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Cr K, D W, M T, T A, W T, Sr W. Axial Ablation versus Terminal Interruption of the Reflux Source (AAVTIRS): A Randomised Controlled Trial. Vasc Endovascular Surg 2024; 58:805-812. [PMID: 39034428 PMCID: PMC11425978 DOI: 10.1177/15385744241265750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
INTRODUCTION Treatment of reflux has been shown to improve time to healing of Venous Leg Ulcers (VLU). Terminal Interruption of the Reflux Source (TIRS) treats reflux within the plexus of veins around an active VLU using foam sclerotherapy. The efficacy of TIRS in managing VLU has never been tested. METHODS We performed a pragmatic, single centre, assessor-blinded, randomised controlled trial comparing endovenous ablation of the axial superficial veins (Axial Ablation-AA) vs TIRS. Patients of any age with VLU of any duration were eligible. RESULTS 98 Participants were randomised to AA or TIRS. 39/55, 70.9% (95%CI; 57.1-82.37) healed their VLU in the AA group, while 29/39, 74.36% (95%CI; 57.87-86.96) healed their VLU in the TIRS group, P = 0.45.4 were lost to follow-up. Median time to ulcer healing was 84 days (95%CI; 74.67-93.33) in the axial ablation group and 84 days (95%CI; 73.02-94.98) in the TIRS group. Hazard Ratio for ulcer healing with AA vs TIRS was 0.96 (95%CI 0.59-1.56). There were no significant quality of life differences. CONCLUSION The AAVTIRS trial did not show that axial ablation was superior to TIRS in the primary outcome of number of VLU healed in 6 months, or time to VLU healing. This trial is not powered to show non-inferiority. TIRS is a viable option for treatment of VLU. Further investigation is necessary before it can be recommended as an alternative to axial ablation.Trial registered at clinicaltrials.gov NCT04484168.
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Affiliation(s)
- Keohane Cr
- National University of Ireland Galway, Galway, Ireland
- University Hospital Galway, Galway, Ireland
| | - Westby D
- National University of Ireland Galway, Galway, Ireland
- University Hospital Galway, Galway, Ireland
| | - Twyford M
- National University of Ireland Galway, Galway, Ireland
- University Hospital Galway, Galway, Ireland
| | - Aherne T
- National University of Ireland Galway, Galway, Ireland
- University Hospital Galway, Galway, Ireland
| | - Tawfick W
- National University of Ireland Galway, Galway, Ireland
- University Hospital Galway, Galway, Ireland
| | - Walsh Sr
- National University of Ireland Galway, Galway, Ireland
- University Hospital Galway, Galway, Ireland
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2
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Shaughnessy MO, Kent DS. Advancing nursing practice in Ireland: A pathway of care for nurse-led integrated venous leg ulcer management. JOURNAL OF VASCULAR NURSING 2024; 42:110-114. [PMID: 38823970 DOI: 10.1016/j.jvn.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/06/2024] [Accepted: 02/19/2024] [Indexed: 06/03/2024]
Abstract
Approximately 80% of patients presenting with leg ulcers are venous in origin. However, lack of standardisation of care has a human and financial impact for patients and service providers. Increases in the aging population and number of patients entering older age with co-morbidities results in increases in the demand for venous leg ulcer treatments. A joint initiative between a Registered Advanced Nurse Practitioner (RANP) in tissue viability and wound care, and a vascular consultant, identified deficits in patient care delivery and quality of life. A joint initiative Implementing the principles of the 'Sláintecare' policy was established as the Leg Ulcer Centre Ireland (LUCI) to deliver a pathway for the treatment and management of lower limb venous ulcers. The RANP provides a "one stop shop" for patients, offering a complete care package from diagnosis to surgical intervention - endovenous ablation, follow-up post operative care and discharge. Audit findings include; reduced hospital admissions and waiting times; increased patient satisfaction; and, improved interdisciplinary integrated referral pathways. The RANP offers an effective, efficient diagnosis-to-end treatment service for patients. The results demonstrate improved treatment, cost outcomes and value-based outcomes for patients. The new integrated service facilitates expansion of the service and further enhancement of the nursing skills and role.
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Affiliation(s)
- Marie O Shaughnessy
- RANP Tissue Viability & Wound Management/Lower Limb Venous Disease Surgical Care, CHO1 & Vascular Services Roscommon University Hospital
| | - Dr Susan Kent
- School of Nursing, Psychotherapy and Community Health, Dublin City University (DCU), Dublin, Ireland.
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3
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Nadaph MI, Meng C, Wu X. Clinical applications of skin traction technique with adjustable tension in treatment of large area skin defects. BMC Musculoskelet Disord 2023; 24:556. [PMID: 37415122 DOI: 10.1186/s12891-023-06628-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE To explore the clinical applications of the adjustable skin traction technique in the treatment of large area skin defects. RESEARCH DESIGN A prospective study. BACKGROUND The skin is the largest organ of the human body and skin tissue exposed to external environment which makes it vulnerable to damage. There are many reasons for skin defects such as trauma, infection, burns, scars, tumors resection, inflammation, pigmented nevus, etc. Skin traction is the application of pulling force to the trunk or extremities for immobilization, fracture reduction and deformity correction. This technique accurately controls skin expansion which is safe, convenient and accelerates wound healing. METHODS A prospective study was conducted on 80 patients suffered from large area skin defects in the department of orthopedics, the first affiliated hospital of Zhengzhou University from September 2019 to January 2023. There were 40 patients in the experimental group who underwent skin traction. In contrast, 40 people in the control group underwent skin flaps or skin grafts without skin traction. The inclusion criteria include large area skin defects, normal peripheral skin & blood supply, normal vital organs, no severe coagulation dysfunction etc. Male & female with and without skin traction are 22 & 18 and 25 & 15 respectively. The skin traction device used was a hook and single rod type. The skin defect area was approximately 15 cm × 9-43 cm × 10 cm. RESULTS Postoperatively, the experimental group with traction showed 2 cases of skin infection, 1 case of skin necrosis and 3 cases of inflammation recurrence. In contrast, the control group without traction showed 8 cases of skin infection, 6 cases of skin necrosis and 10 cases of inflammation recurrence. Skin infection (P = 0.04), skin necrosis (P = 0.02) and inflammatory response (P = 0.03) represented significant differences between two groups. There was also a significant difference in hospitalization costs (P = 0.001). CONCLUSION Skin traction has huge clinical applications including a shorter hospital stay, faster wound healing, lower hospitalization cost, high satisfaction rate, and a fair skin appearance after surgery. It is an effective method of treating skin and musculoskeletal defects.
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Affiliation(s)
- Md Israil Nadaph
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chong Meng
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xuejian Wu
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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4
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Kwong M, Rajasekar G, Utter GH, Nuño M, Mell MW. Updated estimates for the burden of chronic limb-threatening ischemia in the Medicare population. J Vasc Surg 2023; 77:1760-1775. [PMID: 36758910 DOI: 10.1016/j.jvs.2023.01.200] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE Estimates of chronic limb-threatening ischemia (CLTI) based on diagnosis codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) suggest a prevalence of 0.23%-0.32% and incidence of 0.20%-0.26% among Medicare patients. ICD-10-CM includes 144 CLTI diagnosis codes, allowing improved specificity in identifying affected patients. We sought to use ICD-10-CM diagnosis codes to determine the prevalence of CLTI among Medicare patients and describe the patient cohort affected by this condition. METHODS Using two years of data from Centers for Medicare and Medicaid Services, we identified all patients that had at least one CLTI diagnosis code to determine prevalence and incidence rates. Sensitivity analyses were performed to compare our methodology to prior publications and quantify the extent of missed diagnoses. The number and type of vascular procedures that occurred after diagnosis were tabulated. A cohort of patients with two or more CLTI diagnosis codes were then identified for further descriptive analysis. Associations between patient demographics and survival were analyzed using Cox proportional hazards models. RESULTS Over 65 million patients were enrolled in Medicare in 2017 to 2018. Of these, 480,227 had diagnosis of CLTI, with a corresponding to a 1-year incidence of 0.33% and a 2-year prevalence of 0.74%. Patients underwent an average of 43.6 vascular procedures per 100 person-years. Sensitivity analyses identified 89,805 additional patients that had a diagnosis code of peripheral arterial disease who underwent revascularization or amputation. Patients with CLTI were predominantly male (56.2%), white (76.4%), and qualified for Medicare due to age (64.0%). Thirty-seven percent were dual-eligible. One-year survival was 77.7%, significantly lower than estimated actuarial survival adjusted for age, sex, and race (95.1%; P < .001). Cox proportional hazards models demonstrate significantly increased mortality for men vs women (hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), but no association between race and overall survival (hazard ratio, 0.99; 95% confidence interval, 0.98-1.01; P = .83). CONCLUSIONS Using ICD-10-CM diagnosis codes, we demonstrated slightly higher incidence and prevalence of CLTI than in published literature, reflecting our more complete methodology. Sensitivity analyses suggest that increased complexity of the highly specific ICD-10-CM coding may diminish capture of CLTI. Inclusion of patients with non-CLTI peripheral arterial disease diagnoses produces moderate increases in incidence and prevalence at the cost of decreased specificity in identifying patients with CLTI. Medicare patients with CLTI are older, and more commonly male, black, and dual eligible compared with the general Medicare population. Observed mid-term survival for patients with CLTI is significantly lower than actuarial estimates, confirming the importance of focused efforts on identifying and aligning goals of care in this complex patient population.
