CONTINUING MEDICAL EDUCATION / MANAGEMENT

Goals and Objectives Management After reading this article the podiatric physician will be able to: 1) Recognize the problem of peripheral (PVD) and venous leg ul- of Venous Leg cers (VLUS). 2) Learn about the pathophysiology of PVD and VLUs. Ulcers and Venous 3) Become competent in diagnosing these conditions in their patient population. 4) Become familiar with the types of Insufficiency compression therapy available. 5) Denote the different uses of com- pression therapy. Here’s an update on this 6) Understand the factors contributing to the chronicity of VLUs and how to re- common condition. verse them. 7) Encourage the continued investiga- By Windy Cole, DPM tion of new therapies in order to improve 119 patient outcomes.

Welcome to Podiatry Management’s CME Instructional program. Podiatry Management Magazine is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. Podiatry Management Magazine has approved this activity for a maximum of 1.5 continuing education contact hours. This CME activity is free from commercial bias and is under the overall management of Podiatry Management Magazine. You may enroll: 1) on a per issue basis (at $27.00 per topic) or 2) per year, for the special rate of $219 (you save $51). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also take this and other exams on the Internet at www.podiatrym.com/cme. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 124. Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, man- aged care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Program Management Services, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (pg. 124).—Editor

illions of Americans amputation of their limb. Many patients of a condition known as chronic venous are affected with pain- even consider amputation of the limb insufficiency. This malady is caused by ful, open, draining as an option to alleviate the pain. Pain is an abnormality of the in the lower ulcers on their legs. one of the most common complaints in extremity. The lower extremity venous These ulcers are com- patients with VLUs and it can be difficult system is composed of both a superfi- Mmonly referred to as venous leg ulcers to control. A study by Phillips in 1994 cial and deep system connected by an (VLUs).1–5 These ulcers are the cause of found that 65% of patients with VLUs elaborate series of perforating veins.2,3 significant clinical and economic bur- related severe pain and 68% of patients Under normal conditions, valves with- den to the healthcare system and society stated that the ulcers caused negative in these veins direct blood from the as a whole. VLUs often take weeks or emotional and psychological impact. superficial into the deep system that in months of treatment in order to heal. Some of the reported feelings were that turn carries the blood back towards the Oftentimes, even under the best circum- of fear, social isolation, anger, depres- . The flow in the deep system is di- stances, these ulcers can be recalcitrant sion, anxiety and negative self-image.6 rectly impacted by the pumping action and recurring. It is not uncommon for of the musculature in the legs during physicians to see patients who have suf- The Problem physical activity. A host of illnesses and fered for years with VLUs or have faced Venous leg ulcers are the end result Continued on page 120 www.podiatrym.com AUGUST 2018 | PODIATRY MANAGEMENT CME Continuing

