• LecturehallDemystifying Compression
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker 1: Welcome our next speaker who is going to be talking about compression therapy. I've always felt we needed a little more emphasis in this meeting on venous disease, lymphedema. I'm so happy we had the program yesterday. I'm very happy that 3M has agreed to bring Dr. Terry Treadwell to us to talk about the important role of compression. Those of you who've been in their wound care space for enough years certainly recognize Dr. Treadwell. He's been the past president of the AAWC. He's in the wound healing society. He's a clinical editor for wounds. I've heard him speak for 10, 15 years a long, long time. He is a trained vascular surgeon as well who concentrates now primarily in wound management out of Montgomery, Alabama. So let's welcome Dr. Terry Treadwell.


    Male Speaker 2: Thank you so much. It's certainly a pleasure for me to be here with you this afternoon. After that last little discussion we made just here, are there any question and I’ll go home. Perhaps I can identify some of the issues that were talked about, but as you know compression therapy is a big deal. It's really something that we should be concerned about. Historically, compression therapy, especially for swollen legs and things like that, was just kind of after-thought. You know, the leg swollen, big deal. What we found is that there are lot of reasons that we need to progress with getting that fluid out, getting the swelling down. If you were at the lymphedema thing yesterday, you understand about treating lymphedema and the importance of treating all of fluid in the leg because if you don't treat the initial stages of the edema, then it'll progress to lymphedema. We've come far enough to realize that. But as I talk about edema and we talk about compression and whatever disease process that you deal with whether it's just postoperative edema or just a swollen extremity that’s sent to you or someone with the venous ulcers, many questions come up. And so this afternoon we're going to take a little bit different approach and see if I can kind of answer some of the questions, one of which would be, are all compression bandages the same? The second would be a question that comes up every single time we talk about compression therapy and that is, can compression therapy be used in someone with the swollen extremity and a low ABI? The third question would be, can compression therapy be used in patients with edema and cellulitis? Everybody seems to be scared to do that. Does compression therapy improve the skin of patient with venous dermatitis? Compression therapy in patients with edema and congestive heart failure, is that something I should consider? Can compression therapy be used in patients with edema and acute thrombophlebitis? We will look at that one as well. And do patients really care which compression bandage is used? We'll look at those as we go through and take one at a time. The main thing we want to do is look for the evidence. Evidence-based care is something that we're doing our best to make our priority as we look at different things, and so, where you have to look for evidence. It's a good thing to do and hopefully you'll find the best and we'll look at the evidence today. First of all, are all compression bandages the same? You know that we have all kinds of compression therapy. You've got short stretch, you've got inelastic, you've got elastic, you've got single layer, multiple layers, high pressure, low pressure, what's the deal. Are they all reasonable just whatever we can get on? Is that something we should consider? Well, when we look at the leg and you all are very familiar with this situation, just anatomy of a cross section of lower extremity. You know that we have superficial structures, the skin and the subcutaneous tissue and then you have all the muscle compartments there in the leg. And when we're looking at pressures where we're trying to do compression, we're really interested in the couple of them. One is the sub-bandage pressure. The greens would be a bandage and the pressure between the bandage and the skin and also something that we don’t think about a lot and that’s the pressure in the muscles and the interstitial tissues there of the leg. Well, when we put a stretchy bandage on the leg and wrap the leg with that, the physics that are involved is Laplace's Law. If I get too carried away with this, I'll lose myself. So we'll make it very, very simple. As you know, according to the Laplace's Law, the pressure that you're applying has a direct relationship to the tension of the bandage or how tight you wrap it compared to the radius of the legs.


