Pain and powerlessness: the experience of living with peripheral vascular disease

Configuration of vascular services: a multiple methods research programme

Background

Vascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services.

Objectives

To identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life.

Design

This was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration.

Setting

Specialist vascular inpatient services in England.

Data sources

Modelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England.

Interventions

The data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring.

Main outcome measures

Systematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services.

Results

Systematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS.

Limitations

The major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations.

Conclusions

There is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation.

Future work

Further evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required.

Study registration

This study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Illness perceptions in patients with peripheral arterial disease: A systematic review of qualitative studies

BACKGROUND

Patients with chronic diseases create their own subjective beliefs about their conditions based on their illness perceptions. In the common-sense model, illness perceptions constitute personal beliefs about illness with regard to five components: identity, timeline, cause, control/cure, and consequences. Patients' illness perceptions affect both their management of their disease and their adherence to treatment. Since patients with peripheral arterial disease need life-long treatment for secondary prevention, generating knowledge about illness perceptions in patients with peripheral arterial disease is essential.

OBJECTIVES

To systematically review and synthesise the literature on illness perceptions in patients with peripheral arterial disease.

DESIGN

A systematic review DATA SOURCES: PubMed, CINAHL, and PsycINFO.

REVIEW METHODS

A systematic search strategy was conducted in December 2017, with an update in July 2019. Two team members independently screened all titles and abstracts. A relevance and quality appraisal of the studies was performed. The references from the included studies were evaluated for additional studies. The data from 14 studies were extracted and synthesised using a "best-fit" approach to framework analysis. A deductive analysis was conducted using the common-sense model. The data not suitable for the framework were analysed separately using inductive conventional content analysis, yielding an additional component representing the retrospective consequences of peripheral arterial disease.

FINDINGS

The findings showed diversity in illness perceptions in each of the five components of the framework as well as in the additional component. The findings showed participants' lack of understanding of the chronic nature of the disease, i.e., about the timeline, the identity of the symptoms and the cause of the disease. The patients' beliefs about control and cures varied from having high motivation to engage in physical activity to thinking that walking could make their situations worse. There was fear about the future, as patients perceived disease progression and decreasing control to be consequences of their illness. Living with the disease, the emphasis in the additional component, was a process for regaining control and adapting to their situations.

CONCLUSIONS

Patients with peripheral arterial disease shape their own understandings of their conditions. These beliefs may influence their management of their disease and adherence to treatment. Therefore, the current study suggests that illness perceptions should be addressed when planning secondary prevention for patients with peripheral arterial disease.

Beet the Best?

RATIONALE

A primary goal of therapy for patients with peripheral artery disease (PAD) and intermittent claudication is increased ambulatory function. Supervised exercise rehabilitation was recently shown to confer superior walking benefits to pharmacological or surgical interventions. Increases in plasma inorganic nitrite, via oral nitrate, have been shown to increase exercise performance in both human and animal models, especially in hypoxic conditions.

OBJECTIVE

To determine whether a 36-session exercise rehabilitation program while consuming oral inorganic nitrate (4.2 mmol concentrated beetroot juice) would produce superior benefits over exercise plus placebo in pain-free walking and markers of increased skeletal muscle perfusion in patients with PAD and intermittent claudication.

METHODS AND RESULTS

This was a randomized, double-blind, per-protocol study design. After the 12-week protocol, claudication onset time on a maximal treadmill test increased by 59.2±57.3 s for the exercise plus placebo group (n=13) and by 180.3±46.6 s for the exercise plus beetroot juice group (n=11; P≤0.05). This produced a between treatment medium to large standardized effect size (Cohen d) of 0.62 (95% CI, -0.23 to +1.44). The data for 6-minute walk distance showed a similar pattern with increases of 24.6±12.1 and 53.3±19.6 m ( P≤0.05) in the exercise plus placebo and exercise plus beetroot juice groups, respectively. Measures of gastrocnemius perfusion, including ankle-brachial index, peak reactive hyperemic blood flow, and tissue deoxygenation characteristics, during exercise (assessed my near-infrared spectroscopy) all changed significantly for the exercise plus beetroot juice group with moderate-to-large effect sizes over exercise plus placebo changes.

