Diagnosing vein Thrombosis

Again, the only way to diagnose a deep vein thrombosis accurately or to exclude it, to say no, you don't have a deep vein thrombosis, is to get an ultrasound scan. Now the next slide is a little bit scary, I'm sorry, I keep meaning after these presentations to take it out and put a less scary slide in.  It is a little bit scary, if you're squeamish, look away.  Having said that, most people wake up at this stage and it's the slide they all want to see. 

This is a leg ulcer, this is the dreaded complication of varicose veins and reflux.  Once they develop this is quite a severe one once they develop, they are very difficult to heal, they are very difficult to eradicate.  Even when you do get them healed,they heal with a lot of scar tissue.  The area is quite vulnerable and it's never quite normal,so it's always a little bit more vulnerable to knocks and injuries.  So leg ulcers, once they're established, do tend to recur, even with the best available treatment, because of the vulnerability and the scar tissue.  So avoid leg ulcers if you can. I'm sure nobody wants a leg ulcer, but if you've got varicose eczema and you've got any complications from your veins, we know that early treatment will give better results and will reduce the risks of complications. So as I mentioned, many people go and see their doctor, they say "I've got vein problems"but the NHS doesn't treat them.  Why is this? Well, the NHS doesn't see veins as a priority and the majority of people, even with quite severe vein problems, don't get a major complication. The NHS is strapped for money, I think we have to accept that, and there are other,more pressing requirements. 

There's no national target for veins, there's no two-week wait for veins, and there's no targets as there are, as you'd expect, for an ambulance arriving. We all expect, if we're injured, that an ambulance will arrive within a certain time, we all expect that it will take us to a well-equipped hospital with an operating the atre if we need urgent surgery, and we all expect that if we suffer a heart attack, we're taken to coronary care and that we're looked after.  This all costs money, and obviously the NHS has limited resources.  I don't want to get too political, but you can imagine that if the majority of people don't get a major problem from their veins, the NHS can't treat everybody, it has to ration treatment.

The National Institute for Care and Health Excellence (NICE) last year 2012, or no 2013,earlier this year, only in the summer of this year, made several recommendations about the treatment of veins and it said specifically that anyone who's got symptoms from their veins should be referred to a vascular surgeon.  However, we know and I know that currently people, even with varicose eczema, are finding it difficult to get NHS treatment.  So although nice believes that people should have advice, the reality here in this area is that people are finding it difficult to get access to treatment.

Other reasons  thread veins are often regarded as cosmetic, when we now know that the majority of people, even with thread veins, have reflux.  Varicose veins are not a priority, as I've mentioned.  There are other, more pressing problems for the limited resources of the NHS.  I was going to say it's rationed by strict criteria, they seem to be getting stricter and stricter and access seems to be getting poorer and poorer as time goes by, and I see people who have had bad phlebitis or who have had varicose eczema who can't get treatment very difficult.  And, obviously, your doctor needs to keep up-to-date with all sorts of new developments in diabetes and blood pressure and child care and dementia.  He finds it very difficult to keep up-to-date with all the latest treatments on veins.  Not surprisingly,your GP may not be able to refer you to the local hospital for veins so, at the end ofa busy surgery, he's hardly going to spend hours reading up on the latest developments on veins.

When it is varicose veins?

 I came across a lady not so long ago who wouldn't take her children swimming because she felt so embarrassed about the sight of her legs, and the distress that some of these unsightly veins cause can be quite severe.  I say 'even' thread veins we now know that thread veins and spider veins are associated with this condition called reflux, so it's not surprising that even thread veins cause symptoms or are associated with symptoms. 

Until we knew a little bit more about the condition we didn't really, as doctors, believe people who say "well my thread veins hurt and they burn and they itch" but they do, and we now know that if you treat thread veins properly the majority of people get relief of their symptoms as well. So, as I say, a frequent question is "I've got bad varicose veins, will I get a problem". Well, the majority don't but if you do get medical problems they come under one of these four headings.  As I say, the majority will not. The first one I'd like to talk about is phlebitis. 

A frequent question is "I've got phlebitis,what is it and will it cause me any harm?".  Another condition is varicose eczema, a condition of the skin caused by reflux and these other conditions, deep vein thrombosis, bleeding and ulcers.  Let's talk about those very briefly in turn. Now phlebitis is often a misused term, both by the public and by doctors.  The strict medical definition of phlebitis is an inflammation in the vein, that's all it means really, doctors add the word 'itis' on the end of the word to indicate inflammation. 