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Affiliation(s)
- Mimmie Kwong
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Davis, CA.
| | - Ganesh Rajasekar
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA
| | - Garth H Utter
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California Davis School of Medicine, Davis, CA
| | - Miriam Nuño
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA
| | - Matthew W Mell
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Davis, CA
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Keohane CR, Westby D, Twyford M, Ahern T, Tawfick W, Walsh SR. Axial ablation versus terminal interruption of the reflux source (AAVTIRS): a randomised controlled trial. Trials 2022; 23:483. [PMID: 35689289 PMCID: PMC9188187 DOI: 10.1186/s13063-022-06440-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of superficial venous reflux has been shown to improve ulcer healing time and reduce the risk of ulcer recurrence. Terminal ablation of the reflux source (TIRS) is an alternative to formal endovenous ablation or surgery which can be performed by injecting sclerosant foam into the peri-ulcer plexus of the veins. TIRS has been shown to be successful and in our experience is the option preferred by many patients, when offered as an alternative to axial ablation (AA). AIM To determine if the proportion of ulcers healed within 6 months of endovenous treatment differs between patients undergoing AA of varicose veins or TIRS by peri-ulcer foam sclerotherapy. METHODS AAVTIRS is an assessor-blinded randomised controlled trial. Patients will be recruited from a dedicated ulcer clinic in Roscommon University Hospital and from the vascular surgical clinics in University Hospital Galway. All patients attending the ulcer clinic will be screened for eligibility. RANDOMISATION Random computer-generated sequence is stratified by ulcer size. Allocation will be concealed using sealed opaque envelopes. BLINDING Assessors reviewing wounds at follow -p visits will be blinded to patient allocation. PRIMARY ENDPOINT The proportion of ulcers healed within 6 months of enrolment. DISCUSSION This will be the first time that TIRS has been evaluated with a properly powered randomised trial in the setting of venous ulcer management. Streamlining the management of venous ulcers has broad health economic benefits. If it is found that TIRS is superior or non-inferior to AA, then a less expensive, less invasive injection can be offered as an alternative to AA in an attempt to encourage the healing of venous ulcers. If AA is found to be superior to TIRS, then this would suggest that all patients undergoing ablation in the management of venous ulcers should have their superficial reflux fully treated, building on the evidence of the EVRA trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04484168. Registered on 23 July 2020.
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Affiliation(s)
- C R Keohane
- University Hospital Galway, Galway, Ireland. .,National University of Ireland Galway, Galway, Ireland.
| | - D Westby
- Roscommon University Hospital, Roscommon, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - M Twyford
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - T Ahern
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - W Tawfick
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - S R Walsh
- University Hospital Galway, Galway, Ireland.,Lambe Institute for Translational Research, National University of Ireland Galway, Newcastle Rd, Galway, Ireland
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Probst S, Weller CD, Bobbink P, Saini C, Pugliese M, Skinner MB, Gethin G. Prevalence and incidence of venous leg ulcers-a protocol for a systematic review. Syst Rev 2021; 10:148. [PMID: 33980324 PMCID: PMC8117489 DOI: 10.1186/s13643-021-01697-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/03/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) are chronic wounds characterized by slow healing and high recurrence. Information on prevalence and incidence is essential for ascertaining the burden of VLU on the health care system and to inform epidemiological research, priority setting, and health care planning. The objective of this protocol is to present a transparent process for how we plan to review the existing international literature on the prevalence and incidence of VLU as well as the characteristics of the population reported within these studies. METHODS An exploratory search was performed using MEDLINE via PubMed and CINHAL via Ebsco to identify concepts, keywords, MeSH terms, and headings to identify study types looking at data of VLU prevalence and/or incidence and related patient characteristics. The findings of this exploratory search will determine the final search strategy. The titles and abstracts of the identified articles will be screened independently be two authors for relevance. Study which pass the quality assessment will be included. Data extraction will be performed independently by two authors and in accordance with a pre-designed data extraction form. If the data allows, a meta-analysis will be performed otherwise a descriptive summary of the findings will be conducted. DISCUSSION The results of this review will contribute to the evidence base on VLU occurrence and may inform the decision making of healthcare professionals, policy-makers, and consumers. It will also inform future research in this area of VLU care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020205855.
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Affiliation(s)
- S Probst
- HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Avenue de Champel 47, 1206, Geneva, Switzerland.
| | - C D Weller
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, The Alfred Hospital, Monash University, Melbourne, Australia
| | - P Bobbink
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva, Switzerland
| | - C Saini
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva, Switzerland
| | - M Pugliese
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva, Switzerland
| | - Monika Buehrer Skinner
- Institute of Epidemiology, Biostatistics and Prevention, Director of Public Health Education Program, University of Zurich, Zurich, Switzerland
| | - G Gethin
- School of Nursing and Midwifery, Aras Moyola, NUI Galway, Galway, Ireland
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7
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Abstract
BACKGROUND Leg ulcers are open skin wounds that occur below the knee but above the foot. The majority of leg ulcers are venous in origin, occurring as a result of venous insufficiency, where the flow of blood through the veins is impaired; they commonly arise due to blood clots and varicose veins. Compression therapy, using bandages or stockings, is the primary treatment for venous leg ulcers. Wound cleansing can be used to remove surface contaminants, bacteria, dead tissue and excess wound fluid from the wound bed and surrounding skin, however, there is uncertainty regarding the effectiveness of cleansing and the best method or solution to use. OBJECTIVES To assess the effects of wound cleansing, wound cleansing solutions and wound cleansing techniques for treating venous leg ulcers. SEARCH METHODS In September 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We considered randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or RCTs comparing different wound cleansing solutions, or different wound cleansing techniques. DATA COLLECTION AND ANALYSIS We screened studies for their appropriateness for inclusion, assessed their risk of bias using the Cochrane 'Risk of bias' tool, and used GRADE methodology to determine the certainty of evidence. Two review authors undertook these tasks independently, using predetermined criteria. We contacted study authors for missing data where possible. MAIN RESULTS We included four studies with a total of 254 participants. All studies included comparisons between different types of cleansing solutions, and three of these reported our primary outcomes of complete wound healing or change in ulcer size over time, or both. Two studies reported the secondary outcome, pain. One study (27 participants), which compared polyhexamethylene biguanide (PHMB) solution with saline solution for cleansing venous leg ulcers, did not report any of the review's primary or secondary outcomes. We did not identify any studies that compared cleansing with no cleansing, or that explored comparisons between different cleansing techniques. One study (61 participants) compared aqueous oxygen peroxide with sterile water. We are uncertain whether aqueous oxygen peroxide makes any difference to the number of wounds completely healed after 12 months of follow-up (risk ratio (RR) 1.88, 95% confidence interval (CI) 1.10 to 3.20). Similarly, we are uncertain whether aqueous oxygen peroxide makes any difference to change in ulcer size after eight weeks of follow-up (mean difference (MD) -1.38 cm2, 95% CI -4.35 to 1.59 cm2). Finally, we are uncertain whether aqueous oxygen peroxide makes any difference to pain reduction, assessed after eight weeks of follow-up using a 0 to 100 pain rating, (MD 3.80, 95% CI -10.83 to 18.43). The evidence for these outcomes is of very low certainty (we downgraded for study limitations and imprecision; for the pain outcome we also downgraded for indirectness). Another study (40 participants) compared propyl betaine and polihexanide with a saline solution. The authors did not present the raw data in the study report so we were unable to conduct independent statistical analysis of the data. We are uncertain whether propyl betaine and polihexanide make any difference to the number of wounds completely healed, change in ulcer size over time, or wound pain reduction. The evidence is of very low certainty (we downgraded for study limitations and imprecision). The final study (126 participants) compared octenidine dihydrochloride/phenoxyethanol (OHP) with Ringer's solution. We are uncertain whether OHP makes any difference to the number of wounds healed (RR 0.96, 95% CI 0.53 to 1.72) or to the change in ulcer size over time (we were unable to conduct independent statistical analysis of available data). The evidence is of very low certainty (we downgraded for study limitations and imprecision). None of the studies reported patient preference, ease of use of the method of cleansing, cost or health-related quality of life. In one study comparing propyl betaine and polihexanide with saline solution the authors do not report any adverse events occurring. We are uncertain whether OHP makes any difference to the number of adverse events compared with Ringer's solution (RR 0.58, 95% CI 0.29 to 1.14). The evidence is of very low certainty (we downgraded for study limitations and imprecision). AUTHORS' CONCLUSIONS There is currently a lack of RCT evidence to guide decision making about the effectiveness of wound cleansing compared with no cleansing and the optimal approaches to cleansing of venous leg ulcers. From the four studies identified, there is insufficient evidence to demonstrate whether the use of PHMB solution compared with saline solution; aqueous oxygen peroxide compared with sterile water; propyl betaine and polihexanide compared with a saline solution; or OHP compared with Ringer's solution makes any difference in the treatment of venous leg ulcers. Evidence from three of the studies is of very low certainty, due to study limitations and imprecision. One study did not present data for the primary or secondary outcomes. Further well-designed studies that address important clinical, quality of life and economic outcomes may be important, based on the clinical and patient priority of this uncertainty.
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Affiliation(s)
| | - Zena Eh Moore
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pinar Avsar
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
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8
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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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9
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Gethin G, Vellinga A, Tawfick W, O'Loughlin A, McIntosh C, Mac Gilchrist C, Murphy L, Ejiugwo M, O'Regan M, Cameron A, Ivory JD. The profile of patients with venous leg ulcers: A systematic review and global perspective. J Tissue Viability 2020; 30:78-88. [PMID: 32839066 DOI: 10.1016/j.jtv.2020.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes. OBJECTIVES To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area. METHODS A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting. RESULTS twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm2; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together. CONCLUSION a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.
