Venous ulcers

Cutaneous Wound Healing and the Effects of Cannabidiol

Cutaneous wounds, both acute and chronic, begin with loss of the integrity, and thus barrier function, of the skin. Surgery and trauma produce acute wounds. There are 22 million surgical procedures per year in the United States alone, based on data from the American College of Surgeons, resulting in a prevalence of 6.67%. Acute traumatic wounds requiring repair total 8 million per year, 2.42% or 24.2 per 1000. The cost of wound care is increasing; it approached USD 100 billion for just Medicare in 2018. This burden for wound care will continue to rise with population aging, the increase in metabolic syndrome, and more elective surgeries. To heal a wound, an orchestrated, evolutionarily conserved, and complex series of events involving cellular and molecular agents at the local and systemic levels are necessary. The principal factors of this important function include elements from the neurological, cardiovascular, immune, nutritional, and endocrine systems. The objectives of this review are to provide clinicians engaged in wound care and basic science researchers interested in wound healing with an updated synopsis from recent publications. We also present data from our primary investigations, testing the hypothesis that cannabidiol can alter cutaneous wound healing and documenting their effects in wild type (C57/BL6) and db/db mice (Type 2 Diabetes Mellitus, T2DM). The focus is on the potential roles of the endocannabinoid system, cannabidiol, and the important immune-regulatory wound cytokine IL-33, a member of the IL-1 family, and connective tissue growth factor, CTGF, due to their roles in both normal and abnormal wound healing. We found an initial delay in the rate of wound closure in B6 mice with CBD, but this difference disappeared with time. CBD decreased IL-33 + cells in B6 by 70% while nearly increasing CTGF + cells in db/db mice by two folds from 18.6% to 38.8% (p < 0.05) using a dorsal wound model. We review the current literature on normal and abnormal wound healing, and document effects of CBD in B6 and db/db dorsal cutaneous wounds. CBD may have some beneficial effects in diabetic wounds. We applied 6-mm circular punch to create standard size full-thickness dorsal wounds in B6 and db/db mice. The experimental group received CBD while the control group got only vehicle. The outcome measures were rate of wound closure, wound cells expressing IL-33 and CTGF, and ILC profiles. In B6, the initial rate of wound closure was slower but there was no delay in the time to final closure, and cells expressing IL-33 was significantly reduced. CTGF + cells were higher in db/bd wounds treated with CBD. These data support the potential use of CBD to improve diabetic cutaneous wound healing.

CpG methylation changes in Alu repetitive sequences in normal aging due to diastolic hypertension in human dermal fibroblasts from the facial area

Aging fibroblasts, an important factor contributing to skin aging, are affected by numerous mechanisms, including alterations in DNA methylation and age-related diseases. The current study aimed to investigate the role of Alu methylation in aging fibroblasts and hypertension. The Alu methylation levels in dermal fibroblasts obtained from patients of different ages and blood pressure status were analyzed using the combined bisulfite restriction analysis technique. An inverse correlation was observed between Alu methylation in dermal fibroblasts and patient age. Dermal fibroblasts from the high-normal diastolic blood pressure group had higher Alu methylation levels compared with those from the normal group. The findings of the present study suggest that Alu methylation alterations can be observed with chronological aging and hypertension, and are a potential aging marker or therapeutic target.

Use of Intralesional and Perilesional Human Recombinant Epidermal Growth Factor (hrEGF) in the Local Treatment of Venous Ulcer - Review Article - Expert Recommendation

Venous Ulcers (VU) represent 60-80% of all leg ulcers and are the final stage of the disease secondary to venous hypertension or valve insufficiency. Conventional treatment that focuses on its etiological factors continues to be the gold standard; however, 30% of ulcers do not heal with this treatment; thus, it has been seen that the use of growth factor can be used as an adjuvant for this pathology. A literature review was carried out to evaluate the evidence from systematic reviews, meta-analyses, case studies, and quantitative studies that respond to the objective of this analysis review in the different databases with specific inclusion criteria with publications between 2002 and 2022, initially finding the topical application of the factor and later, more recently, the intralesional and perilesional application, the latter being an alternative treatment for this type of pathology and generating some recommendations for using the Factor.