    So if you've got a small leg, you wrap it tight, you're going to have a higher pressure. If you've got a big leg and you don't wrap it so tight, the pressure is going to be less. And that’s the situation when we talk about graded compression from the ankle to the knee. That’s why you don’t have to worry about making it tighter as you go up or loosening it as you go up. Because the radius of the leg changes and so if you wrap it with a same amount of tension or pressure, then by definition, the pressure would get less as the radius of leg gets bigger up from the calf. But the interesting thing about this is when we use elastic compression on the leg, most of the superficial vessels and subcutaneous tissues are affected. It is very difficult to wrap a leg tight enough so that you could actually affect the muscle compartments of the leg just by squeezing the leg itself. So in reality, we need to look for something else to help this because we know that the edema is throughout the muscle compartments as well. And so what we would like to do is generate some pressure from within that leg. And so if we put a bandage around the leg that does not give or is not as stretchy, it's more rigid in nature and when the patient ambulates and these muscles contract and get larger, they try to expand, but they can't because of the restrictive compression bandages on the leg and as a result, we generate a lot of pressure from within and that’s one of the ways that we can actually get pressure on the muscles that are in the leg and help with the edema throughout the leg and not just from the surface. If you want to look at that a little bit differently, let's look at this. If you have a long stretch or an elastic type bandage, normally we put it on about 30 to 40 mmHg pressure. I think everybody would agree with that. That’s pretty much standard. When your patient is resting, that’s where the pressure is. When the patient begins to walk and the muscle contracts, then obviously it tries to get bigger. With your elastic bandage, the bandage does give to some degree and you'll achieve a pressure somewhere along this area. Then when the patient relaxes their muscles, it falls back to your baseline of 30 to 40 mmHg pressure. If we're looking at the other side of the coin, the other situation we talked about, if you have a compression bandage that is rather rigid, you don't put it on quite so tight. Normally, the sub-bandage pressure measures between 25 and 28 mmHg. Because you know if you get it on too tight and it won't stretch at all, then the patients are not going to be appreciative of that. But the cool thing is when the patient begins to walk, you can see their muscle contracts. Well, the muscle can't go anywhere because it's restricted by this dressing and this bandage and you can see the pressures can go as high as 60 to 70 mmHg. When they stop walking and their muscle relaxes, then they fall back to this sub-bandage pressure of around 25 to 28 mmHg. And so actually, we can generate a cyclical high pressure compression system by using a short-stretched compression bandage and it works very, very well for a number of reasons that we look at as we go through here. We mentioned the short stretched systems are effective at lower resting pressure because again we talked about that. And that it also makes it more comfortable for the patient for the most part, but also if you're worried about circulation in the limb and we'll talk more about that in just a moment, then this offers safer compression when you're trying to deal with that. But both systems can help, which you can see one has benefits over another, so all compression bandages are really not the same. Question number two follows very closely on the heels of that one. What about the patient who has an ABI less than 0.8 and I think everyone understands that’s probably what is considered the lower limit and I've heard people tell people that you know you just can’t put a compression bandage on somebody with ABI below 0.8, the legs are going to fall off. Well, I'm a vascular surgeon and I like to work on things like that, but the important thing is you can and let's look at this as we go through because we know that there are lots of patients who have mixed venous and arterial disease. This was a study of over 1400 patients and you can see this group had an ABI that was normal. 14% had an ABI 0.8 to 0.5 and 2% had less than that. So 16% to 18% of our patients who have venous leg ulcers or swollen extremity are going to have arterial insufficiency associated with their problem. And so we got to deal with that because if you don't get the swelling down, the wound is not going to get well. That’s just kind of fact of life.