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Affiliation(s)
- G Gethin
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland.
| | - A Vellinga
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - W Tawfick
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - A O'Loughlin
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - C McIntosh
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - C Mac Gilchrist
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - L Murphy
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - M Ejiugwo
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - M O'Regan
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - A Cameron
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
| | - J D Ivory
- National University of Ireland, Galway, Ireland; Alliance for Research & Innovation in Wounds (ARIW), Ireland
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10
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Thanigaimani S, Phie J, Golledge J. Animal models of ischemic limb ulcers: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2020; 8:e001676. [PMID: 32847840 PMCID: PMC7451953 DOI: 10.1136/bmjdrc-2020-001676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 01/01/2023] Open
Abstract
The aims of this systematic review were to assess the clinical relevance and quality of previously published animal models of ischemic ulceration and examine the available evidence for interventions improving ulcer healing in these models. Publicly available databases were searched for original studies investigating the effect of limb ischemia on wound healing in animal models. The quality of studies was assessed using two tools based on the Animal research: Reporting of In Vivo Experiments (ARRIVE) guidelines and the clinical relevance of the models. A total of 640 wounds (ischemic=314; non-ischemic=326) were assessed in 252 animals (92 mice, 140 rats, 20 rabbits) from 7 studies. Meta-analyses showed that wound healing was consistently delayed by ischemia at all time-points examined (day-7 standard median difference (SMD) 5.36, 95% CI 3.67 to 7.05; day-14 SMD 4.50, 95% CI 2.90 to 6.10 and day-21 SMD 2.53, 95% CI 1.25 to 3.80). No significant difference in wound healing was observed between 32 diabetic and 32 non-diabetic animals with ischemic wounds. Many studies lacked methods to reduce bias, such as outcome assessors blinded to group allocation and sample size calculations and clinically relevant model characteristics, such as use of older animals and a peripheral location of the wound. Five different interventions were reported to improve wound healing in these models. The impaired wound healing associated with limb ischemia can be modeled in a variety of different animals. Improvements in study design could increase clinical relevance, reduce bias and aid the discovery of translatable therapies.
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Affiliation(s)
- Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - James Phie
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
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11
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Histopathologic vasculitis from the periulcer edge: A retrospective cohort study. J Am Acad Dermatol 2019; 81:1353-1357. [DOI: 10.1016/j.jaad.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 03/18/2019] [Accepted: 04/07/2019] [Indexed: 01/25/2023]
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12
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Gethin G, Ivory JD, Connell L, McIntosh C, Weller CD. External validity of randomized controlled trials of interventions in venous leg ulceration: A systematic review. Wound Repair Regen 2019; 27:702-710. [DOI: 10.1111/wrr.12756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/02/2019] [Accepted: 07/27/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Georgina Gethin
- School of Nursing and Midwifery, NUI Galway Galway Ireland
- Alliance for Research and Innovation in Wounds, NUI Galway Galway Ireland
- School of Nursing and Midwifery, Monash University Australia
| | - John D. Ivory
- School of Nursing and Midwifery, NUI Galway Galway Ireland
- Alliance for Research and Innovation in Wounds, NUI Galway Galway Ireland
| | - Lauren Connell
- Alliance for Research and Innovation in Wounds, NUI Galway Galway Ireland
- Discipline of Podiatric Medicine, School of Health Sciences, NUI Galway Galway Ireland
| | - Caroline McIntosh
- Alliance for Research and Innovation in Wounds, NUI Galway Galway Ireland
- Discipline of Podiatric Medicine, School of Health Sciences, NUI Galway Galway Ireland
| | - Carolina D. Weller
- School of Nursing and Midwifery, NUI Galway Galway Ireland
- Alliance for Research and Innovation in Wounds, NUI Galway Galway Ireland
- School of Nursing and Midwifery, Monash University Australia
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13
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Gillespie P, Carter L, McIntosh C, Gethin G. Estimating the health-care costs of wound care in Ireland. J Wound Care 2019; 28:324-330. [DOI: 10.12968/jowc.2019.28.6.324] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective: To estimate the cost of wound care to the Irish health-care system. Methods: A bottom-up, prevalence-based analysis was undertaken using a decision analytic model to estimate costs. Health-care resource activity was identified from a recently published study from the UK and was valued using unit cost data for Ireland. Results: The base case analysis estimated the total annual healthcare cost of wound care to be €629,064,198 (95% Confidence interval (CI): €452,673,358 to €844,087,124), accounting for 5% (95% CI: 3% to 6%) of total public health expenditure in Ireland in 2013. The average cost per patient was €3,941 (95% CI: €2,836 to €5,287). However, this study is subject to many limitations and plausible changes in the model's inputs showed that the total annual health-care cost of wound care could range from €281,438,970 to €844,316,912. Conclusion: Caring for wounds places a substantial burden on the Irish health-care system. In light of growing pressures to finance an already resource-constrained health-care system, these results provide useful information for those charged with future wound care service design and provision in Ireland and elsewhere.
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Affiliation(s)
- Paddy Gillespie
- School of Business and Economics, National University of Ireland (NUI) Galway, Galway, Ireland
| | - Laura Carter
- School of Business and Economics, National University of Ireland (NUI) Galway, Galway, Ireland
| | - Caroline McIntosh
- Alliance for Research and Innovation in Wounds, NUI Galway, Galway, Ireland
- Discipline of Podiatric Medicine, NUI Galway, Galway, Ireland
| | - Georgina Gethin
- Alliance for Research and Innovation in Wounds, NUI Galway, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
- School of Nursing and Midwifery, Monash University, Australia
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14
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Kelly M, Gethin G. Prevalence of Chronic Illness and Risk Factors for Chronic Illness Among Patients With Venous Leg Ulceration: A Cross-Sectional Study. INT J LOW EXTR WOUND 2019; 18:301-308. [DOI: 10.1177/1534734619850444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. Chronic illness and risk factors for chronic illness are rising public health concerns for individuals and health care systems. Individuals with venous leg ulceration (VLU) have at least one chronic illness. As there is a projected increase in VLU prevalence there is a need to determine concurrent prevalence of risk factors for chronic illness among this population. Methods. A cross-sectional design conducted in 8 community, nurse-led, leg ulcer clinics. Results. Fifty patients (58%, n = 29 females) were enrolled. Seventy percent were >65 years old; 90% had at least one chronic illness; 60% had hypertension; 30% had atrial fibrillation; 18% had diabetes; 18% heart failure; and 28.6% musculoskeletal conditions. All had at least one risk factors for chronic illness (mean = 2.26), the most frequent being overweight (30%), obesity (30%), high cholesterol (22.2%), and restricted physical activity (22%). Participants took a mean 5.2 medications daily and 26% were on current oral antibiotics. Conclusions. Comprehensive, holistic assessment and regular reassessment with a preventative focus needs to consider chronic illness and risk factors for chronic illness. Patients with VLU are in frequent contact with their multidisciplinary team. This is an opportunity to improve care and make every encounter count.
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Affiliation(s)
- Maria Kelly
- HSE West, Ireland
- NUI Galway, Galway, Ireland
| | - Georgina Gethin
- NUI Galway, Galway, Ireland
- Alliance for Research and Innovation in Wounds, NUI Galway, Galway, Ireland
- Monash University, Melbourne, Victoria, Australia
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15
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Danwang C, Tochie JN, Mazou TN, Nzalie RNT, Bigna JJ. Contemporary occurrence and aetiology of chronic leg ulcers in Africa: a systematic review and meta-analysis protocol. BMJ Open 2019; 9:e026868. [PMID: 31133589 PMCID: PMC6538029 DOI: 10.1136/bmjopen-2018-026868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Chronic leg ulcers are known as a major and snowballing threat to public health and the global economy. In Africa, there is controversy on the dearth of studies reporting the epidemiology of chronic leg ulcers. The present systematic review and meta-analysis aim at synthesising the prevalence, incidence and aetiologies of this ailment in this continent from contemporary data. METHODS AND DESIGN We will include cohort studies, case-control, cross-sectional studies and case series with more than 30 participants. Electronical databases including African Journals Online, MEDLINE, Excerpta Medica Database and Web of knowledge, and grey literature will be searched for relevant abstracts of studies published and unpublished between 1 January, 2000, and 28 February, 2019, without language restriction. The review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Each study included in this review will be assessed for methodological quality. Clinically homogenous studies will be pooled using random-effects meta-analysis. Visual inspection of funnel-plots and the Egger's test will be used to investigate publication bias. Meta-regression and subgroup analyses will be performed to investigate the possible sources of heterogeneity. ETHICS AND DISSEMINATION The present study will be based on published data; therefore, ethical approval is not required. Result of the review will be presented at conferences, to relevant health authorities and will be published in a biomedical peer-reviewed journal. PROTOCOL REGISTRATION NUMBER CRD42018108250.
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Affiliation(s)
- Celestin Danwang
- School of Public Health, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Joel Noutakdie Tochie
- Department of Surgery and specialities, Universite de Yaounde I Faculte de Medecine et des Sciences Biomedicales, Yaounde, Cameroon
| | - Temgoua Ngou Mazou
- Department of Internal Medicine and Specialities, Universite de Yaounde I Faculte de Medecine et des Sciences Biomedicales, Yaounde, Cameroon
| | | | - Jean Joel Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaoundé, Cameroon
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16
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Bazbouz MB, Tronci G. Two-layer Electrospun System Enabling Wound Exudate Management and Visual Infection Response. SENSORS (BASEL, SWITZERLAND) 2019; 19:E991. [PMID: 30813559 PMCID: PMC6427107 DOI: 10.3390/s19050991] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/11/2019] [Accepted: 02/17/2019] [Indexed: 02/04/2023]
Abstract
The spread of antimicrobial resistance calls for chronic wound management devices that can engage with the wound exudate and signal infection by prompt visual effects. Here, the manufacture of a two-layer fibrous device with independently-controlled exudate management capability and visual infection responsivity was investigated by sequential free surface electrospinning of poly(methyl methacrylate-co-methacrylic acid) (PMMA-co-MAA) and poly(acrylic acid) (PAA). By selecting wound pH as infection indicator, PMMA-co-MAA fibres were encapsulated with halochromic bromothymol blue (BTB) to trigger colour changes at infection-induced alkaline pH. Likewise, the exudate management capability was integrated via the synthesis of a thermally-crosslinked network in electrospun PAA layer. PMMA-co-MAA fibres revealed high BTB loading efficiency (>80 wt.%) and demonstrated prompt colour change and selective dye release at infected-like media (pH > 7). The synthesis of the thermally-crosslinked PAA network successfully enabled high water uptake (WU = 1291 ± 48 - 2369 ± 34 wt.%) and swelling index (SI = 272 ± 4 - 285 ± 3 a.%), in contrast to electrospun PAA controls. This dual device functionality was lost when the same building blocks were configured in a single-layer mesh of core-shell fibres, whereby significant BTB release (~70 wt.%) was measured even at acidic pH. This study therefore demonstrates how the fibrous configuration can be conveniently manipulated to trigger structure-induced functionalities critical to chronic wound management and monitoring.
