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.

Management of leg ulcers

Management of leg ulcers requires attention to a checklist of causes of delay in healing, the commonest cause of which is venous disease. Arterial disease must be excluded before fully effective management of venous disease is possible. Lymphatic failure is also worthy of attention. 'Keep moving' is an important management theme for the whole team, including the patient.

Common causes of leg ulceration

Good treatment of any leg ulcer depends upon an accurate diagnosis of the underlying cause. Most leg ulcers occur secondary to venous or arterial disease but other rarer causes sometimes need to be considered. The treatment of the underlying condition is far more important than the choice of dressing.

Calciphylaxis: a favorable outcome with hyperbaric oxygen

A 66-year-old female with diabetes mellitus and end-stage renal disease presented with painful bilateral lower extremity livedo reticularis and necrotic ulcerations. Her distal lower extremity pulses were intact and plethysmographic studies confirmed relatively normal large vessel arterial perfusion. Extensive laboratory analysis was remarkable for an elevated calcium x phosphorous product and parathyroid hormone level. An ulcer biopsy revealed small vessel medial calcinosis, and calciphylaxis was subsequently diagnosed. Despite aggressive wound debridements, antibiotics and subtotal parathyroidectomy, her ulcers failed to improve significantly prompting a trial of hyperbaric oxygen therapy. After 7 weeks of hyperbaric treatments, her ulcers had essentially healed.

[Magnetic therapy in treatment of patients with leg ulcers]

Various magnetic (continuous current, alternating current and "running" impulse) fields were applied in 74 patients with trophic ulcers of lower limbs. 10-12 days after the beginning of the magnetic therapy wound surface has completely cleaned from necrotic tissues, surrounding inflammatory changes eliminated, epithelization of the wounds began. The most pronounced clinical effect was observed after the use of "running" impulse of magnetic field.

Treatment of leg edema and wounds in a patient with severe musculoskeletal injuries

This case report describes the application of a technique for the treatment of leg edema and wounds resulting from a severe distal tibiofibular fracture. Following injury and numerous fracture- and wound-related surgeries in the first year postinjury, this patient developed leg edema, required daily treatment of 2 leg wounds, and was unable to wear a shoe due to foot swelling. He was referred to the physical therapy clinic 1 year postinjury for ankle rehabilitation and to diminish the leg edema. Therapy consisting of manual lymph drainage, compressive bandaging, exercise, and skin care was provided for 7 weeks. A compression stocking was issued near the end of treatment, which the patient continued to wear daily thereafter. At the time of discharge from therapy, the leg edema had decreased 74% and the wound area of both wounds had decreased 89%. Improvements continued following discharge. By 10 weeks after the start of treatment, edema had decreased 80.9%, one wound had healed, and the second wound was 93% improved. The patient was able to wear a shoe and resume recreational activities. This case report provides insight into a treatment that may shorten rehabilitation and control the cost of caring for injuries complicated by prolonged edema.

[Medico-economic study of the management of leg ulcers of venous origin. Initial results]

PURPOSE

There is little data on the different techniques used in France to treat venous leg ulcers. Due to the lack of a well-accepted standard, it is most likely that therapeutic attitudes vary greatly. An assessment of the respective cost/benefit ratios would be most useful, but requires prior knowledge of the techniques used. We therefore conducted a survey of the main management schemes applied in France.

PATIENTS AND METHODS

A cross-sectional survey involved 800 investigators (85% general practitioners. 15% specialists: angiologists and dermatologists) throughout France. Each investigator was invited to include 2 patients with venous ulcerations of the leg. One patient was to have a long-standing ulceration (at least 6 weeks duration) and the other a new ulceration (less than 2 weeks duration). Patients were followed to cure or to study end-point six months after diagnosis. The clinical observations at inclusion are presented here for 247 patients with venous ulcerations.

RESULTS

The patient population showed a clear predominance and advanced age (mean 72 years). In half of the cases, the diagnosis was made at a home visit and in 20% of the cases at an office visit for a reason other than leg ulceration. History taking revealed a high frequency of varicose veins, osteoarthritis of the lower limbs and high blood pressure as well as a high rate of recurrence (60% for long-standing ulcerations). Treatments prescribed at the first visit were divided into 10 groups. The most frequently used methods were: cleansing, contention and general therapy (antibiotics, anticoagulants, antiaggregates, analgesics). General practitioners focused primary treatment on general therapies and local care while specialists used contention more often (more than 90%) and different skin treatments. These different treatment combinations were then grouped into 7 main types of therapeutic attitudes, differentiating between general practitioners and specialists. There were however three common elements found in the treatments applied by more than 50% of the physicians: cleansing (99%), combined with contention (64%) or a general therapy (56%).

CONCLUSION

The main observation was that contention is used at a relatively high percentage (77%). This survey must be continued with a larger number of inclusion visits and an analysis of follow-up visits in order to identify possible changes in therapeutic attitudes and the associated costs as a function of treatment duration and rate of cure within the 6 month period.