A case of multiple hepatocellular carcinoma experiencing complete responses to sorafenib and atezolizumab-bevacizumab and developing severe, refractory venous congestive cutaneous ulcers on either regimen

A man in his eighties presented with a history of bilateral leg congestive phlebitis, and multiple hepatocellular carcinoma (HCC) treated with sorafenib. When the dose was increased to 400 mg, ulcers appeared under both knees, which worsened, and the drug was discontinued 2 months after administration. However, the ulcers to 30 mm in diameter, requiring debridement and antibiotics. The HCC showed a complete response (CR) based on modified-RECIST criteria; however, after several rounds of locoregional therapy for recurrence, multiple HCCs and metastatic lesions in the Morrison's fossa were detected. Therefore, atezolizumab 1200 mg-bevacizumab 900 mg was started. After the first course, the patient complained of pain below both knees, and when the second course was administered, leg ulcers re-appeared and rapidly worsened. The ulcers were circular and multiple and progressed to deep digging, leading to tendon exposure. Bevacizumab-induced congestive venous ulcer was diagnosed, requiring skin grafts to heal. HCC then showed a CR based on m-RECIST criteria. Initially, the cause of the ulcer was thought to be immune-related adverse effects due to atezolizumab, but experience with sorafenib led us to conclude that the cause was stagnant venous ulcers due to vascular endothelial growth factor receptor inhibitor, which inhibited angiogenesis.

The burden of costs on health services from patients with venous leg ulcers in Singapore

Healthcare costs arising from venous leg ulcers (VLU) are expected to increase due to an aging population and increased prevalence of comorbidities. We aim to estimate the healthcare resources incurred by VLU patients, and to quantify the extent to which predictors explain variation in cost-related outcomes. Retrospective patient-level cohort data for VLU patients were analysed using generalised linear regression models. Data were extracted from a tertiary hospital registry in Singapore, between 2013 and 2017. The outcome variables were length of stay per admission; inpatient and outpatient bill per admission; whether a patient underwent a surgical treatment of the venous system; and, whether they visited the emergency department. Cost outcomes were reported in Singapore dollars (S$). A total of 162 VLU patients were included with a mean age of 67.5 (±14.4). For the inpatient setting the mean length of stay was 8.1 days and the mean inpatient bill was S$7886. For outpatients, the mean number of dressings was 29.4, and mean outpatient bill was S$6962. Heart disease patients incurred longer hospital stays and larger inpatient bills per admission and females had greater odds of undergoing a surgical procedure on the venous system. Certain VLU patient groups were found to be associated with larger cost outcomes.

Curación de úlceras venosas crónicas inducida con un hidrogel de aloe vera, sorbitol, alantoína y glicerol

Objetivo:

Evaluar la eficacia de un hidrogel compuesto con aloe vera, sorbitol, alantoína y glicerol, y estudiar clínicamente los niveles de interleucina 6 (IL-6) para el tratamiento de úlceras venosas (UV).

Método:

Se realizó un ensayo clínico no aleatorizado de un solo brazo en 10 sujetos. Cada sujeto fue tratado con el hidrogel durante ocho semanas. Tras completar el período de seguimiento, se realizó una evaluación final de las puntuaciones clínicas y moleculares de cada paciente, que se comparó con los datos iniciales.

Resultados:

Los pacientes tratados con el hidrogel presentaron una reducción media del área de la UV de -1,12 cm5 (±2,53), reducción media del volumen de -1,47 cm6 (±3,43) y valor medio de IL-6 perilesional de -1,81 pg/mL (±8,07). También, se encontró una reducción media de la puntuación de la gravedad clínica venosa (VCSSr) de -9,3 (±2,62) y de la puntuación del dolor en la escala visual analógica (VAS) de -5,5 (±2,22).

Conclusión:

La IL-6 es un indicador molecular útil para la vigilancia de la cicatrización de heridas. El tratamiento con un hidrogel a base de aloe vera, sorbitol y alantoína favorece la cicatrización de la herida, mejora la calidad de vida y reduce los niveles de dolor de la UV.

Conflicto de interés:

El investigador principal, Dr Jorge Ulloa, declara recepción de recursos para investigación por parte de Humany Care. Este proyecto fue financiado por Humany Care.

Curación de úlceras venosas crónicas inducida con un hidrogel de aloe vera, sorbitol, alantoína y glicerol

Objetivo:

Evaluar la eficacia de un hidrogel compuesto con aloe vera, sorbitol, alantoína y glicerol, y estudiar clínicamente los niveles de interleucina 6 (IL-6) para el tratamiento de úlceras venosas (UV).

Método:

Se realizó un ensayo clínico no aleatorizado de un solo brazo en 10 sujetos. Cada sujeto fue tratado con el hidrogel durante ocho semanas. Tras completar el período de seguimiento, se realizó una evaluación final de las puntuaciones clínicas y moleculares de cada paciente, que se comparó con los datos iniciales.

Resultados:

Los pacientes tratados con el hidrogel presentaron una reducción media del área de la UV de -1,12 cm5 (±2,53), reducción media del volumen de -1,47 cm6 (±3,43) y valor medio de IL-6 perilesional de -1,81 pg/mL (±8,07). También, se encontró una reducción media de la puntuación de la gravedad clínica venosa (VCSSr) de -9,3 (±2,62) y de la puntuación del dolor en la escala visual analógica (VAS) de -5,5 (±2,22).