CONCLUSIONS

Although it is premature to speculate on overall clinical utility of a nitrate-based therapy for PAD, this early pilot study evidence is encouraging. Specifically, our data suggests that increasing plasma nitrite before exercise may allow PAD subjects to train with less pain, at higher workloads for longer durations at each training session, thereby maximizing the beneficial peripheral vascular and skeletal muscle adaptations.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01684930 and NCT01785524.

Living a burdensome and demanding life: A qualitative systematic review of the patients experiences of peripheral arterial disease

Background

Peripheral arterial disease (PAD) has a significant negative impact on the quality of life of individuals. Understanding the experiences of people living with PAD will be useful in developing comprehensive patient-centred secondary prevention therapies for this population.

Aim

The aim of this study is to identify first-hand accounts of patients’ experiences of living with PAD.

Methods

Six databases (CINALH, PsyclNFO, MEDLINE, AMED, EMBASE, Social citation index/Science citation index via Web of Science (WOS)) and reference lists of identified studies were searched until September 2017 (updated February 2018). Qualitative studies reporting patients’ account of living with PAD were eligible for inclusion. A framework thematic synthesis was implemented.

Results

Fourteen studies with 360 participants were included. Pain and walking limitation were recurrent among the varied symptom descriptions. Patients’ ignorance and trivialisation of symptoms contributed to delays in diagnosis. Inadequate engagement in disease understanding and treatment decisions meant patients had poor attitudes towards walking treatments and unrealistic expectations about surgery. Depending on symptom progression, patients battle with walking impairment, powerlessness, and loss of independence which were a source of burden to them. Lack of disease understanding is central through patients’ journey with PAD and, although they subsequently began adaptation to long term living with PAD, many worried about their future.

Conclusions

Disease understanding is vital across the illness trajectory in patients with PAD. Although certain experiences are common throughout patient journey, some might be unique to a particular stage (e.g. unrealistic expectation about surgery, or rationale of walking in spite of pain in a supervised exercise program). Given that PAD is an overarching construct ranging from the mildest form of intermittent claudication to severe critical limb ischemia with ulceration and gangrene, consideration of important patient constructs specific to each stage of the disease may enhance treatment success. Systematic review registration CRD42017070417.

The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation

AIMS AND OBJECTIVES

To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI).

BACKGROUND

CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning.

DESIGN

Longitudinal qualitative study using Heideggerian phenomenology.

METHODS

Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed.

RESULTS

Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity).

CONCLUSIONS

Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy.

RELEVANCE TO CLINICAL PRACTICE

A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.

Accepting, active and in control: older women's experiences of ageing with peripheral arterial disease

The population of Australia is ageing, with women being the primary beneficiaries of this increase in longevity. Increasingly older individuals are being diagnosed with different chronic illnesses such as peripheral arterial disease (PAD) which causes blockages of the blood vessels in the legs resulting in pain, non-healing ulcers, immobility and the potential amputation of the threatened limb. PAD has been traditionally thought to affect men more than women. Resultingly, women have been under-represented in clinical trials of PAD and under-diagnosed in the health-care setting. However, it has recently been acknowledged that women are indeedmorelikely to suffer from PAD than men due to increased presence of disease and survival advantage. As such, very little is known about women's understanding of and the meaning they create of their experiences of PAD. Therefore, how older women with PAD experience the ageing process is the focus of this qualitative research project. Interviews were conducted with 11 women from Sydney, Australia aged over 65 years who had been diagnosed with PAD. The interviews were analysed using an inductive thematic analysis. Three manifest themes were constructed: independence and control, active and involved, and the acceptance of ageing. These findings emphasised the idea that despite the presence of a chronic illness and increased age, remaining independent and engaged with life was vital to these women's wellbeing. Their subjective experiences of ageing reflect the fact that by adapting to the physical, mental and social changes that come with growing older, the focus does not need to be on loss and decline but rather can be about the continuation of life that can be both positive and meaningful.

An integrative review of health-related quality of life in patients with critical limb ischaemia

AIMS AND OBJECTIVES

To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life.

