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Aherne TM, Keohane C, Mullins M, Zafar AS, Black SA, Tang TY, O'Sullivan GJ, Walsh SR. DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers. Pilot Feasibility Stud 2021; 7:42. [PMID: 33541436 PMCID: PMC7860223 DOI: 10.1186/s40814-021-00779-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy. METHODS This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates. DISCUSSION This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence. ETHICAL COMMITTEE REFERENCE C.A. 2111 Galway Clinical Research Ethics Committee REGISTRATION: Clinical Trials.gov registration NCT03640689 , Registered on 21 August 2018.
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Affiliation(s)
- Thomas M Aherne
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland. .,Department of Vascular Surgery, University Hospital Galway, Newcastle Road, Galway, Ireland.
| | - Colm Keohane
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Matthew Mullins
- Department of Interventional Radiology, University Hospital Galway, Galway, Ireland
| | - Adeel S Zafar
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Gerard J O'Sullivan
- Department of Interventional Radiology, University Hospital Galway, Galway, Ireland
| | - Stewart R Walsh
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
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Chan SSJ, Yap CJQ, Tan SG, Choke ETC, Chong TT, Tang TY. The utility of endovenous cyanoacrylate glue ablation for incompetent saphenous veins in the setting of venous leg ulcers. J Vasc Surg Venous Lymphat Disord 2020; 8:1041-1048. [PMID: 32205130 DOI: 10.1016/j.jvsv.2020.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Patients with venous leg ulcers (VLUs) represent the worse spectrum of chronic venous insufficiency (CVI). The Early Venous Reflux Ablation (EVRA) landmark trial published in 2018 demonstrated that early endovenous intervention results in faster healing of VLUs. We describe our post-EVRA experience using endovenous cyanoacrylate glue ablation (ECGA) to treat superficial venous reflux on an early basis and assess its efficacy and safety in the setting of VLUs. METHODS There were 37 patients (39 legs, 43 truncal veins) with 43 discrete venous ulcers who underwent ECGA for CVI symptoms and VLUs. They received compression therapy and regular dressings for the VLUs postoperatively and were reviewed at 1 week, 3 months, 6 months, and 12 months after the procedure. Postoperative healing time for VLUs and complications were recorded along with the patient's satisfaction and postprocedure pain scores. RESULTS The venous ulcers were all <30 cm2 before ECGA. The mean time for VLU healing from operation was 73.6 ± 21.9 days, and the primary occlusion rate of the CVI at both 1 week and 3 months was 100%. No major adverse events were observed except for one case of deep venous thrombosis. There was significant improvement in the revised Venous Clinical Severity Score postoperatively from 11 ± 1.63 (baseline) to 5.6 ± 1.37 (P < .001) at 3-month follow-up (on a scale of 0 to 27, with the severity of symptoms at a maximal 27). The visual analog scale scores for pain were low postoperatively, decreasing from a preoperative score of 6.84 ± 1.42 to 2.72 ± 1.59 (P < .001) at the 3-month follow-up (on a scale of 1-10, with 10 being the most severe pain). The median time to return to normal activities was 7 days (interquartile range, 5-7 days). CONCLUSIONS ECGA together with compression therapy for VLUs is both safe and effective in this population of Asian patients. ECGA for patients with VLUs has excellent patient acceptability, minimal morbidity, and low recanalization rates at 12 months. Larger extensive studies and longer follow-up periods are required to validate the preliminary outcomes of this paper, and if it is proven to significantly improve ulcer healing rates, this will change the way we approach chronic venous ulceration.
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Affiliation(s)
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Seck Guan Tan
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | | | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore.
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The Role of Preference on Outcomes of People Receiving Evidence-Informed Community Wound Care in Their Home or in a Nurse-Clinic Setting: A Cohort Study (n = 230). Healthcare (Basel) 2014; 2:401-16. [PMID: 27429284 PMCID: PMC4934598 DOI: 10.3390/healthcare2030401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/01/2014] [Accepted: 09/04/2014] [Indexed: 11/16/2022] Open
Abstract
This study followed a cohort of community-dwelling individuals receiving wound-care in a large urban-rural region. During a randomized control trial (RCT) evaluating outcomes of receiving care in a nurse-clinic or at home, many approached were willing to participate if they could choose their location of care. This provided a unique opportunity to enroll them as a "choice" cohort, following them in the same manner as the trial participants but allowing them to select their setting of care. The objective was to investigate the role of preference and location of care on care outcomes, including satisfaction with care, healing, health-related quality of life (HRQL), pain, and resource use. This is a secondary analysis of a prospective cohort of 126 individuals enrolled in an RCT to receive care at home or in a nurse-clinic (Allocated group), and an additional 104 who received care at home or in a nurse-clinic based on their preference (Choice group). Mobile individuals with a leg ulcer of venous or mixed venous etiology, referred for community leg ulcer care, were eligible. Specially-trained nurses provided care to both groups using an evidence-informed protocol. Baseline data included socio-demographic, circumstance-of-living and a detailed wound assessment. Mean age of the cohort was 68 years. Satisfaction, healing, recurrence, pain, HRQL, and resource utilization did not differ between groups. If available, individuals should have an option of care venue given almost half of those approached indicated a clear preference for clinic or home. With outcomes being similar, health care planners and decision-makers, as well as individuals and their families, can feel confident that the setting of care will not impact the outcomes. However, larger studies in other contexts are needed to explore the interaction between choice and setting.
