Vascular

Question 1

What is this?

Apart from the rash what are other features (3)

Answer 1

Henoch-Schönlein purpura

Common in 2- 8 year olds

Arthritis/arthralgia (50-75%)

Abdominal pain (50%)

Nephritis (25-50%)

Question 2

Name general aspects for care of venous leg ulcers.

(4)

Answer 2

1. wound cleansing and debridement
2. diagnosing and minimising oedema
3. treating infection, if present (see Ulcer and wound infection)
4. optimising wound moisture balance (see Ulcer and wound dressings).

Question 3

What specific things should you consider when approaching management of venous leg ulcers?

(up to 9)

Answer 3

1. Early Referral to Vascular surgeon to assist ulcer healing (and prevent recurrence)
2. Compression therapy: class 3 (30-40mmHg) compression. Needs to be applied by a trained professional.
3. Address dietary deficiencies of zinc, omega 3 and vitamin C
4. Encourage weight loss of 5-10% of body weight if overweight/obese
5. Pain management- addressed by treating oedema and moisture
6. Leg elevation during inactivity to legs above heart
7. Exercise, especially plantar flexion of the foot, to improve calf pump
8. Treatment of dermatitis (see dermatitis)
9. Pharmacological therapy with Pentoxifylline to be initiated under specialist supervision.

Question 4

What is this and first line treatments?

Dosing required

Answer 4

Seborrhoeic dermatitis

1. Anti-dandruff shampoo about 4 weeks or until clear

Second line: ADD anti-yeast shampoo (ketoconazole, miconazole)

Third line: ADD steroid lotion
methylprednisolone aceponate 0.1% lotion topically, applied to scalp once daily at night for 7 nights

Question 5

How would you describe features of this condition?

Answer 5

Seborrhoeic dermatitis

1. Usually has winter flare ups
2. usually not itchy
3. Combination of oily and dry facial skin
4. Ill defined scaly patches, though diffuse on scalp
5. Can have blepharitis
6. Salmon-pink, thin, scaly, and ill-defined plaques in skin folds or face
7. Petal or ring-shaped flaky patches on the hairline and on anterior chest
8. Malassezia folliculitis (inflamed hair follicles) on the cheeks and upper trunk.

Question 6

This is called Malassezia folliculitis. Which conditions is this linked to?

Answer 6

This is an infection of the pilosebaceous unit caused by lipophilic Malassezia yeasts

Seborrhoeic dermatitis

Pityriasis versicolour

Question 7

What is the definition of a chronic leg ulcer?

Answer 7

A full thickness skin loss for over 3 months

Question 8

What are three common causes for the immediate cause of a leg ulcer?

Answer 8

1. Injury- watch for foreign bodies
2. Pressure

3 Acute infection- staphylococcus, streptococcus

Question 9

What are the 5 broad categories of causes for a leg ulcer?

Answer 9

1. Venous stasis (80%): usually on the shin or above the lateral/medieal malleolus. Usually painless.
2. Arterial insufficiency (10%) usually on feet, heel toes. Usually painful. Reduced or absent pulses. Cold white shiny skin.

3.Neuropathic ulcer. Usually at a pressure point. occurs on numb skin. Unnoticed trauma causes painless ulceration

4. Diabetic. Have a mixed aetiology. Frequently infected. Ulceration is a common precursor to amputation.
5. Pressure ulcers
   Caused by unrelieved pressure, usually over bony prominences like the heel or sacrum. often infected leading to osteomyelitis.

Question 10

What is the TIME principle ?

Answer 10

It is in relation to treating leg ulcers

Tissue

Inflammation and infection

Moisture

Edge/epithelialisation

Question 11

What are the 6 types of interactive wound dressings?

Answer 11

Film dressings

Hydroactive dressings

Hydrocolloid dressings

Foam dressings

Alignate absorbent fibre dressings

Question 12

What is the A2BC2D approach to chronic VENOUS leg ulcers?

Answer 12

A1- assessment of the wound
A2- assessment of the patient
B- best dressing to choose
C- consider COMPRESSION bandage
C-concern of the patient
D-Documentation

Question 13

When you combine the TIME score with the Assessment score of the patient you get a Time-H score, which tells us what?

(this is a chart of the patient assessment)

Answer 13

This is in regards to treating chronic venous leg ulcers.

The TIME principle combined with the Patient assessment gives the TIME-H score which predicts the healing time.

Question 14

What principles do you consider when choosing a dressing for chronic leg ulcers?

Answer 14

Ensure optimum moisture balance
control or eradicate biofilm
Preventing adherence of dressing to the wound bed
Control pain
Provide pressure relief for ulcers due to pressure

Question 15

Debridement of a Chronic leg ulcer is important for healing. So is further managing the exudate. The type of dressing chosen should be matched to the skin condition and exudate.

For a wound (not just ulcer) with a malodorous exudate what would you use?

Vs

Chronic wounds with moderate exudate?

Answer 15

A. Idosorb
Inadine

B. Duoderm

Question 16

Patients with venous ulcers often complain of irritable and itchy skin around the ulcer. What can be done to manage this?