BACKGROUND

Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation.

DESIGN

The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al.

RESULTS

The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia.

CONCLUSIONS

Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required.

RELEVANCE TO CLINICAL PRACTICE

A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.

Efficacy of brief behavioral counselling by allied health professionals to promote physical activity in people with peripheral arterial disease (BIPP): study protocol for a multi-center randomized controlled trial

Background

Physical activity is recommended for people with peripheral arterial disease (PAD), and can improve walking capacity and quality of life; and reduce pain, requirement for surgery and cardiovascular events. This trial will assess the efficacy of a brief behavioral counselling intervention delivered by allied health professionals to improve physical activity in people with PAD.

Methods

This is a multi-center randomised controlled trial in four cities across Australia. Participants (N = 200) will be recruited from specialist vascular clinics, general practitioners and research databases and randomised to either the control or intervention group. Both groups will receive usual medical care, a written PAD management information sheet including advice to walk, and four individualised contacts from a protocol-trained allied health professional over 3 months (weeks 1, 2, 6, 12). The control group will receive four 15-min telephone calls with general discussion about PAD symptoms and health and wellbeing. The intervention group will receive behavioral counselling via two 1-h face-to-face sessions and two 15-min telephone calls. The counselling is based on the 5A framework and will promote interval walking for 3 × 40 min/week. Assessments will be conducted at baseline, and 4, 12 and 24 months by staff blinded to participant allocation. Objectively assessed outcomes include physical activity (primary), sedentary behavior, lower limb body function, walking capacity, cardiorespiratory fitness, event-based claudication index, vascular interventions, clinical events, cardiovascular function, circulating markers, and anthropometric measures. Self-reported outcomes include physical activity and sedentary behavior, walking ability, pain severity, and health-related quality of life. Data will be analysed using an intention-to-treat approach. An economic evaluation will assess whether embedding the intervention into routine care would likely be value for money. A cost-effectiveness analysis will estimate change in cost per change in activity indicators due to the intervention, and a cost-utility analysis will assess change in cost per quality-adjusted life year. A full uncertainty analysis will be undertaken, including a value of information analysis, to evaluate the economic case for further research.

Discussion

This trial will evaluate the efficacy and cost-effectiveness of a brief behavioral counselling intervention for a common cardiovascular disease with significant burden.

Trial registration

ACTRN 12614000592640 Australian New Zealand Clinical Trials Registry. Registration Date 4 June 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3801-7) contains supplementary material, which is available to authorized users.

Association of anger proneness, depression and low social support with peripheral arterial disease: the Atherosclerosis Risk in Communities Study

There is mounting evidence to suggest that psychosocial factors, including anger proneness, depression and social isolation, are risk factors for cardiovascular disease. Nevertheless, evidence relating these factors to peripheral arterial disease (PAD) and intermittent claudication remains sparse. Using data from the Atherosclerosis Risk in Communities Study, we analyzed the relationship of psychosocial variables (Spielberger anger score, depression score from the Maastricht questionnaire, and a perceived social support scale) at study visit 2 with incident PAD (ankle-brachial index ≤0.9; a hospital discharge diagnosis of PAD, leg amputation, or leg revascularization procedures; or intermittent claudication). In 12 965 middle-aged adults with no prior history of PAD, 854 developed PAD over a mean follow-up time of 9.7 years, yielding an incidence rate of 6.8 per 1000 person years. A modest, monotonic dose-response, positive association between anger proneness and incident PAD was observed in a multivariable model: relative risk (RR) = 1.15 (95% confidence interval (CI) 0.99-1.38) in the moderate anger group and RR = 1.38 (95% CI 1.08-1.76) in the high anger group, compared with the low anger group. When compared with a low level of depressive symptoms, moderate and high levels of depressive symptoms were also associated with greater incident PAD, with multivariable RRs of 1.20 (95% CI 0.99-1.45) and 1.44 (95% CI 1.19-1.74) respectively. There was no association of perceived level of social support with the occurrence of PAD. Anger proneness and depressive symptoms may be associated with the occur-rence of PAD, as for other atherosclerotic syndromes. These findings may warrant confirmation in further studies and, if causal, could serve as a unique target for a PAD prevention trial.

