Myringoplasty: a comparison of bismuth iodoform paraffin paste gauze pack and tri-adcortyl ointment ear dressing

OBJECTIVES

To assess the myringoplasty graft take rate, comparing two methods of post-operative ear packing: bismuth iodoform paraffin paste (BIPP) gauze versus tri-adcortyl ointment (TAO).

METHODS

A retrospective study of patients who had undergone myringoplasty at our department within a three-year period was undertaken. Data, including age, site and size of perforation, grade of surgeon, surgical approach, use of post-operative ear dressings, complications, and audiometric outcome, were collected from the patient notes and analysed. The overall success rate of the operation (with success being defined as an intact tympanic membrane at six months) was noted.

RESULTS

One hundred and seventy myringoplasties were performed over the study period, but data were complete on 154 patients and these constituted the study population. Age ranged from nine to 71 years (mean age 34 years) and the mean follow-up period was seven months. Consultants performed 62 per cent of the operations, with an 85 per cent success rate, whereas trainees performed the remaining 38 per cent, with a success rate of 73 per cent (p=0.059). The overall success rate was 80 per cent; 79 per cent for BIPP and 83 per cent for TAO (p=0.55), and 87 per cent for small perforations and 75 per cent for subtotal perforations (p=0.22). There was audiometric improvement in 74 per cent of cases.

CONCLUSION

We found no significant difference in outcome between patients packed with TAO and BIPP. Packing with TAO is therefore a suitable alternative to BIPP gauze ear dressing following myringoplasty.

Prediction and monitoring the therapeutic response of chronic dermal wounds

A significant proportion of chronic wounds fail to heal in response to treatment of underlying pathologies combined with good wound care practice. Current prognostic tests to identify these wounds rely on the use of algorithms based on clinically measurable parameters such as wound dimensions and wound duration. Venous leg ulcers may be stratified into healing/non healing at 24 weeks of compression therapy and diabetic foot ulcer treatment outcome assessed using a 3-parameter algorithm. Accurate and reproducible measurement of wound area is required for these algorithms to have clinical utility. Whilst a number of attempts have been made to develop computerised wound-assessment techniques, wound tracing by clinicians combined with planimetry remains the standard methodology. Once treatment has been initiated, it is important to continuously monitor the wound to assess efficacy of treatment. This can be achieved by measuring wound area change over the first weeks of treatment to identify whether re-assessment of treatment strategy is required. A number of algorithms for assessing rate of wound area change have been evaluated to determine a surrogate endpoint for healing. Retrospective analysis of large patient groups indicates that approximately 75% correct prediction of healing outcome can be achieved.

Standard wound coverage techniques for extremity war injury

Reconstruction of extremity war injuries begins with aggressive forward resuscitative care and stabilization of the trauma patient. After serial care in progressively better supported medical environments, definitive management is done at the level V military treatment facility. Aggressive forward care coupled with rapid air transport has enabled increasingly complex care to be administered at the continental United States military facilities; however, it has also made the decision between limb salvage and amputation more challenging. Yet to be determined are (1) the optimal timing of definitive wound closure or coverage in coordination with fracture stabilization and (2) the optimal types of flap for both upper and lower extremity reconstruction. Records of patients with complex lower and upper extremity wounds who were treated at the National Naval Medical Center between September 2004 and June 2006 reveal useful short-term data. Longer-term data, such as fracture union rate, time to ambulation, range of motion and global function of salvaged limbs, patient satisfaction with limb salvage, and average cost, are not yet available.

Pressure support and elevation following the removal of a radial artery for coronary artery bypass grafting

The saphenous vein was once the standard coronary artery bypass graft. Alternate grafts, primarily the radial artery and the internal mammary artery are now being utilised for revascularisation of the heart. However, the radial artery graft site can be at risk of oedema and the development of haematoma during the post-operative period. Also tension on the suture line may compromise circulation and create functional problems for the patient. The aim of this study was to assess the effect of pressure support (elastic support bandage) and elevation in reducing swelling and arm discomfort in the harvest arm. The patients in the study undergoing coronary artery bypass grafts were randomly assigned to one of three groups: elastic support bandage, collar and cuff sling and elevation on two pillows. There were 30 patients in each group. The circumference at three locations on the forearm was measured pre-operatively and on post-operative days 3 and 5. Pain was measured on a visual pain scale, which went from 1-10, with 10 being the most painful. The patients were also asked whether their arm movement felt restricted. The study found that there was no statistically significant difference (at the 0.05 level) between the three groups in the amount of swelling witnessed at the different forearm locations. There was, however, a significant decrease in swelling for all groups between days 3-5, but no difference in pain scores between the groups. Moreover, the collar and cuff sling group reported movement restriction, which was not apparent in the other two groups. In view of the findings, the researchers advocate the elastic support bandage. Patient compliance has practical implications when applying treatment and this is enhanced by the non cumbersome elastic support bandage. This can be compared to the collar and cuff sling and pillow elevation groups where the patient's daily activities affects compliance with these two treatments. It is recommended that future research be conducted comparing the effects of the elastic support bandage with a control group.

Evidence, prescribing and the Drug Tariff

There is a drive in the NHS to provide clinically effective services to patients that are based on evidence, and it is a responsibility of the government and each NHS trust to ensure that this overall philosophy guides all care.

