2009

Background

Malnutrition is defined as state of nutrition in which there is a deficiency or excess of energy, protein and other nutrients causing measurable adverse effects on tissue/body form, function and clinical outcome. (1) It is recognised that 30% of in-hospital patients are malnourished (undernourished) on admission and the majority of these will lose further weight while in hospital. (2) In this review article the term undernutrition will be used instead of the generalised term malnutrition. Undernutrition develops due to increased losses (vomiting, diarrhoea, malabsorption), decreased intake (anorexia, vomiting, nausea, dysphagia), increased requirements (catabolic state) or a combination of all these processes.

 
Is undernutrition important?
 
Consequences of undernutrition include reduced muscle mass, impaired immune function, poor tissue viability, poor clinical outcome and psychosocial effects. (3) Reduced muscle mass decreases cardio-pulmonary function, lean muscle mass and muscle weakness. Impaired immune function increases infection and sepsis risk. Poor tissue viability can cause pressure sores and poor wound healing. Undernutrition can amplify the length of hospital stay. Psychosocial effects include altered mood and poor quality of life. (4)  It is therefore essential that undernutrition is properly treated to diminish patient morbidity and mortality.
 
How to recognise undernutrition:
 
1. Malnutrition screening tools
 
Screening tools should be performed easily with low-level staff training. Hospital patients at risk of undernutrition are identified by screening methods such as MUST (Malnutrition Universal Screening Tool) (5), SGA (Subjective Global Assessment) (6) or MNA (Mini Nutritional Assessment – validated for > 65 years) (7). These screening methods usually consider current body mass index (BMI), recent weight loss and possible future weight loss.   MUST is currently well advertised as a nutritional screening tool within UK hospitals. The British Association of Parenteral and Enteral Nutrition have endorsed this 5 step-screening tool. The MUST score (low, moderate, high risk) has been shown to correlate with mortality (low risk group 8% vs. high risk group 32%, p 0.01) and length of hospital stay (low risk group 15 days vs. high risk group 28 days, p 0.02) (8).   See Table 1.

 
Table 1

2. Assessment of nutritional status:

 
If a patient is found to be at risk of undernutrition, following screening, then a formal nutritional assessment ensues. This assessment involves anthropometrics, biochemical testing, clinical methods and dietary history.
a) Anthropometrical data: appropriately trained staff can perform weight, height, waist circumference, mid-upper arm circumference and skinfold thickness measurements. Indices can subsequently be calculated. These include percentage weight loss, BMI and waist-hip ratio.
b) Biochemical data: information acquired from blood testing includes renal function as a marker of hydration. Also sepsis markers including CRP, ESR and WBC’s are valuable surrogate markers for stress response.  Albumin is a poor marker of nutritional status. (9)
c) Clinical: medical history including past and present is valuable. It is essential to obtain plans regarding fasting for investigations. Knowledge of current treatment that may cause decreased intake or increased losses is essential.    
d) Dietary History: there are assorted techniques of obtaining dietary history. Mostly recall, record diary and food frequency questionnaires methods are utilised.
The overall nutritional assessment entails considering all the information obtained from these different methods. Subsequently a clinical decision is reached regarding the overall nutritional status. 
 
How to assess nutritional requirements:
 
In-patient energy requirements are calculated using a combination of: 
a) basal metabolic rate equations such as Schofield, Harris Benedict and Ireton Jones
b) stress factors or weight gain/loss
c) combined factor for activity level and diet induced thermogenesis. 
The basal metabolic rate is typically calculated using the Schofield equation (10). Schofield estimates basal metabolic rate of a healthy individual. An adjustment is then made for stress or weight gain/loss. Stress factors have been published for various clinical conditions including brain injury, infection, pancreatitis and surgery. Finally a combined factor (activity and diet-induced thermogenesis) is added to calculate total energy requirements. This combined factor is adjusted depending on patient mobility.   Community patient’s energy requirements are calculated using a separate method. Occupational and non-occupational activity is estimated to determine a physical activity level which is multiplied by basal metabolic rate to achieve overall energy requirements.   
Nitrogen/protein requirements are estimated using current patient clinical state i.e.   hypermetabolic, depleted or normal state. Normal state nitrogen requirements are 0.14-0.20 g/kg/day. Depleted state patients nitrogen requirements are 0.20-0.40 g/kg/day. (1g nitrogen = 6.25g protein)
 
Methods of treating undernutrition
 
Following identification of undernutrition a patient’s treatment can be instituted. Undernutrition is typically treated using a graded stepwise approach and subsequently monitoring response. If however it appears clinically obvious that the first steps would not be advantageous then treatment can be commenced at a more aggressive phase. Improving energy intake using the following methods can treat undernutrition:
Step 1. Increase frequency and quantity of food intake. Consider nutrient dense foods. Encourage foods that are energy and nutrient dense such as meat, fish, cheese, eggs, dairy produce and snack foods.   
Step 2. Increase nourishing drinks including milk based drinks, soups, fruit juices and sugary drinks. Nourishing drinks are simple to make and can provide high calories in a small quantity. 
Step 3. Food fortification. This essentially increases the energy density of foods by adding high-energy components such as addition of cheese, milk powder, cream, jam and butter to other foods.
Step 4. Supplements. These can be milk, yoghurt or juice based. They contain varying calories (1-2kcal/ml) and protein (4-6g protein/100ml). Supplements are very useful at boosting energy intake. Most are nutritionally complete but others contain calories only. Examples include Ensure Plus, Fortisip, Calogen and Calshake. 
Step 5. Enteral feeding. Enteral feeding is used to provide either supplementary or complete nutrition to patients that are unable to maintain adequate nutrition by oral route. It is only likely to benefit malnourished patients or those at risk of malnutrition. This includes patients that have had a failed trial of diet modification or supplementary feeds or patients at pulmonary aspiration risk from oral nutrition.
Step 6. Parenteral nutrition. The development of parenteral nutrition in the 1960’s meant that feeding was possible even in patients that did not have a functioning gastrointestinal tract. Although it is mentioned in this article as a final step in nutritional support it may also be appropriate to use early depending on clinical scenario. 
 
Enteral versus Parenteral feeding
 
Enteral feeding produces gastro-intestinal luminal contents that can decrease the possibility of gut atrophy. Maintaining a normal intestinal mucosa reduces the hazard of bacteria and toxins crossing the gastro-intestinal wall and therefore can decrease proinflammatory mediator levels. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. (11) Hernandez et al have shown that enteral feeds decrease gut mucosal atrophy in critically ill patients. (12) A meta-analysis has shown that in acute pancreatitis use of EN was associated with a significant reduction in infectious morbidity, hospital length of stay, and a trend toward reduced organ failure when compared with use of parenteral nutrition. (13) However it is important to note that many of the studies involving parenteral nutrition had full dose daily calorie intake whereas enteral feeding studies were less likely to reach estimated energy requirements. This is significant since ill stressed patients should not be given full calorie energy requirements in the first 24-48 hours of commencing feeding. Therefore the parenteral feeding groups were disadvantaged in that the patients were overfed initially and received excess energy calorie intake.   National Institute of Clinical Excellence states that parenteral nutrition is only to be used in patients with “inadequate or unsafe oral and/or enteral nutritional intake and a non-functional, inaccessible or perforated (leaking) gastrointestinal tract.”  (14) Enteral nutrition can be provided by a number of methods including nasogastic tubes, nasojejunal tubes, gastrostomy tunes (including PEG tubes) and jejunostomy tubes (including PEG-J and D-PEJ). Parenteral nutrition can be given peripherally for approximately 14 days but central access should be used if greater than 14 days. 
 
Refeeding syndrome
 
Refeeding syndrome is a potentially lethal condition with severe electrolyte and fluid shifts with resulting metabolic disturbances in malnourished patients. (15) It is caused by refeeding in malnourished patients with resulting insulin release and intracellular movement of potassium, phosphate and magnesium and increased thiamine uptake. It is essential that patients are correctly identified (See Table 2) and electrolytes corrected and intravenous Vitamin B and C is given. Feeding should be initiated slowly. Fluid balance and electrolytes should be monitored closely.