I think 'phleb' is a Greek or Latin word that means vein and 'itis' means inflammation, so it's an inflammation of the vein.  It appears clinically, that is on the surface, as a hard, tender lump underneath the skin, so it's quite superficial phlebitis involves the superficial veins, it's superficial and it has all the features of inflammation, so if you've ever had inflammation elsewhere you'll know that it's red, warm, tender and it's quite a severe condition.  These people often can't go to work it's that painful, and it used to be thought to be quite a trivial condition so if you went to see your doctor he'd say "oh that's just a bit of phlebitis,take some painkillers and go away". We now know, however, that to diagnose phlebitis correctly, you should have an ultrasound scan.

People who are diagnosed as having phlebitis are often misdiagnosed, and when you look with an ultrasound scan there's another condition, so having an ultrasound firstly confirms that it is phlebitis because you can actually look at the superficial vein and the appearance on ultrasound is quite characteristic of the condition and you can make sure there's nothing else amiss, because we now know that phlebitis is frequently associated with deep vein thrombosis.

The clot that occurs inside these veins can extend further and into the deep veins and that can be quite a significant problem, quite a severe condition. Last week I saw a patient in Bristol who had been treated by his doctor with phlebitis and in fact he had a deep vein thrombosis all along so the diagnosis was wrong it would have been established with an ultrasound scan and he had quite a significant deep vein thrombosis that put him at risk. 

So phlebitis is not a trivial condition, it should now have an ultrasound scan, that's the recommendation of two very influential bodies, one in the United Kingdom and one in America, and that recommendation came out last year that all people with phlebitis should have an ultrasound scan.

Varicose vein : Doctors interventions

 In fact when I see people with thread veins, one of the important things is that you check very carefully for underlying reflux so that the problem is treated correctly. Are they simply cosmetic?

Well, a question I get asked a lot is "I've been to my doctor with my veins and he tells me that treatment is not available on the NHS" and often that person is told that they're simply cosmetic.  Well, they're not simply cosmetic as you can see from this slide, a healthy vein is nice and straight and it's got strong folds,strong valves in the lining that meet properly, keeping blood directed upwards from the leg back to the heart. 

On the right we have a varicose vein, it's wider than it should be,it's tortuous, it's wiggly and the valves, these little folds, are weak and floppy and they're allowing blood down in the wrong direction, so varicose veins are unhealthy veins with faulty valves and this condition called reflux.  So it's not simply a cosmetic issue. As you can see in this slide, we've got a leg where we've got a superficial vein, that's a vein underneath the skin that is refluxing and faulty, and the blood is coming down in the wrong direction from the top of the thigh down into these lumpy varicose veins and further down into these little spidery veins.  So the underlying problem is reflux, it's not simply a cosmetic issue, it's a shorthand way of saying the majority of people don't get major problems but to dismiss them as simply being cosmetic is not correct. This is a lady I saw a few years ago and she too was denied NHS treatment initially. 

She had quite bad reflux in the veins in her thigh, feeding into varicose veins in her calf, which were causing quite a lot of swelling of her leg, and they were causing quite a lot of thread veins and spidery veins around the ankle, and also after a little while were causing a condition called varicose eczema, which I'll come on to in a moment.  In her case they weren't simply cosmetic, she actually had to argue her case quite strongly and at that time had to appeal to the Primary Care Trust, the PCT.  Eventually she was granted NHS treatment but her operation was cancelled three times, twice on the day of her operation she'd been all prepared and got ready and in frustration she decided that she would have her veins treated privately and she was concerned, quite rightly, about the possibility of ulcers.

So what problems can arise? 

One of the questions I get asked again quite a lot is "I've got bad varicose veins, will I get a leg ulcer, I'm worried about leg ulcers".  Well in fact the majority of people with even quite severe varicose veins do not come to any harm and i think this is the main reason why the NHS doesn't treat veins.  They do, however, cause a lot of ache, a lot of itch, swelling, these symptoms do tend to be worse in hot weather.

They tend to be worse at the end of the day and they are also very unsightly. I think it's sometimes difficult for us men to understand how much distress they cause to women particularly, and increasingly men.  It interferes with what you can wear, what sort of holidays you can take, what sort of social activities you might be involved in.

Varicose veins : Medical introduction

What are varicose veins? 

Well you don't need to be medically trained, you don't need to be a doctor, to look at your leg or somebody else's leg and know that there's something wrong with the veins.  So, for example, this person has a cluster of spider veins at the back of the leg with varicose lumpy veins to the side and medically they are abnormally large, they are wider and bigger than they should be, they are obviously twisty and they have a condition in them called reflux. 