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Meagher H, Ryan D, Clarke-Moloney M, O'Laighin G, Grace PA. An experimental study of prescribed walking in the management of venous leg ulcers. J Wound Care 2014; 21:421-2, 424-6, 428 passim. [PMID: 22990394 DOI: 10.12968/jowc.2012.21.9.421] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the relationship between the level of patient activity in the form of walking and the rate of venous leg ulcer (VLU) healing. METHOD Forty patients with newly diagnosed VLUs were recruited to the study a nd randomly allocated to either control or exercise groups. All patients were treated with multilayer compression bandaging for 12 weeks, or until their ulcer had fully healed. Daily stepping rate was recorded at initial assessment and following 4 weeks of treatment. Participants in the exercise group were encouraged to increase their daily steps with a target of 10 000 steps per day. The control group were n ot asked to change their daily steps. RESULTS In total, 33% of the exercise group achieved an average of 10 000 steps per day. Participants who took more steps at both the baseline and 4-week assessment healed more quickly than those who took fewer steps (p=0.052 and p=0.008 for baseline and week 4, respectively). Sixty-seven per cent of the participants who increased their daily steps had venous ulcers, which were healed by week 8, compared with 35% of those who did not. CONCLUSION Participants who took more steps per day showed faster venous ulcer healing times when compared with those who took fewer steps, emphasising the benefit of walking in this patient group. Further studies are necessary to confirm these early findings. DECLARATION OF INTEREST There were no external sources of funding for this study. The authors have no conflict of interest to declare.
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Harrison MB, VanDenKerkhof EG, Hopman WM, Graham ID, Carley ME, Nelson EA. The Canadian Bandaging Trial: Evidence-informed leg ulcer care and the effectiveness of two compression technologies. BMC Nurs 2011; 10:20. [PMID: 21995267 PMCID: PMC3214126 DOI: 10.1186/1472-6955-10-20] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 10/13/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND OBJECTIVE To determine the relative effectiveness of evidence-informed practice using two high compression systems: four-layer (4LB) and short-stretch bandaging (SSB) in community care of venous leg ulcers. DESIGN AND SETTING Pragmatic, multi-centre, parallel-group, open-label, randomized controlled trial conducted in 10 centres. Cognitively intact adults (≥18 years) referred for community care (home or clinic) with a venous ulceration measuring ≥0.7cm and present for ≥1 week, with an ankle brachial pressure index (ABPI) ≥0.8, without medication-controlled Diabetes Mellitus or a previous failure to improve with either system, were eligible to participate. METHODS Consenting individuals were randomly allocated (computer-generated blocked randomization schedule) to receive either 4LB or SSB following an evidence-informed protocol. Primary endpoint: time-to- healing of the reference ulcer. SECONDARY OUTCOMES recurrence rates, health-related quality of life (HRQL), pain, and expenditures. RESULTS 424 individuals were randomized (4LB n = 215; SSB n = 209) and followed until their reference ulcer was healed (or maximum 30 months). An intent-to-treat analysis was conducted on all participants. Median time to ulcer healing in the 4LB group was 62 days [95% confidence interval (CI) 51 to 73], compared with 77 days (95% CI 63 to 91) in the SSB group. The unadjusted Kaplan-Meier curves revealed the difference in the distribution of cumulative healing times was not significantly different between group (log rank χ2 = 0.001, P = 0.98) nor ulcers recurrence (4LB, 10.1%; SSB, 13.3%; p = 0.345). Multivariable Cox Proportional Hazard Modeling also showed no significant between-bandage differences in healing time after controlling for significant covariates (p = 0.77). At 3-months post-baseline there were no differences in pain (no pain: 4LB, 22.7%; SSB, 26.7%; p = 0.335), or HRQL (SF-12 Mental Component Score: 4LB, 55.1; SSB, 55.8; p = 0.615; SF-12 Physical Component Score: 4LB, 39.0; SSB, 39.6; p = 0.675). The most common adverse events experienced by both groups included infection, skin breakdown and ulcer deterioration. CONCLUSIONS The Canadian Bandaging Trial revealed that in the practice context of trained RNs using an evidence-informed protocol, the choice of bandage system (4LB and SSB) does not materially affect healing times, recurrence rates, HRQL, or pain. From a community practice perspective, this is positive news for patient-centred care allowing individual/family and practitioner choice in selecting compression technologies based on circumstances and context. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00202267.
