OBJECTIVE:This prospective cohort study aimed to determine the relationship between serum vitamin C, D, and zinc on foot wound healing and compare time to healing in individuals who are deficient versus those who have adequate levels. APPROACH:One hundred adults with foot wounds were recruited from Blacktown high-risk foot service with a follow-up period of 12 months. Serum vitamin C, D, and zinc as well as routine baseline blood testing was undertaken. Wounds were measured using a three-dimensional wound camera and classified using the Wound Ischemia and Foot Infection system at regular intervals. RESULTS:Vitamin C deficiency was present in 75% of participants, 50% had vitamin D deficiency, and 38% had zinc deficiency. Diabetes was present in 91% of participants, and 50% had a history of previous amputation. Wound chronicity (p = 0.03) and toe pressures (p = 0.04) were predictive of wound healing. Serum vitamin C, D, and zinc were not associated with significant differences in wound healing or time to wound healing. INNOVATION:Deficiencies in vitamin C, D, and zinc were highly prevalent in participants with active foot ulceration. Wound chronicity was predictive of healing outcomes, highlighting the importance of rapid access to best practice care. CONCLUSION:This cohort had high deficiency rates of vitamin C, D, and zinc consistent with previous literature; however, there was no relationship between these deficiencies and wound healing or time to heal. Large randomized controlled trials are required to comprehensively determine if adequate levels of these nutrients improve wound healing outcomes. [Figure: see text].

Objective To evaluate the effectiveness of a twice-daily application of a wipe impregnated with emollient and barrier ingredients in reducing incidence of pressure injury (PI) in aged care consumers.Design A single-blinded, multicentre randomised controlled trial. Randomisation was stratified by facility, using simple 1:1 randomisation within each stratum.Setting 20 residential aged care facilities in Rural and Metropolitan New South Wales and the Australian Capital Territory, Australia.Participants 858 aged care consumers aged ≥65 years at risk of developing a PI.Intervention Participants were randomised 1:1 to receive either standard hygiene practices, repositioning and use of pressure redistribution surfaces (standard care) or twice-daily applications of a pre-packaged wipe impregnated with emollient and barrier ingredients (Contiplan) to the sacrum, buttocks and heels in addition to standard care for the study duration.Primary outcome and analysis The primary outcome was the incidence of PIs per 1000 consumer days. Treatment effects were estimated using an intention-to-treat approach, with the absolute difference and 95% CI estimated using the Wald method. The relative difference in the incidence of PIs was estimated using a negative binomial regression model (with log link).Results 858 participants were included in the study. There was a 50% relative reduction in the incidence of PI in the intervention compared with the control (95% CI 0.31 to 0.81, p=0.005), with an absolute rate difference of 0.31 fewer PIs per 1000 consumer days (95% CI 0.11 to 0.51).Conclusion The use of wipes with emollient and barrier properties significantly reduced the incidence of PIs and prolonged the time to first PI, demonstrating efficacy as a PI preventive strategy in aged care.Trial registration Australian and New Zealand Clinical Trials Registry, ACTRN12622001360707.

SIGNIFICANCE:Pressure injuries are prevalent, yet preventable global health care problem estimated to affect 14% of hospital patients and up to 46% of aged care residents. One common prevention strategy is improving skin integrity through emollient therapy to optimize hydration and avoid skin breakdown. Therefore, this study aimed to review the literature and determine effectiveness of inert emollients, moisturizers, and barrier preparations compared with standard care, to prevent pressure injury in aged care or hospital settings. RECENT ADVANCES:Search terms were derived with database searches, including ProQuest, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, Science Direct, Scopus, and the Cochrane library. The Robins1 and Risk of Bias 2 (Rob2) quality appraisal tools were used. A meta-analysis of the effects of interventions was conducted (random effects). Four studies met the inclusion criteria, with heterogeneous quality. Pooling of nonrandomized studies found that the application of emollients, moisturizers or barrier preparations did not significantly reduce incidence of pressure injury compared with standard care (relative risk 0.50, 95% confidence interval: 0.15-1.63, Z = 1.15, p = 0.25). CRITICAL ISSUES:This review suggests that the use of inert moisturizers, emollients, or barrier preparations for preventing pressure injuries was not effective to prevent pressure injury in aged care or hospital settings. However, there was a distinct lack of randomized controlled trials (RCTs), with only one meeting the inclusion criteria. Furthermore, most of the included studies did not report on the frequency of application of the product, making it difficult to determine if application was in line with current international guidelines. One included study, which utilized a combination of neutral body wash and emollient demonstrated a significant reduction in the development of stage one and two pressure injuries. This combination of care may further support skin integrity and should be further examined in future trials. FUTURE DIRECTIONS:Future studies should ideally be RCTs, which control for skin cleansing, and implement an inert moisturizer emollient or barrier preparation as part of a pressure injury reduction bundle of care. Standardization of the application of the product, the volume of product applied at each application, and the quality of the product should also be considered.