An analysis of the ability of nurses to identify the anxiety levels of patients in general medical and surgical wards

The study investigated whether qualified nurses could distinguish between low and high anxiety in general medical and surgical wards. The sample comprised 94 patients and 62 nurses in two district general hospitals. The patients completed the Spielberger State-Trait Anxiety Inventory Version Y and were divided into high and low anxiety groups by reference to the published norms for the inventory. The nurses independently rated the patients into either high or low anxiety groups according to whether or not they believed individual patients needed more nursing time than was usual to help them to manage their anxiety. The joint ratings were signficant beyond the 0.01 level, supporting the hypothesis that the nurses could distinguish between high and low anxiety patients. However when data from the two hospitals were separated, the overall results were only significant in the hospital where patients had reported significantly lower average levels of anxiety. A tentative explanatory hypothesis is that assessment of patients may be easier where the general background level of patient anxiety in a ward is relatively low. In a subsidiary part of the study, feedback and group training failed to increase the correspondence between nurses' ratings and those obtained from the patients' questionnaires. The research method for comparing the views of patients with those of nurses proved practical for implementation in busy hospital wards and may therefore be useful for other investigations in similar settings.

Patient education interventions to improve physical activity in patients with intermittent claudication: a protocol for a systematic mixed-studies review

INTRODUCTION

Peripheral arterial disease (PAD) and intermittent claudication (IC) decrease an individual's capacity to engage in physical activity (PA) with potentially negative effects on PA behaviour. Strategies to improve PA among this population may provide a range of positive health benefits. We present a protocol to assess the components of patient education interventions that improve PA capacity and PA behaviour in patients with PAD and IC.

METHODS AND ANALYSIS

Published peer-reviewed studies will be searched in the following databases: CINAHL, the Cochrane Library, OVID, ProQuest, AMED, MEDLINE, PsycINFO, Web of Science Core Collection and PEDro, to identify literature investigating the effect of patient education on PA of patients with PAD and IC, or studies that investigated patients' perceptions or experience with these interventions. Two authors will independently perform screening for study eligibility, result synthesis and then appraise study quality. For interventions without follow-up, primary outcome measures will include change in PA capacity, or change in free-living PA behaviour; where there was a follow-up postintervention, the primary outcome will be rate of adherence to PA behaviour improvement. A three-phase sequential explanatory synthesis of mixed studies will be employed to answer the research questions. Homogenous quantitative data will be analysed using a random-effects model of meta-analysis with results presented as relative risk for dichotomous outcomes and as weighted or standardised means for continuous outcomes. Qualitative data will be analysed using thematic synthesis. This review protocol is reported according to the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines.

TRIAL REGISTRATION NUMBER

CRD42015027314.

Illness beliefs and walking behavior after revascularization for intermittent claudication: a qualitative study

PURPOSE

Patients with peripheral artery disease (PAD) are recommended to increase physical activity to reduce cardiovascular risk. Vascular intervention (surgery or angioplasty) treats the symptom (intermittent claudication), but not the underlying cardiovascular disease. This study aims to explore the beliefs and physical activity behavior of patients with PAD who have received vascular intervention.

METHODS

Twenty participants who had received a vascular intervention for intermittent claudication between 6 months and 2 years previously participated in semistructured interviews. The interviews explored illness and treatment beliefs and walking behavior. Data were transcribed verbatim and analyzed thematically.

RESULTS

Participants described a high level of ongoing symptoms (particularly pain) in their legs, despite having received vascular intervention. They viewed their illness as acute and treatable, and believed that pain was an indication of walking causing damage. They controlled their symptoms by avoiding walking and slowing their pace. Participants were generally unaware of the causes of the disease and were unaware of their increased risk of future cardiovascular health problems. There was a low level of congruence between participant beliefs about their illness and the recommendation to increase physical activity that may affect physical activity behavior.

