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Poor blood flow in the veins of the legs, known as chronic venous insufficiency, is a common health problem, particularly with ageing. It can cause leg pain, swelling (oedema), itchiness (pruritus) and tenseness as well as hardening of the skin (dermatosclerosis) and fatigue. Wearing compression stockings or socks helps but people may find them uncomfortable and do not always wear them. A seed extract of horse chestnut (Aesculus hippocastanum L.) is a herbal remedy used for venous insufficiency. Seventeen randomised controlled trials were included in the review. In all trials the extract was standardised to escin, which is the main active constituent of horse chestnut seed extract.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Multiple sclerosis (MS) is an inflammatory disease of the nervous system and the most frequent cause of neurological disability in young adults. Myelin, the material that wraps around and protects the nerves becomes damaged and this results in scarring and the formation of scar‐like plaques.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

We aimed to assess the efficacy of Centella asiatica for improvement of the signs and symptoms of chronic venous insufficiency (CVI). We searched 13 electronic databases including the Cochrane Central Register of Controlled Trials for randomised controlled trials assessing the efficacy of Centella asiatica for CVI. Two review authors independently selected studies, assessed the risks of bias of included studies and extracted data. The treatment effects of similar studies were pooled whenever appropriate. Eight studies met the inclusion criteria. The pooling of data of similar studies showed that Centella asiatica significantly improved microcirculatory parameters such as transcutaneous partial pressure of CO2 and O2, rate of ankle swelling and venoarteriolar response. Three out of the eight studies did not provide quantitative data. However, these studies reported that patients treated with Centella asiatica showed significant improvement in CVI signs such as leg heaviness, pain and oedema. Our results show that Centella asiatica may be beneficial for improving signs and symptoms of CVI but this conclusion needs to be interpreted with caution as most of the studies were characterised by inadequate reporting and thus had unclear risks of bias, which may threaten the validity of the conclusions.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

We aimed to assess the efficacy of Centella asiatica for improvement of the signs and symptoms of chronic venous insufficiency (CVI). We searched 13 electronic databases including the Cochrane Central Register of Controlled Trials for randomised controlled trials assessing the efficacy of Centella asiatica for CVI. Two review authors independently selected studies, assessed the risks of bias of included studies and extracted data. The treatment effects of similar studies were pooled whenever appropriate. Eight studies met the inclusion criteria. The pooling of data of similar studies showed that Centella asiatica significantly improved microcirculatory parameters such as transcutaneous partial pressure of CO2 and O2, rate of ankle swelling and venoarteriolar response. Three out of the eight studies did not provide quantitative data. However, these studies reported that patients treated with Centella asiatica showed significant improvement in CVI signs such as leg heaviness, pain and oedema. Our results show that Centella asiatica may be beneficial for improving signs and symptoms of CVI but this conclusion needs to be interpreted with caution as most of the studies were characterised by inadequate reporting and thus had unclear risks of bias, which may threaten the validity of the conclusions.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

The Chronic Venous Insufficiency (CVI) of inferior limbs is a widespread disease, with an increasing incidence as a consequence of longer life expectance, life-style, obesity, smoking, use of drugs as oestrogens and progestins and working conditions. Medical therapy is still lacking for evidence of efficacy, and compression therapy is useful only in preventing a worsening of this condition. Surgical treatment is the only radical therapy effective for the advanced phases of the disease. In this context spa balneotherapy can be considered as a possible chance to improve some subjective and objective symptoms of CVI of inferior limbs, and to prevent worsening of this condition. The authors performed a review of the relevant scientific literature concerning the treatment of CVI of inferior limbs with mineral water balneotherapy, in order to evaluate its effects on objective and subjective symptoms and its effectiveness to prevent further worsening. We searched the PubMed/Medline, Cochrane Library, Embase, Web of Science databases for articles published between 1990 and 2011 on this topic. To this end, the authors selected few clinical-controlled and case-controlled studies; patients affected from CVI of inferior limbs were treated with balneotherapy at health spas with sulphureous, sulphate, salsojodic or salsobromojodic mineral waters. Baths in mineral waters were often associated with idromassotherapy and vascular pathway. Effects of spa balneotherapy are related to some aspecific properties, like hydrostatic pressure, osmotic pressure and water temperature, partly related with specific chemico-physical properties of the adopted mineral water. The controlled clinical studies on spa therapy showed significant improvement of subjective (such as itch, paresthesias, pain, heaviness) and objective symptoms (namely edema and skin discromias). These studies suggest that spa balneotherapy may give a good chance of secondary prevention and effective therapy of CVI of inferior limbs, but also that it needs of other clinical controlled trials.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