Conclusión:

La IL-6 es un indicador molecular útil para la vigilancia de la cicatrización de heridas. El tratamiento con un hidrogel a base de aloe vera, sorbitol y alantoína favorece la cicatrización de la herida, mejora la calidad de vida y reduce los niveles de dolor de la UV.

Conflicto de interés:

El investigador principal, Dr Jorge Ulloa, declara recepción de recursos para investigación por parte de Humany Care. Este proyecto fue financiado por Humany Care.

Nutrition and cutaneous wound healing

Wound healing is a complex and energy-demanding process. The relationship between nutrition and wound healing has been recognized for many centuries. Several studies have indicated that nutritional deficiencies are more prevalent among patients with chronic wounds. Malnutrition may alter the inflammatory response, collagen synthesis, and wound tensile strength, all of which are crucial for wound healing. Although the specific role of nutrition and supplementation in wound care remains uncertain, it is necessary to identify and correct nutritional imbalances to avoid any potential deterioration of the healing process. It is also important to recognize the differences in pathophysiology between acute and chronic wounds. A burn, surgical, or a traumatic wound is different from a diabetic foot ulcer, which is different from a pressure ulcer. Chronic wounds are more prevalent in the aging population, and patients often have underlying comorbidities, such as diabetes mellitus, peripheral vascular disease, connective tissue disease, or other systemic illnesses that may alter energy metabolism and contribute to impaired healing. Management approaches to acute wound care may not apply universally to chronic wounds. In this review, we discuss the available data and possible roles for nutrition in wound healing.

Topical Sevoflurane: A Novel Treatment for Chronic Pain Caused by Venous Stasis Ulcers

In the US, an estimated 1 - 2% of chronic venous insufficiency (CVI) patients (of 6 - 7 million nationwide) develop at least one venous stasis ulcer (VSU) during their illness. Of these, approximately 40% develop subsequent ulcers, making VSU prognostically poor. Current management of VSU is costly, with poor prognosis, high recurrence rate, inadequate pain management, and significantly reduced quality of life (QoL). Topical volatile anesthetic agents, such as sevoflurane, offer improved pain relief and symptom control in patients suffering from chronic VSU. The immediate impact of topical sevoflurane in reducing pain associated with ulcer bed debridement has several implications in improving the quality of life in patients with CVI induced ulcers and in the prognosis and healing of the ulcers. This review summarizes a topical formulation of a volatile anesthetic and its implications for the management of VSUs.

Trends of hospital-based surgery for varicose veins in the elderly

OBJECTIVE

The treatment of varicose veins has shifted during the past decade to the office setting. Although recent studies have demonstrated the safety of venous ablation for the elderly in the office, a paucity of data is available on the contemporary outcomes of surgery for varicose veins in the operating room. The present study analyzed the trends and outcomes of varicose vein surgery in the elderly using a large national database.

METHODS

The American College of Surgeons National Surgical Quality Initiative Program database (2005-2017) was reviewed. Patients undergoing vein ablation or open surgery (ie, high ligation, stripping, phlebectomy) for venous insufficiency were identified using Current Procedural Terminology codes and the principal diagnosis. The patients were stratified into 3 age groups <65, 65 to 79, and ≥80 years. The preoperative and operative characteristics and outcomes were compared. Logistic regression was performed to identify the risk factors associated with any adverse event, defined as any morbidity or mortality.

RESULTS

A total of 48,615 venous surgeries had been performed, with 9177 (18.9%) performed in patients aged 65 to 79 years and 1180 (2.4%) in patients aged ≥80 years. The proportion of patients in the 65- to 79-age group had steadily increased during the study period from 12.8% in 2005 to 22.3% in 2017 (P < .01). The proportion of patients aged ≥80 years had remained stable (P = .23). Patients aged ≥80 years had significantly more comorbidities, were more likely to have undergone vein ablation alone (P < .01), were more likely to be treated for ulceration (P < .01) and less likely to have received general anesthesia (P < .01) compared with the younger age groups. Overall morbidity increased significantly with increased age group (P < .01) but remained low (2.5%). Mortality was very low (0.02%) and not significantly different among the age groups. The factors independently associated with any adverse event were dialysis (odds ratio [OR], 7.12; 95% confidence interval [CI], 3.3-15.6), American Society of Anesthesiologists classification per unit increase (OR, 1.2; 95% CI, 1.02-1.3), use of general anesthesia (OR, 1.2; 95% CI, 1.0-1.4), and combined venous ablation and open procedures compared with venous ablation alone (OR, 1.3; 95% CI, 1.0-1.5). However, age was not associated with adverse events (OR, 1.0; 95% CI, 1.0-1.0).