 
Table 2

Cardiovascular disease and nutrition

 
Research has confirmed link between cardiovascular disease and serum cholesterol.  The NHANES II data has shown that patients who died form myocardial infarction had increased cholesterol. (16) Hooper et al confirmed that dietary fat is linked to cardiovascular risk. (17) This group demonstrated that decreasing total dietary fat over 6 month period reduced cardiac events by 16%. The Seven Countries Study illustrated that cardiovascular mortality was linked to saturated fat intake. (18)
There has been recent interest in the role of the Mediterranean diet in the prevention of cardiovascular disease. (See Table 3)  
 

Table 3

Patients were previously educated regarding low fat diet benefits but Mediterranean diet appears to have enhanced beneficial effects. There is however some complexity with definition of a Mediterranean diet. The diet is based on dietary patterns of Greece, Crete and Southern Italy in 1960’s. This diet was abundant in plant foods, fresh fruit, olive oil as principal fat source (monounsaturated fatty acid), low red meat intake, fish (polyunsaturated fatty acid) and red wine in low to moderate amounts. In respect to dietary fats the Mediterranean diet is low in saturated fat but high in monounsaturated fatty acid and polyunsaturated fatty acid. 
 
Diabetes and nutrition
 
The diabetic diet is essentially a healthy diet. The total fat intake should be less than 35% with saturated fat less than 10%. Total monounsaturated fatty acid 10-20% and polyunsaturated fatty acid less than 10% which corresponds to oily fish 1-2 per week. Interestingly polyunsaturated fatty acid supplements should be avoided in this group as they have been shown to increase LDL-cholesterol. Diabetic patients should also be encouraged to eat regular starchy carbohydrate, avoid sugar, increase fibre, eat regular meals and snacks and avoid diabetic foods.
 
Cancer and nutrition
 
Is there a link between diet and cancer?
 
The World Cancer Research Fund states that 30% of all cancers could be prevented by a change in diet, increased physical activity and healthy weight. Animal studies and metabolic studies have been performed that reveal evidence linking diet and cancer. An ecological study linking diet and cancer compared risk of cancer against intakes of fat, cereals and vegetables in 39 countries (19). The ATBC was a clinical trial that related Vitamin A and E to increased lung cancer rates. (20) 2 large cohort studies have been performed in relation to colorectal cancer and dietary fibre. (21, 22). EPIC showed a significant benefit of dietary fibre against colorectal cancer. The EPIC data showed a 40% difference in colorectal cancer rates between the lowest and highest quintile dietary fibre groups. NIH-AARP however showed no benefit when adjusted for multivariate analysis. The American Gastroenterology Association suggest that available evidence form animal, epidemiological and interventional studies does not unequivocally support protective role of fibre against development of CRC. However the whole body of evidence is analysed overall the overall conclusion is that there is an inverse relationship between dietary fibre and CRC.
 
Cancer cachexia
 
Cancer cachexia is defined as anorexia, weight loss and muscle wasting, fatigue and weakness in a cancer patient. Cancer instigates an inflammatory response and production of tumour products. This triggers metabolic abnormalities that produce lipolysis, protein loss and anorexia. As with all disease processes the dietary management of cancer cachexia is initiated by a nutritional assessment. Any symptoms including vomiting and nausea should be treated. There has also been some research regarding fish oils and cancer cachexia. One available product contains docosahexaenoic acid, eicosapentaenoic acid and antioxidants. However a Cochrane review has shown no benefit in relation to beneficial effects of fish oils and cancer cachexia. (23)
 
Critical care
 
Injury and sepsis cause major disturbance to clinical state. There is rapid weight loss, increased metabolic rate, protein losses and sodium retention. There are also changes in hormone levels including increased insulin, catecholamines, growth hormone, glucagons and cortisol. The energy requirements in critical care can vary greatly.   The Ireton-Jones equation is often used to calculate energy requirements in the critical care setting (See Table 4).
 

Table 4

 
The specific immune modulating aspects of nutrients have been widely researched in the critical care setting. This field of immunonutrition has shown disparaging results.
 
Arginine has been investigated as an immune modulating nutrient. Arginine levels can increase or decrease in relation to clinical state. It produces nitric oxide that can lower blood pressure and has been revealed to have detrimental effects in critically ill patients. (24) Glutamine is another possible immune modulating nutrient. It has lots of metabolic functions. It enhances heat shock protein that protect against sepsis. It is thought to be useful in septic shock. Omega-3 fatty acids (alpha-linolenic acid, docosahexaenoic acid, eicosapentaenoic acid) have also been investigated as an immune modulating nutrient. Omega-3 fatty acids produce less proinflammatory eicosanoids than omega-6 fatty acids. There is some evidence that omega-3 fatty acids decrease duration of hospital stay (25) Antioxidants have also been researched as an immunomodulator.   Antioxidant levels are lower in critically ill patients. Vitamins A,C,E and Selenium have been studied. A recent meta-analysis has suggested overall mortality benefit but no septic complications benefit in anti-oxidant trials. (26)
 
Gastrointestinal disease and nutrition
 
Liver disease
 
The energy requirements in chronic liver disease are dependent on clinical state i.e. compensated or decompensated. Nutritional requirements for compensated liver disease are 25-35 kcal per kg (dry body weight) day and protein 1.2g per day. Nutritional requirements for decompensated liver disease are energy 35-45 kcal per kg (dry body weight) day and protein 1.5grams per day.
 
Porto-systemic encephalopathy
 
This disease process is multifactorial and comprises increased ammonia levels, increased aromatic amino acids, decreased branched chain amino acids and alterations of brain neurotransmitters. There is a widely held belief among doctors that protein intake should be restricted but this is mistaken.   Protein requirements are approximately 1g/kg/day and should be divided throughout day.
 
Ascites
 
Low salt intake (<6g per day) is an essential component of ascites treatment. Advice should include no salt in cooking, no added salt, avoid processed foods, and avoid foods rich in salt.  
 
Inflammatory Bowel Disease
 
Inflammatory bowel disease patients are often undernourished due to meagre intake (anorexia, vomiting), amplified losses (diarrhoea and malabsorption) and increased demands (catabolic state). Protein requirements are also increased due to nitrogen losses and catabolic state. It is therefore important that nutritional measures are instituted to improve calorie and protein intake. Interestingly nutrition has been investigated as a treatment for active Crohn’s Disease. Elemental diet is used in active paediatric Crohn’s Disease more than adult Crohn’s Disease to achieve remission. (27). Often this has to be given via naso-gastric tube due to unpalatability. After 4-6 weeks if the patient is in remission foods are introduced slowly over a 3-week period. 
 
Coeliac Disease
 
Coeliac disease is genetically determined chronic inflammatory disease secondary to gluten (glaidin is the alcohol-soluble fraction) that is a component of wheat. In addition the allergy involves similar proteins found in barley, rye and possibly oats. Coeliac patients consequently exclude these dietary sources. Oats can be reintroduced later depending on response. Dietary sources can be obvious or hidden as gluten can be found in numerous manufactured foods. Coeliac patients can however eat natural gluten-free foods or gluten-free proprietary foods (e.g. Schar, Juvela, Dietary Specials, Glutafin).
 
Irritable Bowel Syndrome
 
Simple healthy eating advice is suggested. Diet is tailored to either constipation or diarrhoea symptoms. Typically increasing dietary fibre gradually ameliorates constipation symptoms. Soluble fibre appears to offer benefit more than non-soluble fibre. Decreasing dietary fibre intake treats diarrhoea symptoms. There is not enough evidence regarding exclusion diets although some centres do offer exclusion diets. 
 
Renal disease
 
Acute renal failure and nutrition is divided into non-catabolic and catabolic patients. Non-catabolic patients do not usually have increased energy requirements. Catabolic patients have high protein requirements but no benefit of >0.2 g nitrogen per kg per day. Their energy requirements should be no greater than >20% above resting energy expenditure. 
 