Answer 16

This is essentially venous dermatitis.

Apply a moderate potency topical steroid to the area, such as triamcinalone 0.02% cream/ointment.

Question 17

if you are concerned a leg ulcer is not healing, what investigation should you do?

Answer 17

A biopsy for potential malignancy, may need to get multiple biopsy sites if it’s a large enough ulcer

Question 18

What are the three grades of Peripheral Vascular Disease?

Answer 18

1. Asymptomatic
2. Intermittent Claudication
3. Chronic Limb threatening Ischemia

Question 19

What is PAD?
What are its risk factors?

Answer 19

Peripheral Artery Disease.
Narrowing of the arteries in the low limbs due to mostly atherosclerosis.

Risk factors are similar as for Cardiovascular Disease.
-smoking is number 1
-diabetes
-Hypertension
-hypercholesterolaemia

Question 20

What is the mortality rate from CLTI (critical limb threatening ischemia)?

Answer 20

ranges from 20-25% in a year.

Question 21

What are the differences in history/exam for persons at the three different stages/levels of peripheral vascular disease?

Answer 21

1.Asymptomatic. No symptoms but may have reduced or absent peripheral pulses on exam

2. Intermittent claudication: Reproducible pain in the calf, thigh or buttock on exertion/exercise. Will Also have reduced or absent peripheral pulses
3. CLTI. Rest pain in the calves- especially when elevated. Nocturnal pain. Tissue loss- gangrene, ulcers, necrosis. May see hair loss on the leg, muscle wasting and clawed toes.

Question 22

What is ALI and is it part of the pathogenesis in PAD?

Answer 22

Acute Iimb Ischemia e.g. cardioembolism of a clot (due to AF) that gets lodges in a peripheral vessel.

No, this is more due to thromboembolic events and other risk factors. It has a seperate pathology to peripheral vascular disease.

Question 23

What is the screening recommendation for PAD and how do you screen?

Answer 23

There is no screening recommendation, especially in low risk groups.

Can screen those with higher risk- Cardiovascular disease, other comorbid conditons.

Use an Ankle Brachial Index (ABI).

if that is high >1.4 it may demonstrate incompressibility of the arteries and can follow up with an U/S duplex of arteries.

Question 24

6 Corner stones of management for secondary prevention in PAD?

Answer 24

1. Smoking Cessation
2. Aspirin 100mg OR clopidogrel 75mg. after stenting some may need both. And other high risk persons may get anti-coagulants and anti-platelets
3. Antihypertensives with ACEi ONLY IF patient is hypertensive
4. Statin therapy- high dose therapy to achieve targets
5. Glycemic control (may avoid SGLT2i)
6. Diet and exercise

Question 25

Cornerstones of management to specifically treat PAD?

Answer 25

1. Revascularisation therapy, only if symptomatic 2. Exercise programs only to those with intermittent claudication or post revascularisation 3. Pharmacotherapy: cilostazol or pentoxifylline for claudicaiton 4. Foot Care; 1-3 monthly foot checks as those with PAD have an increased risk of diabetes ulceration

Question 26

This is a graded approach to exercise in PAD: 45 minutes walking on a treadmill or outside (including rest), aiming for 3-5 days a week Walk on a zero incline or grade 1 until pain/discomfort is felt. stop and rest until it subsides then go again aiming to get to the same level of pain. Keep this pattern going up to 45 minutes. The incline or walking pace can be increased once the patient manages 8 straight minutes on their current level without pain. What are other tips to sucess?

Answer 26

Tell patient it will only work if trialled consistently for at least 2 months Pain is not causing damage, but is stimulating vessels to grow When the pain is moderate to severe, stop walking completely rather than slowing down If walking outside try to stick to the same route so you can monitor it Keep a diary of how far you walk or use a smart device.

Question 27

Chronic venous insufficiency is impaired venous __(a)__, sometimes causing lower extremity discomfort, __(b)__, and skin changes. Postphlebitic (postthrombotic) syndrome is symptomatic chronic venous insufficiency after __(c)___

Answer 27

a. return b. edema c. DVT

Question 28

In aiding the diagnosis of chronic venous insufficiency lower-extremity duplex __(A)__ reliably excludes or confirms DVT. Absence of edema and a reduced ankle-brachial index suggest __(B)___rather than chronic venous insufficiency and postphlebitic syndrome.

Answer 28

A. Ultrasonography B. peripheral ARTERIAL disease

Question 29

Treatment of chronic venous insufficiency?

Answer 29

Elevation Compression using bandages, stockings, and pneumatic devices Topical treatments Treatment of secondary infection, when present

Question 30

What pressures should stockings be, when treating chronic venous insufficiency?

Answer 30

Stockings that provide 20 to 30 mm Hg of distal circumferential pressure are indicated for smaller varicose veins and mild chronic venous insufficiency; 30 to 40 mm Hg is indicated for larger varicose veins and moderate disease; and 40 to > 60 mm Hg is indicated for severe disease