Pycnogenol® is a herbal dietary supplement extracted from French maritime pine bark whose main ingredient is procyanidin. Procyanidin is a powerful antioxidant also found in food such as grapes, berries, pomegranates, red wine and various nuts. Supplements containing procyanidin are widely marketed worldwide for the promotion of health, and for the prevention and treatment of chronic disorders. The rationale for this is that antioxidants neutralise reactive oxygen species (ROS; frequently referred to as "free radicals") which, apart from performing important bodily functions, can cause damage to cells and tissues if present in excessive amounts. Available supplements vary in the source and quantity of procyanidin, as well as in number and type of other ingredients they contain. We chose to focus on Pycnogenol® as this supplement is a standardised product, many trials have been conducted, and it is extensively marketed internationally. Our review aimed to assess the efficacy and safety of Pycnogenol® as a treatment for chronic disorders. We identified 15 eligible randomised controlled trials with a total of 791 participants which addressed seven different chronic conditions: asthma (two studies); attention deficit hyperactivity disorder (one study), chronic venous insufficiency (two studies), diabetes (four studies), erectile dysfunction (one study), hypertension (two studies) and osteoarthritis (three studies). Due to small sample size, limited number of trials per condition, variation in outcomes evaluated and outcome measures used, as well as the risk of bias in the included studies, no definite conclusions regarding the efficacy and safety of Pycnogenol® are possible.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Chronic venous insufficiency (CVI) causes much discomfort and sick leave. Many randomized clinical trials (RCTs) have shown a beneficial effect of calcium dobesilate, but consensus is lacking about efficacy and safety. The authors report a meta-analysis of the effectiveness and safety of calcium dobesilate in CVI. Ten RCTs (778 patients) in which calcium dobesilate for CVI was compared with placebo met the inclusion criteria. Only 3 trials (608 patients) were of good methodological quality. Calcium dobesilate significantly improved night cramps and discomfort nearly twice as well as placebo, with the number needed to treat (NNT) being 8 (95% CI 4-50) and 4 (95% CI 3-7), respectively. Frequency of adverse events was not significantly different from placebo. Subgroup analysis found a differential response with respect to disease severity, with greater improvements in pain, heaviness, and malleolar swelling being seen in the severe group than in the mild group. Calcium dobesilate improved paresthesias significantly more than placebo in the severe but not in the mild group and the effect on leg volume was also significantly better in the severe group (-7.2% vs -1.6%). No difference in effect was found for different doses of calcium dobesilate (1,000 or 1,500 mg/day). Sensitivity analyses did not affect the results. Current evidence suggests that calcium dobesilate is more effective than placebo in improving some CVI symptoms, that there is higher efficacy in more severe disease, and that a dose of 1,000 mg/day is as effective and safe as 1,500 mg/day. Further adequately powered trials are needed to further evaluate these hypotheses.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2004

There are a number of different types of skin grafts that can be used to treat leg ulcers caused by venous insufficiency. There is a lack of research on most of them, but some studies suggest that bilayer artificial skin made from human cells can improve the likelihood of venous leg ulcers healing within six months.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: September 23, 2015

Chronic venous insufficiency (CVI) is a disorder in which veins fail to pump blood back to the heart adequately. It can cause varicose veins, skin ulcers, and superficial or deep vein thrombosis in the legs. The ambulatory conservative hemodynamic correction of venous insufficiency (CHIVA) method is a minimally invasive surgical technique to treat varicose veins. The aim of the CHIVA treatment is to eliminate the venousvenous shunts by disconnecting the escape points, preserving the saphenous vein and normal venous drainage of the superficial tissues of the limb.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Long‐term poor blood flow in the leg veins, also known as chronic venous insufficiency (CVI), is a chronic illness. It occurs when the veins in the leg cannot return blood to the heart, resulting in increased blood pressure in the legs. The term CVI encompasses a wide spectrum of symptoms including feelings of heaviness in the legs, itching, tingling, cramps, pain, oedema (swellings), varicose veins, skin pigmentation, signs of skin atrophy and venous ulceration.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Veins are a type of blood vessel that carry blood from the body back to the heart (termed venous blood return). The process is aided by contractions of a series of muscle pumps within the legs. Problems with the veins or muscle pumps in the legs in some people can impair this process, resulting in a condition known as chronic venous insufficiency (CVI). CVI may cause pain, oedema (the retention of fluid leading to swelling) and leg ulcers, and can impair a person's quality of life. Research suggests that treatments, such as physical exercise, that aim to increase the movement of the ankle joint and strengthen the muscle pump in the calf of the leg may be useful to prevent worsening of the disease and its consequences. We have looked at the evidence supporting physical exercise as a treatment for CVI.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Insufficient blood circulation in the veins of the legs might be caused by genetic factors, may occur after trauma, or may result from a blood clot. Poor movement of blood up the legs may cause swelling and puffiness, feelings of heaviness, tingling, cramps, pain, varicose veins and changes in skin pigmentation. If severe insufficient blood circulation occurs, ulcers and skin wasting can develop. Drugs such as natural flavonoids extracted from plants and similar synthetic products may improve blood circulation. These drugs are known collectively as venoactive drugs or phlebotonics. This review examined evidence from randomised controlled clinical trials comparing these drugs versus inactive treatment (placebo), generally given over one to three months.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Deep venous incompetence (DVI) is a problem in the veins that can lead to leg ulcers (sores), pain and swelling. It may be caused by a problem in the valves of the vein, by a blockage of the veins or by a combination of these events. For most people, wearing special compression stockings and treating the ulcers is enough. When this does not ease the problem, surgery is sometimes tried. This review includes four studies with a total of 273 participants. All included studies reported on outcomes following surgical repair of venous valves (valvuloplasty). We did not identify studies investigating other surgical procedures for the treatment of patients with DVI. All included studies investigated primary valve incompetence (when valves do not close properly because of laxity of the vein wall or valve cusps). We found no trials that investigated the results of surgery for secondary valvular incompetence (when valves do not close properly, for example, when valves are damaged as a result of deep vein thrombosis) or for the obstructive form of DVI. As different outcomes were reported, it was not possible to combine the results of these studies. The methodological quality of the included studies was low, mainly because information regarding allocation of treatment and blinding was missing, or because data were incomplete or were poorly presented. Ulcer healing and ulcer recurrence were not reported in one study, and the remaining three studies did not include patients with ulcers or active ulceration. Three studies reported no significant complications of surgery or no incidence of DVT during follow‐up. One study did not report on the occurrence of complications.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

