[The third venous system of the lower extremity and its clinical significance]

In deep venous thrombotic and aplasia cases superficial veins become dilated. With the resulting incompetence of the valves, venous blood stream is not directed to the heart, but to the ankle as well. In these cases the superficial system does not support the venous drainage of the limb, but gives a further load. The question is if one can ameliorate the venous drainage with removal of insufficient varicose veins, or does it make the outcome worse? A new examination was developed to determine if collateral veins in the subfascial space are enough to drain the venous blood of the limb. A tensiometer cuff was placed on the limb and inflated. The patient was asked to walk, if it was performed without complaints then the results was negative and the superficial veins were removed. In these cases no venous disturbances were detected during the operation or following that, in spite of the absence of deep venous circulation and radical removal of varicose venous bed. It means, that in the absence of deep venous circulation develops a collateral circulation not only in the subcutaneous, but in the subfascial space as well and it can alone maintain the venous drainage of the limb, this is the third venous system of the leg.

Economic evaluation of the treatment of chronic wounds: hydroactive wound dressings in combination with enzymatic ointment versus gauze dressings in patients with pressure ulcer and venous leg ulcer in Germany

OBJECTIVE

The treatment costs for pressure ulcers and venous leg ulcers were estimated based on the hospital administrator's perspective in Germany.

DESIGN

A spreadsheet model using input data from various hospitals in Germany was developed.

INTERVENTIONS

Five currently used treatment strategies were analysed: gauze, impregnated gauze, calcium alginate and hydroactive wound dressing with enzymatic ointment.

PARTICIPANTS

All cases used for and in the analysis were treated in the inpatient setting (4 hospitals and 120 patients were included).

MAIN OUTCOME MEASURES AND RESULTS

The outcome distributions were calculated using the Monte Carlo method. For the whole treatment process, the attributable costs for the hospital were calculated for different cases (severity) and all treatment strategies (1997 values). The costs for treatment with gauze were the highest, whereas the costs for treatment with hydroactive wound dressings and enzymatic ointment were the lowest. The relation between personnel and material costs for gauze is approximately 95 to 5% and for hydroactive wound dressings 67 to 33%, respectively. The cost savings per case were between 1196 deutschmark (DM) and DM9826 using hydroactive wound dressings instead of gauze dressings (depending on the severity of the pressure ulcer), and between DM135 and DM677 for venous leg ulcers. The results were robust and did not change in any performed sensitivity analysis (parameter: 'personnel costs per minute', 'time required for changing a wound dressing', 'total number of wound dressing changes').

CONCLUSIONS

Despite the higher material costs of the hydroactive wound dressings in combination with enzymatic wound cleaning compared with other wound dressings, they should be recommended for the treatment of pressure ulcers and venous leg ulcers. This therapy alternative brings about significant reductions in total costs for hospitals because of significant reductions in personnel costs and the duration of treatment.

Risk factors associated with the failure of a venous leg ulcer to heal

BACKGROUND

Venous leg ulcers afflict a significant portion of the population. The most popular form of therapy for venous leg ulcers is a compression bandage (eg, Unna boot), a therapy that is frequently unsuccessful.

OBJECTIVE

To describe risk factors associated with the failure of a wound to heal when treated with a limb-compression bandage for 24 weeks.

DESIGN

A retrospective cohort study.

SETTING

Single-center outpatient specialty clinic at an academic medical center.

PARTICIPANTS

Two hundred sixty consecutive patients with chronic venous leg ulcers.

MAIN OUTCOME MEASURE

The magnitude of the effect of a given risk factor on the probability that a wound will heal within 24 weeks of care.

RESULTS

Based on an assessment of leg wounds during initial office visits, we observed that the failure of a wound to heal within 24 weeks was significantly associated with larger wound area, measured in square centimeters (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.11-1.27), duration of the wound in months (OR, 1.09; 95% CI, 1.04-1.16), history of venous ligation or venous stripping (OR, 4.58; 95% CI, 1.84-11.36), history of hip or knee replacement surgery (OR, 3.52; 95% CI, 1.12-11.08), ankle brachial index of less than 0.80 (OR, 3.52; 95% CI, 1.12-11.08), and the presence of fibrin on more than 50% of the wound surface (OR, 3.42; 95% CI, 1.38-8.45).

CONCLUSIONS

Several risk factors are associated with the failure of a patient's venous leg ulcer to heal while using limb-compression therapy. It is prudent to consider these factors when referring a patient to a wound care subspecialists or for alternative therapies.

Maggot therapy for the treatment of intractable wounds

BACKGROUND

Fly maggots have been known for centuries to help debride and heal wounds. Maggot therapy was first introduced in the USA in 1931 and was routinely used there until the mid-1940s in over 300 hospitals. With the advent of antimicrobiols, maggot therapy became rare until the early 1990s, when it was re-introduced in the USA, UK, and Israel. The objective of this study was to assess the efficacy of maggot therapy for the treatment of intractable, chronic wounds and ulcers in long-term hospitalized patients in Israel.