CONCLUSIONS

Our findings suggest that patients with PAD do not change physical activity behavior after diagnosis and treatment, because they hold dysfunctional and incongruous beliefs about PAD, treatment, and physical activity.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1% of people at some time in their lives and are often painful. The main treatments are compression bandages and dressings. Topical treatments to reduce pain during and between dressing changes are sometimes used.

OBJECTIVES

To determine the effects of topical agents or dressings for pain in venous leg ulcers.

SEARCH METHODS

For this third update the following databases were searched: Cochrane Wounds Group Specialised Register (searched 9 May 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4); Ovid MEDLINE (2009 to April Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations May 08, 2012); Ovid EMBASE (2009 to 2012 Week 18); and EBSCO CINAHL (2009 to May 2 2012). No date or language restrictions were applied.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of topical agents or dressing for the treatment of pain in venous ulcers were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed trial selection, data extraction and risk of bias assessment.

MAIN RESULTS

Six trials (343 participants) evaluated Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream for the pain associated with ulcer debridement. The between-group difference in pain measured on a 100 mm scale was statistically significant in favour of EMLA (MD -20.65, 95% CI -12.19 to -29.11). No significant between-group differences in burning or itching were observed.Two trials (470 participants with venous leg ulcers) evaluated ibuprofen slow-release foam dressings for persistent venous leg ulcer pain. Compared with local best practice, significantly more participants in the ibuprofen dressing group achieved the outcome of >50% of the total maximum pain relief score between day 1 and day 5 than participants in the local best practice group (RR 1.63, 95% CI 1.24 to 2.15). The number needed to treat was 6 (95% CI 4 to 12). In the second trial, compared with an identical non-ibuprofen foam dressing, there was no statistically significant difference in the proportion of participants experiencing slight to complete pain relief on the first evening of treatment.Limited data were available to assess healing rates or adverse events.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that ibuprofen dressings may offer pain relief to people with painful venous leg ulcers. EMLA (5%) appears to provide effective pain relief during the debridement of venous leg ulcers. Further research should consider standardised pain assessment methods and assess both the effect on ulcer healing and the impact of long term use of these treatments.

Experiences of living with intermittent claudication

Intermittent claudication is a symptom caused by peripheral arterial disease (PAD) and is associated with pain, impaired mobility and loss of control. Walking ability is reduced due to the pain, and both physical and social functions are often negatively affected, which may lead to patients feeling they are a burden to others. An interview study using a qualitative descriptive design to describe experiences of living with intermittent claudication caused by PAD was carried out during Winter and Spring 2009/2010. Fifteen people suffering from intermittent claudication were interviewed, and the interviews were analyzed using qualitative thematic analysis. Intermittent claudication greatly affects daily living. Six themes were identified: "Experiencing discomfort in the legs," "Moving around in a new way," "Feeling inconvenient when forced to stop," "Missing previous life," "Incorporating intermittent claudication in daily life," and "To lead a strenuous life." The main theme was "Adjusting to a restricted life." The findings show that intermittent claudication has a major impact on daily life. Apart from the severity of symptoms, how the illness is experienced differs among patients, depending on how active the ill person is or wants to be. These findings suggest that increased knowledge about living with intermittent claudication is important to understand the effects on the ill person's life, as a complement to physical examinations when planning individual treatment.

Health-related quality of life in patients with peripheral arterial disease undergoing percutaneous transluminal angioplasty: a prospective one-year follow-up

Measuring Health Related Quality of Life has become more and more important in evaluating patients with peripheral arterial disease. This prospective longitudinal survey aimed to investigate health related quality of life over time in patients with peripheral arterial disease (PAD) undergoing percutaneous transluminal angioplasty (PTA) between December 2005 and June 2008. Health Related Quality of life was assessed using the Claudication Scale (CLAU-S) and EQ5D and the Sense of Coherence Scale was used to estimate the patients' sense of coherence. The findings of this study shows that the total CLAU-S score was improved both at one-month follow-up (p < 0.0001) and one-year follow-up (p < 0.0001) compared to baseline. There were significant differences regarding all five dimensions: every day life, pain, social life, illness-specific fears and psychological wellbeing. The EQ5D computed by index improved significantly both at one-month follow-up (p = 0.0006) and one-year follow-up (p = 0.0019) compared to baseline. Differences were found between the groups with low and moderate sense of coherence (p = 0.0169) as well as between the groups with low and high sense of coherence (p = 0.0208) regarding health related quality of life (HRQoL). This study showed that PTA improves HRQoL among individuals suffering from PAD and that the effect is sustainable over time. For more accurate results, a disease-specific instrument should be used to evaluate HRQoL.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1 per cent of people at some time in their lives. The main treatments are compression bandages and dressings. As these ulcers are often painful some clinicians choose particular dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes.