Chronic kidney disease patients have estimated energy requirements of 35 kcal/kg/IBW/day. (IBW = Ideal Body Weight which in the UK this approximates to BMI 23kg/m2). There has been much research regarding protein restriction and possibility of slowing progression of chronic kidney disease. The Northern Italian Co-op study (protein <0.6grams/day) did show possible slower progression of CKD. However it is known that low protein diets have poor compliance and can increase risk of malnutrition. The Renal Association Standards suggest protein intake 0.75g/kg/IBW/day. 
 
Discussing the dietary management of end-stage renal disease, nephrotic syndrome and renal stones is beyond the scope of this article.
 
Conclusion
 
This review article has highlighted the importance of undernutrition in patients under our care. There are numerous methods of screening and assessing patients for undernutrition. There is also a stepwise approach to improving calorie intake: improving oral intake by various methods to enteral and parenteral nutrition. Nutrition is an important aspect of treatment of different disease processes that include cardiovascular disease, diabetes, gastrointestinal disease, renal disease, critical care and cancer.  This review article will hopefully provide the medical practitioner with improved knowledge that can be translated into improved awareness and treatment of undernutrition.
 

INTRODUCTION:

% =Percentage,     n= Individual type of sample,  N=Total number of sample,      AK= Amikacin (R =>22 mm),    CRO= Ceftriaxone (R=>21 mm),     CTX=Cefotaxime (R=>22 mm),    SCF= Sulzone (R= > 20 mm) (Cefapeozone+Sulbactum), MEM=Meropenam (R= >18 mm), CIP=Ciprofloxacin (R= > 21mm),     FOS=Fosfomycin (R= > 18mm ),    µgms= micro grams, S= sensitive

Introduction:

Bronchogenic cysts are lesions of congenital origin derived from the primitive foregut. They form due to ectopic budding of the foregut during the first trimester. Epithelial cells of the developing trachea and lung are pinched off and grow separately from the airways. Bronchogenic cysts are most commonly mediastinal, unilocular and contain clear fluid. Clinically, most cysts are symptomatic and occur in infancy or early childhood. Respiratory distress is the most common presentation in paediatric patients, manifested by recurring episodes of cough, stridor, and wheezing.  Patient Description: A 13-year-old female presented with a two month history of right-sided back pain and five days of intermittent fever. The pain was worse on inspiration and made sleeping difficult. She denied wheezing, chest pain, or cough. She continued daily participation in competitive sports. Previous trials of antibiotics and an inhaled bronchodilator for presumed exercise-induced asthma were unsuccessful. Chest x-ray (CXR) showed a large cyst (10x10x8 cm³) in the posterior right lung. (Image 1).  Image 1: Initial chest x-ray revealing bronchogenic cyst in the posterior right middle lobe (10x10x8 cm³) Computerized tomography (CT) scan showed a large cystic lesion arising entirely within the right lower lobe and extending the width of the hemithorax. (Image 2)   Image 2: Chest CT shows bronchogenic cyst extending the entire width of the right hemithorax and approximately 50% full of fluid. There was an air-fluid level occupying ~50% of the cavity. She was diagnosed with a multilocular bronchogenic cyst. She was briefly hospitalized and discharged on azithromycin with plans to resect the cyst in one month.  Severe cough, fever, and chills prompted readmission after 3 weeks of antibiotic therapy. CXR and CT showed cyst enlargement (16x9x11 cm³) with over 95% fluid. (Images 3 and 4)   Image 3: Substantial bronchogenic cyst (16x9x11 cm³), over 95% full of fluid.   Image 4: Lateral chest x-ray revealed opacification along superior margin of cyst. She was started on ampicillin/sulbactam. Percutaneous drain placement yielded a large volume of turbid fluid. Aerobe, anaerobe and fungal studies of the fluid were negative. Resection was postponed due to significant inflammation surrounding the cyst cavity. She was discharged on a seven day course of amoxicillin/clavulanate. Following six weeks of cyst drainage, a thoracoscopic right lower lobectomy was performed. Extensive inflammation and induration made dissection of the lower lobe and pulmonary vessels challenging. Fibrinoid adhesions extended to the pleural surface. Operative time was 418 minutes.  Surgical pathology showed diffuse necrotizing granulomatous inflammation with acid-fast bacilli and multiple nodules up to 3.3 cm in diameter. Ninety-five percent of the pleural surface had nodular involvement. (Image 5) Areas of non-indurated lung also showed small nodules with a miliary appearance. Inflammation was present at the bronchovascular margins, hilar nodes, and distal lung.   Image 5: Gross specimen of right lower lobe: Approximately half of the lobe was indurated and 95% of surfaces showed nodular involvement. Sectioning through indurated region revealed diffuse nodules up to 3.3 cm. Nonindurated lung showed small nodules with miliary appearance. The patient had no history of tuberculosis exposure, foreign travel or immunodeficiency. There was no family history of tuberculosis or respiratory disease. Based on the acid-fast bacilli identified on pathology stain, fluid drained from her chest tube was sent for acid-fast bacilli culture and smear. Mycobacterium was not isolated. It was determined that the source of the atypical mycobacterial infection was likely colonizing mycobacteria from her oropharynx that became entrapped in the cyst. A six-week course of clarithromycin, rifampin, and ethambutol was prescribed to treat any remaining organisms.  At two-month follow-up, she had minimal pulmonary symptoms and inflammatory markers were improved. Erythrocyte sedimentation rate (normal: 0-15) and C-reactive protein level (normal: 0-10) decreased from 88 and 173 during her hospitalization, to 10 and 3.6, respectively. At four-month follow-up, she had resumed competitive sports and had no evidence of ongoing infection.  Discussion: This case highlights a unique presentation of infected bronchogenic cyst after substantial cyst growth. Unusual aspects include the late onset of symptoms, multilocular intraparenchymal cyst appearance, turbid drainage, extensive nodularity, necrotizing granulomatous inflammation, and atypical Mycobacterium infection. Although comorbid infection is not uncommon, causative organisms are typically Haemophilus influenzae^1,2 and Streptococcus pneumoniae.³ Cases of Streptococcus pyogenes,⁴ Escherichia coli,⁵and Salmonella enteritidis⁶have been reported. However, only four cases of bronchogenic cyst with Mycobacterium infection have been documented.^7,8,9 Three of the Mycobacterium-infected cases are adult patients. Lin et. al reported a 39-year-old female with bronchogenic cyst complicated by Mycobacterium avium infection.⁷ The organism was identified by genetic sequencing of biopsied lung tissue. Sputum acid-fast stain and mycobacterial cultures were negative. Liman et al. reported two adult cases: a 20 year-old male with Mycobacterium identified in a right lower lobe specimen but with negative sputum culture, and a 32 year-old female with Mycobacterium isolated in a sputum culture but a negative microscopic exam and cyst fluid culture.⁸  The only documented paediatric case, a 9 year-old female with a 6 cm right lower lobe bronchogenic cyst, was reported by Houser et al.⁹ She underwent lobectomy; Kinyoun stain of the cyst specimen showed Mycobacterium. Sputum culture and acid-fast bacilli stain were negative. Tuberculin skin test was positive. Comorbid infection with Mycobacterium tuberculosis was suggested, but they were unable to isolate an organism. Treatment consisted of four months of rifampin and two years of isoniazid with pyridoxine.  This is the first documented paediatric case of bronchogenic cyst infected with atypical Mycobacterium. Her presentation is noteworthy, given the substantially greater size of the cyst (16x9x11 cm), extensive pathologic findings, and success with a different antibiotic regimen. 

Bronchogenic cyst should be included in the differential diagnosis of a child with cough, dyspnoea, and fever. Although rare, we stress the importance of keeping mycobacterial infection in mind in cases of an infected cyst. Acid-fast culture should be done on sputum and cyst contents. Due to the frequency of negative cultures, stains should also be performed on resected cyst specimens. Antibiotic therapy should be considered and administered based on the extent of infection. All symptomatic or enlarging cysts warrant surgical excision. Prophylactic removal of asymptomatic cysts is recommended due to higher rates of perioperative complications once cysts become symptomatic.¹⁰ We raise the question of whether earlier CXR is indicated to rule out bronchogenic cyst, particularly when patients do not improve after trials of watchful waiting, antibiotics, and bronchodilators for other possible respiratory diagnoses.