Pressure injuries (PI) are a prevalent and challenging global healthcare problem. Technology including eHealth presents an opportunity to improve the prevention and management of PI. However, the lived experience of the end users is essential to ensure applicability and acceptability of future designs. This qualitative study aimed to explore the experiences and perceptions of PI prevention and management devices and eHealth technologies in those at risk of, or living with PI. A reflexive thematic analysis of semi-structured interviews exploring experiences and perceptions of 10 individuals living with, or at risk of PIs, along with the strategies they underwent for management and prevention was completed (Braun and Clarke, 2006; Braun and Clarke, 2021) [1,2]. Four themes were derived: 'It makes life so much easier'; were reflections of potential for eHealth, 'No one really tells us how to stop it' related to current patient education neglecting prevention; 'You've got to make them listen to you' reflecting the challenge of finding consistent PI care; 'I can't even move', which relates to the immobility related to PI. The use of eHealth in the prevention and management of PI should include the consumers in the design and implementation of the device, to ensure its suitability and acceptability, as part of aperson-centred care plan.

BACKGROUND:Oral care has a critical role in hospital-acquired infection prevention, is part of fundamental nursing care, yet is poorly undertaken in hospital. The study's aim was to understand Australian nurses' perceptions of their role in oral care and their experience providing oral care in hospital, with the focus on enablers and barriers. METHODS:A qualitative exploratory descriptive design. Seven registered nurses working in acute adult in-patient hospitals in Australia participated in three semi-structured focus groups in October and November 2023. Data analysis followed thematic analysis procedures. The study is reported using Standards for Reporting Qualitative Research. RESULTS:Three themes were identified: nurses' perceptions of their role in oral care; barriers to providing oral care for hospitalised patients; and enablers to providing oral care for hospitalised patients. Nurses' experiences revealed expectations for different clinical settings. In the intensive care unit where patients required mechanical ventilation, oral care was inextricably linked to that care. In palliative care or oncology units, oral care was intrinsically linked to holistic care. Reported challenges include time and staffing constraints; limited resources; nurses' limited knowledge about the importance of oral care, and patient-related factors. Opportunities to promote oral care include empowering patients and educating nurses about the importance of oral care to health. CONCLUSIONS:Nurses have a pivotal role in oral care and it is important that this is part of patient care in hospital. The findings will inform a comprehensive co-design process to develop an intervention to be examined in a multi-centre randomised control trial.

The aim of this scoping review was to map the literature pertaining to the use of eHealth interventions to prevent pressure injuries in populations at risk of the complication, and describe the interventions encountered with the help of Greenhalgh et al.'s Nonadoption, Abandonment, Scale-up, Spread and Sustainability framework. Articles were retrieved using database queries to CINAHL, Medline, ScienceDirect and the Cochrane library with a search string strategy that considered articles from the inception of each database until the 29th of January 2024. The interventions from the 27 included studies were then evaluated using the Nonadoption, Abandonment, Scale-up, Spread and Sustainability framework. The included studies had a publication date range from 1997 to 2023 and included diverse study designs encompassing experimental trials, qualitative designs, mixed-methods, cohort studies and randomised control trials (including secondary analyses). There was a preference for app-based interventions (15/27) that are installed on smartphones, while other interventions encompassed a bed with sensors that automatically adjusted air cell pressure, clinical support algorithms and continuous sensing devices. In conclusion, this scoping review provides an overview of the various technological solutions currently available for pressure injury prevention as well as recommendations for improving the long-term adoption of future eHealth interventions.