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Affiliation(s)
- Mohamed Basel Bazbouz
- Textile Technology Research Group, School of Design, University of Leeds, Leeds LS2 9JT, UK.
| | - Giuseppe Tronci
- Textile Technology Research Group, School of Design, University of Leeds, Leeds LS2 9JT, UK.
- Biomaterials and Tissue Engineering Research Group, School of Dentistry, St. James's University Hospital, University of Leeds, Leeds LS9 7TF, UK.
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17
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Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies. Ann Epidemiol 2019; 29:8-15. [DOI: 10.1016/j.annepidem.2018.10.005] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 09/20/2018] [Accepted: 10/17/2018] [Indexed: 12/15/2022]
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18
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Davies HOB, Popplewell M, Bate G, Ryan RP, Marshall TP, Bradbury AW. Publication of UK NICE Clinical Guidelines 168 has not significantly changed the management of leg ulcers in primary care: An analysis of The Health Improvement Network database. Phlebology 2018; 34:311-316. [DOI: 10.1177/0268355518805658] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background NICE Clinical Guidelines (CG) 168, published in July 2013, recommend specialist vascular referral for all leg ulcers, defined as a break in the skin below the knee that has not healed within two weeks. Aim To examine the impact of CG168 on the primary care management of leg ulcers using The Health Improvement Network database. Methods An eligible population of approximately two million adult patients was analysed over two 18-month periods before and after publication of CG168. Those with a new diagnosis of leg ulcers in each time period were analysed in terms of demographics, specialist referral and superficial venous ablation. Results We identified 7532 and 7462 new diagnoses of leg ulcers in the pre- and post-CG168 cohorts, respectively. Patients with a new diagnosis of leg ulcers were elderly (median age: 77 years both cohorts) and less likely to be male (47% both cohorts). There were 2259 (30.0%) and 2329 (31.2%) vascular service referrals in the pre- and post-CG168 cohorts, respectively (hazard ratio, 1.05, 95% CI: 0.99, 1.11, p = 0.096). The median interval between general practitioner diagnosis and referral was 1.5 days in both cohorts. Patients from both cohorts who were referred for a new diagnosis of leg ulcers were equally likely to receive superficial venous ablation. Conclusions Disappointingly, we have been unable to demonstrate that publication of NICE CG168 has been associated with a meaningful change in leg ulcer management in primary care in line with guideline recommendations.
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Affiliation(s)
- Huw OB Davies
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - Matthew Popplewell
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - Gareth Bate
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - Ronan P Ryan
- Medical Innovation Development Research Unit (MIDRU), Heartlands Hospital, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tom P Marshall
- Medical Innovation Development Research Unit (MIDRU), Heartlands Hospital, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
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19
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Xie T, Ye J, Rerkasem K, Mani R. The venous ulcer continues to be a clinical challenge: an update. BURNS & TRAUMA 2018; 6:18. [PMID: 29942813 PMCID: PMC6003071 DOI: 10.1186/s41038-018-0119-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/11/2018] [Indexed: 01/18/2023]
Abstract
Venous ulcers are a common chronic problem in many countries especially in Northern Europe and USA. The overall prevalence of this condition is 1% rising to 3% in the over 65 years of age. Over the last 25 years, there have been many developments applicable to its diagnosis and treatment. These advances, notwithstanding healing response and recurrence, are variable, and the venous ulcer continues to be a clinical challenge. The pathogenesis of venous ulcers is unrelieved or ambulatory venous hypertension resulting mostly from deep venous thrombosis leading to venous incompetence, lipodermatosclerosis, leucocyte plugging of the capillaries, tissue hypoxia and microvascular dysfunction. It is not known what initiates venous ulcers. Triggers vary from trauma of the lower extremity to scratching to relieve itchy skin over the ankle region. Venous ulcers can be painful, and this condition presents an increasing burden of care. A systematic analysis of the role of technology used for diagnosis and management strongly supports the use of compression as a mainstay of standardised care. It further shows good evidence for the potential of some treatment procedures to accelerate healing. This article reviews the pathogenetic mechanisms, current diagnostic methods and standard care and its limitations.
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Affiliation(s)
- Ting Xie
- 1Wound Healing Centre at Emergency Department, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- 2Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kittipan Rerkasem
- 3NCD Centre of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand.,4NCD Centre and Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rajgopal Mani
- 4NCD Centre and Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,5Academic Division of Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK.,6Shanghai Jiao Tong University, Shanghai Jiao Tong School of Medicine, Shanghai, China
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20
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Lurie F, Bittar S, Kasper G. Optimal Compression Therapy and Wound Care for Venous Ulcers. Surg Clin North Am 2017; 98:349-360. [PMID: 29502776 DOI: 10.1016/j.suc.2017.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Venous leg ulcers remain a major public health issue with significant economic impact. Two main components of the management of patients with venous leg ulcers are compression therapy and wound care. This article addresses principles and specific aspects of compression therapy and focal wound care for patients with venous leg ulcers.
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Affiliation(s)
- Fedor Lurie
- ProMedica Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH 43606, USA; University of Michigan, Ann Arbor, MI, USA.
| | - Samir Bittar
- ProMedica Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH 43606, USA
| | - Gregory Kasper
- ProMedica Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH 43606, USA
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21
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Mitchell A. Assessing the value of practice-based leg ulcer education to inform recommendations for change in practice. Br J Community Nurs 2017; 22:S28-S34. [PMID: 29189067 DOI: 10.12968/bjcn.2017.22.sup12.s28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The purpose of this paper is to assess the value of accredited leg ulcer education in influencing changes in practice. This is a before and after educational evaluation that adopted a qualitative survey approach of 12 primary care nurses attending the Nurse-Led Assessment and Management of Leg Ulcers accredited CPD module at a London university. The findings revealed that 6 out of the 8 nurses who completed the final interviews were satisfied that all learning outcomes for the module had been met. All of the nurses commented they had changed at least one aspect of practice following the module with the majority stating a number of improvements had been made relating to improved knowledge, practical skills, treatment and patient concordance. The evaluation was limited to a small cohort of primary care nurses and further longitudinal research is required to investigate the effectiveness across multiple cohorts.
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Affiliation(s)
- Aby Mitchell
- Lecturer Health Promotion, Public Health and Primary Care, University of West London
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22
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Alkhater M, Jockenhöfer F, Stoffels I, Dissemond J. May-Thurner syndrome: an often overlooked cause for refractory venous leg ulcers. Int Wound J 2017; 14:578-582. [PMID: 28251803 DOI: 10.1111/iwj.12724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/25/2017] [Indexed: 11/28/2022] Open
Abstract
We report a 53-year-old female patient presenting with a refractory venous leg ulcer and unremarkable findings in the doppler Ultrasound venous mapping of the leg veins. Further comprehensive diagnostics demonstrated an underlying May-Thurner syndrome. After resolution of the primary mechanical obstruction, rapid wound healing in the following 3 weeks was documented. Iliac vein compression syndrome, commonly known as May-Thurner syndrome, is a distinguishable anatomical variant that results from an external compression over the left iliac vein exerted by the overriding adjacent right common iliac artery. It is mostly seen among young, healthy female patients and can easily be under-diagnosed. Lower extremities duplex ultrasonography remains the gold standard in diagnosing venous insufficiency, but it should not solely depend on it. Instead, clinicians should consider other possibilities, assessing the patency within the truncal veins, which in turn might contribute to the venous insufficiency along the lower limbs. An active early diagnostic approach can prevent significant overall morbidity and help patients to ease back into their daily-life activities. Therefore, it is recommended that all patients with suspected venous insufficiency and normal lower limbs duplex findings should undergo further evaluation of the truncal venous system pattern. May-Thurner syndrome, along with other causes of iliac veins compression, should be considered in the differential diagnosis in unclear persistent cases of unilateral venous symptoms.
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Affiliation(s)
- Maryam Alkhater
- Department of Dermatology, Venerology and Allergology, University Hospital of Essen, Essen, Germany
| | - Finja Jockenhöfer
- Department of Dermatology, Venerology and Allergology, University Hospital of Essen, Essen, Germany
| | - Ingo Stoffels
- Department of Dermatology, Venerology and Allergology, University Hospital of Essen, Essen, Germany
| | - Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University Hospital of Essen, Essen, Germany
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23
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Davies HOB, Popplewell M, Bate G, Kelly L, Darvall K, Bradbury AW. Impact of UK NICE clinical guidelines 168 on referrals to a specialist academic leg ulcer service. Phlebology 2017; 33:84-88. [DOI: 10.1177/0268355516688357] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management. Aim Determine the impact of CG168 on referrals to a leg ulcer service. Methods Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012–June 2013) and an 18-month period commencing six months after (January 2014–June 2015) publication of CG168 were compared. Results There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006). Conclusions Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.