METHODS

Twenty-five patients, suffering mostly from chronic leg ulcers and pressure sores in the lower sacral area, were treated in an open study using maggots of the green bottle fly, Phaenicia sericata. The wounds had been present for 1-90 months before maggot therapy was applied. Thirty-five wounds were located on the foot or calf of the patients, one on the thumb, while the pressure sores were on the lower back. Sterile maggots (50-1000) were administered to the wound two to five times weekly and replaced every 1-2 days. Hospitalized patients were treated in five departments of the Hadassah Hospital, two geriatric hospitals, and one outpatient clinic in Jerusalem. The underlying diseases or the causes of the development of wounds were venous stasis (12), paraplegia (5), hemiplegia (2), Birger's disease (1), lymphostasis (1), thalassemia (1), polycythemia (1), dementia (1), and basal cell carcinoma (1). Subjects were examined daily or every second day until complete debridement of the wound was noted.

RESULTS

Complete debridement was achieved in 38 wounds (88.4%); in three wounds (7%), the debridement was significant, in one (2.3%) partial, and one wound (2.3%) remained unchanged. In five patients who were referred for amputation of the leg, the extremities was salvaged after maggot therapy.

CONCLUSIONS

Maggot therapy is a relatively rapid and effective treatment, particularly in large necrotic wounds requiring debridement and resistant to conventional treatment and conservative surgical intervention.

Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration

This paper reports the results of an analysis designed to estimate the expected annual cost per patient of treating venous leg ulcers, and to evaluate the relative cost-effectiveness of a systematic treatment regimen using a four-layer compression bandaging system (Profore) compared with usual care. A Markov model has been developed which simulates the transition of patients between health states (healed and unhealed) over a 52-week period. Healing rates used in the model are derived from those reported in the literature. By running the model for a cohort of 100 patients over 52 weeks it is possible to estimate expected outcomes and annual budgetary costs for alternative treatment regimens. Results suggest that, when compared with usual care, a systematic treatment regimen using Profore is unambiguously more cost-effective. Patient outcomes are improved and annual treatment costs reduced. An important implication is that failure to co-ordinate treatment policies and to use the most cost-effective treatments may result in substantial inefficiency in the use of NHS resources. This inefficiency could represent the equivalent of between 350,000 Pounds and 1.08 million Pounds annually for a typical health authority.

[Calciphylaxis of the skin as a sequela of terminal kidney failure. Report and discussion of 3 cases]

Calciphylaxis is a rare syndrome mostly affecting patients with secondary hyperparathyroidism and in some cases with functional protein C or protein S deficiency. Skin lesions begin as superficial painful patches that progress to deep necrotic lesions. The findings are often misdiagnosed as livedo vasculitis and the prognosis is poor. Histopathologically, calcification in the media of small arteries and arterioles with intimal hyperplasia is seen. It is unclear if this morphologic hallmark is pathogenetic. Therapeutically, the calcium-phosphate product should be lowered pharmacologically by an intensified and modified dialysis treatment and parathyroidectomy.

Successful methods of treating leg ulcers. The tried and true, plus the novel and new

The cause of a leg ulcer should be determined before a course of treatment is undertaken, and this often can be accomplished through history taking, physical examination, and use of simple noninvasive testing. Most leg ulcers are caused by venous disease, arterial insufficiency, neuropathy, or a combination of these factors. Complete management should address the patient's general health as well as specific findings, and treatment of any underlying cause is paramount. In venous ulcers, compression is the cornerstone of treatment, and a variety of effective stockings and other compression devices are available. Arterial ulcers usually require reestablishment of an adequate vascular supply, often through surgery. Neuropathic ulcers need thorough debridement to allow good granulation and epithelialization. Five types of occlusive dressings are available that achieve debridement less painfully but also more slowly than the surgical approach. Several adjunctive methods are now available that facilitate successful therapy in these ulcers, which have often been considered nonhealing wounds.

The cost-effectiveness of high compression

A recent systematic review1 indicated that compression bandaging was an effective treatment for venous leg ulceration. The economic evaluation by Carr et al in this issue (page 243-248) suggests that a compression regimen of four-layered bandaging is resource saving, in contrast to the results of a recent randomised trial.2

A follow-up study of leg ulcer patients in south Stockholm

The objective of this study was to follow up patients with leg ulcers, previously identified in an epidemiological study in South Stockholm. Rate of healing, non-healing, recurrence, amputation and mortality were recorded. A total of 254 patients were identified for follow-up after 18 months, 217 of whom were included. The use of a questionnaire revealed that, during this period, 43 (20%) of the patients had died; of the remaining 174 patients, 61% had healed, 29% were unhealed, 8% had recurring ulceration after healing; 2% had required amputation. Venous aetiology was found to be more common than arterial aetiology. However, among those who had died, arterial disease was found to be more common than venous insufficiency. A further objective was to investigate 21 patients with non-healed venous leg ulcers who had been treated in community care. They were assessed by means of a standardised form and given a triple-layer bandaging treatment for a three-month period. Two ulcers had healed and nine ulcers had improved and were healing. In the group of patients with healed or improved ulcers, five had normal mobility.