Medical EducationVenous (from page 119) junctions, as well as communicating prevent retrograde flow or reflux from through the perforator veins (Figure 1). the deep to the superficial system.2,4 disease states can directly affect the Perforator veins either connect directly Dysfunction in venous return oc- anatomic function of the venous sys- to the main axial veins or link to the curs through incompetent valves in the tem. Some examples include a history veins and venous sinuses within the superficial, perforating or deep veins, of deep throm- muscles, thus drain- outflow obstructions in the deep veins, bosis in patients ing indirectly into the and/or calf muscle pump failure be- who may have had main axial veins.2,3 cause of immobility or disease of the damage caused to The bicuspid lower limb. These conditions contribute their valves in their valves in veins en- to venous reflux resulting from val- veins. Women who sure that the venous vular incompetency, leading to sus- have experienced return is unidirec- tained increases in venous pressure in pregnancy may expe- tional towards the the superficial system.8,9,10 This venous rience functional and heart.3,4 Valves in the is the hallmark of chron- structural changes perforator veins also ic venous insufficiency (CVI). Clinical in the venous sys- serve to protect the manifestations of CVI can include: tem due to increased superficial venous • or spider veins hormone levels and system from high • damage caused by compartmental pres- • Dependent in the lower leg pressures put on the sures present in the • Atrophy blanche or smooth inferior vena cava Perforating veins connect the deep deep veins during white scar tissue by the enlarging system with the superficial system contraction of the • Hyperpigmentation caused by fetus.7 There is also calf muscle pump. deposition of red blood pigments 120 Figure 1: The superficial and deep venous a hereditary predis- system of the lower leg. The muscle pump in the dermis position in some in- assists in the return • eczematous skin changes, such dividuals to develop valve dysfunction of blood against gravity.5 In a leg with as dry, flaky skin over time. Obesity and sedentary life- normal venous return, the hydrostat- • Induration of the lower leg style can quicken this progression. In ic pressures within the superficial and caused by fibrosis of subcutaneous these instances, blood can then flow in a reverse fashion from the deep vein system to the superficial system.2,3 This The superficial venous system reversal of flow leads to pooling of the blood and fluid in the legs. The patient is composed of the long and short saphenous veins. may first experience swelling or edema in the lower extremities. Over time, hallmark trophic changes in the tissues deep venous systems • Leg ulceration of occurs. These include hyper-pigmen- are both approximately the lower extremity tation, , hemo- 80 mmHg when a per- siderin deposits, loss of hair, thickened son is upright at rest.4 The microcircula- nails, atrophy blanch, and lipodermato- However, during exer- tory cascade form ve- sclerosis. As a result of these changes, cise such as walking or nous hypertension to skin breakdown can occur, resulting in plantarflexion, calf mus- ulceration of the leg has ulcerations. VLUs typically occur in the cle contraction increases still not been fully de- gaiter region of the lower leg. pressure within the deep scribed. Although the veins. This action closes understanding of the The Pathophysiology the valves in the perfora- pathogenesis of venous The venous system in the leg is tor veins and propels the leg ulcers is incomplete, made up of two distinct networks, the blood in the deep veins many hypotheses exist. superficial and the deep venous sys- towards the heart.2 Sub- Some of these theories tem.2,3 The superficial system is com- sequent muscle relax- include pericapillary posed of the axial superficial veins (the ation causes pressures in Figure 2: Murals from the Neolithic cuff formation, long and short saphenous veins) and the deep venous system period showing what appears to be presenting a barrier to early compression therapy. their tributaries. These offshoots drain to fall abruptly to a level diffusion,11,12 blood from the microcirculatory bed. lower than that in the perforator veins. white cell plug in causing The deep venous system consists of the This sudden pressure drop of between tissue hypoxia,13,14 and fibrin cuffs trap- main axial veins between muscle com- 0 and 10 mmHg ensures the valves in ping growth factors.15 The most current partments and the venous sinuses with the superficial system open to refill the theory of pathogenesis is thought the calf muscles.2,3 The superficial and deep venous system.4 Proper function- to be an inflammatory chain brought deep venous systems connect at the ing of this venous return is dependent on by a chronic -reperfusion sapheno-popliteal and sapheno-femoral on competent valves within the veins to Continued on page 121