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Affiliation(s)
- Margaret B Harrison
- School of Nursing, Queen's University, Kingston, Ontario, Canada
- Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Elizabeth G VanDenKerkhof
- School of Nursing, Queen's University, Kingston, Ontario, Canada
- Department of Anesthesiology, Queen's University, Kingston, Ontario, Canada
| | - Wilma M Hopman
- Clinical Research Centre, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada
| | - Ian D Graham
- Canadian Institutes of Health Research, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Meg E Carley
- School of Nursing, Queen's University, Kingston, Ontario, Canada
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Harrison MB, Graham ID, Lorimer K, VandenKerkhof E, Buchanan M, Wells PS, Brandys T, Pierscianowski T. Nurse clinic versus home delivery of evidence-based community leg ulcer care: a randomized health services trial. BMC Health Serv Res 2008; 8:243. [PMID: 19036149 PMCID: PMC2630316 DOI: 10.1186/1472-6963-8-243] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 11/26/2008] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND International studies report that nurse clinics improve healing rates for the leg ulcer population. However, these studies did not necessarily deliver similar standards of care based on evidence in the treatment venues (home and clinic). A rigorous evaluation of home versus clinic care is required to determine healing rates with equivalent care and establish the acceptability of clinic-delivered care. METHODS Health Services RCT was conducted where mobile individuals were allocated to either home or nurse clinic for leg ulcer management. In both arms, care was delivered by specially trained nurses, following an evidence protocol. PRIMARY OUTCOME 3-month healing rates. SECONDARY OUTCOMES durability of healing (recurrence), time free of ulcers, HRQL, satisfaction, resource use. Data were collected at base-line, every 3 months until healing occurred, with 1 year follow-up. Analysis was by intention to treat. RESULTS 126 participants, 65 randomized to receive care in their homes, 61 to nurse-run clinics. No differences found between groups at baseline on socio-demographic, HRQL or clinical characteristics. mean age 69 years, 68% females, 84% English-speaking, half with previous episode of ulceration, 60% ulcers at inclusion < 5 cm2 for < 6 months. No differences in 3-month healing rates: clinic 58.3% compared to home care at 56.7% (p = 0.5) or in secondary outcomes. CONCLUSION Our findings indicate that organization of care not the setting where care is delivered influences healing rates. Key factors are a system that supports delivery of evidence-based recommendations with care being provided by a trained nursing team resulting in equivalent healing rates, HRQL whether care is delivered in the home or in a community nurse-led clinic. TRIAL REGISTRATION ClinicalTrials.gov Protocol Registration System: NCT00656383.
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Affiliation(s)
- Margaret B Harrison
- School of Nursing, Queen's University, 78 Barrie Street, Kingston, Ontario, Canada, K7L 3N6
| | - Ian D Graham
- School of Nursing, University of Ottawa, 550 Cumberland Street, Ottawa, Ontario, Canada, K1N 6N5
- Ottawa Health Research Institute, Clinical Epidemiology Institute, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9
| | - Karen Lorimer
- Carefor Health and Community Services, 1200 St. Laurent Blvd., Ottawa, Ontario, Canada, K1K 3B8
| | | | - Maureen Buchanan
- School of Nursing, Queen's University, 78 Barrie Street, Kingston, Ontario, Canada, K7L 3N6
| | - Phil S Wells
- University of Ottawa, The Ottawa Hospital Dept. of Medicine, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9
- Ottawa Health Research Institute, 725 Parkdale Ave., Ottawa, Canada, K1Y 4E9
| | - Tim Brandys
- Dept. of Surgery, 550 Cumberland St, Ottawa, Ontario, Canada, K1N 6N5
- University of Ottawa, 550 Cumberland Street, Ottawa, Ontario, Canada, K1N 6N5
| | - Tadeusz Pierscianowski
- Dept of Medicine, University of Ottawa, 550 Cumberland Street, Ottawa, Ontario, Canada, K1N 6N5