    This is the work that Dr. Marston did, Bill Marston, University of North Carolina. And you can see he looked at one group with healing and patients who had normal ABIs compared to ones who had modified compression and lower ABIs. And you can see this definitely affects the healing. Obviously if you've got someone with vascular insufficiency and you can get it taken care of or there are candidates for revascularization by whatever means, that’s the ideal situation. But then we know that there are number of patients for whatever reason secondary comorbidities, all kinds of things, age, whatever you might want to put out there that really can undergo revascularization but need compression therapy. And so this is pretty much that group that we are stuck with. So how do we deal with those folks? One thing you can interestingly find out is that if you have a swollen extremity and you get the edema out of it, you actually improve the circulation. Stop and think about it a minute. A leg that is really entirely swollen is almost like an internal tourniquet because it's pushing everything out against the skin, and so the small blood vessels and everything that’s in that compartment is being squeezed by the fluid against the skin. And as a result if we can get that swelling down, we will help the circulation and this is work that Dr. Harvey [Indecipherable] [0:11:18] at University of Miami and you can see the flow done by nuclear magnetic resonance flow detection before compression and after the edema was significantly improved with compression therapy. And so actually, don't be afraid to compress the leg. You're going to actually make it better as far as the circulation is concerned. This is a rather interesting and somewhat overlooked studies that was done a few years ago that has to do with venous disease and capillary density which in essence is talking about our circulation. And let's read just from right to left if you will. We're looking at the capillary density and tcPO2, all of you are familiar with these. In a healthy leg, you can see the numbers are right in here. This is the capillary density over here and the tcPO2 over here. As you develop edema, you can see that the capillary density seems to go down, but it's still okay. By the time your leg has developed the hyperpigmentation, you are beginning to see signs of chronic venous disease. You can see that both are decreasing. By the time you have that hard [Indecipherable] [0:12:22] tissue, the lipodermatosclerosis if you will, you can see again that they're falling even further. By the time we have an ulcer, you look at the age of the ulcer, the tcPO2 is the 10 to 20 range. If I were to ask any of you, if a wound with tcPO2 of 10 to 20 would heal, I'm sure everybody in the room would say, no not hardly. And so that’s where we live with most of our ulcers and you can see though that the capillary density is very low as well. So this is kind of interesting finding. What do we do about that? Well, this is the study that was done compression therapy in patients who had this type of situation. And you can see that the capillary density at the stage zero, one week and two weeks, the capillary density begin to return upward toward normal. And so compression therapy relieves the pressure on the small vessels and that may be what's opening the vessels and again allowing more circulation. And this is even more interesting if you stop and think from a therapeutic standpoint. The diamond shaped ones are the people who responded very well to compression therapy and started healing. You and I both know patients who do that. On the other hand, you know some that we can press and they don’t seem to get any better and that’s the patient represented with this structure. And you can see the patients who responded to healing or capillary density went up dramatically. The ones who didn't show signs of significant healing, their capillary density never return to normal. You think that’s going to change maybe the way we treat people who don't respond to compression therapy who have venous leg ulcers? Are we going to need something that will stimulate new blood vessel formation? Are we going to need something that we will improve the circulation? Do we think maybe that’s something we are going to look forward to in the future? I think so. Obviously, just an offhanded compression guide for you. Obviously if you got an ankle brachial index of 0.8 or higher, you can do anything you want. That’s no big deal. And you know the sub-bandage pressures anywhere between 30 and 40. If you have an ankle brachial index greater than 0.5 but less than 0.8, then we would recommend to you that you go two-layer, short-stretched compression because the sub-bandage pressure is less. If your ankle pressure is less than 25, just your normal pressure, then you're going to have a hard time with any healing. That [Indecipherable] [0:14:54] will fall off. So I think that it should be fine.


    This is always cool to me only with medical supervision and who is that. That’s us. Okay. So if it's less than 0.5, you need to use good common sense and again we'll talk about that. Studies --obviously, we have studies. This was a study that was done with 15 patients and you can see all of them had ankle brachial index of less than 0.8 and some of them actually in 0.5 to 0.6 range. And they were treated with short-stretched compression Coban two-layer Lite system and the bandage remain no wonder for days as you can see. The average sub-bandage pressure at the time of application was about 28 mmHg. The interesting thing was that at the end of study there were no pressure related skin damage problems and there was no pain related to tissue hypoxia. The one good thing about this when the patient has a short-stretched compression bandage on and they start walking, I showed you how high the pressures can go and that’s certainly true, but if that’s enough if they develop claudication, what's going to happen; they'll stop walking. And when they stop walking, their pressure will return to baseline, their circulation will end, they will return