CONCLUSIONS

Varicose vein surgery is safe for all age groups and is being increasingly offered to the elderly. High-risk patients might benefit from the avoidance of hybrid procedures and general anesthesia when possible to minimize the occurrence of adverse events. Conservative measures should be exhausted before surgery for the dialysis population.

Tissue Oxygenation Changes to Assess Healing in Venous Leg Ulcers Using Near-Infrared Optical Imaging

Objective: Venous leg ulcers (VLUs) comprise 80% of leg ulcers. One of the key parameters that can promote healing of VLUs is tissue oxygenation. To date, clinicians have employed visual inspection of the wound site to determine the healing progression of a wound. Clinicians measure the wound size and check for epithelialization. Imaging for tissue oxygenation changes surrounding the wounds can objectively complement the subjective visual inspection approach. Herein, a handheld noncontact near-infrared optical scanner (NIROS) was developed to measure tissue oxygenation of VLUs during weeks of treatment. Approach: Continuous-wave-based diffuse reflectance measurements were processed using Modified Beer-Lambert's law to obtain changes in tissue oxygenation (in terms of oxy-, deoxy-, total hemoglobin, and oxygen saturation). The tissue oxygenation contrast obtained between the wound and surrounding tissue was longitudinally mapped across weeks of treatment of four VLUs (healing and nonhealing cases). Results: It was observed that wound to background tissue oxygenation contrasts in healing wounds diminished and/or stabilized, whereas in the nonhealing wounds it did not. In addition, in a very slow-healing wound, wound to background tissue oxygenation contrasts fluctuated and did not converge. Innovation: Near-infrared imaging of wounds to assess healing or nonhealing of VLUs from tissue oxygenation changes using a noncontact, handheld, and low-cost imager has been demonstrated for the first time. Conclusion: The tissue oxygenation changes in wound with respect to the surrounding tissue can provide an objective subclinical physiological assessment of VLUs during their treatment, along with the gold-standard visual clinical assessment.

Using a modified Delphi methodology to gain consensus on the use of dressings in chronic wounds management

OBJECTIVE

Managing chronic wounds is associated with a burden to patients, caregivers, health services and society and there is a lack of clarity regarding the role of dressings in improving outcomes. This study aimed to provide understanding on a range of topics, including: the definition of chronicity in wounds, the burden of illness, clinical outcomes of reducing healing time and the impact of early interventions on clinical and economic outcomes and the role of matrix metalloproteinases (MMPs) in wound healing.

METHOD

A systematic review of the literature was carried out on the role of dressings in diabetic foot ulcer (DFU), and venous leg ulcer (VLU) management strategies, their effectiveness, associated resource use/cost, and quality of life (QoL) impact on patients. From this evidence-base statements were written regarding chronicity in wounds, burden of illness, healing time, and the role of MMPs, early interventions and dressings. A modified Delphi methodology involving two iterations of email questionnaires followed by a face-to-face meeting was used to validate the statements, in order to arrive at a consensus for each. Clinical experts were selected, representing nurses, surgeons, podiatrists, academics, and policy experts.

RESULTS

In the first round, 38/47 statements reached or exceeded the consensus threshold of 80% and none were rejected. According to the protocol, any statement not confirmed or rejected had to be modified using the comments from participants and resubmitted. In the second round, 5/9 remaining statements were confirmed and none rejected, leaving 4 to discuss at the meeting. All final statements were confirmed with at least 80% consensus.

CONCLUSION

This modified Delphi panel sought to gain clarity from clinical experts surrounding the use of dressings in the management of chronic wounds. A full consensus statement was developed to help clinicians and policy makers improve the management of patients with these conditions.

A case study of venous leg ulceration

Venous ulcers or stasis ulcers account for 80% of lower extremity ulcerations. Approximately 1-2% of the population will suffer from the chronic debilitating condition, with chronic venous insufficiency affecting up to 50% of the adult population. There are many methods of treatment and common treatments include conventional, surgical or mechanical methods. This article examines the complications of leg ulcer management, with the emphasis on the use of antibiotics. The case study demonstrates the positive impact self-care can have as part of a treatment plan.

Extracorporeal shock wave therapy for the healing and management of venous leg ulcers

BACKGROUND

Leg ulcers are chronic wounds of the lower leg, caused by poor blood flow, that can take a long time to heal. The pooling of blood in the veins can damage the skin and surrounding tissues, causing an ulcer to form. Venous leg ulcers are associated with impaired quality of life, reduced mobility, pain, stress and loss of dignity. The standard treatment for venous leg ulcers is compression bandages or stockings. Shock wave therapy may aid the healing of these wounds through the promotion of angiogenesis (the formation and development of blood vessels) and reduction of inflammation, though this process is poorly understood at present.

OBJECTIVES

To assess the effects of extracorporeal shock wave therapy on the healing and management of venous leg ulceration.