OBJECTIVES

To assess the effectiveness of dressings, local anaesthetics or topical analgesia for pain relief in venous leg ulceration.

SEARCH STRATEGY

For this update the search strings were revised and the following databases were searched: The Cochrane Wounds Group Specialised Register (Searched 16/12/09) The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 50; EBSCO CINAHL - 1982 to December 16 2009. No date or language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials which evaluated local interventions used to relieve venous leg ulcer pain were considered. Pain was defined as either persistent pain or pain at dressing changes or debridement. Ulcer healing and reported adverse events were also considered as further outcomes.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two review authors who independently assessed the potential trials.

MAIN RESULTS

Two trials evaluating interventions for persistent venous leg ulcer pain were identified for this review update. Both studies evaluated ibuprofen slow release foam dressings; one comparing it with local best practice and the other with an identical foam comparator. The primary end point for both studies was "pain relief achieved". When compared with a foam dressing alone, there was no evidence of a statistically significant effect of the ibuprofen foam dressing in terms of achieving some pain relief the first evening after treatment: 74% in the ibuprofen group (46/62) had pain relief compared with 58% (35/60) in the foam group (no significant difference: RR 1.27, 95%CI 0.98 to 1.65). In the second study 100% (32/32) of people with venous ulcers achieved some pain relief with the ibuprofen dressing on the first evening of treatment compared with 93% (26/28) in the local best practice group (no significant difference: RR 1.08, 95% CI 0.96 to 1.21). Pooling these studies in a meta-analysis (using a random effects model as significant heterogeneity present (p=0.1), I(2) = 64%) there is no evidence that ibuprofen dressings increase the pain relief experienced by the first evening of use (RR 1.15, 95% CI 0.91 to 1.44). We were not able to extract sufficient data to combine other pain outcomes from these trials. There was no difference in healing rates but slightly more adverse events with ibuprofen dressings than with a similar foam dressing without ibuprofen.Six trials evaluated interventions for the pain associated with debridement and were considered sufficiently similar to pool. There was a statistically significant reduction in debridement pain scores with 5% Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream; the difference in means (measured on a 100 mm scale) was 20.6 mm (95% CI 12.19 to 29.11). Of these six trials, only one small trial measured healing as an outcome and found no difference in the numbers of ulcers healed at the end of the study.

AUTHORS' CONCLUSIONS

There is no evidence that ibuprofen dressings offer pain relief, as measured at the first evening of use, to people with painful venous leg ulcers compared with foam dressings or best practice.EMLA appears to provide effective pain relief for venous leg ulcer debridement but the effect (if any) of EMLA on ulcer healing remains unknown.

Clinician's perspectives on the treatment of venous leg ulceration

Treatment of venous leg ulcers (VLU) represents a considerable challenge to the health care professional and to the patient alike. Much of the current literature regarding VLU focuses on either wound pathophysiology and treatment of chronic venous insufficiency or the patients' experience of the condition. We present two studies that examine more closely the clinicians' experience of treating VLU and reflect upon how that understanding may further enhance better outcomes for patients in the future. The first of these studies is a qualitative investigation of 49 clinicians treating VLU in the UK and USA. The second is a quantitative, online survey of 304 clinicians' beliefs, attitudes and practices in the UK, Germany and USA. Findings show that the clinicians' experience of treating VLU is often accompanied by frustration and dissatisfaction with treatment challenges and uncertain outcomes. Practices and treatment choices were found to vary widely and differ by countries. We conclude that a key aspect in improving VLU treatment is in listening to the frustrations of the clinician when considering new approaches to therapy.