Introduction Dysmenorrhoea and other premenstrual symptoms are common among women of reproductive age and lead to suffering and impact on home, school, and work performance. Earlier studies have focused on the prevalence and risk factors of dysmenorrhoea ^{1, 2, 3}. Surveys in Pakistan have found the prevalence of premenstrual symptoms varying from 53% to 67% in college girls ^{4, 5, 6}. About 57% of students in one study reported that dysmenorrhoea affected their work⁵. Although these surveys document the prevalence and severity of symptoms they do not correlate it with the impact of specific symptoms on daily activities or with healthcare seeking behaviour. A population-based survey of 2262 women from Goa, India, revealed a linear association between pain severity and treatment seeking and time off from work ³. However the impact of specific symptoms of premenstrual syndrome on treatment seeking and rest was not reported. Aims Primary objective: The authors carried out a cross-sectional study to explore the impact of dysmenorrhoea and other premenstrual symptoms among women of reproductive age.Secondary objective: The authors intended to find out the predictors of healthcare-seeking behaviour including self-treatment for premenstrual symptoms. Methodology A cross-sectional survey study design was chosen. A 13-item questionnaire was administered to women, aged 16 to 50, who were not pregnant and had no known gynaecological, medical, musculoskeletal or neurological diagnosis. Participants were recruited from multiple sites using convenience sampling within urban areas of Islamabad and Rawalpindi in Pakistan. Trained interviewers (physicians, medical students, nursing staff, and high school students) filled out questionnaires interviewing female students at a medical college, a nursing college, and at city schools; as well as housekeeping staff and patients’ attendants at a tertiary care teaching hospital in Islamabad. A proportion of women completed the questionnaire themselves. Ethical approval was obtained from the Shifa International Hospital Ethics committee. No personally identifiable data such as the respondents’ names were recorded. Results Study population characteristics A total of 1236 women from multiple locations within Islamabad and Rawalpindi, Pakistan, participated in the survey. Most of the women were in the younger age groups: 402 women (33%) were 16–20 years old and 622 (50%) were 21–35 years old. Fewer women were in the older age groups: 147 women (12%) were 36–45 years old and 63 (5%) were more than 45 years old. About 55% were unmarried and 61% had no children. The distribution of educational achievement was weighted towards the more educated: 16% were able to read a religious book (basic literacy); 49% had some school education (up to 12th grade); and 34% had professional level education. About 27% of the respondents were homemakers (among women with professional level education, 10% reported staying at home). Age at menarche was less than 12 years old for 16%; between 12 and 14 years for 62%; and more than 14 years old for 23% of the respondents. Severity of dysmenorrhoea and its correlation with premenstrual symptoms On the 10-point visual pain scale, 465 women (38%, 95% CI 35–41) reported mild dysmenorrhoea severity from 0 to 3; 517 women (42%, 95% CI 39–45) reported moderate severity from 4 to 7; and 248 women (20%, 95% CI 18–23) reported severe pain rated from 8 to 10. The linear regression coefficient between dysmenorrhoea severity score and the number of days unable to work in a month was 0.59 (standard error: 0.031). Table 1: Prevalence of premenstrual symptoms and their contribution to pain severity and days lost from work

* Statistically significant values (P < 0.005)^a Respondents were allowed to select more than one option. Total respondents: 1236.^b Linear regression coefficients for a 10-point visual pain score categorized into three levels.^c Linear regression coefficients for self-reported days unable to work in a month. Table 1 shows the prevalence of primary symptoms of preceding menstruation and their contribution to a 10-point visual pain scale and to self-reported days unable to work in a month. Low back pain and headache contributed most to the pain score while headache and swelling correlated with days out of work. Impact of dysmenorrhoea Among the working women (366 professionals and housekeeping staff) 49% (95% CI 44–54) reported one or more days out of work in a month due to pain. Similarly, among the 452 students surveyed, 53% (95% CI 48–58) reported dysmenorrhoea affecting school performance (Table 2).

Table 2: Impact of premenstrual symptoms and dysmenorrhoea on household, school and work performance

Percentages do not add up to 100% as respondents were allowed to select more than one affected domain.Values for 50% or more respondents acknowledging an impact in a domain are given in bold.

Treatment taken for dysmenorrhoea relief 

Table 3 outlines the remedies sought for the relief of dysmenorrhoea symptoms and the reported effectiveness of each type of remedy. All treatments except homeopathic were felt to be effective. Logistic regression analysis showed that the use of any treatment type was related to low back pain (odds ratio 2.2, 95% confidence interval 1.6–2.9), pain severity (OR 2.0, 95% CI 1.6–2.5), headache (OR 1.7, 95% CI 1.2–2.4), depressed mood (OR 1.7, 95% CI 1.3–2.2), increasing education (OR 1.1, 95% CI 1.0–1.2) and not being unmarried (OR 0.52, 95% CI 0.34–0.79).

Table 3: Remedies sought for dysmenorrhoea relief and their patient-reported effectiveness

a Respondents were allowed to select more than one option. Total respondents: 1236.
b Unconditional logistic regression (converged, 6 iterations, 878 cases included, using Epi Info 3.4.3). All odds ratios with P < 0.005, except homeopathic, P = 0.12.[CI, confidence interval]

Conventional medicine was sought by women with higher pain scores (OR 2.2, 95% CI 1.8–2.8) and greater years of education (OR 1.2, 95% CI 1.1–1.3); other factors such as age and specific symptoms were not statistically related. Women with a greater number of days unable to work were more likely to use herbal treatment (OR 1.4, 95% CI 1.1–1.9) while household remedies like hot water bottles and warm drinks were more commonly taken by women with headache (OR 1.66, 95% CI 1.2–2.4), depressed mood (OR 1.6, 95% CI 1.2–2.3) and lesser years of education (OR 0.88, 95% CI 0.78–0.99). Discussion This paper is the first, to the best of our knowledge, to show an association between specific premenstrual symptoms and dysmenorrhoea severity and healthcare-seeking behaviour. We found that certain symptoms, namely low back pain and headache, contributed more to the perceived severity than other complaints. This finding may be of importance to clinicians treating women with menstrual complaints especially when the treatment is symptom-oriented. In women working outside their homes clinicians may wish to target headache and swelling as these symptoms correlated with days unable to work. Prevalence of premenstrual symptoms in the present study was higher than a Japanese survey⁷ that reported back pain in 6.9% of women and headache in 11% of women (compared with our results of 72% and 22% respectively). This difference may be due to cultural differences in perception and reporting of symptoms, overall better health, and being strong and hardworking. It may simply be the perception difference in underdeveloped or developed country i.e. lack of resources, poor diet, and poor health. Menstrual symptoms caused a heavy impact on social, school, and work responsibilities in women, a finding we share with previous studies. A cross-sectional survey from India found that 17% of adolescent girls reported missing school classes due to dysmenorrhoea while 60% reported disruption of their daily activities⁸. In an Australian study, 53% of high school girls reported that dysmenorrhoea limited daily routines and 37% stated that it affected schoolwork⁹. A study from New York found 46% of students missing one or more days of school due to dysmenorrhoea¹⁰. Corresponding figures from the present study were: 62% students reported missing at least one day of school and 53% reported an impact on school performance. The authors would like to reiterate the need for screening for and treating menstrual symptoms because of the impact on daily activities and the potential to reduce avoidable suffering. Women seek a variety of sources for relief of menstrual symptoms. A survey of 2411 high school girls in Malaysia showed that 11% sought medical care although the majority (80%) obtained advice from their mothers regarding premenstrual symptoms¹¹. A study of adolescent girls in Haryana, India, found that 5.3% consulted a physician for menstrual symptoms and 22% self-treated with over-the-counter medicines¹². 52% reported self-treatment and 7.7% used complementary medicines in a Japanese study¹³. In the present study, although conventional medicine was felt to be most effective, it was used by only half of the women. This indicates poor access or awareness of available effective treatments. Even household and herbal remedies were infrequently used possibly due to their limited effectiveness. As menstruation and its associated symptoms are often thought to be a ‘normal’ part of women’s lives these issues may remain untreated in the community. Women who were more educated tended to seek more effective treatments, as did those who had more severe symptoms. Clinicians and public health professionals need to proactively reach women from less privileged background to reduce suffering from menstrual symptoms. Educational campaigns to improve awareness of safe and effective conventional medicine, such as non-steroidal anti-inflammatory drugs, could reach women not aware of these options. These public health campaigns may be addressed toward high-school girls, homemakers, and professionally employed women through separate targeted channels. The present study was limited by non-random (convenience) sampling yielding a study sample skewed towards more educated women. This may be due to sampling in urban areas only. The questionnaire was designed using closed-ended questions, to reduce subjectivity in data recording, limiting exploration of unanticipated variables. Psychosocial issues, such as socio-economic disadvantage and mental health, play an important role in the perception and reporting of menstrual symptoms3 but these factors were not explored in this study. Further research in this area should focus on awareness, access to care, and quality of life outcomes with different treatment options. Conclusion Low back pain and headache contribute the most to severity of dysmenorrhoea while headache and body swelling (fluid retention) were predictive of days unable to work. Conventional medicine is commonly used by more educated women, as well as those with more severe symptoms, and was perceived to be effective more often than other treatment modalities. Effective treatments for the relief of menstrual symptoms remain underutilized causing avoidable suffering.