SEARCH METHODS

In April 2018 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. We applied no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We considered all published and unpublished randomised controlled trials (RCTs) assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias of included studies, extract study data and rate the certainty of the evidence using GRADE.

MAIN RESULTS

We found no RCTs that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We found no RCTs assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration. The lack of high-quality evidence in this area highlights a gap in research and may serve to justify the need for further research and evidence to provide guidance concerning the use of this treatment option for this condition. Future trials should be of clear design and include concomitant use of the current best practice treatment, multilayer compression therapy. Recruitment should aspire to best represent patients seen in clinical practice and patient-related outcome measures should be included in study design.

Association of Venous Leg Ulcers With Ankle Range of Motion in People Attending Chiropractic Mobile Clinics in the Dominican Republic

Objective

The goal of the study was to determine if there was an association between chronic venous disorders (CVDs), particularly venous leg ulcers, and ankle range of motion (ROM) in the Dominican Republic.

Methods

Chronic venous disorders were classified using the clinical manifestations portion (C) of the CEAP (clinical manifestations, etiology, anatomy, pathophysiology) method. The legs of participants attending mobile chiropractic clinics in rural, low-income areas in the Dominican Republic were assessed for clinical signs of CVD and venous ulcers. Ankle ROM was then measured, and photographs of the legs were taken. The 6 clinical stages of CVD were divided into 3 groups: normal legs (normal), no ulcer CVD, and ulcer CVD (healed and active). Multiple linear regression of ankle ROM against CVD grouping was used to test the association.

Results

Eight of the 837 patients for whom CVD classification was obtained had venous ulcers (healed or active) on at least 1 leg. About 30% relative reduction in ROM (ankle dorsiflexion plus plantar flexion) was observed between the ulcer group and the normal group. Regression analysis comparing legs with ulcers to healthy legs (normal), adjusted for age, gender, indicator for obesity, and previous leg trauma, revealed a significant decrease of approximately 14° (P = .0007) in ankle ROM. Age was also found to be strongly significant in the regression analysis, 1 year of aging was associated with a decrease of 0.16° (P < .0001) in ankle ROM (approximately 1.6° in 10 years).

Conclusion

A significant decrease was observed in ankle ROM for participants with active and healed leg venous ulcers compared with those without ulcers. There appeared to be an association between venous leg ulcers and ankle ROM in this sample.

In vitro significance of SOCS-3 and SOCS-4 and potential mechanistic links to wound healing

Wound healing and the management of chronic wounds represent a significant burden on the NHS. Members of the suppressor of cytokine signalling (SOCS) family have been implicated in the regulation of a range of cellular processes. The current study aims to explore the importance of SOCS-3 and SOCS-4 in regulating cellular traits associated with wound healing. SOCS-3 over-expression and SOCS-4 knockdown mutant lines were generated and verified using q-PCR and western blotting in human keratinocytes (HaCaT) and endothelial cells (HECV). Over-expression of SOCS-3 resulted in a significantly reduced proliferative rate in HaCaT keratinocytes and also enhanced the tubule formation capacity of HECV cells. SOCS-4 knockdown significantly reduced HaCaT migration and HECV cell tubule formation. Suppression of SOCS-4 influenced the responsiveness of HaCaT and HECV cells to EGF and TGFβ and resulted in a dysregulation of phospho-protein expression in HaCaT cells. SOCS-3 and SOCS-4 appear to play regulatory roles in a number of keratinocyte and endothelial cellular traits associated with the wound healing process and may also be able to regulate the responsiveness of these cells to EGF and TGFβ. This implies a potential regulatory role in the wound healing process and, thus highlights their potential as novel therapies.

Stress, Illness Perceptions, Behaviors, and Healing in Venous Leg Ulcers: Findings From a Prospective Observational Study

OBJECTIVE

The aim of the study was to investigate the impact of stress, illness perceptions, and behaviors on healing of venous leg ulcers.

METHODS

A prospective observational study of 63 individuals for 24 weeks investigated possible psychosocial predictors of healing. There were two indices of healing: rate of change in ulcer area and number of weeks to heal. Psychological variables were assessed at baseline using self-report measures (Perceived Stress Scale, Hospital Anxiety and Depression Scale, Revised Illness Perception Questionnaire, adapted Summary of Diabetes Self-Care Activities, Adherence Questionnaire, and Short-Form Health Survey).

