of the infection and the likely cause of death. Heritabilities and genetic correlations are presented for resistance to a natural PD challenge and smolt input weight. The results indicate that the susceptibility of salmon to SPDV could be reduced by selective breeding based on the survival in a natural challenge to the virus.

Virological, serological and histopathological evaluation of fish strain susceptibility to experimental infection with salmonid alphavirus

Pancreas disease (PD) of farmed Atlantic salmon Salmo salar L., which is caused by an alphavirus known as salmon pancreas disease virus (SPDV), can have serious economic consequences. An epidemiological survey carried out in Ireland in 2003 indicated that within individual farms there were significant differences in the susceptibility of different strains of farmed Atlantic salmon to infection with SPDV, as measured by levels of clinical disease and mortality. The aim of this preliminary study was to investigate this field observation by comparing lesion development, viraemia and serological responses of 3 commercial strains of Atlantic salmon (A, B and C) experimentally infected with SPDV. Highly significant differences in the severity of lesions in the pancreas at Day 21 post-infection (pi) were detected (p < 0.01), with Group B being more severely affected. There were also significant differences in the prevalence and severity of lesions in heart and skeletal muscle at Day 21 and 35 pi respectively, with Group B results again significantly higher than those from both Groups A and C (p < 0.05). There was no overlap between viraemia and the presence of specific SPDV antibody. Some fish in all groups had no viraemia, lesions or evidence of seroconversion. There were no significant differences seen between the challenged groups in relation to the percentage of viraemic fish at each time point. Viral loads were not determined. Differences between the number of antibody-positive fish in each challenge group were found at Days 28 and 35 pi (p < 0.1). Highly significant differences (p < 0.01) in the geometric mean titres of seropositive fish were detected at Day 28. These results, obtained using a challenge model, confirm that there are strain differences in the susceptibility to experimental SPDV infection in commercial farmed Atlantic salmon.

Development of a holistic admission assessment: an integrated care pathway for the hospice setting

This article describes the development of a holistic admission assessment for all inpatients admitted to a 66-bedded hospice, structured in the form of an integrated care pathway (ICP). The need for an improved assessment process was identified by clinical staff, who recognized that the existing assessment was not truly holistic and was dependent on the skills of the assessors. The assessment also lacked appropriate goals and actions. The recently published National Institute for Clinical Excellence (NICE) guidance on Improving Supportive and Palliative Care for Adults with Cancer, has also highlighted key areas for the improvement of patient assessment in specialist palliative care (NICE, 2004). Implementation of the ICP has resulted in a systematic and timely holistic assessment process for patients. The ICP addresses effectively the NICE recommendations for the assessment of specialist palliative care patients.

Is acoustic analysis of snoring an alternative to sleep nasendoscopy?

Previous studies have suggested that acoustic analysis may be useful in distinguishing different types of snoring prior to possible corrective surgery. This study aimed to establish whether it could replace sleep nasendoscopy in a clinical setting. Thirty-five patients undergoing sleep nasendoscopy had their snoring recorded and analysed using commercially available equipment. It was found that centre frequency can be used to distinguish pure palatal from tongue base snoring, with a clear cut-off value of 90 Hz between the two. Multisegmental snoring cannot be identified on the basis of centre frequency alone. It may be distinguished from tongue base, but not palatal snoring by the nature of the frequency distribution plot (sensitivity 77%, specificity 81%). Blinded assessment of waveforms of individual snores gave poor accuracy (53%) and poor interobserver agreement (kappa = 0.10). Acoustic analysis may help screen for pure tongue base snoring. However, we feel that it is unlikely to replace sleep nasendoscopy.

Management of failed intubation in a septic parturient

We describe a case in which regional anaesthesia for Caesarean section was initially avoided because of the presence of systemic infection. However, attempted induction of general anaesthesia resulted in failed tracheal intubation and so an epidural catheter was sited and used for the operation. Awake fibreoptic tracheal intubation was performed after surgery, when it was clear that ventilatory support on the intensive care unit would be needed. The relative risks of regional versus general anaesthesia when infection and difficult laryngoscopy coincide are discussed.