AIM:This study aimed to compare cognitive function and quality of life (QoL) in individuals with diabetes and a diabetes-related foot ulcer (DFU) to a control group with diabetes and no active foot ulceration. MATERIALS & METHODS:A cross-sectional case-control study was conducted between December 2022 and August 2024. Forty-two adults with diabetes and an active DFU were compared to forty age- and sex-matched controls with diabetes but no DFU. Cognitive function was assessed using the Trail Making Test (TMT), and QoL was measured using the EuroQol EQ-5D-5L. Statistical analyses included Mann-Whitney U tests, logistic regression, and correlation analyses to evaluate differences and associations between cognitive function and QoL. RESULTS:Individuals with a DFU demonstrated significantly poorer cognitive function compared to controls, taking approximately twice as long to complete the TMT (p < 0.001). Both rote memory (TMT-A) and executive functioning (TMT-B) were significantly impaired in the DFU group. QoL scores were also significantly lower in the DFU group (p = 0.005), with a notable association between cognitive impairment and reduced QoL (p = 0.01, r = -0.29). Logistic regression indicated that longer TMT completion time was associated with 4.13 increased odds of DFU (p < 0.001). CONCLUSIONS:Cognitive function is significantly impaired in individuals with DFU and is associated with poorer QoL. These findings highlight the need to integrate cognitive assessments into DFU management to optimise adherence and improve patient outcomes.

BACKGROUND:Lower limb peripheral artery disease (PAD) is associated with poor outcomes including ulceration, gangrene, amputations, and mortality. Clinicians therefore routinely perform point-of-care tests in high-risk populations to identify PAD and subsequently implement cardiovascular management and appropriate interventions. Pulse oximetry has been suggested as a useful adjunct test for identifying PAD.OBJECTIVE:The aim of this systematic review was to determine the sensitivity and specificity of pulse oximetry in the lower limb for identifying PAD.METHODS:MEDLINE, EMBASE, and CINAHL were searched up until January 10, 2023, to identify studies of sensitivity and specificity of pulse oximetry that used criterion standard diagnostic imaging as a reference standard. Two authors screened articles for inclusion and appraised quality of included studies using the Quality Appraisal for Diagnostic Accuracy Studies, version 2.RESULTS:A total of 6371 records were screened, and 4 were included. The included studies had a total of 471 participants, with an age range of 41 to 80.6 years. All studies were cross-sectional and conducted in hospital settings. Sensitivity values for pulse oximetry compared with diagnostic imaging in identifying PAD ranged from 44% to 76%, and specificity values ranged from 85% to 96%. There was no consensus regarding measurement techniques and diagnostic thresholds for pulse oximetry, which precluded meta-analysis.CONCLUSIONS:There is currently inadequate evidence to support the use of pulse oximetry for identifying PAD. Current evidence suggests that pulse oximetry has low levels of sensitivity and is therefore likely to miss PAD when it is present.

Aim To achieve consensus on priorities for chronic wound research in Australia. Methods A three-round modified online Delphi survey using RAND/UCLA methods was undertaken to seek consensus from a random sample of Australian multidisciplinary expert chronic wound practitioners and researchers. Participants rated their agreement/disagreement on a nine-point Likert scale for each potential research topic. Customised software calculated median scale scores and 30-70% inter-percentile range for each item. Results A sample of 20 practitioners and researchers were invited and 12 agreed to participate. After three rounds, 102 topics achieved consensus as national priorities, including 26 items on diabetes-related foot ulcers, 25 on pressure injuries, 17 on mixed chronic wounds, and 16 on venous leg ulcers. The highest rated topics included pain management, compression therapy to prevent venous leg ulcers, pressure injury management for heels and wheelchair users, and compression therapy adherence. Conclusion This study found that while diabetes-related foot ulcers and pressure injury topics had the greatest number of consensus national priority topics for chronic wound research in Australia, pain management, compression therapy for venous leg ulcers and pressure injury management were the highest rated priorities. These findings could be used to target funding for national grant schemes.