RESULTS

Controlling for sociodemographic and clinical variables, for the 24 weeks, a slower rate of change in ulcer area was predicted by greater stress (standardized β = -0.61, p = .008), depression (standardized β = -0.51, p = .039), and holding negative perceptions or beliefs about the ulcer (standardized β = -1.4, p = .045). By 24 weeks, 69% of ulcers had closed. A more negative emotional response to the ulcer at baseline (i.e., emotional representation of the ulcer) was associated with a greater number of weeks to heal (hazard ratio [HR] = 0.63, 95% confidence interval [CI] = 0.41-0.95, p = .028). Higher educational attainment (HR = 3.22, 95% CI = 1.37-7.55, p = .007) and better adherence to compression bandaging (HR = 1.41, 95% CI = 1.06-1.88, p = .019) were associated with fewer weeks to heal. No other psychosocial variable (stress, perceptions about the ulcer, health behaviors) predicted weeks to heal.

CONCLUSIONS

Alongside ulcer-related predictors, psychological and sociodemographic factors were associated with healing. Future research should explore mediating mechanisms underlying these associations and develop interventions to target these variables.

Validation of a Screening Questionnaire for Chronic Leg Ulcers

The use of a validated screening questionnaire to identify individuals with chronic leg ulcers allows large-scale population-based studies to be conducted that measure and monitor the prevalence of the disease. The aim of this study was to design and validate such a screening questionnaire to identify patients with chronic leg ulcers. A simple 3-item questionnaire was developed at the Department of Dermatology, University Hospital of Zealand, Denmark. In total, 90 patients attending the department’s outpatient clinic for dermatological diseases and chronic wounds were included in this study. All included participants completed the questionnaire and were subsequently examined by dermatologists. We found that the constructed 3-item questionnaire in this study had a sensitivity and specificity of 95% and 93% and a positive predictive value and negative predictive value of 78% and 95%, respectively. Moreover, we found that the use of the 3-item questionnaire, as compared with a single question, in which the participants were asked whether they currently have a leg ulcer, resulted in significantly higher positive predictive value (+11.6%, P = .035) and specificity (+5.6%, P = .046) of the diagnostic test. Future studies are merited to investigate the diagnostic accuracy of the questionnaire in other populations and settings.

Infection in Venous Leg Ulcers: Considerations for Optimal Management in the Elderly

Venous leg ulcers are the most common cause of chronic leg wounds, accounting for up to 70 % of all chronic leg ulcers and carrying with them a significant morbidity, especially for elderly patients. Among people aged 65 years and older, the annual prevalence is 1.7 %. Billions of dollars per year are spent caring for patients with these often difficult-to-heal and sometimes recurrent chronic wounds. Chronic non-healing wounds of the lower extremities are susceptible to microbial invasion and can lead to serious complications, such as delayed healing, cellulitis, enlargement of wound size, debilitating pain, and deeper wound infections causing systemic illness. Recognition and treatment of the infected venous leg ulcer is an essential skill set for any physician caring for geriatric patients. Most physicians rely on subjective clinical signs and patient-reported symptoms in the evaluation of infected chronic wounds. The conventional bacterial culture is a widely available tool for the diagnosis of bacterial infection but can have limitations. Systemic antibiotics, as well as topical antiseptics and antibiotics, can be employed to treat and control infection and critical colonization. Better understanding of microbial biofilms in the wound environment have caused them to emerge as an important reason for non-healing and infection due to their increased resistance to antimicrobial, immunological, and chemical attack. A sound understanding of the microbial-host environment and its complexities, as well as the pathophysiology of venous hypertension, must be appreciated to understand the need for a multimodality approach to treating an infected venous leg ulcer. Other treatment measures are often required, in addition to systemic and topical antibiotics, such as the application of wound bandages, compression therapy, and wound debridement, which can hasten clearance of the infection and help to promote healing.

[People with vascular ulcers in outpatient nursing care: a study of sociodemographic and clinical variables]

The aim of this study was to analyze the sociodemographic and clinical characteristics of people with vascular ulcers and to investigate the association between these variables. This cross-sectional, observational clinical study was conducted in outpatient clinics from February to August 2009. Interview, clinical exam, Pressure Ulcer Scale Healing and photographic registry of the wounds were performed. Forty-two individuals participated who were, on average, 60 (± 12) years old, 73.8% males, with single wounds (66.7%) resulting from alterations in venous circulation (90.5%). Their wounds had lasted for up to one year (55.5%). There was an association between the PUSH score (p=0.019) and depth of wound (p=0.027) with currently performing occupational activity, as well as between history of tobacco use and gender (p=0.049). The sociodemographic characteristics that were observed were similar to the others, except for being male, which indicates the need for more studies in the population in Goiânia, Brazil.

Falls, Balance Confidence, and Lower-Body Strength in Patients Seeking Outpatient Venous Ulcer Wound Care

PURPOSE & ABSTRACT

To provide information about a quality improvement project examining falls in persons seeking outpatient wound care.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to:1. Describe the scope of the problem and the related quality improvement project. 2. Delineate the results of the project and their implications for treatment of patients with venous ulcers.