Qualidade do sono em pacientes idosos com patologias vasculares periféricas

Patologias vasculares periféricas freqüentemente acometem idosos e, sendo crônicas, interferem na qualidade de vida desses indivíduos, inclusive no sono. Portanto, este estudo objetivou avaliar a qualidade do sono de idosos com patologias vasculares periféricas em acompanhamento ambulatorial no Hospital das Clínicas da Universidade Estadual de Campinas. Os voluntários (n=50, idade média de 74 8 anos) responderam ao Índice de Qualidade de Sono de Pittsburgh (PSQI), forneceram dados sociodemográficos e sobre a vasculopatia (35 idosos apresentavam obstrução arterial em membros inferiores). Verificou-se que 34 idosos apresentavam sono de má qualidade. A duração do sono era de 5,8 ( 2,3) horas e, segundo 23 idosos, as dores perturbavam o sono noturno freqüentemente (três vezes na semana ou mais). Somente 18 idosos usavam analgésicos e quatro, medicamentos para dormir. Os achados podem subsidiar o enfermeiro na implementação de medidas para melhorar esse quadro e promover a qualidade de vida das pessoas acometidas.

Dying cancer patients' experiences of powerlessness and helplessness

GOALS OF WORK

Experiences of powerlessness and helplessness are closely linked to incurable diseases but seldom studied in patients with disseminated cancer. The aim is to explore the perception, experiences and significance of powerlessness and helplessness, to study triggering factors and to make quantifications.

MATERIALS AND METHODS

One hundred three patients, enrolled in four different palliative home-care settings, completed a questionnaire with both Likert-type questions and open-ended questions. The response rate was 58%, and background data was reported as frequencies, whereas the main material was analysed using a qualitative content analysis.

MAIN RESULTS

Impending death, symptoms, loss of control and autonomy, ignorance, isolation and uncertainty constituted the basis for powerlessness and helplessness, but each factor was reinforced by the occurrence of suddenness, high intensity and/or lengthiness. In total, 65% reported definite experiences of powerlessness and helplessness. These feelings also held a deeper meaning, involving aspects such as existential loneliness and hopelessness. They were ultimately caused by an incapacity to control feelings and cope with the situation related to the impending death. The results are discussed in relation to Cassel's theory of suffering and existential psychology.

Being in pain: a phenomenological study of young people with cerebral palsy

This study explored the experience and impact of chronic pain on the lives of adolescents and young adults with cerebral palsy (CP). Six participants with CP (four males, two females; age range 14-24y) who were known to experience chronic pain participated in individual in-depth interviews. Five participants had quadriplegia and used wheelchairs; one had left hemiplegia and walked independently. Pain was located in the hips, back, bladder, and upper limbs. Interviews were analyzed using a six-step phenomenological process. Participants in the study were found to live with constant pain that was difficult to relieve and pervaded their lives. They often felt isolated and became frustrated due to their loss of independence and inability to participate in activities. Participants indicated the importance of having their experience of pain acknowledged, supporting the need for greater attention to ongoing holistic management. Further research into effective interventions may enable increased activity participation and prevent later chronicity.

The long-term experience of living with peripheral arterial disease and the recovery following revascularisation: a qualitative study

BACKGROUND

The long-term experience of living with peripheral arterial disease (PAD) and the durability of improvements after revascularisation are sparsely described in the literature. The primary goals of medical treatment and nursing care for PAD are to provide relief of symptoms, improve quality of life, and prevent the progression of arterial disease and cardiovascular complications. The majority of patients are elderly with a significantly increased risk of myocardial infarction, stroke, and cardiovascular death. Which can limit mobility and functional status even in the absence of ischaemic claudication, rest pain, or ulceration after a successful revascularisation.

OBJECTIVES

To illuminate the long-term experience of living with PAD and the recovery following revascularisation.

METHODS

Fourteen patients were interviewed 6 months and 212 years after revascularisation. The transcribed texts were analysed using manifest and latent content analysis.