OBJECTIVE:Pedal acceleration time (PAT) is a novel method of using diagnostic ultrasound to evaluate the haemodynamic characteristics of pedal arteries and has potential as an adjunctive vascular testing method. The primary objective of this study was to assess the diagnostic accuracy of PAT in identifying peripheral artery disease (PAD) in a population with clinically suspected PAD. METHODS:This was a multicentre cross sectional study to estimate the diagnostic test accuracy. Participants with clinically suspected PAD were recruited via consecutive sampling at four centres. Colour duplex ultrasound (reference standard) and toe brachial index (TBI) were measured by a vascular sonographer. A second vascular sonographer, blinded to all other measures, conducted the PAT measurements on the same limb. PAD was defined as a > 50% stenosis in any vessel from the distal aorta to the foot. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were estimated for all PAT values. Receiver operating characteristic curves were also generated. RESULTS:One hundred and eighty-eight participants (227 limbs) were recruited, with a mean age of 71 years (standard deviation 10, range 43 - 93) with 56 women (29.8%) including 133 (70.7) limbs having PAD (59%) and 61 (32.4%) claudicants. Area under the curve for PAT: lateral plantar artery 0.72 (0.65 - 0.79), medial plantar artery 0.72 (0.65 - 0.79), dorsal metatarsal artery 0.77 (0.70 - 0.84), arcuate artery 0.71 (0.64 - 0.78), and deep plantar artery 0.73 (0.67 - 0.80). Utilising the worst case PAT measure for the limb for identifying PAD had an AUC of 0.79 (0.74 - 0.85) and positive and negative predictive values of 0.81 (0.57 - 0.89) and 0.66 (0.57 - 0.75), respectively. Area under the curve for the toe brachial index was 0.78 (0.71 - 0.85) and that of ankle brachial index was 0.70 (0.62 - 0.77). CONCLUSION:PAT had an acceptable diagnostic test accuracy as an assessment tool to identify PAD in a population with clinically suspected PAD. All five measures yielded similar accuracy to toe pressure and TBI; however, using the worst case PAT value yielded the highest diagnostic test accuracy of all PAT measures. The PAT diagnostic threshold for the presence of PAD may be revised to > 85 ms to optimise the performance of the test for the identification of PAD.

INTRODUCTION:Current guidelines for noninvasive lower limb vascular testing specify a preference for toe brachial pressure measurement to aid in the diagnosis of peripheral arterial disease populations with high suspicion of peripheral vessel calcification, such as those with kidney failure with replacement therapy. OBJECTIVES:The aim was to identify the current literature on toe systolic blood pressure and toe brachial pressure index for individuals with kidney failure who are receiving replacement therapy. DESIGN:A scoping review. METHODS:MEDLINE, CINAHL, AMED and SPORTDiscus were systematically searched between July 15 and July 30, 2023. The scoping review followed the Arksey and O'Malley framework, with data reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. RESULTS:Sixteen studies were included in the review. There was limited data examining the significance of toe systolic blood pressure and toe brachial pressure index during a dialysis session. There were differences in the normative values for toe brachial pressure index values used in the studies and limited reporting on the measurement protocols used to determine toe systolic blood pressure and toe brachial pressure index. CONCLUSION:The review found limited data examining the clinical utility of toe systolic blood pressure and toe brachial pressure index in populations receiving dialysis. The use of toe systolic blood pressure and toe-brachial index to identify peripheral artery disease in this population is important. However, there is limited evidence and conflicting information on measurement protocols, reliability, diagnostic accuracy, and prognostic capacity.

Aims The aim of this pilot randomised controlled trial (RCT) is to evaluate feasibility and acceptability of a personalised medical nutrition therapy (MNT) intervention on wound healing in individuals with diabetes-related foot ulceration (DFU) attending high risk foot clinics in New South Wales. It's hypothesised that the personalised MNT intervention will be more acceptable and will improve diet quality compared to standard care. Methods A six week superiority pilot multicentre, parallel-group two arm RCT for individuals (n=40) with type 1 and 2 diabetes, living with active DFU classified as VL or L as per WIfI grading and recruited from two-high risk foot clinics. The primary outcome is feasibility and acceptability, assessed by a process evaluation. The intervention group will receive MNT delivered by a dietitian at baseline, and weeks 2 and 4, with nutrient-dense food boxes provided at MNT consultations. The control group will receive a healthy eating brochure. Both groups received standardised podiatry care. Discussion The results from this pilot study will enhance understanding of feasibility and acceptabilty of MNT for those with DFU and its potential for impact on wound healing. Results will inform future fully powered RCTs investigating effectiveness of MNT in individuals with DFU.