OBJECTIVE

The authors aim to examine fall occurrence and fall injuries in persons seeking outpatient wound care and to compare falls, balance confidence, and lower-body strength in persons with injection-related venous ulcers (IRVUs) versus persons with venous ulcers (VUs) related to other risk factors besides injection drugs (VUs-other).

DESIGN

This quality improvement project used a cross-sectional, comparative design. Participants responded to demographic questions, the Activities-specific Balance Confidence (ABC) Scale, fear of falling, fall numbers, and injuries and performed the 30-second chair-rise test.

SETTING

Outpatient wound service.

PATIENTS

Patients (N = 106; mean age, 59.94 years) included men (66%) and women.

RESULTS

Sixty patients reported falling; 47 were recurrent fallers. Twenty patients stated they were injured, but did not go to an emergency department. A higher number of total falls was significantly related to more comorbidities. Total falls were significantly related to fear of falling and ABC Scale scores. Those with VUs-other had significantly more comorbidities and higher body mass index values than those with IRVUs. Those with IRVUs were comparable to those VUs-other on number of falls and fear of falling, respectively. Those with IRVUs (7.30) performed significantly more chair rises than those with VUs-other (4.72). Persons with IRVUs had significantly higher ABC Scale scores (63.24%) than those with VUs-other (49.38%).

CONCLUSIONS

Falls are a common occurrence in persons seeking outpatient wound care. Despite greater strength sufficient to perform more chair rises among those with IRVUs, fall rates were comparable to those of weaker individuals with other types of VUs. With the high occurrence of falls during the project, long-term risk for fall injury would be high. Further research is needed to clarify interactions between VU risk and patient factors such as strength, age, agility, and impaired cognition.

Telemedical Wearable Sensing Platform for Management of Chronic Venous Disorder

Enabled by emerging wearable sensors, telemedicine can potentially offer personalized medical services to long-term home care or remote clinics in the future, which can be particularly helpful in the management of chronic diseases. The wireless wearable pressure sensing system reported in this article provides an excellent example of such an innovation, whereby periodic or continuous monitoring of interface pressure can be obtained to guide routine compression therapy, the cornerstone of chronic venous disorder management. By applying a novel capacitive, iontronic sensing technology, a flexible, ultrathin, and highly sensitive pressure sensing array is seamlessly incorporated into compression garments for the monitoring of interface pressure. The linear pressure sensing array assesses pressure distribution along the limb in a real-time manner (up to a scanning rate of 5 kHz), and the measurement data can be processed and displayed on a mobile device locally, as well as transmitted through a Bluetooth communication module to a remote clinical service. The proposed interface pressure measuring system provides real-time interface pressure distribution data and can be utilized for both clinical and self-management of compression therapy, where both treatment efficacy and quality assurance can be ascertained.

Evaluation of wound healing and anti-inflammatory activity of the rhizomes of Rumex abyssinicus J. (Polygonaceae) in mice

Background

Rumex abyssinicus Jacq (Polygonaceae) is widely used in Ethiopia for treatment of wound and other diseases. Although reports are available in the literature on some of the claimed activities, nothing has so far been reported about the wound healing activity of R. abyssinicus. Thus, this work was initiated to investigate the wound healing and anti-inflammatory activities of 80 % methanol extract of the rhizomes of R. abyssinicus in mice.

Methods

Following extraction of the rhizomes of the plant with 80 % methanol, the extract was formulated as ointment (5 % & 10 % w/w) with simple ointment base B.P. The ointment was then evaluated for wound healing activity using excision and incision wound models. Parameters, including wound contraction, epithelization time and hydroxyproline content were determined using the excision model, whereas tensile strength was measured from the incision model. In parallel, anti-inflammatory activity of the rhizome was evaluated with carrageenan induced hind paw edema model by dissolving the 80 % methanol extract in 1 % carboxyl methyl cellulose and administering orally in various doses (250, 500 and 750 mg/kg).

Results

Wound treated with 5 % and 10 % (w/w) hydroalcoholic extract ointment exhibited significant wound healing activity in both models, as evidenced by increased wound contraction, shorter epithelization time, higher tissue breaking strength and increased hydroxyproline content. The hydroalcoholic extract also produced dose-related significant reduction (p < 0.05–0.001) of inflammation.

Conclusions

The results of this study demonstrated that the hydroalcoholic extract of the rhizomes of R. abyssinicus facilitated wound healing at least in part via its anti-inflammatory activity, supporting its traditional claim as a wound healing agent.

Lymphatic transport in patients with chronic venous insufficiency and venous leg ulcers following sequential pneumatic compression

BACKGROUND

Recent advancements in near-infrared fluorescence lymphatic imaging (NIRFLI) technology provide opportunities for non-invasive, real-time assessment of lymphatic contribution in the etiology and treatment of ulcers. The objective of this study was to assess lymphatics in subjects with venous leg ulcers using NIRFLI and to assess lymphatic impact of a single session of sequential pneumatic compression (SPC).