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Clarke Moloney M, Lyons GM, Breen P, Burke PE, Grace PA. Haemodynamic study examining the response of venous blood flow to electrical stimulation of the gastrocnemius muscle in patients with chronic venous disease. Eur J Vasc Endovasc Surg 2005; 31:300-5. [PMID: 16242978 DOI: 10.1016/j.ejvs.2005.08.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 08/02/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to explore the option of stimulating calf muscle contraction through externally applied neuromuscular electrical stimulation (NMES) and to measure venous blood flow response to this stimulation. METHODS Ten patients with class 6 chronic venous disease (CEAP clinical classification) were recruited. Measurements of peak venous velocities in the popliteal vein were recorded by Duplex scanning in response to six test conditions; 1. Standing, 2. Voluntary calf muscle contraction, 3. Standing with NMES applied, 4. Standing with compression bandaging applied to the leg, 5. Voluntary calf muscle contraction with compression bandaging applied to the leg, 6. Stationary with compression bandaging applied to the leg and NMES applied. Comfort assessment was completed using visual analogue scales at each test stage and on study completion each patient completed a short structured interview to determine comfort and acceptability of NMES. Statistical analyses were carried out using SPSS, Version 9. Non-parametric testing was used in all analyses using the Wilcoxon Signed Ranks Test for paired samples. RESULTS There was a significant increase in venous velocities on voluntary contraction of the calf muscle (median resting vel 7.3 cm/s; voluntary contraction median 70 cm/s) and with the introduction of NMES, both with compression (median velocity 15 cm/s, p = 0.005 Wilcoxon) and without compression (median velocity 13 cm/s, p = 0.005 Wilcoxon). The greatest increase with NMES was when combined with compression bandaging. All patients reported the stimulus as an acceptable treatment option with 90% reporting NMES as comfortable. CONCLUSIONS Healing rates in venous ulceration with the application of compression bandaging remain between 50 and 70%. This study shows a positive haemodynamic response to NMES. Further research is needed to quantitatively measure the effect of NMES on ulcer healing.
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Affiliation(s)
- M Clarke Moloney
- Department of Vascular Surgery, The Regional Hospital and St John's Hospital, Limerick, Ireland.
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Margolis DJ, Bilker W, Santanna J, Baumgarten M. Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol 2002; 46:381-6. [PMID: 11862173 DOI: 10.1067/mjd.2002.121739] [Citation(s) in RCA: 276] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Venous leg ulcer is a disease most common in those aged 65 years and older. However, the incidence and prevalence have not been well established. OBJECTIVE Our purpose was to estimate the prevalence and incidence of venous leg ulcers in the elderly. METHODS We studied the General Practice Research Database, validated our case ascertainment strategy, and estimated the annual prevalence and incidence of venous leg ulcer. RESULTS The positive predictive value of our ascertainment strategy was 98.3% (95% confidence interval [CI], 90.0, 100.0). The annual prevalence of venous leg ulcer among the elderly was 1.69 (95% CI, 1.65, 1.74). The overall incidence rate was 0.76 (95% CI, 0.71, 0.83) for men and 1.42 (1.35, 1.48) per 100 person-years for women. CONCLUSION Venous leg ulcer is a significant problem in those aged 65 years and older. As compared with previous studies, because we used medical records from a population of known size, our results are precise and less biased.
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Affiliation(s)
- David J Margolis
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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O'Brien JF, Grace PA, Perry IJ, Burke PE. Prevalence and aetiology of leg ulcers in Ireland. Ir J Med Sci 2000; 169:110-2. [PMID: 11006665 DOI: 10.1007/bf03166911] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prevalence of leg ulcer disease in Ireland has been poorly documented. AIMS This study aimed to investigate the aetiology and prevalence of leg ulcers in one health district. METHODS All patients receiving healthcare for an active leg ulcer in the Mid-Western Health Board (MWHB) region of Ireland (population: 317,069) were identified in a defined two-month period. A cross-sectional survey of all healthcare workers providing care to patients with leg ulceration was carried out. Patients with leg ulcers of uncertain cause were invited for follow-up assessment to establish the underlying cause. RESULTS There were 389 patients with leg ulcers with a mean (standard deviation [SD]) age of 72.3 (11.1) years. The prevalence was 0.12% but it was 1.03% in patients aged 70 years and over. Women were twice as likely to be affected. Venous disease accounted for 81% of ulcers, and arterial disease for 16.3%, while ulceration due to diabetic neuropathy and rheumatoid vasculitis was unusual. CONCLUSION Leg ulcers are an important source of morbidity in our ageing population. Effective treatment programmes could diminish the impact of this debilitating disease on the health service.
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Affiliation(s)
- J F O'Brien
- Department of Vascular Surgery, Mid-Western Regional Hospital, Limerick
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