Cohesive short-stretch vs four-layer bandages for venous leg ulcers

Nurses today are employing more and more evidence base within their practice. This must be carefully balanced with their ability to offer patients choice about treatment options for venous leg ulceration. Knowledge of only one particular compression bandage system is inadequate for nurses working within this area. This article aims to examine the evidence base for the use of compression bandaging in the treatment of leg ulceration. It explores results of current randomised controlled trials in this area pertaining to four-later bandage (4LB) and cohesive short-stretch bandage (CSSB) systems. The advantages and disadvantages of the 4LB and CSSB are explored and application method of CSSB is explained. Concordance is and important issue that affects successful leg ulcer management (Moffatt, 2004a): if this can be achieved through offering patients choice of treatment bandages, then more successful treatment will be achieved for patients.

New, improved Kerraboot: a tool for leg ulcer healing

Lower limb ulcers can be debilitating to the individual affected, and are costly for the NHS to treat. The aim of treatment is to address the underlying pathology that caused the ulcer, and to create a warm, moist wound environment that promotes wound healing, This article discusses the improved Kerraboot, which effectively draws excess moisture away from the wound, but also keeps the wound warm, moist and clean. Although evidence of cost-effectiveness has yet to be collected, anecdotal reports suggest that the device heals wounds quickly and reduces input from health professionals.

A prospective, open-label study to assess the clinical performance of a foam dressing in the management of chronic wounds

Polyurethane foam dressings are used to help absorb wound exudate while maintaining a moist wound environment. To assess the clinical performance of a foam dressing, a prospective, open-label evaluation of 57 outpatients (mean age 69 years) with delayed/non-healing wounds (one per patient, average duration 1.4 +/- 4.1 years) of different etiologies was conducted in 15 medical centers in Germany. Physicians assessed the clinical appearance of the wound bed, periwound skin, and exudate level at the beginning and final evaluation and dressing performance characteristics were rated. Patients were asked to assess their wound pain as none, mild, moderate, or strong. After three dressing changes (performed approximately 3 days apart), slough and necrotic tissue on the wound surface changed from an average of 54% (+/- 33%) to 29% (+/- 25%). At baseline, granulation tissue covered an average of 41% (+/- 31%) of the wound bed compared to 59% (+/- 24%) at the final assessment and the proportion of wounds assessed as heavily exudating decreased from 32% to 11%. During the evaluation, the proportion of patients without periwound skin problems increased from 49% to 66% and the percentage of patients with wound pain decreased from 45% to 26%. Between 80% and 90% of the participating physicians rated the product attributes assessed as "very good" or "good."

Anti-embolism stockings: are they used effectively and correctly?

Anti-embolism stockings are widely advocated in the prevention of deep vein thrombosis. But do they do more harm than good? This article explores the effectiveness of this intervention and the possible link with heel pressure ulceration, an increasing problem which costs the NHS millions of pounds and causes suffering to patients. With the aid of an audit tool the author assesses nursing knowledge and reveals that, although there is a high level of understanding regarding post-application care, the appropriate initiation of the intervention and subsequent documentation of this intervention are severely lacking, leaving the health profession wide open to litigation.

Measurement of Lower Leg Compression In Vivo: Recommendations for the Performance of Measurements of Interface Pressure and Stiffness

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.

Prevention of venous thrombosis in patients with acute intracerebral hemorrhage

OBJECTIVE

To assess intermittent pneumatic compression (IPC) in the prevention of venous thromboembolism (VTE).

METHODS

The authors randomly allocated patients with a documented intracerebral hemorrhage (ICH) to elastic stockings (ES) alone or combined with IPC. The primary outcome was a combined criteria assessed at day 10: a symptomatic and well-documented VTE, or a death arising before day 10 and related to pulmonary embolism (PE), or an asymptomatic deep vein thrombosis (DVT) of the lower limbs detected by compression ultrasonography (CUS). Outcome assessment was blinded.

RESULTS

One hundred fifty-one patients were randomized; 133 (88%) patients were evaluated at day 10. No clinical suspicion of VTE arose before day 10. Fourteen patients died before having a CUS but no death was definitely related to PE. Fourteen asymptomatic DVT were detected by CUS: three (4.7%) in the ES + IPC group (all distal) and 11 (15.9%) in the ES group (three proximal and eight distal). ES combined with IPC is associated with a reduced risk of asymptomatic DVT compared to ES alone: relative risk, 0.29 (95% CI 0.08 to 1.00).

CONCLUSIONS

Asymptomatic deep vein thrombosis (DVT) was detected at day 10 in 15.9% of patients wearing elastic stockings alone. Intermittent pneumatic compression significantly decreased the occurrence of asymptomatic DVT for patients with intracerebral hemorrhage.

CUSUM: a tool for early feedback about performance?

BACKGROUND

Modern day clinical practice demands evidence justifying our choice of treatment methods. Cumulative sum techniques (cusum) are amongst the simplest statistical methods known. They provide rapid analysis and identification of trends in a series of data. This study highlights use of these techniques as an early performance indicator of a clinical procedure before its implementation.

METHODS

Twenty consecutive patients who underwent total hip or knee arthroplasty received a simple dressing--blue gauze and Tegaderm. Cusum charting was used to assess the dressing with regards to skin blistering. At an acceptable level of performance the curve would oscillate about the horizontal axis and the overall trend therefore said to be flat. If performance is unacceptable, the cusum slopes upward.

RESULTS

The cusum plot for the twenty patients did not cross the specified control limits. This showed that our simple dressing met specified standards with regards to wound blistering postoperatively.

CONCLUSION

We recommend the use of this simple, yet versatile cusum technique in the early evaluation of a clinical procedure before its implementation.

[How to select and change a dressing]

To minimize pain when changing dressing for peripheral venous catheters, to select the adequate dressing in functions of the circumstances presented by each patient, and to utilize as references the recommendations by Centers for Disease Control and Prevention (CDCs) form the fundamental bases for this article.