AbstractBackgroundIn podiatry, there are a variety of clinical tasks that require precision and skill and it is expected that clinicians will obtain these skills during their training. Simulation is a dynamic teaching tool used in healthcare to enhance skill and knowledge acquisition. Currently, the extent and nature of the research on the use of simulation in podiatry teaching and learning are not clear.AimA scoping review was conducted to identify the extent and nature of research activity on the use of simulation in podiatry teaching and learning and identify gaps in the existing literature.MethodsAny research relating to simulation use in podiatry teaching including various designs and focusing on simulations aimed at improving podiatry teaching or learning were eligible for inclusion. A systematic search was conducted on February 14, 2024 of the following databases: Embase (via Embase.com), MEDLINE (via PubMed), CINAHL, and the Web of Science. Additional papers were identified via bibliographies of included studies. Content analysis of content relating to podiatry teaching and learning was performed and grouped into broad themes, then further narrowing to six themes.ResultsA total of 21 research studies were deemed eligible for inclusion focusing on diverse aspects of podiatry simulation utilized in high‐income countries exclusively. Conducted between 1997 and 2023, these studies were categorized into six key themes: skill improvement, communication and professionalism, clinical competencies and patient safety, educational enhancement, and anatomy and histology education. The simulations, carried out by or assessed for podiatry professionals, staff, or students, ranged from high‐fidelity medical mannequins to low‐fidelity simulations such as a grapefruit model of a diabetes‐related foot ulcer.ConclusionOverall, the findings suggest that simulation teaching in podiatry, whether through direct skill enhancement or through educational impact assessments, holds potential in improving competency, confidence, and educational outcomes in podiatry practice. This scoping review identified a small yet diverse evidence base for simulation modalities in podiatry education, demonstrating gaps in long‐term effects and comparative effectiveness studies. It highlights the urgent need for research focused on longitudinal impacts, evaluating various simulation technologies and standardizing best practices to improve podiatry education and align with clinical and patient care needs.

OBJECTIVE:Most podiatry-led high-risk foot services (HRFS) in Australia are located in metropolitan areas or large regional centres. In rural areas, where there are limited specialist services, individuals with diabetes-related foot ulceration are more likely to undergo amputation. This study aimed to explore clinicians' perceptions of a recently implemented HRFS in rural New South Wales, Australia, and compare trends of amputation and hospitalisation prior to and post-implementation of the service.SETTING:Rural HRFS in Tamworth, New South Wales, Australia.PARTICIPANTS:Health professionals working within the HRFS were recruited to participate.DESIGN:This was a multiple-methods study. For the qualitative arm, semi-structured interviews were conducted, which were analysed using a reflexive thematic approach. The quantitative arm of the study utilised a retrospective analytic design which applied an interrupted time series to compare amputation and hospitalisation trends pre- and post-implementation of the HRFS utilising diagnostic and procedural ICD codes.RESULTS:The qualitative arm of the study derived three themes: (1) navigating the divide, (2) rural community and rural challenges and (3) professional identity. Results of the interrupted time series indicate that there was a downward trend in major amputations following implementation of the HRFS; however, this was not statistically significant.CONCLUSION:Clinicians were aware of the inequity in DFD outcomes between rural and metropolitan areas and were committed to improving outcomes, particularly with respect to First Nations peoples. Future research will explore service use and amputation rates in the longer term to further evaluate this specialised multidisciplinary care in a rural community.