Veins should be carrying blood up the leg back from the foot to the heart - if the little folds in the lining are not meeting properly and gravity is pulling blood down in the wrong direction then we give this the term 'vein reflux', and the underlying problem with these thread veins and these spider veins is that the direction of flow is wrong, the valves are not working properly and blood is coming down in the wrong direction, that's the medical underlying problem.

What causes varicose veins? 

Well, top of the list is heredity.  Unfortunately you can pick your friends but you can't pick your parents and most cases of vein problems are inherited or have a genetic basis.  It's been estimated that if both your parents have a vein problem,then you unfortunately have an 80% chance of developing a vein problem yourself.  It's not inevitable, but it's a high risk if you have a strong family history.  Other thing son this list don't actually cause varicose veins but they contribute, so if you've inherited a weakness of your veins and you have an underlying problem, often veins will appear for the first time during pregnancy because of the added strain on the vein circulation.

 It doesn't actually cause it but it's another risk factor which declares itself if you have an underlying problem and all these other things contribute. Having said that we know lots of people, don't we, who have had lots of children, who are possibly overweight and don't have a particularly healthy lifestyle - not a blemish on their legs, doesn't seem fair does it really but equally there are many young men who are quite athletic and very fit, obviously they've never had any children themselves, and they've got dreadful varicose veins so it does appear that heredity is the main risk factor.

What causes thread veins? 

Well, I've already mentioned that reflux is the underlying problem so it's not a surprise really, is it, that top of the list is heredity.  Again many people have not a blemish on their leg because they've inherited good veins from their parents. 

Others,unfortunately, haven't had any children, not overweight, very healthy and they're covered in spider veins and thread veins.  The underlying problem is a weakness of the veins and it's a problem called reflux, so heredity tops the list.  All these others are contributing or risk factors, they don't actually cause them, however I would say that reflux, which also causes varicose veins, varicose veins are often associated with thread veins.

Programming the intervention

Now, the programming, none of this can be possible without a strong team. So the programmer  and I,we used live survey, and live survey it's a free, open-source online survey, in which we use. This provided the adult participants the adult consent form.

Then we also use, is where the study participants, once they've chosen an avatar and named that avatar, all of that information was stored there and matched with their email address. So that was kind of the way. Again, this was apre-test/post-test study, so we needed a way to follow that through. We had to restrict access to this because second life is a virtual open world. Our island,we restricted it to--the only way you could get to our island was that once you receive that token,then that token allowed you to enter our island,so that our data was not skewed in any way. This type of research,this type of platform does require high-speed Internet,and Web hosting.

I've shared with you that my sequel and PHP was used as a Web hosting supporting browsers. There are many, from Firefox to MS Internet Explorer. The later the software the better this seems to run. Budget.  So in order to capture this and to maintain it we rented an island, a new island eight. We rented this island for--this study was 12 months in length. It costs us 1,100 dollars to rent this island,which is about 1000U. S.  dollars. The programmer I hired and the researchers I hired as OPS, hourly wage. The programmers used her instructional design along with my health care background to create the games,the platforms. I knew what I wanted. She knew how to make that happen in design. Each and everything that you saw in this platform took time. It wasn't like you could take wallpaper and kind of just put it up. Everything that instructional designer actually built. So she set up the domain,did the configurations,build and exhibited it,and then she hosted it the entire time that we were running this study. So as part of the--at the end again you see another token to exit it.

At that point they would email the survey,and the survey results with this pilot study provided me with useful information in the sense that the majority of the participants had no experience with second life,but again about more than 40 percent of them said that they found this type of platform for research very useful. Quickly, the next steps, i would like to now move from a pilot study to a feasibility study. This study was A-synchronized. I would like to use this amphitheater here to build a--if you can imagine it,it can happen. So I imagine making this more of a synchronized session,much like we're doing today,a set date, a set topic and invite the avatars,these person as to join the topic and dialogue real time with questions and answers and an information session. So that's the next step for second life and how I plan to use this as a research study.

Nothing happens alone. Nothing happens on our island by itself. This is the research group that I-- this is the research team that I had the pleasure of working with. is the programmer with  being there search assistant and my research team there. None of this would have been possible without the funding of the rebel,which scholars program. So with that said,I will turn it over to, and we'll open it up for questions. Thank you.

Technlological interventions

Once they interacted with these boards, walked away, within 10 seconds there was a timer that would re-close--that would recover the boards so the next person came through. For example,this is what I call an HPV patch. So within this HPV patch the minute lands there,the sensor senses her and provides me with information such as how long she's--how much time did she spend walking around this patch looking at genital warts on the pup as of a penis or within the anus?