The authors concluded that compared with open perforating vein surgery subfascial endoscopic perforator vein surgery was associated with a reduction in wound infection, ulcer recurrence and hospital stay. The authors' conclusion reflected the evidence presented. However, without further details on study quality and given the other methodological concerns it is difficult to judge the reliability of these conclusions.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

Venous leg ulcers (VLUs) are the most common type of leg ulcers (sores) and are caused by poor blood flow in the veins of the legs (chronic venous insufficiency). Chronic venous insufficiency leads to high blood pressure in the veins (venous hypertension), which triggers many alterations in the skin of the leg. Leg ulcers are the end stage of these alterations. VLUs can occur spontaneously or after minor trauma, they are often painful and produce heavy exudation (loss of fluid). VLUs are a major health problem because they are quite common, tend to become chronic (long‐lasting) and also have a high tendency to recur. They affect older people more frequently, have high costs of care, and a high individual and social burden for those affected.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

In summary, a large number of women in the UK experience menopausal symptoms which, in many cases, can significantly affect their quality of life. It is probable that a minority of these women seek medical treatment and for those who do there is considerable variation in the help available, with many being told that the symptoms will get better with time. Since symptoms may often continue for 7 years or more, this advice is inappropriate and help should be offered where possible. Women need to know about the available options and their risks and benefits, and be empowered to become part of the decision-making process.

NICE Guideline - National Collaborating Centre for Women's and Children's Health (UK).

Version: November 12, 2015

Minor injuries to our skin usually heal quite quickly on their own. But some wounds close very slowly, keep on opening up, or do not heal at all. Doctors refer to a wound that that does not heal for a long time as a chronic wound. A circulation disorder or diabetes are common causes.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: September 23, 2015

In order to inform policy work and clinical decisions, a health technology assessment was undertaken by CADTH. For this project CADTH worked in partnership with the Canadian Collaboration for Drug Safety, Effectiveness and Network Meta-Analysis (ccNMA), funded by the Drug Safety and Effectiveness Network (DSEN) of the Canadian Institutes of Health Research (CIHR). The health technology assessment includes both a clinical and an economic evaluation. The clinical component was conducted by ccNMA, and the economic evaluation was conducted by CADTH. This report provides findings from the economic evaluation.

CADTH Technology Review - Canadian Agency for Drugs and Technologies in Health.

Version: March 2016

This is an evidence report prepared by the University of Connecticut/Hartford Hospital Evidence-based Practice Center (EPC) examining the comparative efficacy and safety of prophylaxis for venous thromboembolism in major orthopedic surgery (total hip replacement [THR], total knee replacement [TKR], and hip fracture surgery [HFS]) and other nonmajor orthopedic surgeries (knee arthroscopy, injuries distal to the hip requiring surgery, and elective spine surgery).

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US).

Version: March 2012

The Veterans Health Administration (VHA) System serves a largely older, male population with a high prevalence of chronic atrial fibrillation (AF) and venous thromboembolism (VTE). Many veterans with chronic AF have risk profiles for stroke that, according to current clinical guidelines, place them in a risk group where chronic anticoagulation is recommended. Adjusted-dose warfarin has been the preferred approach to chronic anticoagulation in the VHA, and in many VHA settings, specialized therapeutic drug-monitoring services provide high-quality warfarin treatment. However, the advent of newer anticoagulants with the promise of simplified long-term anticoagulation requires reconsideration of current treatment practices. The purpose of this systematic review was to study the comparative effectiveness of warfarin and the newer oral anticoagulants used for the long-term prevention and treatment of arterial and venous thromboembolism. An evaluation of newer oral anticoagulants for VTE prophylaxis in the perioperative period will be the subject of a later report.

Evidence-Based Synthesis Program - Department of Veterans Affairs (US).

Version: April 2012

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