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Venous (from page 120) sion produced by any bandage sys- pression bandage at the ankle tem is influenced by several complex as compared to the knee.21 To cycle.9,16 An inflammatory cascade in- factors. Of particular importance is achieve true graduated compres- volving , oxygen-derived the physical structure and elastomeric sion, the bandage should be applied at free radicals, and activated polymor- properties of the bandage itself. Sec- a consistent tension and be able to keep phonuclear neutrophils promotes the ondly, the number of layers and the its shape over time. The pressure exert- deposition of cuffs, trapping technique in which it is applied comes ed on the limb is also directly attributed growth factors and cellular adhesion into play. The shape and size of the to the number of layers applied. The molecules. These matrix plugs attract limb should also be considered. The more layers, the increased pressure.21 and activate more white blood cells. skill and technique of the bandager There are two main forms of com- The repeated activation of this plays a role as well. Lastly, the type pression bandages, elastic and inelas- cascade eventually overwhelms the and amount of physical activity that tic (Figure 3). Inelastic bandages, also body’s compensatory capacity and the patient participates in is crucial.20 known as short stretch bandages, only the balance tips in the offer effective compres- favor of tissue destruc- sion during movement. tion.17 Although the ob- These types of bandag- served causes of lower es rely on muscle con- leg ulcers may, in many Elastic Material (long-stretch) traction to contribute cases, seem to be me- to the volume changes chanical (traumatic), in the leg. Short stretch cascades are ar- bandages have minimal rested or counteracted stretch and can only ex- by the ischemic-reper- Multicomponent Multilayer (short/long-stretch) tend to 30 to 70 percent fusion cycle.17 Correc- of their length.22 This 121 tion of the underlying attribute may allow for venous hypertension is safer use in patients the crux of treatment having venous ulcers for VLUs. Non Elastic Material (short-stretch) with mildly decreased arterial flow. Inelastic Compression Therapy bandages may not be The therapeutic the choice for patients mainstay in the man- Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic with inadequate calf agement of venous leg bandages. Dermatol Surg. 1999;25:695-700. pumps or limited mobil- ulcerations is graduated Figure 3: Examples of elastic and inelastic bandage materials. ity. Examples of inelas- compression bandag- tic bandages, otherwise ing. Compression therapy is one of the LaPlace’s Law known as short-stretch, include Unna most ancient treatments employed by LaPlace’s law must therefore be Boots, Coban, and Coloplast. The rec- man. Its role has been defined over considered when applying compres- ommended method of application of centuries by a wealth of experience sion therapy. In its essence, this law ac- inelastic bandages is a spiral wrapping and scientific studies. The first docu- counts for sub-bandage pressure by de- technique from the base of the toes to mentations our ancient ancestors left termining the relationship between the two fingerbreadths under the patella. behind were prehistoric cave paintings pressure and tension of the bandage as Elastic bandages, as implied by from the Neolithic period 500–2500 well as the radius of the limb. Applied their name, have high elasticity and can BC (Figure 2).18 Hippocrates used cloth pressure is directly proportional to the stretch up to several times their length. compression dressings for the treat- tension in a bandage, but inversely pro- These products are therefore often re- ment of lower leg ulcers. He also held portional to the radius of the limb to ferred to as long-stretch. Elastic ban- to the belief that this therapy helped to which it is applied. With increased ap- dages exert continuous pressures on redirect blood flow back to the heart.19 plication tension, the bandage applied the leg, allowing them to adjust to vol- In 1783, Dr. Benjamin Collins Brodie pressure will increase. As the number ume changes in the limb during both was the first to scientifically describe of bandage layers increases so does the ambulation and relaxation.21 These venous insufficiency. He devised the bandage pressure. The circumference compression bandages are therefore very first test for valvular incompe- of the limb will then inversely affect recommended in immobile patients or tency called the Brodie-Trendelenburg bandage pressure.21 The practical con- those having inadequate calf pumps. percussion test.19 Dr. Paul Gerson Unna sequence of LaPlace’s law is that with They are contra-indicated in patients introduced his famed zinc paste boots constant tension and increase of limb with arterial insufficiency. Examples of in 1885 for the treatment of stasis der- radius applied bandage pressures will elastic compression bandages include matitis and leg ulcerations.19 decrease. Therefore, the natural pres- ACE, Setopress, and SurePress wraps. Compression therapy works by sure gradient of the leg will be main- Multilayer compression bandages harnessing the powers of the laws tained. Subsequently, it is not advised are composed of a combination of in- of physics. The degree of compres- to apply increased tension to the com- Continued on page 122 www.podiatrym.com AUGUST 2018 | PODIATRY MANAGEMENT CME Continuing