The surveillance and treatment of Barrett’s Oesphagus remains an area of interest and controversy. This is heightened by the inability to discriminate those patients with BO which are most likely to progress to high grade dysplasia and then to adenocarcinoma of the oesophagus. This places greater emphasis on the endoscopic surveillance programme to identify this potentially pre-malignant state at an early stage. Future advances, particularly in endoscopic techniques, will help to increase efficacy of treatment and minimise complication rates. Further developments include progress in identification of genetic biomarkers which may help elucidate those patients at greatest risk. The management of Barrrett’s Oesophagus is becoming increasingly more important, particularly with the rise in incidence of oesophageal carcinomas in the Western world. The issues to address therefore include the identification and screening of at-risk groups and the further management from diagnosis of BO. Patients with chronic GORD symptoms are most in need of screening. Currently this should include the gold-standard four quadrant biopsy technique. This may include techniques to enhance visualisation as described above. In the authors opinion, non-biopsy screening does not carry enough evidence to support its use in replacement of biopsy as of yet. Medical treatment with PPI (if necessary in high-dose) as well as surgical treatment of GORD are essential considerations in the prevention and treatment of BO. Their use in combination with endoscopic therapy has proven benefits as outlined. Of the endoscopic therapies, the lack of complications combined with excellent post-procedure rates of disease elimination seen with RFA are most encouraging. Oesophagectomy should be reserved for those patients with disease not amenable to conservative or endoscopic therapy.  Continual research is required to help us gain more understanding into the pathogenesis of this condition, enabling us to effectively target and manage BO appropriately.   

Chlamydia Screening In General Practice
Sexually transmitted infections are reaching epidemic proportions in Britain and Chlamydia is the commonest sexually transmitted bacterial infections.
 
Prevalence
Chlamydia is thought to be prevalent in 5-10% of 20-24 years old. About 75% of women and 50% of men are asymptomatic. The National Chlamydia Screening Programme currently finds about 8% of young people tested to be positive ¹ but this may represent selective testing of higher risk individual.
 
National Chlamydia Screening Programme (NCSP)
This was initiated in 2003.The aims & objectives were early detection and treatment of asymptomatic infection, to reduce the onward transmission and to prevent the development of sequelae by screening all sexually active under the age of 25 years annually or with each change of sexual partner.
 
The positive rate for this group in 2008 was 8.7% ¹.
 
An ideal setting to provide screening is General Practice. The nationally agreed target is for 25% of 15-25 years olds-males and females to be screened by 2009/2010 and 35% by 2010/2011.
 
Pathogenesis
Chlamydia is an intracellular bacteria and causes disease by chronic inflammation which is exacerbated by re-infection. It infects the female & male genital tract and is primarily sexually acquired. It can be carried in the throat, thus oral sex can transmit the bacteria.
 
Symptoms
Over 70% of women and 50% of men are asymptomatic.
 
Women may experience:
•  post coital or inter- menstrual bleeding
•  pelvic pain
•  dysuria
•  increased vaginal discharge
•  P.I.D with infertility (10-40% incidence)
 
Men may experience:                      
•   urethral discharge
•   dysuria
•   epididymo- orchitis
•   urinary frequency
 
Symptoms in both men and women:
•   rectal discharge
•   rectal bleed following rectal infection
•   pharyngeal infection - rare.
 
History
Early diagnosis and treatment will reduce the risk of long term complications. A detailed history of following should be taken-
1) History of discharge-Enquire about:
•   colour & consistency of the discharge
•   odour
•   is it aggravated by sexual intercourse
•   any associated itching
•   when was it first noticed
•   any past history of the discharge
•   was it diagnosed and treated earlier
•   any association of the discharge with menstrual cycle
2) Sexual history:
•   date of last sexual intercourse
•   were condoms used
•   and if so were they used consistently
•   regular partner or not
•   any other partners in the last six months
•   has she or her partner had sex with some one else of the same sex
•   any history of sex with a partner from a different country
•   any drug abuse in either the woman or her partner
3) Contraception and cytology:
•    which contraception does she use
•    any recent change of contraception 
•    whether she is up to date with cervical cytology
•    whether all previous screens have been normal
4) Menstrual history:
•    date of LMP
•    are periods regular or have they altered recently
•    any bleeding in between periods or after intercourse
5) History of sexually transmitted infection:
•    any past history of STI
•    was it treated
•    was the partner also treated
•    did they have a test of cure
6) Others symptoms:
•   ower abdominal pain
•   dysparunia
•   dysuria
•   any soreness or warts.
7) History of treatment:
•   any medication been prescribed.
•   any usage of over the counter medications
 
Examination
Examination of the female patient is usually normal but may show some muco -purulent discharge with contact bleeding. If pelvic inflammation is present there will be tenderness on uterine and adnexal bimanual palpation. The patient may sometimes be unwell with temperature. In suspected rectal chlamydia, Proctoscopy may be normal or may show changes of bloody/muco-purulent discharge or ulceration of mucosa.In men with epididymo-orchitis there may be epididymal and testicular tenderness with or with out systemic features.
 
Investigations
•  The older less sensitive (EIAs) Enzyme immunoassays are replaced by Nucleic acid amplification tests (NAATs) .They are based on polymerase chain reaction technology.
•  In some areas a combined NATT is in use for diagnosis of both Chlamydia & gonorrhoea. NATTs are not licensed for rectal or pharyngeal sampling.
•  Men should have a first void urine sample tested. In symptomatic women an endocervical swab is the sample of choice. If the patient does not require a per speculum examination a blind vulvovaginal swab could be an appropriate sample. These are almost as accurate and have become the basis for self test kits, now available widely.
•  A first catch urine (FCU) sample may be taken for women (having not passed urine for at least one hour before) but this is less sensitive in women than in men²
•  Sexually transmitted infection screen should include serological testing for HIV and syphilis. Current guidelines for HIV testing can be found at www.bashh.org.
 
Prevention
No opportunity should be lost to discuss safe sex with young people at the time of new patient check up and when prescribing contraception. It is a good practice to screen Chlamydia with informed consent when performing cervical screening in sexually active women under 25 and those over 25 with two or more partners in the last year or a change of partner in the past year.
 