[Leg perforating veins]

Our knowledge of the so-called incompetent leg perforating veins remains questionable. Anatomic and hemodynamic studies show that perforators in a healthy subject do not always convey inward flowing blood. Are incompetent perforating veins more frequent with increasing severity of chronic venous disease? Answering this question is difficult as no consensus has been established on how to assess incompetent leg perforating veins and we have no gold standard to refer to. The number of incompetent leg perforating veins is generally greater in severe chronic venous disease although their frequency in clinical stage 4 to 6 (CEAP classification) is not statistically different. This means that incompetent leg perforating veins are not markers of severity of chronic venous insufficiency. When analyzing published series which take into account etiology (primary or secondary venous diseases) the frequency of incompetent perforating veins is variable. Is surgical management required when incompetent leg perforating veins are present? Angiologists and surgeons have not come to an agreement on this point. What can be recommended today? It is generally accepted that the more severe the disease the more worthwhile surgical treatment. Technically speaking, subfascial endoscopic ligature is a promising new method although long-term results are still lacking. We must watch carefully the prospective and randomized studies which have been started in different countries. A lot of questions, only a few reliable answers.

Developing venous gangrene in deep vein thrombosis: intraarterial low-dose burst therapy with urokinase--case reports

Two patients with developing venous gangrene of the lower extremity and contraindications to systemic thrombolytic therapy are presented. Low-dose intraarterial burst therapy with urokinase provided rapid amelioration of symptoms and avoided amputation without any serious bleeding complications in both patients.

[Economic aspects of the treatment of leg ulcers using classical methods and modern bandages]

Costs of conventional and advanced treatments of leg ulcers are compared. Conventional treatment consisted in the application of calcaria solution and camphor ointment onto the wound and an indifferent pasta onto the surrounding skin. The advanced treatments included the use of the novel dressings Granuflex, Actisorb and Inadine. The latter treatments consider the sequence of healing phases and at the same time shorten the healing period by up one half. Comparisons of treatment costs have shown marked benefits of the novel dressings. The costs of complete healing of an ulcer with an area of 8 x 8 cm at the healing duration of 4 weeks were 503.48 CZK, 432.38 CZK and 329.62 CZK for Granuflex, Actisorb and Inadine, respectively. Direct costs of the conventional treatment of an ulcer with the same size were 863.28 CZK and the healing period extended to 6 weeks. The use of the novel dressing is apparently less expensive and affords more comfort to the patient.

Measurement of forces associated with compression therapy

Compression therapy is the principal treatment for leg ulcers associated with venous disease. The efficacy of compression therapy can be variable, which may in part be owing to the degree of compression applied. However, if the mechanism of action of this treatment could be better understood, it might be possible to improve its efficacy. It is not clear whether assessment of the degree of compression should be made under static or dynamic conditions, or both. A review of methods used previously suggests the need for a new method of assessment allowing continuous monitoring, even during movement. A system for continuous static and dynamic measurements of compression is described. Using an air chamber and manometer to test the system, agreement within +/- 3 mmHg is observed. The system is applied to investigate changes in forces, expressed as pressure, under bandages and compression stockings. Application of five bandage systems by experienced nurses to a volunteer shows a marked variation in applied pressure. During short periods of walking, rapid changes in pressure under compression stockings are observed, including some transients of less than 0.25 s. The method is simple to apply and may help to understand further the mechanism of action of compression therapy.

A computerised leg ulcer database with facilities for reporting and auditing

A review of a new computerised reporting and auditing system.

The Limerick Leg-Ulcer Project: early results

Nurse led clinics in joint hospital and community settings are now being advocated as the most effective and economic way of dealing with leg ulcers. However, little information exists on the profile and outcome of patients with venous ulcers treated either in the community or in the hospital setting. Over a 2 yr period we assessed 134 patients with leg ulcers of whom 122 were deemed suitable for compression bandaging therapy. Thirty-four patients (28 per cent) were treated by the newly developed community service and 88 (72 per cent) were treated at the hospital clinic. Our overall healing rate for venous ulcers was 50 per cent @ 40 weeks. This probably reflects the long duration (48 per cent > 2 yr) and large size (0.5-600 cm2) of ulcer prior to treatment. There were no differences in outcome between hospital (50 per cent @ 40 weeks) and community (35 per cent @ 40 weeks) based treatment (p > 0.05). We conclude that most venous ulcers can be effectively treated in the community and resources should be provided to achieve this goal.