Medical EducationVenous (from page 121) matrix (ECM) plays an important role Conclusions in tissue regeneration and provides a Edema causes an alteration in the elastic and elastic bandages. Patients structural support for cells.24 Biologics endothelium that begins a complex cas- with poor calf pump function can ben- contain reconstituted or natural col- cade of detrimental events. Neutrophils efit from the elastic components with lagen matrix that aims to mimic the become activated and adhere to capil- the inelastic layers provide high working structural and functional characteristics lary walls, thus creating a reperfusion pressures with lower resting pressures. of native ECM. CTPs have emerged injury. These adhesion molecules re- There are many multi-layer compression over the past 20 years as the most care- lease cytokines, oxygen free radicals, kits on the market. These products vary fully studied and proven of the ad- and proteolytic enzymes that are detri- widely and it is always wise to review vanced wound management technolo- mental to the soft tissue structures. As the product insert prior to application. gies. The ideal skin substitute is non- hypoxia increases, so does Intermittent pneumatic compression pumps may also be used to treat lymph- edema, venous insufficiency, PVD, ve- Elastic bandages are contraindicated in patients nous stasis ulcers, and ineffective mus- cle pumps. These garments typically act with arterial insufficiency. on a short cycle, utilizing overlapping compression chambers of adjustable pressure to pump the limb from distal toxic, has little or no antigenicity. CTPS and harmful matrix metalloproteinases, to proximal. Contra-indications to this should be immunologically compatible. causing dermal tissue fibrosis and ul- therapy include DVT/PE, inflammatory Processing of these products renders ceration.24 With the use of compression , infection, decompensated car- them safe to be used in human sub- therapy, blood flow accelerates, subse- diac failure, and severe PAD.23 jects without transmission of disease. quently causing detach- 122 After venous ulcers have healed, it Most bio-engineered tissue can be ment from the endothelium. As perfu- is imperative to transition patients into divided into two major categories: Cel- sion improves, the tissue environment maintenance compression therapy to lular and Acellular. Acellular products, stabilizes and tissue fibrosis and break- prevent recurrence. Physicians should such as cadaveric human dermis, have down decreases.25 Compression therapy prescribe some type of daily wear gar- had all cellular components removed. in and of itself can only do so much to ment. Graduated compression stock- They contain a matrix of hyaluronic help heal that are already pres- ings with slip-on adjustable devices are acid, collagen and fibronectin.25 When ent. Additional research and advances among the most common options re- placed in the wound bed, the three-di- in care are still needed to aid in healing cently gaining favor. Compression levels mensional matrix provides a temporary of these chronic and often painful ulcers of 30 to 40 mmHg are recommended for scaffold or support into which cells can caused by long-standing PVD. the treatment of chronic venous insuffi- migrate and proliferate. Cellular prod- The need for clinical trials providing ciency and venous ulcer prevention. ucts contain living cells such as kerat- level one evidence is a must in this seg- inocytes, fibroblasts, or mesenchymal ment of medicine. One such study is the Advanced Therapies stem cells within a matrix.26 These cells investigation of a Beta-Glucan topical Biologic matrices, both with and can be autologous, allogeneic, or from cream. In essence, the cream contains without living cells, provide clini- another species all together. the skeletal polysaccharide structure of cians with additional viable therapeu- The thought is that by introduction a yeast cell envelope while the active tic options in the treatment of chronic of these cells into the wound it will pro- cellular constitutes are removed. The wounds. These products are especially vide the patient the components need- product is thought to act by increasing useful in the management of venous ed to help heal the wound. A multitude the activity of specific macrophages, re- leg ulcers found in patients with PVD. of biologically active CTPs have been sulting in enhanced physiologic wound These therapies are intended to facilitate developed. Their availability has ex- debridements. As previously mentioned, the innate human repair mechanisms panded the options for the wound care VLUs are in a state of inflammatory re- for tissues and skin. Cellular and tis- physician when faced with managing sponse and this is possibly one meth- sue-based products (CTPs), formerly complex wounds such as VLUs. Under- od of reversing the chronicity of these known as skin substitutes, are tissue-en- standing the composition, advantages/ wounds and altering impaired wound gineered, biologically active products de- disadvantages, and risk/benefit of each healing. Many more such investigations signed to replace, either temporarily or product, as well as the indications for are necessary in order to improve pa- permanently, the form and function of each product’s use facilitates the se- tient outcomes across the continuum. the skin. CTPs are used in the treatment lection of the appropriate CTP in pa- While we have some answers as to the of chronic ulcerations to improve heal tients with chronic wounds. Adjunctive physiology of this far-reaching condition, rates and decrease risks of infection. therapies such as biologically active we still look to understand the entire is a dynamic pro- CTPs can speed healing time in VLUs pathogenesis of venous dysfunction and cess involving interactions between in a clinically meaningful way and can VLU formation more thoroughly. PM cells, (ECM) and result in overall lower treatment costs References growth factors that reconstitute tis- as well as reducing risks and complica- 1 Ballard JL, Bergan JJ, editors. Chronic sue following injury. The extracellular tions in this patient population. Continued on page 123