Management
•  It is appropriate to treat Chlamydia in a general practice setting. Treatment is with either macrolides or tetracyclines.
•  Oral Azithromycin (Zithromax) 1gm stat should be the first choice as it avoids compliance issues. Patients must be advised to avoid sex for 7 days after the treatment. An alternative is oral Doxycycline (Vibramycin) 100 mg twice daily for 7 days or oral Erythromycin (Erymax) 500 mg twice daily for 14 days.
•  Interaction with oral contraceptive pill should be discussed. In pregnant women or those at risk of pregnancy, Azithromycin is still an option.
•  Retesting to verify cure is not advocated, partly because of the high cure rate and partly the test using NAA may remain positive for up to five weeks causing confusion.
•  All at risk partners in the last six months for females and asymptomatic males or four weeks for symptomatic males should be informed. They should be invited and treated even if the test is negative ³.The discussion and treatment can take place by the GP if the patient is registered with the practice or by referral to local genitourinary clinic.
 
Locally Enhanced Service
Each primary care trust has a Chlamydia screening officer. This year the target from the Department of Health is to screen 25% of patients aged 16 to 25 years registered at the practice who are sexually active.
 
Fee Structure
On agreeing a service plan with the PCT the general practice can receive: ( this may vary from one PCT to another PCT)
•  £4.50 per test received in the laboratory for coverage of ≤ 10% of the practice population aged 15-24 years.
•  £5.00 per test received in the laboratory for coverage of 10% to ≤20% of the practice population aged 15-24 years.
•  £6.50 per test received in the laboratory for coverage of 20% to ≤25% of the practice population aged 15-24 years.
•  £8.00 per test received in the laboratory for coverage of over 25% of the practice population aged 15-24 years.
 
How To Achieve Targets
•  Do a computer search of all the target patients.
•  Have a practice meeting
•  Involve the whole team: practice nurses, health care assistants and receptionists
•  Delegate, delegate and delegate! Practice nurses or health care assistants can screen at risk groups
• “new patient health check” is an ideal opportunity to offer screening. Involve the receptionist to hand out leaflets, forms and urine pots
• Make sure the reception area is suitable for handing out these items otherwise use a side room to ensure privacy
• Decide who would be dealing with positive results, treatment and partner notification
• To earn the money for extra effort you and your staff has made, make sure you use the appropriate read codeand ask the practice manager to send the claims monthly
• Remember only patients tested with in the practice premises are included when calculating the percentage screened 

• Make sure you reward your staff appropriately with the money otherwise their enthusiasm may soon vanish 

Leg ulcers are defined as discontinuity of the epidermis and dermis in the lower limb of more than 6 weeks duration ^{1, 2}. They are a common presentation in the elderly population and are associated with a negative impact on the quality of life of patients and they also cause a substantial burden on the health budget ³. Pathogenesis of leg ulceration is heterogeneous ⁴. Prevention strategies, early identification and proper management are paramount in improving quality of life of patients and reducing costs on an already strained health budget. In this article we review the prevalence of leg ulcers in the elderly people, its common causes and management.

Prevalence                          The estimated prevalence of leg ulcers in the UK is between 1.5 and 3 per 1,000 population ³.A studies by Moffat et al 2004 showed a prevalence of 0.45 per 1000 which is less than the previously reported figures ⁵. In the same study leg ulceration was found to be more common in females than males  ⁵. In a systematic review of prevalence studies for leg ulcer, the authors also reported an increase in prevalence of leg ulcers with age and in women ⁶.The overall prevalence of ulcers is not affected by social class although ulcers tend to take longer to heal in lower socio economic classes ⁷. Quality of life Several studies have shown that patients with leg ulcers have a poor quality of life compared to age matched controls ^{8, 9.A} systematic review of studies measuring quality of life of patients with leg ulcers showed a negative impact on several domains of quality of life ⁸. In most of the studies pain was shown to be the major complaint among leg ulcer patients compared to controls, with males experiencing greater pain intensity than female patients. ^{10, 11} Restricted mobility and sleep disturbance due to pain was also reported in other studies.¹² Leg ulcer patients often complain of itchiness, odour and leg swelling ⁸.  In one study, unpleasant odour was reported as causing social embarrassment leading to higher anxiety and depression scores as well as altered body image ¹².Reduced mobility due to leg ulceration can restrict working capacity in younger patients¹³.A negative emotional impact on life with symptoms such as anger, depression, and social isolation was reported by 68% of patients in another study looking at impact of leg ulcers on quality of life ¹⁴. Aetiology Several factors contribute to the development of leg ulcers. However majority of ulcers are due to venous insufficiency which accounts for about 80-85% of all cases. ^{15, 16.} Frequency of venous ulcers increases with age as a result of several factors such as immobility and venous disease¹⁵.  Other risk factors for venous ulceration include obesity, previous deep vein thrombosis, thrombophlebitis, previous fracture, and varicose veins ¹⁷.Venous ulcers(also referred to as varicose or stasis ulcer)are commonly found between the malleoli and lower calf and are associated with a shallow base covered with granulation tissue and fibrinoid material, and have irregular margins ^16,17. The mechanism of venous ulceration involves initial damage to valves as a result of thrombosis or valve incompetence in varicose veins leading to pooling of blood in lower limbs. Extravasation of red blood cells then follows which causes a local inflammatory reaction and collagen deposition. This impairs the healing process eventually resulting in tissue breakdown and hence ulceration¹⁶. Venous ulcers are also associated with symptoms such as oedema, eczema.Arterial ulcers form the second largest group of leg ulcers and account for about 20% of leg ulcers. Atherosclerosis and diabetes are the commonest causes of this group of ulcers. Thrombotic episodes secondary to vasculitis, thromboangitis, and sickle cell disease can also result in arterial ulcers¹⁷.Arterial insufficiency causes hypoxia, ischaemia, tissue necrosis and consequently ulceration ¹⁸.Arterial ulcers are usually found below the ankle especially on the toes. The ulcers are characteristically small, have steep edges and a dry base. Risk factors for arterial ulcers include conditions that predispose to peripheral vascular disease such as smoking, diabetes, hypertension, hyperlipidaemia and obesity ¹⁷. It is worth mentioning that diabetes causes foot ulcers via two mechanisms: ischemia and neuropathy. Neuropathic ulcers are usually found on the plantar surface of metatarsal heads or on the toes. They are a consequence of poor glycaemic control¹⁹. The risk of malignancy in chronic leg ulcers is generally believed to be small, but a study by Yang et al 1997 showed a rate of 4.4% in chronic leg ulcers. The diagnosis should be considered in patients with non healing ulcers despite optimum management ²⁰.  Chronic inflammatory conditions such as rheumatoid arthritis, inflammatory bowel diseases are also associated with leg ulceration. Rare causes of leg ulceration such as ill fitting shoes have also been reported in literature. In a study looking at complications of ill fitting footwear among 65 elderly patients, foot ulceration was reported by 15% of the patients ²¹. Although small, this study showed that simple measures such as appropriate foot wear may be useful in preventing foot ulcers. Table 1: summarises causes of ulcers and main characteristics of leg ulcers ^{16, 17}

 Management  Like all medical conditions, management of leg ulcer should include a detailed history of the onset of the problem (as well as past medical history), examination of the legs and skin, investigations and modalities of treatments. The underlying causes need to be identified as this has crucial implications for management. A medical history suggestive of venous and arterial ulcers have been mentioned above but other factors to consider while assessing leg ulcer are: general health status, cigarette smoking, nutrition, limitation to self care, pedal pulses, Ankle Brachial Pressure Index (ABPI), oedema, limb size and shape, sensation and pain (Table 2). Table 2: Assessment of lower limb ulcers 