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Affiliation(s)
- Huw OB Davies
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | - Matthew Popplewell
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | - Gareth Bate
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | - Lisa Kelly
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | | | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
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24
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Jockenhöfer F, Gollnick H, Herberger K, Isbary G, Renner R, Stücker M, Valesky E, Wollina U, Weichenthal M, Karrer S, Kuepper B, Roesch A, Dissemond J. Aetiology, comorbidities and cofactors of chronic leg ulcers: retrospective evaluation of 1 000 patients from 10 specialised dermatological wound care centers in Germany. Int Wound J 2016; 13:821-8. [PMID: 25483380 PMCID: PMC7949738 DOI: 10.1111/iwj.12387] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/02/2014] [Accepted: 10/07/2014] [Indexed: 12/16/2022] Open
Abstract
Numerous comorbidities and cofactors have been known to influence wound healing processes. In this multicentre study, clinical data of 1 000 patients with chronic leg ulcers from ten specialised dermatological wound care centers were analysed. The patient cohort comprised 567 females and 433 males with an average age of 69·9 years. The wounds persisted on average for 40·8 months and had a mean size of 43·7 cm(2) . Venous leg ulcers represented the most common entity accounting for 51·3% of all chronic wounds, followed by mixed-type ulcers in 12·9% and arterial ulcerations in 11·0% of the patients. Vasculitis was diagnosed in 4·5%, trauma in 3·2%, pyoderma gangrenosum in 2·8%, lymphoedema in 1·7%, neoplasia in 1·0% and delayed post-surgical wound healing in 0·6% of the included patients. In total, 70·5% of patients suffered from arterial hypertension, 45·2% were obese, 27·2% had non-insulin dependent diabetes, and 24·4% dyslipidaemia. Altogether 18·4% suffered from metabolic syndrome. Cofactors and comorbidities of patients with chronic leg ulcers have previously been studied but not in detail. Here, we were able to demonstrate the existence of several potentially relevant cofactors, comorbidities of their associations and geographical distributions, which should be routinely examined in patients with chronic leg ulcers and - if possible - treated.
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Affiliation(s)
- Finja Jockenhöfer
- Department of Dermatology, Venereology and Allergology, University Hospital of Essen, Essen, Germany
| | - Harald Gollnick
- Department of Dermatology and Venereology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Katharina Herberger
- Institute for Healthcare Research of Dermatology and Health Care Professions, University Hospital of Hamburg, Hamburg, Germany
| | - Georg Isbary
- Department of Dermatology, Allergology and Environment Medicine, Clinical Centre Schwabing Munich, Munich, Germany
| | - Regina Renner
- Department of Dermatology and Venereology, University Hospital of Erlangen, Erlangen, Germany
| | - Markus Stücker
- Department of Dermatology, Centre for venous disease of the dermatological and vascular surgery, University Hospital of Bochum, Bochum, Germany
| | - Eva Valesky
- Department of Dermatology and Venereology, University Hospital of Frankfurt a. M., Frankfurt, Germany
| | - Uwe Wollina
- Department of Dermatology, Venereology and Allergology, Hospital Dresden-Friedrichstadt, Dresden, Germany
| | - Michael Weichenthal
- Department of Dermatology, Venereology, University Hospital of Kiel, Keil, Germany
| | - Sigrid Karrer
- Department of Dermatology, Venereology, University Hospital of Regensburg, Regensburg, Germany
| | - Bernhard Kuepper
- General Medical Department, Timaru Public Hospital, SCDHB, Timaru, New Zealand
| | - Alexander Roesch
- Department of Dermatology, Venereology and Allergology, University Hospital of Essen, Essen, Germany
| | - Joachim Dissemond
- Department of Dermatology, Venereology and Allergology, University Hospital of Essen, Essen, Germany.
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Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, Morley R, O’Meara S, Goncalves PS, Soares M, Stubbs N. Wounds research for patient benefit: a 5-year programme of research. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04130] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BackgroundComplex wounds are those that heal by secondary intention and include lower-limb ulcers, pressure ulcers and some surgical wounds. The care of people with complex wounds is costly, with care mainly being delivered by community nurses. There is a lack of current, high-quality data regarding the numbers and types of people affected, care received and outcomes achieved.ObjectivesTo (1) assess how high-quality data about complex wounds can be captured effectively for use in both service planning and research while ensuring integration with current clinical data collection systems and minimal impact on staff time; (2) investigate whether or not a clinical register of people with complex wounds could give valid estimates of treatment effects, thus reducing dependence on large-scale randomised controlled trials (RCTs); (3) identify the most important research questions and outcomes for people with complex wounds from the perspectives of patients, carers and health-care professionals; (4) evaluate the potential contributions to decision-making of individual patient data meta-analysis and mixed treatment comparison meta-analysis; and (5) complete and update systematic reviews in topic areas of high priority.MethodsTo meet objectives 1 and 2 we conducted a prevalence survey and developed and piloted a longitudinal disease register. A consultative, deliberative method and in-depth interviews were undertaken to address objective 3. To address objectives 4 and 5 we conducted systematic reviews including mixed treatment comparison meta-analysis.ResultsFrom the prevalence survey we estimated the point prevalence of all complex wounds to be 1.47 per 1000 people (95% confidence interval 1.38 to 1.56 per 1000 people). Pressure ulcers and venous leg ulcers were the most common type of complex wound. A total of 195 people with a complex wound were recruited to a complex wounds register pilot. We established the feasibility of correctly identifying, extracting and transferring routine NHS data into the register; however, participant recruitment, data collection and tracking individual wounds in people with multiple wounds were challenging. Most patients and health professionals regarded healing of the wound as the primary treatment goal. Patients were greatly troubled by the social consequences of having a complex wound. Complex wounds are frequently a consequence of, and are themselves, a long-term condition but treatment is usually focused on healing the wound. Consultative, deliberative research agenda setting on pressure ulcer prevention and treatment with patients, carers and clinicians yielded 960 treatment uncertainties and a top 12 list of research priorities. Of 167 RCTs of complex wound treatments in a systematic review of study quality, 41% did not specify a primary outcome and the overall quality of the conduct and reporting of the research was poor. Mixed-treatment comparison meta-analysis in areas of high priority identified that matrix hydrocolloid dressings had the highest probability (70%) of being the most effective dressing for diabetic foot ulcers, whereas a hyaluronan fleece dressing had the highest probability (35%) of being the most effective dressing for venous ulcers; however, the quality of this evidence was low and uncertainty is high.ConclusionsComplex wounds are common and costly with a poor evidence base for many frequent clinical decisions. There is little routine clinical data collection in community nursing. A prospective complex wounds register has the potential to both assist clinical decision-making and provide important research evidence but would be challenging to implement without investment in information technology in NHS community services. Future work should focus on developing insights into typical wound healing trajectories, identifying factors that are prognostic for healing and assessing the cost-effectiveness of selected wound treatments.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Nicky Cullum
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Hannah Buckley
- Department of Health Sciences, University of York, York, UK
| | - Jo Dumville
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Jill Hall
- Department of Health Sciences, University of York, York, UK
| | - Karen Lamb
- Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Mary Madden
- Department of Health Sciences, University of York, York, UK
| | - Richard Morley
- Department of Health Sciences, University of York, York, UK
| | - Susan O’Meara
- Department of Health Sciences, University of York, York, UK
| | | | - Marta Soares
- Centre for Health Economics, University of York, York, UK
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Kelechi TJ, Mueller M, Dooley M. Sex differences in symptom severity and clusters in patients with stage C4 and stage C5 chronic venous disease. Eur J Cardiovasc Nurs 2016; 16:28-36. [PMID: 26888961 DOI: 10.1177/1474515116634526] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple symptoms associated with chronic venous disease (CVD) are poorly understood, under-recognized, and ill-managed. AIMS The aim of this study was to determine whether there are differences in symptoms and symptom clusters between men and women with stage C4 and stage C5 CVD. METHODS Data were collected via interviews with 264 patients using a demographic survey and an 11-item VEINES-SYM questionnaire. ANALYSIS An intrinsic scoring algorithm was developed to calculate the overall t scores for each item by sex. Exploratory factor analysis identified symptom clusters using oblique rotation to account for correlations between factors. RESULTS The average age was 61.7 years; 54.5% of the patients were women, 58% were African American or black, and 60.6% had diabetes. The top three symptoms for women in order of frequency were achy legs, swelling, and pain; for men, these were swelling, achy legs, and heavy legs. For the total group, two symptom clusters emerged: distressful and discomfort. There was no statistically significant difference in factor score between the sexes. Different factor loadings for symptom clusters were observed: women reported hurting and annoying clusters; and men reported nagging and irritating clusters. CONCLUSION The data suggest differences in CVD symptoms and clusters by sex. Symptoms in the two clusters were different; however, there was consistency in the factors associated with each cluster. Co-morbid conditions and sex differences in pain responses may play a part in symptom presentation. This study supports the need for increased sex-delineated clinical assessment and consideration of the potential differences between the sexes in the management of CVD symptoms.
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Affiliation(s)
- Teresa J Kelechi
- Medical University of South Carolina, College of Nursing, Charleston, SC, USA
| | - Martina Mueller
- Medical University of South Carolina, College of Nursing, Charleston, SC, USA
| | - Mary Dooley
- Medical University of South Carolina, College of Nursing, Charleston, SC, USA
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Abstract
Leg ulcers are a common health problem. Ulcers of any etiology including venous ulcers may be very painful, but until recently, health professionals have not been good at recognizing or managing this type of pain. It is important to clarify the type, severity, and frequency of pain and to anticipate pain at dressing changes. The measurement of pain by the use of pain scales is very useful, particularly in assessing the efficacy of an intervention. Neuropathic pain and unusually painful ulcerations are discussed in this article.
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Affiliation(s)
- Susan M Cooper
- Department of Dermatology, Churchill Hospital, Oxford, UK.