without having any further problems and that will also help get their edema down. The other interesting thing that was followed with this study showed that in patients who had this study had poor circulation, had compression bandaging. They actually measured their laser Doppler flow under the bandages to see what would happen. And you can see a baseline was here under the bandage 20 to 30 mmHg after one week, you can see the circulation increased by 33%; 30 to 40 mmHg, it increased to about 28%; 40 to 50 mmHg, it was 10%. Now, I would not ever recommend that you wrap somebody who has got vascular disease 40 to 50 mmHg pressure. Just forget that’s on the slide. But you notice in the 20 to 40 range, we are increasing the amount of circulation underneath the bandage significantly. This shows the toe pressure that was done with the Doppler and you can see that again 20 to 30 went up 6%, 30 to 40 up 9%, 40 to 50 up 13%. But again the main thing is it's not getting worse, it's getting better just by getting the circulation edema out of the leg. tcPO2 30 to 40 mm bandage, it went up to 7%. So again, we're not hurting these people by compressing them using good common sense and the appropriate compression, they actually are getting better. We also treating their venous disease because you can see their ejection fraction went up significantly and that’s what we want to happen when we're treating someone with venous insufficiency. And so the results if you will show that under laser Doppler, it increased microperfusion. It reduced the respiratory influx, maintain capillary perfusion. We got the swelling down and it was comfortable for those people to wear. They did not have any problem. Now, this is just one of my favorite patients. As you can see she was a 99 year old lady that came to see us with an eight-month history of this ulcer. Her ankle brachial index was 0.45. She had had numerous vascular reconstructions through the years and was to the point where nothing more could be done. And they told the lady that she needed a BKA amputation. Well, first of all, I would suggest to you that BKA amputation in a 99-year-old should not be done unless you really have a good reason. If nothing else, then this lady should go into palliative wound care program and I hope that she knows what that means is that we treat the wound to try to keep her from getting worse and not affect her general outcome. But we treated this for a little while and then we began to notice that she is developing granulation tissue in the wound bed. I would suggest to you that if you can have a patient who develops granulation tissue in the wound bed, you have got a reasonable chance to get that wound to close and I don't care what their ankle brachial index is. If they have enough blood to generate granulation tissue, it's going to take you longer and you have to be little more careful, but there is a reasonable chance that you can get that wound to close over time. And so we attempted that with this lady. We used a lot of compression and with that I mean just ACE wrap. And you can see the swelling that she had in the forefoot and ankle. And by the time she healed, you can see the swelling is now down. So we were treating something there. We did some polymer tissue-engineered skin in this particular patient and you can see it took her a while. It took 47 weeks to get her well but where was she going, she wasn't in any big hurry. The patient is now 101 years old. She is still walking around. No evidence of recurrence and when she comes by to see us, we all just sit around and smile and congratulate her on healing her wound and keeping it well for this period of time. I really and truly believe that it will probably last as long as she is going to live.


    But I would suggest to you that this shows that with good careful, thoughtful treatment of edema and these wounds that we can have some good outcomes. Obviously, if you do it wrong and don't pay attention, these compression bandages can cause problems and it's something you should be aware of. So how do you manage it? The sustained bandage pressure should never exceed your arterial perfusion pressure and that’s at the ankle. And so the main thing is if they come in and they're telling you that the bandage is killing them. You know they call you in the middle of the night which is never a good thing and they say, doctor this bandage is killing me. Don't hesitate to say take it off. Take it off and we'll deal with when we see you back tomorrow or whenever. Remove the bandages that kill you. You got to use common sense with these. But again, if you do it correctly, I think you'll see a good outcome. Compression therapy in the patient with edema and cellulitis. Always has been interesting to talk about that because patients all have swelling when they have the cellulitis and they question sometimes which come first, the swelling or the infection. More than likely, it's the swelling but we could debate that and I have had people come up to me and say you know I can't compress somebody who has got an acutely infected leg and I don't care how smaller it is, because if I squeeze all that infected fluid out of the leg, it's going to get into their circulation and they're going to die. You ever seen that happened. Actually it's never been reported in the world's literature. Sounds good. I would agree with that, but it's kind of interesting how sometimes we take things on hearsay and longtime suggestion. So we take a patient and we look at them. We know that the fluid in the leg interestingly inactivates the normal antistreptococcal properties of our skin. We have these little peptides in our skin called defensins that keep infection away. And we have a swollen extremity, most of these especially the ones that are for staphylococcus are inactivated. That fluid just does that so that it will resume if they're at higher risk for developing cellulitis. And so we're setting our patients up by not treating their edema to get cellulitis. Once we get that under control, it's also easier for us to treat their disease if you will because