Examination of the legs and skin identifies markers of underlying pathology. Venous disease may present with some or all of the following: brawny skin, haemosiderin staining, lipodermatosclerosis, atrophie blanche (patchy areas of ischemia),and stasis eczema, while the skin of patients with arterial disease is often shiny, hairless, pale and cool; with thickened nails and changes in foot structure. The absence of venous or arterial signs and symptoms raises the possibility of less common causes of ulceration like: Sun damaged skin, Bowen disease or a history of previous skin cancer treatment is an alert to a malignant lesion.                                                                    Site & Appearance: Most venous ulcer occur in the “gaiter” area of the leg (i.e. area extending from just above the ankle to below the knee and tends to occur on both lateral and medial aspect of the leg), they are usually superficial with poorly defined margins. The base of the wound is usually red granulation tissue with moderate to high levels of exudates. Arterial ulcers can occur anywhere on the lower leg and may appear in the gaiter region, especially with coexisting venous disease. Many arterial/ischaemic ulcers occur over bony prominences and have a history of pressure related cause. They are often deeper with a punched out appearance and may involve structures such as muscles, tendon and bone in the base. They have sloughy, devitalized tissue in the wound base and low levels of wound exudates. Ulcers occurring in atypical site with an atypical appearance require further investigation to determine the cause. Ulcers with a violaceous (purple) border, inflammation, and extreme pain, may be related to vasculitis problem or underlying connective tissue disorder. Size: Dimensions of the ulcer should be taken at first presentation and fortnightly thereafter and recorded in the notes. This is important as it gives an objective assessment of the effectiveness of the current treatment plan, and modify as necessary²².There are a range of techniques available such as digital photography, ruler based vertical, horizontal and depth measurements and circumferential tracings of wound margins using acetate sheets over cling film .The system chosen needs to reflect consistency, accuracy, and reduced operator error, and also provide visual feedback to the patient. Pain: The level of pain associated with ulcer must be assessed on presentation and at each visit thereafter using a standardized pain scale (0-10). Pain may suggest infection or arterial disease, so careful assessment is required.Surrounding skin area should be observed for the presence of eczema, hyperkeratosis skin, maceration, cellulitis, signs of irritation and scratching which are signs and symptoms associated with underlying venous disease.Assessment should also include palpation of peripheral pulses, regular blood pressure measurement, weight (with reference to a Body Mass Index chart) as well as routine urinalysis (to screen for diabetes). Vascular Assessment: This is mainly carried out by the use of Doppler ultrasound to measure the Ankle Brachial Pressure Index (ABPI).This is mandatory and must be repeated every 3 months. All patients with a non healing wound on the leg of greater than 4-6weeks should have a vascular assessment to eliminate any underlying ischaemic disease²².The result of ABPI are used to determine the likelihood of arterial insufficiency and can be used to guide the management plan, especially in relation to healing potential, referral for vascular assessment and use of appropriate compression bandages. ²³ The normal range for ABPI is 0.8-1.2. An ABPI of less than 0.5 or greater than 1.2 needs vascular opinion. Treating the ulcer Many dressing materials are available for the treatment of leg ulcers and there is no adequate evidence from clinical trials to recommend one dressing type over another, but we have to bear in mind few criteria in choosing a particular dressing. The dressing should be low adherent, cost effective and must also be comfortable as well as acceptable for the service user. The choice of product should be determined by   the level of exudate. Products which commonly cause skin sensitivity such as those containing lanolin and topical antibiotics should not be used on any service user²². The use of white soft paraffin has been identified as a potential fire hazard risk, hence a water based emollient should be considered as an alternative to a paraffin emollients e.g aqueous cream. Please note water based emollients are not as effective in providing sustained emollient therapy as an ointment and also contain preservatives, which are known potential irritants. Other modalities of treatments of leg ulcers are described below.  Compression Therapy The mainstay of treatment of any venous component to ulceration is the application of sustained, graduated compression at therapeutic level ²⁴ .Graduated compression increases venous flow, decreases valvular reflux while walking and increases the effectiveness of the calf muscle pump resulting in a “thinning leg”. The most effective level of compression to overcome venous hypertension has been determined to be around 40mmHg at the ankle ²⁵. Correct application of bandages is essential to avoid pressure ulceration over the bony high points and along the anterior border of the tibia. It is acknowledged that the application of compression bandaging is a specialized skill traditionally undertaken by nurses. The combination of compression bandages used to achieve compression of 40mmHg at the ankle will depend on ankle circumference, according to Laplace’s law, which states that the sub bandage pressure is inversely proportional to the circumference of the limb. A modified compression regimen is necessary when pain is present. This may be achieved by providing periods of relief until pain is controlled or removing the bandage at night when the leg is elevated. Patients with mixed arterial and venous disease may only tolerate up to 20mmHg compression to treat oedema. Bandage choices include short stretch, long stretch, multilayer systems and stockings. A Cochrane Review of compression regimens identified increased healing rates with compression compared to no compression²⁶ . A high compression bandages were better than moderate compression bandages, and that multi-layered bandages were better than single layered bandages. Comparisons between various high compression bandages systems, e.g. 4 layer and short stretch bandages, were unable to find any difference in effectiveness. For venous ulcer with ABPI > 0.8, use 4 layer bandages as per ankle circumference below (Table 3) Ulcers with ABPI between 0.6-0.8: Reduced compression is achieved by omitting the outer cohesive bandage (e.g. Coban) Table 3: Multilayered bandage regime in relation to ankle circumference. 