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Abstract
BACKGROUND Venous ulcers (also known as varicose or venous stasis ulcers) are a chronic, recurring and debilitating condition that affects up to 1% of the population. Best practice documents and expert opinion suggests that the removal of devitalised tissue from venous ulcers (debridement) by any one of six methods helps to promote healing. However, to date there has been no review of the evidence from randomised controlled trials (RCTs) to support this. OBJECTIVES To determine the effects of different debriding methods or debridement versus no debridement, on the rate of debridement and wound healing in venous leg ulcers. SEARCH METHODS In February 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting. In addition we handsearched conference proceedings, journals not cited in MEDLINE, and the bibliographies of all retrieved publications to identify potential studies. We made contact with the pharmaceutical industry to enquire about any completed studies. SELECTION CRITERIA We included RCTs, either published or unpublished, which compared two methods of debridement or compared debridement with no debridement. We presented study results in a narrative form, as meta-analysis was not possible. DATA COLLECTION AND ANALYSIS Independently, two review authors completed all study selection, data extraction and assessment of trial quality; resolution of disagreements was completed by a third review author. MAIN RESULTS We identified 10 RCTs involving 715 participants. Eight RCTs evaluated autolytic debridement and included the following agents or dressings: biocellulose wound dressing (BWD), non-adherent dressing, honey gel, hydrogel (gel formula), hydrofibre dressing, hydrocolloid dressings, dextranomer beads, Edinburgh University Solution of Lime (EUSOL) and paraffin gauze. Two RCTs evaluated enzymatic preparations and one evaluated biosurgical debridement. No RCTs evaluated surgical, sharp or mechanical methods of debridement, or debridement versus no debridement. Most trials were at a high risk of bias.Three RCTs assessed the number of wounds completely debrided. All three of these trials compared two different methods of autolytic debridement (234 participants), with two studies reporting statistically significant results: one study (100 participants) reported that 40/50 (80%) ulcers treated with dextranomer beads and 7/50 (14%) treated with EUSOL achieved complete debridement (RR 5.71, 95% CI 2.84 to 11.52); while the other trial (86 participants) reported the number of ulcers completely debrided as 31/46 (76%) for hydrogel versus 18/40 (45%) for paraffin gauze (RR 0.67, 95% CI 0.45 to 0.99). One study (48 participants) reported that by 12 weeks, 15/18 (84%) ulcers treated with BWD had achieved a 75% to 100% clean, granulating wound bed versus 4/15 (26%) treated with non-adherent petrolatum emulsion-impregnated gauze.Four trials assessed the mean time to achieve debridement: one (86 participants) compared two autolytic debridement methods, two compared autolytic methods with enzymatic debridement (71 participants), and the last (12 participants) compared autolytic with biosurgical debridement; none of the results achieved statistical significance.Two trials that assessed autolytic debridement methods reported the number of wounds healed at 12 weeks. One trial (108 participants) reported that 24/54 (44%) ulcers treated with honey healed versus 18/54 (33%) treated with hydrogel (RR (adjusted for baseline wound diameter) 1.38, 95% CI 1.02 to 1.88; P value 0.037). The second trial (48 participants) reported that 7/25 (28%) ulcers treated with BWD healed versus 7/23 (30%) treated with non-adherent dressing.Reduction in wound size was assessed in five trials (444 participants) in which two autolytic methods were compared. Results were statistically significant in one three-armed trial (153 participants) when cadexomer iodine was compared to paraffin gauze (mean difference 24.9 cm², 95% CI 7.27 to 42.53, P value 0.006) and hydrocolloid compared to paraffin gauze (mean difference 23.8 cm², 95% CI 5.48 to 42.12, P value 0.01). A second trial that assessed reduction in wound size based its results on median differences and, at four weeks, produced a statistically significantly result that favoured honey over hydrogel (P value < 0.001). The other three trials reported no statistically significant results for reduction in wound size, although one trial reported that the mean percentage reduction in wound area was greater at six and 12 weeks for BWD versus a non-adherent dressing (44% versus 24% week 6; 74% versus 54% week 12).Pain was assessed in six trials (544 participants) that compared two autolytic debridement methods, but the results were not statistically significant. No serious adverse events were reported in any trial. AUTHORS' CONCLUSIONS There is limited evidence to suggest that actively debriding a venous leg ulcer has a clinically significant impact on healing. The overall small number of participants, low number of studies and lack of meta-analysis in this review precludes any strong conclusions of benefit. Comparisons of different autolytic agents (hydrogel versus paraffin gauze; Dextranomer beads versus EUSOL and BWD versus non-adherent dressings) and Larvae versus hydrogel all showed statistically significant results for numbers of wounds debrided. Larger trials with follow up to healing are required.
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Affiliation(s)
- Georgina Gethin
- National University of Ireland GalwaySchool of Nursing and MidwiferyAras Moyola, National University of Ireland GalwayGalwayIreland0
| | - Seamus Cowman
- Royal College of Surgeons in Ireland BahrainP.O. Box 15503AdliyaManamaBahrain
| | - Dinanda N Kolbach
- Huidcentrum LimburgDepartment of DermatologyReinaartsingel 50MaastrichtNetherlands6218AC
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Affiliation(s)
- Emer Shanley
- HSE South; West Cork Community Care; Coolnagurrane Skibbereen Cork Ireland
| | - Zena EH Moore
- Royal College of Surgeons in Ireland; School of Nursing & Midwifery; 123 St. Stephen's Green Dublin Ireland D2
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Affiliation(s)
- Niamh EM McLain
- Health Service Executive; Community Care; Centenary House 35 York Road, Dun Laoghaire Dublin Ireland
| | - Zena EH Moore
- Royal College of Surgeons in Ireland; School of Nursing & Midwifery; 123 St. Stephen's Green Dublin Ireland D2
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Rosales A, Sandbæk G. Haemodynamics and catheter-based imaging in the diagnosis of venous disease. An interventional targeted approach. Phlebology 2013; 28 Suppl 1:162-8. [PMID: 23482554 DOI: 10.1177/0268355513475957] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The investigation of patients with severe chronic venous insufficiency (CVI, C3-C6) represents a challenge that requires the understanding of venous pathophysiology and a multidisciplinary approach; it should be aimed to assess valve function, evaluate the haemodynamic significance of obstruction and assess the function of the vein-muscle pump. Combining haemodynamic tests and imaging techniques best accomplish the investigation of these three aspects of the pathophysiology in CVI. The information obtained from ambulatory venous pressure and color duplex ultrasound is accurate when assessing reflux in the different segments of the different venous systems. The valve anatomic location and dynamic picture is supplied by descending phlebography. In case of venous obstruction, the haemodynamic tests lack accuracy and sensitivity. Therefore, imaging catheter techniques have to fill-in to depict vein morphology as well as inflow/outflow characteristics. The participation of several specialties in the investigation of these patients widens the treatment possibilities by identifying those who may benefit from advanced surgical and/or endovascular procedures. This interventional-targeted approach should be a centralized function.
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Affiliation(s)
- A Rosales
- Department of Vascular Surgery, Oslo Vascular Centre, Oslo University Hospital, Postbox 4950 Nydalen, 0424 Oslo, Norway.
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Abstract
Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress. The condition affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and greatly reduce patients' quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases. As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment. A correct diagnosis is essential to avoid inappropriate treatment that may cause deterioration of the wound, delay wound healing, or harm the patient. The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.
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Abstract
BACKGROUND Venous leg ulcers affect up to 1% of people at some time in their lives and are often painful. The main treatments are compression bandages and dressings. Topical treatments to reduce pain during and between dressing changes are sometimes used. OBJECTIVES To determine the effects of topical agents or dressings for pain in venous leg ulcers. SEARCH METHODS For this third update the following databases were searched: Cochrane Wounds Group Specialised Register (searched 9 May 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4); Ovid MEDLINE (2009 to April Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations May 08, 2012); Ovid EMBASE (2009 to 2012 Week 18); and EBSCO CINAHL (2009 to May 2 2012). No date or language restrictions were applied. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of topical agents or dressing for the treatment of pain in venous ulcers were included. DATA COLLECTION AND ANALYSIS Two review authors independently performed trial selection, data extraction and risk of bias assessment. MAIN RESULTS Six trials (343 participants) evaluated Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream for the pain associated with ulcer debridement. The between-group difference in pain measured on a 100 mm scale was statistically significant in favour of EMLA (MD -20.65, 95% CI -12.19 to -29.11). No significant between-group differences in burning or itching were observed.Two trials (470 participants with venous leg ulcers) evaluated ibuprofen slow-release foam dressings for persistent venous leg ulcer pain. Compared with local best practice, significantly more participants in the ibuprofen dressing group achieved the outcome of >50% of the total maximum pain relief score between day 1 and day 5 than participants in the local best practice group (RR 1.63, 95% CI 1.24 to 2.15). The number needed to treat was 6 (95% CI 4 to 12). In the second trial, compared with an identical non-ibuprofen foam dressing, there was no statistically significant difference in the proportion of participants experiencing slight to complete pain relief on the first evening of treatment.Limited data were available to assess healing rates or adverse events. AUTHORS' CONCLUSIONS There is some evidence to suggest that ibuprofen dressings may offer pain relief to people with painful venous leg ulcers. EMLA (5%) appears to provide effective pain relief during the debridement of venous leg ulcers. Further research should consider standardised pain assessment methods and assess both the effect on ulcer healing and the impact of long term use of these treatments.
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Clarke-Moloney M, Keane N, O'Connor V, Ryan MA, Meagher H, Grace PA, Kavanagh E, Walsh SR, Burke PE. Randomised controlled trial comparing European standard class 1 to class 2 compression stockings for ulcer recurrence and patient compliance. Int Wound J 2012; 11:404-8. [PMID: 23078587 DOI: 10.1111/j.1742-481x.2012.01108.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to determine the rate of venous ulcer recurrence and the level of compliance in patients wearing European class 1 or class 2 compression stockings. A total of 100 patients with healed venous leg ulcers were recruited, and were randomised to either class 1 (n = 50) or class 2 (n = 50) compression stockings. Follow-up was at 1 week, 3, 6, 9 and 12 months to monitor ulcer recurrence and compliance. Patients had a duplex scan to identify the source of venous incompetence. The rate of ulcer recurrence after 12 months was 16·1%, and the difference in recurrence rate between classes was not statistically significant (P = 0·287) although greater numbers in class 1 developed a recurrence. Participants (88·9%) were compliant; non-compliant patients were at a significantly greater risk of recurrence (P≤ 0·0001). Thirteen patients had both superficial and deep incompetence; those randomised to class 1 stockings (n = 4) developed ulcer recurrence. Patients with a history of multiple episodes of ulceration were more likely to develop a recurrence (P = 0·001). The lowest venous ulcer recurrence rates were seen in patients who were compliant with hosiery regardless of the compression level. Patients with both superficial and deep incompetence had a lower rate of recurrence with class 2 compression.