compression therapy will remove that fluid that’s in the subcutaneous tissues. A lot of that contains protein and the bacteria down there in that stuff just having wonderful time, like, hey this is dessert, protein, fluid. The antibiotics can't get to us because we're sitting out in a puddle of fluid. The fluid is pushing against the capillaries and arterials, so the antibiotics really can’t get there. You start to get high levels of antimicrobial in to that fluid and so by getting that out, we increase the flow, we increase the amount of antibiotics concentration to the tissues so that we can help patient with cellulitis. This is a patient who had been in our hospital with 10 days of IV antibiotic therapy and that’s a pretty significant cellulitis. I'll give you that. And they send her over to us because they couldn’t get the redness to go away. Inflammatory reaction and everything that was in that tissue was not doing well since she still had active infection in her leg. So we treated with compression therapy and you can see that within five weeks, not only was the infection completely gone but the leg was returned to normal. So it's really important that we think about that and try to deal with pathophysiology of these processes that we're looking at. Now I know you can say, well that’s just one patient. We have been involved with a program in Africa through the World Health Organization. We're treating an infectious ulcer called Buruli ulcer. It's created by microbacterium and that’s the first cousin to the TB and leprosy bacteria, but all of these people have active infections with that and it eats their skin off. The way that we've been treating these now for the last four years is to start antibiotics and then start compression bandaging. We now have over 275 patients completed the study. I'm headed back over there in first of November to see about the other 80. We're looking for 350 or so in total study. The 275 that we know that have completed, not one single patient got septic as a result of compression therapy in the face of acute infection. So maybe that will give you little confidence to go ahead and try that. Does compression therapy improve the skin of patients with venous dermatitis? This is a very difficult thing to do and we use creams, ointments, all kind of stuff on this try to improve the patient's skin.


    And the interesting thing is this also has to do with the fluid that’s in the leg. As you can see the edema fluid inhibits mitogenic activity and DNA synthesis. So as the skin is trying to repair itself, heal itself, maintain itself, it really has a very difficult time doing that with the cells because it can't make new cells. You can see up there too that the cytokine environment is very inflammatory and as a result protease activity is exceedingly high in that edema fluid. These inflammatory cytokines and I'll keep that in inflammatory phase of wound healing we talked about and you can see that the protease is really a problem even here. And it says as you see growth factor levels are decreased simply because the proteases are eating them up. Proteases are big deal. This inflammatory process we see in all of our chronic wounds is a big deal. I digress half a second to Friedberg [phonetics] to maybe answer your question. We know that when you put tissue-engineered skin, polymer tissue engineered skin on it that the fibroblast actually make inhibitor of proteases. So that’s a big deal but again we have had other products that have fibroblast in them as well. But the other thing is that this product has a collagen matrix and we know that collagen will actually help reduce protease levels in wounds as well. And so I think part of your answer may be that because of the collagen matrix as well as the protease inhibitors that we're seeing a little better outcome when we use polymer product as opposed to just one it doesn't have a good collagen matrix, just a sideline thought. But we know too that the cells in most venous ulcers are not real healthy. We have those cells that are called senescent. They look good. They're sitting there eating all your food, taking all your oxygen up, but they're not helping you close the wound at all. And these are called senescent cells. And it's hard to kind of get a grasp on something that looks good but not doing anything for you. And so it's like having your Mercedes in the driveway with no gas in it. It looks good, but it's not going anywhere. Well, these are biopsies of wounds, biopsies of normal tissue in patients who had venous ulcers and you can see the percentage of these senescent cells is pretty low. But then when they got down and biopsied the edge of the wound, you can see the percentage went way up and so these cells really are there in these wound, they can't divide, they're not helping maintain your skin or help you close your wound and so that’s an issue as well. Another study showing the results of that. These are fibroblasts that are grown in tissue culture. You can see they're having grand old time growing and everything like that. But then they dump the wound fluid from the venous ulcer into that mix and you can see the amount of growth almost stopped. This is looking at it a little bit different. This is an enzyme called senescence-associated beta-galactosidase. You have no idea how long it took me to learn how to say that. But it is an enzyme that cells that are senescent actually produce. And you can see the ones that were growing like crazy and very little percentage of senescence-associated beta-galactosidase cells. But when they dump the wound fluid in after eight hours, you can see that the percentage is almost 25% of those cells were now producing that senescent property. By the time 24 hour came along, it was almost 100% and so this is a real deal. These cells do not work but it appears lot of this has to do with the wound fluid that is being produced, edema fluid if you will. The only difference between edema fluid and wound fluid is holding your leg. And so as a result of that, we see that’s the situation that we have to deal with. As of right