Once the ulcer site is well healed, continue with the compression bandages for at least 4 weeks and then maintain compression at a slightly lower level indefinitely as tolerated. It must be replaced annually. Other factors to consider and deal with include: Infection This requires regular cleansing, more frequent changes of dressing (especially if exudates levels are high), topical antimicrobial dressings or systemic antibiotics. Pain Ranging from simple analgesia to potent opioid (depending on severity of pain), non steroidal anti inflammatory drugs may be beneficial. For neuropathic pain, amitriptyline can be started which can be replaced by gabapentin if no improvement. The dose can be titrated upwards. Pressure: Requires pressure relief for the ulcer to heal especially over bony prominences. Larval Therapy Larval therapy has been used for debridement of wounds for many years.²⁷ Debridement is an essential component of wound care as the presence of devitalized tissue can impede the healing process. While the exact mechanism of larval therapy remains unknown, it encompasses three processes: debridement, disinfection and promotion of healing. The beneficial effects of larval therapy were first observed during the Napoleonic war by Larrey, who noted that soldiers whose wounds had become infested with maggots had an improved prognosis ²⁷. During the First World War, Baer documented the successful treatment of leg ulcers and osteomyelitis using larval therapy, and paved the way for further use of it by doctors of that time. However, the development of antibiotics and improvements in surgical techniques reduced larval therapy to a “treatment of last resort”, reserved for the most intractable wounds ²⁸. The emergence of antibiotic- resistant strains of bacteria such as methicillin resistant staphylococcus aureus (MRSA) and the curiosity of researchers has prompted a resurgence of interest in larval therapy. Larval therapy has been employed effectively to treat a wide spectrum of wounds including venous and arterial leg ulcers²⁹.Some of the benefits of larval therapy include: reduction in wound pain and odour, and promoting healing process with relatively few side effects³⁰ .Larval therapy is also reported as being cost-effective in comparison with conventional wound dressings. The use of larval therapy often resulted in quicker healing, and a subsequent reduction of nursing time and materials³⁰. A further advantage of larval therapy is that, as larvae are typically applied for 3 days, wounds are disturbed less frequently than conventional dressings that require changing every 1-2days.In addition to this, a further advantage is that treatment can usually be carried out in outpatient and community settings. A study   at an outpatient wound clinic on chronic wounds, of varying aetiologies reported that using larval therapy resulted in a 62% decrease in need of amputation ³¹. Larvae offer the benefit of eliminating bacteria from the wound through ingestion and subsequent degradation within their intestinal tract. They also act to reduce bacterial activity through the production of inhibitory secretions. The most commonly mentioned disadvantage of larval therapy is the negative perception with which it is regarded by both patients and practitioners because of the unpleasant appearance. The use of “Biobags”, which completely enclose the larvae within a polyvinyl alcohol membrane, has become a popular method of improving the application of this treatment, as larvae are able to feed freely through the open cell polymer. Pain has occasionally been reported by patients, the cause may be the sharp mouth hooks and spicules with which larvae anchor themselves onto tissue. A case history has suggested larval therapy to be contraindicated with fistulae, exposed wounds connecting to vital organs³²  because bloodstream infections have been reported with some larvae³³.Alteration of the disinfection process appeared to eliminate this problem, and with no further cases of sepsis occurring during the subsequent 12 months The risk of cross-infection by escaped larvae may be greatly reduced through careful dressing. Vacuum Assisted Closure therapy Vacuum Assisted Closure (VAC) therapy involves the application of controlled negative pressure to wounds ³⁴. Negative pressure, as a method of management for difficult to heal wounds, was initially explored in 1970, with the first wound drainage system being introduced in 1989. The use of negative pressure to heal wounds, however, is more commonly associated with the work of Argenta and Morykwas in 1997.³⁵ VAC therapy was designed with the aim of improving healing, decreasing morbidity, and decreasing the cost and length of hospital stay in patients with chronic, non healing wounds. VAC therapy promotes healing in several ways. Firstly, the foam dressing, in combination with adhesive tape, creates an occlusive dressing. This alone prevents dessication and increases the rate at which epithelial tissue is developed, therefore aiding healing times. Occlusive dressing prevents an increase in infection. Secondly, the suction effect and the mechanical forces generated at the interface of the foam work to decrease interstitial fluid accumulation, control wound exudates, stimulate granulation tissue formation, reverse tissue expansion, decrease bacterial colonisation and increase blood flow and dermal perfusion. In summary, VAC therapy aids wound healing by:       Maintaining a moist environment       Increasing local blood flow       Removing wound exudates       Promoting granulation tissue formation       Reducing infection       Exerting mechanical pressuresVAC therapy is suitable for the following wound types/processes ³⁶        Acute   (trauma, burns)        Chronic (pressure sores, leg ulcers, diabetic ulcers)        Surgical (skin grafts, flap surgery, wound bed preparation)        Salvage (wound dehiscence, wound infection, post operative sternum infections) Contraindications to the use of vacuum therapy include: wounds with untreated osteomyelitis, grossly infected wounds, when necrotic tissue is present or when there is unspecified disorder of the blood. VAC therapy should also not be used in wounds with malignancy .Dressings should not be placed over any exposed vessels or organs and VAC therapy should be used with caution in patients with active bleeding, difficult wound haemostasis and in patients taking anticoagulants. Skin grafting Skin grafting is the transplanting of skin, and, occasionally, other underlying tissues to another location of the body. It is the only means of reconstructing a defect in the skin, regardless of the cause of the defect ³⁷. Generally, skin grafting is used when, in the opinion of the reconstructive surgeon, other methods of reconstruction such as primary closure, secondary intention healing, or local skin flap are inappropriate, are unavailable or would produce a suboptimal result. Skingraft are divided into 2 major categories: full thickness skin graft (FTSGs) and split thickness skin graft ( STSGs).STSGs may be subdivided into thin (0.008-0.012mm),medium(0.012-0.018mm) and thick (0.018-0.030mm)grafts ³⁷. STSGs are the one used in covering chronic unhealing cutaneous ulcer. Split skin grafting is technically demanding and requires hospital admission²⁵. The discharge from the surface of venous ulcers tends to dislodge continuous sheets of split skin, leaving a choice between mesh and pinch skin grafting. Pinch skin grafting provides epithelial islands, from which epithelial growth may spread outwards as well as inwards from the ulcer margin. Pinch skin grafting has been done by district nurses in the community and has been found to be cost effective accelerating healing when used with multilayer compression bandaging.²⁵ Some contraindications to the use of skin graft generally include: vascular tissues such as exposed bone or cartilage (as this will lead to graft necrosis), uncontrolled bleeding of the recipient because of haematoma and/or seroma formation under the graft compromises graft survival. Venous Surgery Superficial venous surgery has been shown to improve ulcer healing in patients with only superficial venous incompetence³⁸. In patients with no deep reflux on duplex imaging, superficial venous surgery has been shown to reduce long term ulcer recurrence²⁵ . Indications for superficial venous surgery are:

•  Patient fit for surgery
•  Sufficient mobility to activate calf muscle pump
•  Prepared to attend hospital for investigation and surgery
•  Obesity controlled (BMI <30)
•  Superficial venous incompetence

 There are few other modalities of treatment of leg ulcers currently in use, although no strong evidence has been found to show they really improve healing. Intermittent Pneumatic Compression Intermittent pneumatic compression (IPC) is a mechanical method of delivering compression to swollen limbs that can be used to treat venous leg ulcers and limb swelling due to lymphoedema.It uses an air pump to inflate and deflate an airtight bag wrapped around the leg.³⁹ However, review of trials found conflicting evidence about whether it is better than compression bandages. It may increase healing compared with no compression but it is unclear whether it improves healing when added to treatment with bandages. Electromagnetic Therapy  Electromagnetic therapy involves the use of electromagnetic, microwave, or infrared energy to diagnose or treat an illness by detecting and correcting imbalances in the body's energy fields. Electronic devices that emit some form of low-voltage electrical current or radio frequency are often involved. It has been used in the treatment of chronic diseases like venous leg ulcers. Cochrane wound group conducted trials on several occasions comparing electromagnetic therapy with other treatments and up till now, there is no reliable evidence of benefit of electromagnetic therapy in the healing of venous leg ulcers.⁴⁰ Further research is still needed.  Oral Zinc Supplement Leg ulcers may take long time to heal despite good wound care. This may be due to poor nutrition which reduces the ability of the body to repair itself. Minerals such as zinc are necessary for good healing and so it has been thought that taking zinc sulphate tablets might aid healing of ulcers especially if patients were found to have low baseline Zinc level. Few trials were found where zinc was used to treat leg ulcers but all were too small to pick up on any benefit, if such a benefit exists. In addition, the quality of those trials was mediocre. On the basis of the evidence available so far, it appears that taking zinc tablets does not improve leg ulcer healing, however more good quality trials are needed.⁴¹ Laser Therapy Low level laser therapy (LLLT) refers to the use of red beam or near infrared laser with a wavelength between 600and 1000nm power from 5-500 milliwatts.It is also referred to as cold laser therapy, low power laser therapy (LPLT), low intensity laser and low energy laser therapy. The exact effect of its mechanism is unknown; however, hypotheses have included improved cellular repair and stimulation of the immune, lymphatic and vascular system. Several randomised controlled trials involving patients with venous ulcers failed to demonstrate any significant benefits of LLLT when compared to standard treatment methods or placebos.⁴² Hyperbaric Oxygen Therapy Oxygen is one of the most versatile and powerful agents available to the modern medical practitioner. The therapeutic use of oxygen under pressure is known as hyperbaric oxygen therapy (HBO₂) and has been used to assist wound healing for almost 40 years. HBO₂ has several specific biological actions which can enhance wound healing processes .These include: Hyper-oxygenation of tissue, vasoconstriction, down regulation of inflammatory cytokines, up-regulation of growth factors, antibacterial effects, potentiation of antibiotics, and leukocyte effects.⁴³ Systemic oxygen can be administered via 2 basic chambers: Type A( multiplace) and Type B(monoplace). Both types can be used for routine wound care, treatment of most dive injuries, and treatment of patients who are ventilated or in critical care.HBO₂ is a relatively safe non-invasive therapy. Side effects include middle ear and pulmonary barotraumas and myopia. Contraindications include poor cardiac output and severe obstructive pulmonary disease. Conclusion In this article, we have been able to show that leg ulcers are a common presentation in the elderly population and have negative impact on the quality of life of affected patients. It has been found to be more common in females. Most leg ulcers (about 80-85%) are caused by venous insufficiency, followed by arterial ulcers. A comprehensive assessment of the patient, skin, vascular status, limb and ulcer is required to determine aetiology and to formulate an appropriate management plan as described above. Several researches are still going on other modalities of treatment of leg ulcers. However, all patients should be provided with both verbal and written information to help them understand their condition and treatments they receive, as this will enable them to better understand their conditions, and will support concordance between patients and staff.