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Venous (from page 122) New Engl J Med 2006;355:488-498. 17 Cullum N, Fletcher AW, Nelson EA, Sheldon TA. Com- venous insufficiency. Diagnosis and treatment. London: Springer- pression bandages and stockings I the treatment of venous ulcers. Verlag, 2000. Cochrane Database syst Rev 2000; CD000265:DOI:10.1002/14651858. 2 Negus D. Leg ulcers: A practical approach to management. 18 Partsch H, Rabe H, Stemmer R. (Eds.) (2009) Compression 2nd ed. Oxford: Butterworth Heinemann, 1995. therapy of the extremities. Paris: Editions Phlebologiques Francaises. 3 Olivencia JF. Pathophysiology of venous ulcers: surgical im- 19 Gloviczki P, (Ed.) (2009) Handbook of venous disorders: plications, review and update. Dermatol Surg 199: 25:880-885. guidelines of the American Venous Forum. 3rd ed. London: Arnold. 4 Valencia IC, Falabella A, Kirsner RS, Eaglstein WH. Chronic 20 Martani F. (Ed.) Compression: consensus document based on venous insufficiency and venous leg ulceration. J Am Acad Derma- scientific evidence and clinical experiences. The Compression Thera- tol 2001: 44:401–421. py Study Group. Task Force 2009. Farrara University, Torino Italy. 5 Vowden K, Goulding V, Vowden P. Hand-held Doppler assess- 21 Thomas S. The use of the Laplace equation in the calculation ment for peripheral arterial disease. J Wound Care 1996: 5:125–127. of sub-bandage pressure. EWMA Journal. 2003; 3 (1): 21–23. 6 Phillips T, Stanton B, Provan A, Lew R. A study of the impact 22 Hettrick H. The science of compression therapy for chronic ve- of leg ulcers on quality of life: Financial, social and psychologic impli- nous insufficiency edema. Journal of the American Collage of CWS. cations. J Am Acad Dermatol 1994; 31:49–53. 2009;1: 20–24. 7 Ginekol Pol. Risk factors for the development of venous insuf- 23 Bryant R, Nix D. (Eds.) (2010) Acute and chronic wounds cur- ficiency of the lower limbs during pregnancy—part 1. Review Article rent management concepts. 4th ed. St. Louis: Mosby. 2012 Dec; 83(12):939–42. 24 Wiegand C, Schonfelder U, Abel M, Ruth P, Kaatz M, Hipler 8 Sandor T. Pathomechanism of chronic venous insufficiency and UC. Protease and proinflammatory concentrations are ele- leg ulcer. Acta Physiolog Hung 2004; 91:131–145. vated in chronic compared to acute wounds and can be modulated 9 Schmid-Schobein GW, Takase S, Bergan JJ. New advances in by collagen type I in vitro. Arch Dermatol Res2010;302(6):419-28. the understanding of the pathophysiology of chronic venous insuffi- 25 Braumann C, Guenther N, Menenakos C, Muenzberg H, ciency. Angiology 2001; 52(Suppl 1):S27–S34. Pirlich M, Lochs H, Mueller JM. Clinical experiences derived from 10 Browse NL. The cause of venous ulceration. Lancet 1982; implementation of an easy to use concept for treatment of wound 2(8292):243–5. healing by secondary intention and guidance in selection of appro- 123 11 Browse NL. Venous ulceration. BMJ 1983; 286:1920–1922. priate dressings. Int Wound J 2011;8(3):253-60. 12 Coleridge Smith PD, Thomas P, Scurr JH, Dormandy JA. Caus- es of venous ulceration: a new hypothesis. BMJ 1988;296:1726–1727. Dr. Cole is an Adjunct Professor and Director of 13 Coleridge Smith PD. Causes of venous ulceration-a new hy- Wound Care Research at Kent State University pothesis. Br Med J (Clin Res Ed) 1988; 296(6638):1726-7. College of Podiatric Medicine. She also serves as 14 Falanga V. The “trap” hypothesis of the venous ulceration. Director of Wound Care Services for Cleveland Lancet 1993; 341:1006–1008. Regency East Hospital and is the Medical Director 15 Agren MS, Eaglestein WH, Ferguson MW, Harding KG, Moore at University Hospitals Ahuja Wound Care Center. K, Saarialho-Kere UK, et al. Causes and effects of the chronic inflam- She is board certified by the American Board of Po- mation in venous leg ulcers. Acta Derm Venereol Suppl (Stockh) diatric Surgery. Her practice focus is on advanced 2000; 210 (suppl):3–17. wound care modalities and regenerative medicine. 16 Bergan JJ, Schmid-Schonbein GW, Coleridge Smith PD, She has published on these topics and speaks na- Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. tionally and internationally on limb preservation and wound care.

CME EXAMINATION See answer sheet on pagE 125.