now, we don't have a way to turn those around and to reverse that process. A number of us are looking at that and hopefully we'll have some information in the next year or so. And again Dr. Marston looked at venous leg ulcers and protease levels. These are the lot of proteases that we see in the wound care. We are mostly interested in MMP8, MMP9. You can see the white lines were very high in venous leg ulcers. What they did was they biopsied the venous ulcer and measured the protease levels and then they wrapped them with compression bandaging. After one week, they remove the compression, re-biopsied the leg and you can see that in almost every single situation, the protease levels began to decrease. They would have carried it out further but not everybody was real thrilled about getting a biopsy every week. And so you can see though that this was making a big dent in this protease level that is causing so much problem with our healing, again having to do with the amount of edema in the leg.


    Just a further example of inflammatory cytokines and you can see before and after one week of compression in all of these showed signs of improvement. So again compression therapy not only gets the leg smaller, but it seems to be doing a lot of things for us on the molecular level as well. Couple of examples about the skin. You can see before and after just one week of compression therapy. You can see how much improvement as the fluid came down and the skin was able to repair itself. This was a very dense hyperkeratotic type of lesion on this leg. It took a while but all she got was compression therapy and you can see the improvement. Can compression therapy be used in the patient with edema and congestive heart failure? Always a question, am I going to make it worse or anything like that? Well, the answer is when you see the patient that really is bad, this is one of my patients who tried to walk in our door. He couldn't get very far. Every two to three steps, he had to sit down because he was in florid pulmonary edema and you can see he was a big guy to begin with. He wound up in the ICU on the ventilator for three months trying to get this under control. But the answer to your question is, yes for the most part. If there is no acute pulmonary edema, you can certainly compress those people with swollen extremities. And certainly once treatment is started with their cardiostimulatory medications and diuretics, there is no reason why you can't go ahead and treat their extremities with compressive bandaging. If you don't, you know that the legs will continue to swell and it will be more of a problem as you go through into the future. Almost a related issue, can compression therapy be used in the patient with edema and acute DVT? That’s always scary because I hear people say, if I wrap that leg, we're going to squeeze those clots out and they're going to go to the lungs, they're going to have pulmonary embolus and they're going to get really sick and they're going to die. Interesting comment but the question really revolves around the fact that when you do compression therapy, you're actually increasing venous flow which has been shown to prevent further clotting. If you got superficial vessels that you are concerned about, these generally compress them enough that they're occluded and so they can't clot. And the interesting thing is the studies have shown through the years that it does not cause any increase in pulmonary embolism. I asked all of my friends and I would ask you a rhetorical question, if you have a patient with DVT and starting them on anticoagulant therapy, how long would you let them stay in bed before you got them up? Almost everybody says well within 24 to 48 hours you can get them out of bed. I would suggest to you that getting someone out of bed is increasing their risk of not getting clot loose a lot more than if you wrap their legs with compression bandaging. Again just think about that, but again this does not increase pulmonary embolism and it actually shows that their response to your anticoagulant is actually faster. The only contraindication to that would be if the leg was so painful that the compression could not be tolerated. This is a disease called phlegmasia cerulea dolens and if they have got that, compression is going to be way down on your list of thoughts to get that under control. Do patients care which compression bandage is used? Most people don't like any compression bandage. I don't know if any of you here in the audience had to wear compression for any length of time other than support socks, but it's really not a fun thing to do. We've tried it on few, try to wear them around while we work all day. It's really not something that you really want to get used to. But in this particular study, interestingly only 48% to 49% of patients claim that they were the compression bandages. This is entire study but I can tell you experience from our wound center. We have patients come in and my nurses will look at the bandage and say, you took that off, didn't you? And they say, oh no, it's been there all week. And she says, you know I'm right-handed, I don’t wrap left-handed. We also sometimes can look out the front windows of the wound center and you see patients out in the car rewrapping their legs. So as you know, it's not something they want. 48% to 49% admitted in this study that they didn't wear the compression wraps and it may be as high as 80%. In that particular study, the determinants for not wearing compression bandages; age, I can understand that. You know the older we get, harder we are to get along with and so you know I just don't like it, just want to get it off. Pain, obviously, it's hard. I don't blame you, I get it off too. But this is interesting, wound size and wound depth was the determinant for not wearing your bandage. The bigger it was, the less they wanted to wear the bandage. That’s kind of strange to me, but I guess when you have one that’s very large and all that, people just get to where they accustomed to having it and they just don't get rid of it. It is really interesting to me.