AbstractBackgroundDiabetes‐related foot disease (DFD) is a leading cause of the Australian and global disease burdens and requires proportionate volumes of research to address. Bibliometric analyses are rigorous methods for exploring total research publications in a field to help identify volume trends, gaps and emerging areas of need. This bibliometric review aimed to explore the volume, authors, institutions, journals, collaborating countries, research types and funding sources of Australian publications investigating DFD over 50 years.MethodsA systematic search of the Scopus® database was conducted by two independent authors to identify all Australian DFD literature published between 1970 and 2023. Bibliometric meta‐data were extracted from Scopus®, analyzed in Biblioshiny, an R Statistical Software interface, and publication volumes, authors, institutions, journals and collaborative countries were described. Publications were also categorised for research type and funding source.ResultsOverall, 332 eligible publications were included. Publication volume increased steadily over time, with largest volumes (78%) and a 7‐fold increase over the last decade. Mean co‐authors per publication was 5.6, mean journal impact factor was 2.9 and median citation was 9 (IQR2‐24). Most frequent authors were Peter Lazzarini (14%), Vivienne Chuter (8%) and Jonathon Golledge (7%). Most frequent institutions affiliated were Queensland University Technology (33%), University Sydney (30%) and James Cook University (25%). Most frequent journals published in were Journal Foot and Ankle Research (17%), Diabetic Medicine (7%), Journal Diabetes and its Complications (4%) and International Wound Journal (4%). Most frequent collaborating countries were the United Kingdom (9%), the Netherlands (6%) and the United States (5%). Leading research types were etiology (38%), treatment evaluation (25%) and health services research (13%). Leading funding sources were no funding (60%), internal institution (16%) and industry/philanthropic/international (10%).ConclusionsAustralian DFD research increased steadily until more dramatic increases were seen over the past decade. Most research received no funding and mainly investigated etiology, existing treatments or health services. Australian DFD researchers appear to be very productive, particularly in recent times, despite minimal funding indicating their resilience. However, if the field is to continue to rapidly grow and address the very large national DFD burden, much more research funding is needed in Australia, especially targeting prevention and clinical trials of new treatments in DFD.

BackgroundHospital-acquired pneumonia (HAP) also known as non-ventilator associated pneumonia, is one of the most common infections acquired in hospitalised patients. Improving oral hygiene appears to reduce the incidence of HAP. This study aimed to describe current practices, barriers and facilitators, knowledge and educational preferences of registered nurses performing oral health care in the Australian hospital setting, with a focus on the prevention of HAP. We present this as a short research report.MethodsWe undertook a cross sectional online anonymous survey of Australian registered nurses. Participants were recruited via electronic distribution through existing professional networks and social media. The survey used was modified from an existing survey on oral care practice.ResultsThe survey was completed by 179 participants. Hand hygiene was considered a very important strategy to prevent pneumonia (n = 90, 58%), while 45% (n = 71) felt that oral care was very important. The most highly reported barriers for providing oral care included: an uncooperative patient; inadequate staffing; and a lack of oral hygiene requisite. Patients' reminders, prompts and the provision of toothbrushes were common ways believed to help facilitate improvements in oral care.ConclusionFindings from this survey will be used in conjunction with consumer feedback, to help inform a planned multi-centre randomised trial, the Hospital Acquired Pneumonia PrEveNtion (HAPPEN) study, aimed at reducing the incidence of HAP. Findings may also be useful for informing studies and quality improvement initiatives aimed at improving oral care to reduce the incidence of HAP.

AbstractAimsThis study explored the reliability, validity and perceived comfort of a novel thumb pressure measure and calculation of a toe–thumb index to identify their suitability as an adjunct or alternatives to ankle–brachial and toe–brachial indices.Methods and ResultsRepeated manual thumb and toe systolic blood pressures were conducted using two raters, over two time points, on 34 healthy participants. Concurrent automated toe, thumb and brachial systolic blood pressures as well as comfort ratings for these measures (using a 10 mm visual analogue scale) were captured once by a research assistant. Automated thumb and brachial measures showed fair correlation (ρ = 0.36, p = 0.03) and a toe–thumb index and toe–brachial index good correlation (ρ = 0.62, p < 0.01). Intraclass correlation coefficients (ICC) identified moderate intra‐rater reliability for manual thumb pressures for Rater 1 and 2 (ICC 0.57, 95% CI [0.14, 0.79] and ICC 0.74, 95% CI [0.49, 0.87], respectively), while inter‐rater reliability was poor (ICC = 0.16, 95% CI [−0.85, 0.47]). Concurrent validity comparing manual and automated measures for thumb pressure was also poor (ICC −0.05, 95% CI [−1.06, 0.72] and ICC 0.42, 95% CI [−0.16, 0.72] Rater 1 and 2 respectively). Thumb measures were significantly more comfortable than brachial measures (5 mm, p < 0.00).ConclusionThumb systolic pressures are correlated with brachial systolic pressures, with reasonable intra‐rater reliability, however, correlation is only fair and measurement error wider than clinically acceptable. Furthermore, manual measures are poorly correlated with automated units. Consequently, caution is required in applying these techniques. As thumb measures were perceived as significantly more comfortable than brachial measures and have an advantage where brachial pressures cannot, or should not, be obtained, further evaluation is warranted.