1) Which is a true statement regarding venous leg ulcers? B) Popliteal vein. A) They affect millions of Americans. C) The short saphenous vein. B) Frequently, loss of employment occurs in those D) Both a and c patients afflicted. C) Pain is one of the frequent complaints in these patients. 4) Which of these statements about the function of D) All of the above. bicuspid valves are true ? A) They serve to protect the superficial venous system 2) The venous system of the leg is composed of which of from high compartment pressures. the following? B) They activate with contraction of the calf muscle A) A two-way flow system. pump. B) A superficial and deep system connected by a C) They assist in propelling the blood in the deep veins series of perforating veins. toward the heart. C) Deep vein aiding in blood flow to the D) All of the above are true. extremities. D) A system that channels blood flow from the heart 5) Dysfunction in venous return can be the result of all of to the extremities. the following EXCEPT: A) Incompetence in the valves of the veins. 3) What vein(s) compose the superficial venous system? B) Correct mechanics of the venous system. A) The long saphenous vein. Continued on page 124 www.podiatrym.com AUGUST 2018 | PODIATRY MANAGEMENT $ CME EXAMINATION PM’s Continuing

Medical EducationC) Outflow obstructions in the deep vein system. CME Program D) Calf muscle pump failure.

6) Clinical manifestations of chronic venous disease Welcome to the innovative Continuing Education include which of these conditions: Program brought to you by Podiatry Management A) Telangiectasia and/or spider veins. Magazine. Our journal has been approved as a B) Varicose veins and hyperpigmentation. C) Dependent edema in the lower leg. sponsor of Continuing Medical Education by the D) All of the above. Council on Podiatric Medical Education.

7) Venous hypertension is thought to cause microcircu- latory dysfunction by: Now it’s even easier and more convenient to A) Activating white blood cells. B) Increasing oxygenation to the tissues. enroll in PM’s CE program! C) Resulting in fibrin cuff formation posing a barrier You can now enroll at any time during the year to oxygen diffusion. D) Delivering growth factors into the dermis. and submit eligible exams at any time during your enrollment period. 8) What is the most defining property of compression bandages? CME articles and examination questions A) The product manufacturer location. from past issues of Podiatry Management B) The structure and the elastomeric quality of the bandage itself. can be found on the Internet at http://www. C) The length of the bandage. podiatrym.com/cme. Each lesson is approved 124 D) The color of the wrap. for 1.5 hours continuing education contact hours. 9) What is the practical consequence of LaPlace’s law Please read the testing, grading and payment in the role of compression? instructions to decide which method of participa- A) With increased application tension, the bandage applied pressure will decrease. tion is best for you. B) The number of layers and the technique in which Please call (631) 563-1604 if you have any it is applied is not important. C) Applied pressure is directly proportional to the questions. A personal operator will be happy to tension in a bandage, but inversely proportional to assist you. the radius of the limb to which it is applied. D) As the number of bandage layers increases, the Each of the 10 lessons will count as 1.5 credits; bandage pressure decreases. thus a maximum of 15 CME credits may be earned

10) All of the following are true of compression ban- during any 12-month period. You may select any 10 dages except: in a 24-month period. A) There are two main forms of compression ban- dages, elastic and inelastic. B) Elastic bandages exert continuous pressures on The Podiatry Management Magazine CME the leg, allowing them to adjust to volume changes in the limb during both ambulation and relaxation. program is approved by the Council on Podi- C) Elastic bandages are not contraindicated in atric Education in all states where credits in patients with arterial insufficiency. instructional media are accepted. This article is D) Inelastic bandages, also known as short stretch bandages, only offer effective compression during approved for 1.5 Continuing Education Contact movement. Hours (or 0.15 CEU’s) for each examination successfully completed. See answer sheet on page 125. PM’s privacy policy can be found at http:// The author(s) certify that they have NO affiliations with or involvement in any organization or entity with podiatrym.com/privacy.cfm. any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; member- This CME is valid for CPME-approved credits ship, employment, consultancies, stock ownership, or other equity interest), or non-financial interest (such for three (3) years from the date of publication. as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materi- als discussed in this manuscript.

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EXAM #6/18 Management of Venous Leg Ulcers and Venous Insufficiency (Cole) Circle: 1. A B C d 6. A B C d 2. A B C d 7. A B C d 3. A B C d 8. A B C d 4. A B C d 9. A B C d 5. A B C d 10. A B C d

Medical Education Lesson Evaluation Strongly Strongly agree Agree Neutral Disagree disagree 126 [5] [4] [3] [2] [1]

1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on this lesson ____

5) This lesson presented quality information with adequate current references ____

6) What overall grade would you assign this lesson? ABCD

7) This activity was balanced and free of commercial bias. Yes _____ No _____

How long did it take you to complete this lesson? ______hour ______minutes

What topics would you like to see in future CME lessons ? Please list : ______

AUGUST 2018 | PODIATRY MANAGEMENT www.podiatrym.com