    But people don't as you will know. And again if you saw [Indecipherable] [0:35:04] there was a study done few years ago to look at the slippage if you will after 24 to 48 hours. That’s the time you will see the majority of slippage because after you put the bandage on within 24 to 48 hours, you will get rid of more of edema than you will at the rest of time. But as you can see the slippage was most with the four-layer compression that we use with the Coban 2, Coban 2 Lite was the one that showed the least amount of slippage in this particular study. The outcome did show the 72% of the patient preferred the two-layer compression system over the four-layer. Showed less slippage and the quality of life assessment which were done showed that they really like them better than the other system. So the question is we've looked at a number things today and I'll ask the questions again. Are all compression bandages the same? The answer is no. I would suggest to you that we have compression bandages that are good for certain things. If you need higher pressure, then you can use a short-stretched compression because you know when the patient walks that they will get higher compression. If the patient has vascular insufficiency, you probably want to use a short-stretched compression because it has a lower sub-bandage pressure even at rest. And so I would encourage you to think about that. So there is a difference in what we're looking at with the compression. Can compression therapy be used in the patients with edema and ABI of less than 0.8? The answer is yes. If you would do it safely and thoughtfully and consider your patient and not just the wrapping. Can compression therapy be used in someone with edema and cellulitis? I hope you would say that the answer to that is yes and I encourage you to try to see how much better your patients will get. They actually get out of hospital about two to three days quicker when you use compression wrapping than when you don't. Does compression therapy improve the skin of patient with venous dermatitis? I think that showed yes and why based on the molecular environment of the tissue and skin. Can it be used in patients with edema and congestive heart failure? It can be as long as they're not in florid pulmonary edema and are safely under treatment. Can it be used for patients with edema and acute venous thrombosis? The answer should be yes. It will actually help them ambulate quicker and be more stable as you continue your anticoagulant therapy. Do patients care which compression bandage is used? The answer is obviously yes and I think you would as well. So I encourage you to think about compression. It is now the standard of care and we need to use it in anyone who has a swollen extremity for whatever reason because of the things that we talked about. But I would remind you that you need to be careful about how we do things and that’s not true with just wrapping legs as Dr. Peck [phonetics] has said it’s the individual patient that we're treating. It's not the disease, it’s the patient who recovers or dies not the illness. The illness will be around. We're treating patients. And so when it comes to compression therapy, I would encourage you to treat everybody like you would want to be treated or you would want your mother or grandmother or family member to be treated. [Indecipherable] [0:38:27.8] review shows that some compression works better than none. So if not everyone wants a two-layer, not everyone wants a four-layer, whatever. Some compression is better than none and I would encourage you to remember that and just be patient with people. Compliance is a big issue as we talked about, but compliance would be better if we consider their feelings as well and let them help us choose what compression bandaging we would use because we want them to get better. Thank you very much.


    TAPE ENDS - [38:57]