RESULTS

The long-term experience of living with PAD meant gradually becoming aware of having a chronic disease. This was interpreted through the following themes, representing the transition from being in an acute phase of PAD to the recovery after revascularisation and entering a chronic phase of PAD: (I) 'becoming better but not cured'; (II) 'recapturing control over life'; (III) 'reappraising meaning in life'.

CONCLUSIONS

Becoming aware of having a chronic disease results in a need to adapt to and accept permanent restrictions in daily life. The findings showed that revascularisations offer several benefits. However, when PAD symptoms were relieved, other ailments became discernable, which reflects the complex course of PAD and atherosclerotic disease. Moreover, several critical points and events such as other concurrent diseases, unrealistic hopes for recovery, and the complex course of PAD and atherosclerotic disease complicated the transition process towards health and well-being.

Patients’ experiences of living with peripheral arterial disease awaiting intervention: a qualitative study

The aim of this study was to investigate patients' experiences of living with peripheral arterial disease (PAD) and the influence on activities of daily living. Twenty-four patients with various degrees of PAD were interviewed. The transcribed texts were analysed using manifest and latent content analysis. Living with PAD meant carrying a hard-to-bear physical, social and emotional burden, and struggling for relief. The experience of burden was interpreted in the following themes representing consequences and strategies for gaining control in daily life: (I) "being limited by the burden" (II) "striving to relieve the burden" (III) "accepting and adapting to the feeling of burden". The use of different coping strategies was crucial to achieve some relief. Pain and sleep disturbance emerged as a major feature of living with PAD, and by combining both analgesics and non-pharmacological methods some pain relief was received. To provide optimal alleviation of pain for these patients, education about pain and pain management is of great importance followed by regular evaluations of the pain and pain management. Furthermore, the study underlines the importance of preventing the progression of the vascular disease and from the individual power and knowledge support and preserve as independent life as possible.

Antiphospholipid antibody thrombosis. Another source of chronic wounds

Antiphospholipid antibody thrombosis syndrome is currently not well known and probably underdiagnosed. The risk it presents for recurrent thromboembolism is both life threatening and chronic. Because patients often develop long-standing wounds, it is important for the wound care nurse to identify clients suspect for the disease. Several theories exist speculating on the mechanism of thrombosis involving antiphospholipid antibodies, and each focuses on changes at the interface between the vessel, cell wall membrane, and its interaction with circulating antibodies. As wound care nurses, we should consider antiphospholipid antibody thromboses whenever encountering a recalcitrant wound without obvious underlying cause. Thrombosis can occur anywhere, although 41% of presentations are cutaneous. Recurrent deep vein thrombosis with coexisting venous insufficiency can lead to a missed diagnosis of antiphospholipid thrombosis syndrome, despite evidence of pain and tissue necrosis that is typical of the disease. In any event, long-standing nonhealing wounds are always a signal to revise a diagnosis and seek alternative causes for failure of healing.

How living with a leg ulcer affects people's daily life: a nurse-led study

OBJECTIVE

This descriptive phenomenological study explored patients' experiences of living with a leg ulcer.

METHOD

Eight participants (five female and three male) were recruited from a secondary care leg ulcer clinic in a large UK teaching hospital. All had current venous leg ulceration, lasting between five months and 34 years. Data collection was via in-depth semi-structured interviews. Data categories were: symptoms; treatment; perceptions, emotions and coping strategies; and restrictions.

RESULTS

Leg ulcers have a significant impact on individuals' lives. The degree to which this occurs varies between each person.

CONCLUSION

Patients need consistent treatment that incorporates benchmarking. A support network to address the needs of those living with a leg ulcer should be considered. This study's findings should be promoted to raise awareness among health-care professionals, enabling them to provide more responsive care.

Patients with non-malignant disease deserve an equitable service

Palliative care has often challenged the status quo. With the wider health agenda focused on technology, cure and waiting lists, palliative care has strongly supported and valued quality care of the dying, the patients agenda and multidisciplinary working. Yet when faced with the new frontier of palliative care in non-malignant disease, the palliative care movement seems cautious, perhaps even daunted.

Foot impulse technology in arteriovenous disease

A review exploring the use of a mechanical impulse system in patients with chronic venous and/or arterial insufficiency.