Then as you look up,which you can't really see,but depicted here, again more information. That is  wanted to support what she was seeing,there was more visual information there. As long as was there the timers captured how long she was there. This is another example of an information board. This board actually showed external genital warts from mild to severe on the vulva of a female. Then when whomever was there,once they walked away,this board was automatically become covered again in ten seconds. So it was more than just kind of walking around and then reading information. We attempted to also make it interesting and find ways to make it stimulating. So this is a simulation,first it starts off with just kind of giving them information about the external warts. Then it gives instructions to walk into the simulation. It makes it clear to walking to the simulation of a vagina.

Once they reach the end of this vagina that there's a cervix with different stages,moderate to mild dysplasia. So the avatar again will enter this vaginal canal. Then they would end-up facing the cervix here. So the time and the minute they entered the canal, the timer started and I would then allow them to have the ability to capture how long they stayed and viewed this cervical dysplasia. Here's another example again where they were more interactive. So as they moved around,again this was a maze so they couldn't skip any part of it. They move from one area to the other. At a minimum they had to touch or interact with whatever's therefor seconds or minutes,however the timer was before they could move onto the next section. Here they were instructed to--they would tap here with HPV. Then they would try to match HPV with cervical cancer,or hepatitis B with jaundice. Each time they did this matching correctly, they earn points or their scores increase. This was again a test of their knowledge about viral STIs. Not only did I get the back to the correct number they got correct, but also the time that they spent there,and if they came backt o manipulate that. This was research study. This was the second part to a first--there was a first part where there was are search study. Then the control groups were invited to enter this pilot study. I don't expect that you can read this,but this is just a process flow as to how that research study went.

So there was who was a research assistant,would get the emails of these participants. The participants then would be emailed a URL. This URL was a token,in second life we use the term token. So once they received these tokens they could go in,register within second life and change their email to something other than their university email,and then this email was not tracked with their avatar. The avatar that they created is now their avatar going forth and forever. Then they would get the token, and once they received the token, created the avatar,they were now allowed to enter,and make sure that it was again clear,they would receive an adult consent form informing them that they were now agreeing to become part of a research study. That's kind of how the process went. Again, this was just a process flow to kind of give you an idea how this works.

The 3D World for Medical interventions

We know that HPV is a virus,with that being said,there's no cure. What we do know is that HPV is strongly linked,and HPV high-risk strains are strongly linked to cervical, anal, oral and penile cancer.

  We're learning more and more every day about orthogonal cancer. We also know that it's linked to genital warts. We do have prophylactic vaccines, Bivalent and Quadrivalent vaccines. The Bivalent vaccine is actually marketed as an orthogenic vaccine, not licensed for men. The Quadrivalent vaccine is marketed as orthogenic and wart prevention that is marketed for men and both women. While we're here today is to talk about second life,and how this internet-based application plays a role in cancer prevention,specifically the sequel of HPV. Well, there's 20 million users of second life as of today,20 million or more. Among those 20 million each one has a unique avatar. Avatars are digital person as in which once they enter the3D world, they can become an animal, the can stay a person,a female can become a male,ethnicity, gender,anything that you can image can be changed within your personal, which works well for me because my population was college students. My hope is that for them to take on a different persona that was actually made them comfortable moving around within this environment to learn about this viral STI. The great thing is that the Internet is everywhere and anywhere.


You can be at a park,you can be at coffee shop,you can be in your own bedroom. When we're talking about this platform,sexually transmitted infections are a private matter. So wherever you want to gain this information,increase your knowledge,it's that person's call. It's real time. Second life is real time. It also allowed me to get real time information and immediate response from my study participants as they move through this first pilot test. So again just a little bit about the sample, the majority of them were females within their second year of college.

Again, this is just a depiction of some of the personal person as that the college students took on while they were in this virtual world. Here you can see,this is when you first come into second life and going to our island,this is the entrance into our platform. Before you could actually enter this, because it was a study,a research study,I did provide a disclosure. As you can read here,we talked about stages of diseases, and we talked about several different viral STIs. Today we're going to focus on HPV. So before the study participant can enter this 3D world,they had to read and accept that Not everyone is familiar with second life,and how to manipulate your avatar. Again, there was a video that was embedded into second life so that the study participants could learn to walk,and learn to fly around in second life. Putting one foot in front of the other is not that easy in second life if you do not have some experience with it. So within that this video was embedded and it could go forward, fast-forward through itor repeat any sections that they felt the need to,to learn how to use the avatar within this world. Once they entered the world,there was one entrance and one exit.

The 3D world was setup like a maze. So as they move through it there were invisible sensors there. I use the sensors to capture my data. I could tell how long they would stay at certain teaching are as or teaching platforms within this. There were educational boards.