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Affiliation(s)
- Mary Clarke-Moloney
- Vascular Research Unit, Department of Vascular Surgery, University Hospital Limerick, Limerick, IrelandDepartment of Public Health Nursing, HSE West Ennis, Co Clare, IrelandSt. John's Hospital Limerick, Limerick, Ireland
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Körber A, Klode J, Al-Benna S, Wax C, Schadendorf D, Steinstraesser L, Dissemond J. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey. J Dtsch Dermatol Ges 2010; 9:116-21. [DOI: 10.1111/j.1610-0387.2010.07535.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Gethin G, Cowman S, Kolbach DN. Debridement for venous leg ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND Venous leg ulcers affect up to 1 per cent of people at some time in their lives. The main treatments are compression bandages and dressings. As these ulcers are often painful some clinicians choose particular dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes. OBJECTIVES To assess the effectiveness of dressings, local anaesthetics or topical analgesia for pain relief in venous leg ulceration. SEARCH STRATEGY For this update the search strings were revised and the following databases were searched: The Cochrane Wounds Group Specialised Register (Searched 16/12/09) The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 50; EBSCO CINAHL - 1982 to December 16 2009. No date or language restrictions were applied. SELECTION CRITERIA Randomised controlled trials which evaluated local interventions used to relieve venous leg ulcer pain were considered. Pain was defined as either persistent pain or pain at dressing changes or debridement. Ulcer healing and reported adverse events were also considered as further outcomes. DATA COLLECTION AND ANALYSIS Eligibility for inclusion was confirmed by two review authors who independently assessed the potential trials. MAIN RESULTS Two trials evaluating interventions for persistent venous leg ulcer pain were identified for this review update. Both studies evaluated ibuprofen slow release foam dressings; one comparing it with local best practice and the other with an identical foam comparator. The primary end point for both studies was "pain relief achieved". When compared with a foam dressing alone, there was no evidence of a statistically significant effect of the ibuprofen foam dressing in terms of achieving some pain relief the first evening after treatment: 74% in the ibuprofen group (46/62) had pain relief compared with 58% (35/60) in the foam group (no significant difference: RR 1.27, 95%CI 0.98 to 1.65). In the second study 100% (32/32) of people with venous ulcers achieved some pain relief with the ibuprofen dressing on the first evening of treatment compared with 93% (26/28) in the local best practice group (no significant difference: RR 1.08, 95% CI 0.96 to 1.21). Pooling these studies in a meta-analysis (using a random effects model as significant heterogeneity present (p=0.1), I(2) = 64%) there is no evidence that ibuprofen dressings increase the pain relief experienced by the first evening of use (RR 1.15, 95% CI 0.91 to 1.44). We were not able to extract sufficient data to combine other pain outcomes from these trials. There was no difference in healing rates but slightly more adverse events with ibuprofen dressings than with a similar foam dressing without ibuprofen.Six trials evaluated interventions for the pain associated with debridement and were considered sufficiently similar to pool. There was a statistically significant reduction in debridement pain scores with 5% Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream; the difference in means (measured on a 100 mm scale) was 20.6 mm (95% CI 12.19 to 29.11). Of these six trials, only one small trial measured healing as an outcome and found no difference in the numbers of ulcers healed at the end of the study. AUTHORS' CONCLUSIONS There is no evidence that ibuprofen dressings offer pain relief, as measured at the first evening of use, to people with painful venous leg ulcers compared with foam dressings or best practice.EMLA appears to provide effective pain relief for venous leg ulcer debridement but the effect (if any) of EMLA on ulcer healing remains unknown.
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Affiliation(s)
- Michelle Briggs
- School of Healthcare, University of Leeds, Baines Wing, Leeds, UK, LS2 9JT
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Abstract
Chronic leg ulceration impacts negatively on the quality of life of the sufferer and has financial implications for the economy. Government health policy aims to tackle long-term conditions and restructure services from acute to community care. Community nurses play a pivotal role in managing and co-ordinating care to leg ulcer patients, yet their personal experience in this clinical situation is poorly explored. This qualitative study aims to gain an understanding of community nurses' personal experience of treating clients with leg ulcers; this is necessary to develop leg ulcer services which are effective, efficient and client-centred.
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Affiliation(s)
- Eileen Walsh
- Public Health Nurse for Health Service Executive, Southern Area, Co Cork.
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Renner R, Teuwen I, Gebhardt C, Simon JC. Mathematical model for wound healing following autologous keratinocyte transplantation. Int Wound J 2008; 5:445-52. [PMID: 18593393 DOI: 10.1111/j.1742-481x.2007.00404.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In times of increasing economical pressure on the health care systems, it is important to optimise the outpatient treatment of chronic wounds. Another aim of wound healing research is to discover agents to accelerate healing. Wound healing trajectories or healing velocities can provide information to demonstrate the endpoints for wound healing. A great problem in clinical trials is to specify these parameters. Therefore, we developed a mathematical model for more transparency. In this initial project, we observed 19 wounds to construct the wound healing trajectories after transplantation of autologous keratinocytes, and the results are so encouraging that investigation in this area will continue. The developed mathematical model describes the clinical observed healing process. It was possible to find parameters to distinguish between old and young patients, retrospectively or prospectively calculate the healing rates and to determine exactly the endpoint of healing. Therefore, our model might be very useful in practices or for studies.
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Affiliation(s)
- Regina Renner
- Department of Dermatology, Venereology and Allergology, University of Leipzig, Medical Center, Leipzig, Germany.
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Gethin G, Cowman S. Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. J Clin Nurs 2008; 18:466-74. [PMID: 18752540 DOI: 10.1111/j.1365-2702.2008.02558.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Comparison of desloughing efficacy after four weeks and healing outcomes after 12 weeks in sloughy venous leg ulcers treated with Manuka honey (Woundcare 18+) vs. standard hydrogel therapy (IntraSite Gel). BACKGROUND Expert opinion suggests that Manuka honey is effective as a desloughing agent but clinical evidence in the form of a randomised controlled trial is not available. There is a paucity of research which uses Manuka honey in venous ulcers. DESIGN Prospective, multicentre, open label randomised controlled trial. METHOD Randomisation was via remote telephone. One hundred and eight patients with venous leg ulcers having >or=50% wound area covered in slough, not taking antibiotics or immunosuppressant therapy were recruited from vascular centres, acute and community care hospitals and leg ulcer clinics. The efficacy of WoundCare 18+ to deslough the wounds after four weeks and its impact on healing after 12 weeks when compared with IntraSite Gel control was determined. Treatment was applied weekly for four weeks and follow-up was made at week 12. RESULTS At week 4, mean % reduction in slough was 67% WoundCare 18+ vs. 52.9% IntraSite Gel (p = 0.054). Mean wound area covered in slough reduced to 29% and 43%, respectively (p = 0.065). Median reduction in wound size was 34% vs. 13% (p = 0.001). At 12 weeks, 44% vs. 33% healed (p = 0.037). Wounds having >50% reduction in slough had greater probability of healing at week 12 (95% confidence interval 1.12, 9.7; risk ratio 3.3; p = 0.029). Infection developed in 6 of the WoundCare 18+ group vs. 12 in the IntraSite Gel group. CONCLUSION The WoundCare 18+ group had increased incidence of healing, effective desloughing and a lower incidence of infection than the control. Manuka honey has therapeutic value and further research is required to examine its use in other wound aetiologies. RELEVANCE TO CLINICAL PRACTICE This study confirms that Manuka honey may be considered by clinicians for use in sloughy venous ulcers. Additionally, effective desloughing significantly improves healing outcomes.
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Affiliation(s)
- Georgina Gethin
- Dip Anatomy, Dip Applied Physiology, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Gethin G, Cowman S. Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT. J Wound Care 2008; 17:241-4, 246-7. [DOI: 10.12968/jowc.2008.17.6.29583] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- G. Gethin
- Research Centre, Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - S. Cowman
- Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Firth J, Hale C, Helliwell P, Hill J, Nelson EA. The prevalence of foot ulceration in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 59:200-5. [PMID: 18240257 DOI: 10.1002/art.23335] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To establish the prevalence of foot ulceration in patients with rheumatoid arthritis (RA) in secondary care. METHODS A postal survey of all patients with RA (n = 1,130) under the care of rheumatologists in Bradford, West Yorkshire, UK was performed. The prevalence data were validated through clinical examination, case-note review, and contact with health professionals. The false-negative rate was investigated in a subsample of patients (n = 70) who denied any history of ulceration. RESULTS The postal survey achieved a 78% response rate. Following validation, the point prevalence of foot ulceration was 3.39% and the overall prevalence was 9.73%. The false-positive rate was initially high at 21.21%, but use of diagrammatic questionnaire data to exclude leg ulceration reduced the rate to 10.76%. The false-negative rate was 11.76%. The most common sites for ulceration were the dorsal aspect of hammer toes, the metatarsal heads, and the metatarsophalangeal joint in patients with hallux abducto valgus, with 33% of patients reporting multiple sites of ulceration. Patients with open-foot and healed-foot ulceration had significantly longer RA disease duration, reported significantly greater use of special footwear, and had a higher prevalence of foot surgery than ulcer-free patients. CONCLUSION Foot ulceration affects a significant proportion of patients with RA. Further work is needed to establish risk factors for foot ulceration in RA and to target foot health provision more effectively.
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Affiliation(s)
- Jill Firth
- Postgraduate Suite, School of Healthcare, Baines Wing, University of Leeds, Leeds, UK.
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Clarke-Moloney M, Keane N, Kavanagh E. Changes in leg ulcer management practice following training in an Irish community setting. J Wound Care 2008; 17:116, 118-21. [DOI: 10.12968/jowc.2008.17.3.28669] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M. Clarke-Moloney
- Department of Vascular Surgery, HSE Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland
| | - N. Keane
- Ennis leg ulcer clinic, Department of Public Health Nursing, HSE Midwest Area, Limerick, Ireland
| | - E. Kavanagh
- Department of Vascular Surgery, HSE Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland
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Pesteil F, Oujaou-Faïz K, Drouet M, Roussane MC, Aboyans V, Cornu E, Laskar M, Lacroix P. [Cryopreserved amniotic membranes use in resistant vascular ulcers]. ACTA ACUST UNITED AC 2007; 32:201-9. [PMID: 17881172 DOI: 10.1016/j.jmv.2007.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 07/25/2007] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Amniotic membranes are used with success in ophthalmology to treat corneal wounds and ulcers. In this pilot study, we attempt to assess the tolerance of amniotic membranes in the management of resistant venous and/or arterial vascular ulcers. MATERIAL AND METHODS We prospectively included 8 patients, 7 males and 1 female, mean age 69.5+/- 9.6 years, with venous and/or arterial ulcers resistant after 6 months with usual medical care and/or after revascularisation failure. Amniotic membranes were applied on a weekly basis with the fetal side on the ulcer, covered by a secondary bandage. The primary end-point was evaluation of tolerance of amniotic membranes on vascular ulcers. The secondary end-points were a >50% reduction of ulcer's area, a significant (P< or =0.05) improvement of pain visual scale score and the quality of life assessed by the SF-36 questionnaire. RESULTS Tolerance was excellent in all cases. We observed no adverse effect. We observed complete healing at weeks 19 and 26 for 2 patients and a >50% reduction of ulcer area at weeks 26, 31 and 32 for 3 patients. A sixth patient had an ulcer area reduction <50% and the 2 remaining showed no improvement. A significant improvement was noticed for visual pain scale and the health feeling dimension in the SF-36 questionnaire. No adverse effect or amputation requirement was noted. CONCLUSION These preliminary results are encouraging and require a larger confirmatory study. Further studies are required to clarify the action mode of this therapeutic option.
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Affiliation(s)
- F Pesteil
- Service de chirurgie thoracique, cardiovasculaire et d'angiologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87000 Limoges, France.
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Clarke-Moloney M, Keane N, Kavanagh E. An exploration of current leg ulcer management practices in an Irish community setting. J Wound Care 2006; 15:407-10. [PMID: 17044358 DOI: 10.12968/jowc.2006.15.9.26963] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To establish the prevalence of leg ulceration in the Irish Health Service Executive (HSE) mid-western region and to determine the level of assessment and treatment patients have been receiving in the local community. METHOD Before the introduction of a Doppler training programme, all public health and community health nurses working in the Irish HSE mid-western area were requested to complete an audit form on each patient being treated for leg ulceration during a predefined one-week period. This form recorded details on patient demographics, ulcer aetiology, assessment and treatment. Out of 97 nurses, 96 responded to this audit, giving a response rate of 98.9%. RESULTS A total of 429 patients with 449 leg ulcers were identified. Mean age was 75.5 years (standard deviation 10.7). Overall prevalence was 0.12%, which increased to 1.2% in those aged 70 years and over. Women were almost twice as likely as men to be affected (ratio of 1.8:1). The main causes of ulceration were reported as venous incompetence accounting for 63.3% (284/449) and arterial insufficiency accounting for 8% (36/449) of all ulcers. Only 59.9% (269/449) of all ulcerated limbs had ABPI measurements performed. Of those reported as venous in origin, 71.8% (204/284) had ABPI measurements recorded. Evidence-based care was generally apparent in this group, with 47.5% (97/204) receiving high compression and 18.1% (37/204) receiving reduced compression. However, in venous leg ulcers where ABPIs were not recorded (n=80) care appeared haphazard and inappropriate. CONCLUSION Our study has identified the benefit of ABPI Doppler assessment.This assessment could be done in local health centres by trained nurses who could provide more appropriate and timely care to patients, thereby improving outcomes and relieving pressure on acute hospital clinics.
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Affiliation(s)
- M Clarke-Moloney
- Department of Vascular Surgery, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland.
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Wallace HJ, Vandongen YK, Stacey MC. Tumor Necrosis Factor Alpha Gene Polymorphism Associated with Increased Susceptibility to Venous Leg Ulceration. J Invest Dermatol 2006; 126:921-5. [PMID: 16439968 DOI: 10.1038/sj.jid.5700143] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mwaura B, Mahendran B, Hynes N, Defreitas D, Avalos G, Adegbola T, Adham M, Connolly CE, Sultan S. The Impact of Differential Expression of Extracellular Matrix Metalloproteinase Inducer, Matrix Metalloproteinase-2, Tissue Inhibitor of Matrix Metalloproteinase-2 and PDGF-AA on the Chronicity of Venous Leg Ulcers. Eur J Vasc Endovasc Surg 2006; 31:306-10. [PMID: 16169261 DOI: 10.1016/j.ejvs.2005.08.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2004] [Accepted: 08/14/2005] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Alteration in the expression of extracellular matrix metalloproteinase inducer (EMMPRIN), matrix metalloproteinase-2 (MMP-2), tissue inhibitors of matrix metalloproteinases (TIMP-2) and platelet derived growth factor (PDGF-AA) may contribute to poor healing in venous leg ulcers. AIM The aim of this study is to determine the expression of EMMPRIN, MMP-2, TIMP-2 and PDGF-AA in the ulcer exudates and perivascular tissue of healing and non-healing chronic venous ulcers. PATIENTS, MATERIALS AND METHODS Forty patients with chronic venous ulcers were included in this study, with a mean age of 60 years. Eleven patients were males and 29 were females. All patients had normal ankle brachial index and a venous ulcer of at least 8 weeks duration. Immuno-histochemistry using monoclonal antibodies to PDGF-AA, MMP-2, TIMP-2 and EMMPRIN was carried out on paraffin embedded punch biopsy skin specimens from the ulcer edge. Enzyme linked immunosorbent assay for PDGF, MMP-2 and TIMP-2 were carried out on wound fluids collected from patients. The ulcer size and character at the initial assessment and after 8 weeks were assessed to determine the status of ulcer healing. RESULTS No significant difference was seen in the expression of TIMP-2, MMP-2 and EMMPRIN between the two groups. However, in the non-healing group high levels of MMP-2 and low levels of TIMP-2 in the wound fluid suggest a strong correlation of these two markers in the state of healing. Analysis of wound fluid by ELISA demonstrated high PDGF-AA in the healing group (p = 0.021). Significantly increased levels of PDGF-AA (p<0001) was noted in the perivascular area on immuno-histochemistry of healing ulcers. These data suggest that PDGF-AA plays an important role in healing of venous ulcers. CONCLUSION Non-healing venous ulcers are associated with greater activity MMP-2 activity. The ratio of MMPs to their inhibitors TIMPs, dictate the rate of healing of the ulcers. PDGF-AA activity is associated with ulcer healing, though the mechanism is unclear. EMMPRIN expression in chronic venous ulcers probably parallels the chronicity of the condition rather than propagate it. However, further studies with larger samples are needed.
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Affiliation(s)
- B Mwaura
- Department of Vascular and Endovascular Surgery, and Western Vascular Institute, University College Hospital, Galway, Ireland
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Bechara FG, Sand M, Sand D, Stücker M, Altmeyer P, Hoffmann K. Shave therapy for chronic venous ulcers: a guideline for surgical management and postoperative wound care. Plast Surg Nurs 2006; 26:29-34. [PMID: 16543855 DOI: 10.1097/00006527-200601000-00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
This article presents a practice-oriented concept in the treatment of chronic venous ulcers with accompanying lipodermatosclerosis by shave therapy. Besides the indication for shave therapy, we focus on the operative technique and important therapy during postoperative convalescence time.
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Affiliation(s)
- Falk Georges Bechara
- Department of Dermatology and Allergology, Ruhr-University Bochum, St. Josef Hospital, Gudrunstrasse 56, 44791 Bochum, Germany.
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Clarke-Moloney M, O'Brien JF, Grace PA, Burke PE. Health-related quality of life during four-layer compression bandaging for venous ulcer disease: a randomised controlled trial. Ir J Med Sci 2005; 174:21-5. [PMID: 16094908 DOI: 10.1007/bf03169124] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Venous leg ulceration is a chronic debilitating condition which negatively impacts on patients' quality of life. Despite the application of gold standard treatment a number of patients suffer from 'slow to heal' ulcers, which can require treatment for years. AIMS The aim of this study was to compare the effects of four-layer compression bandaging (4LB) for treating venous leg ulcers with other available treatments on health-related quality of life duringtreatment. METHODS In this pragmatic trial, 200 patients with venous leg ulceration were randomised either to 4LB (intervention group; n = 100) or to continue their usual system of care (control group; n = 100). Analysis was by intention to treat; quality of life measurements were taken at randomisation and after six weeks of treatment. RESULTS 4LB provided greater quality of life benefits than the control group particularly in the area of physical activity and social functioning. CONCLUSION Due to the long-term nature of treatment for many of these patients, the effects on quality of life should be considered when prescribing treatment. This study has shown that 4LB significantly improves the quality of life of patients during treatment for venous leg ulceration.
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Affiliation(s)
- M Clarke-Moloney
- Department of Vascular Surgery, Mid-Western Regional Hospital, Limerick, Ireland.
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Affiliation(s)
- Deidre D Wipke-Tevis
- MU Sinclair School of Nursing, University of Missouri-Columbia, Columbia, MO, USA
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