METHODS

Following intradermal microdoses of indocyanine green (ICG) as a lymphatic contrast agent, NIRFLI was used in a pilot study to image the lymphatics of 12 subjects with active venous leg ulcers (Clinical, Etiologic, Anatomic, and Pathophysiologic [CEAP] C6). The lymphatics were imaged before and after a single session of SPC to assess impact on lymphatic function.

RESULTS

Baseline imaging showed impaired lymphatic function and bilateral dermal backflow in all subjects with chronic venous insufficiency, even those without ulcer formation in the contralateral limb (C0 and C4 disease). SPC therapy caused proximal movement of ICG away from the active wound in 9 of 12 subjects, as indicated by newly recruited functional lymphatic vessels, emptying of distal lymphatic vessels, or proximal movement of extravascular fluid. Subjects with the longest duration of active ulcers had few visible lymphatic vessels, and proximal movement of ICG was not detected after SPC therapy.

CONCLUSIONS

This study provides visible confirmation of lymphatic dysfunction at an early stage in the etiology of venous ulcer formation and demonstrates the potential therapeutic mechanism of SPC therapy in removing excess fluid. The ability of SPC therapy to restore fluid balance through proximal movement of lymph and interstitial fluid may explain its value in hastening venous ulcer healing. Anatomical differences between the lymphatics of longstanding and more recent venous ulcers may have important therapeutic implications.

Clinical evaluation of the efficacy and safety of a medical device in various forms containing Triticum vulgare for the treatment of venous leg ulcers - a randomized pilot study

This study was carried out to assess the efficacy and tolerability of the topical application of an aqueous extract of Triticum vulgare (TV) in different vehicles (cream, impregnated gauzes, foam, hydrogel, and dressing gel) for the treatment of venous lower leg ulcers. Fifty patients were randomized to receive one of the five investigational vehicles. Treatment was performed up to complete healing or to a maximum of 29 days. The wound size reduction from baseline was the primary efficacy variable, which was measured by means of a noninvasive laser scanner instrument for wound assessment. In all groups, apart from the foam group, a similar trend toward the reduction of the surface area was observed. The cream showed the greatest effect on the mean reduction of the lesion size. At last visit, six ulcers were healed: two in the cream group, three in the gauze group, and one in the dressing gel group. In the patients treated with the cream, the gauzes, the hydrogel, and the dressing gel, the reduction of lesion size was 40%–50%; the reduction was smaller in the foam group. No impact in terms of age on the healing process was found. The Total Symptoms Score decreased in all groups during the study; a greater efficacy in terms of signs/symptoms was observed in the patients treated with the gauzes. In the dressing gel group, one patient had an infection of the wound after 3 weeks of treatment and 2 of colonization, leading to a systemic antibiotic treatment. The events were judged as nonrelated to the device used. On the basis of the results, it could be argued that the medical device may be useful in the treatment of chronic venous ulcers.

Venous leg ulceration pathophysiology and evidence based treatment

Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.

A Multicenter Randomized Controlled Trial Comparing Treatment of Venous Leg Ulcers Using Mechanically Versus Electrically Powered Negative Pressure Wound Therapy

Objective: This study compares two different negative pressure wound therapy (NPWT) modalities in the treatment of venous leg ulcers (VLUs), the ultraportable mechanically powered (MP) Smart Negative Pressure (SNaP^®) Wound Care System to the electrically powered (EP) Vacuum-Assisted Closure (V.A.C.^®) System. Approach: Patients with VLUs from 13 centers participated in this prospective randomized controlled trial. Each subject was randomly assigned to treatment with either MP NPWT or EP NPWT and evaluated for 16 weeks or complete wound closure. Results: Forty patients (n=19 MP NPWT and n=21 EP NPWT) completed the study. Primary endpoint analysis of wound size reduction found wounds in the MP NPWT group had significantly greater wound size reduction than those in the EP NPWT group at 4, 8, 12, and 16 weeks (p-value=0.0039, 0.0086, 0.0002, and 0.0005, respectively). Kaplan-Meier analyses showed greater acceleration in complete wound closure in the MP NPWT group. At 30 days, 50% wound closure was achieved in 52.6% (10/19) of patients treated with MP NPWT and 23.8% (5/21) of patients treated with EP NPWT. At 90 days, complete wound closure was achieved in 57.9% (11/19) of patients treated with MP NPWT and 38.15% (8/21) of patients treated with EP NPWT. Innovation: These data support the use of MP-NPWT for the treatment of VLUs. Conclusions: In this group of venous ulcers, wounds treated with MP NPWT demonstrated greater improvement and a higher likelihood of complete wound closure than those treated with EP NPWT.

Impact of skin grafting of venous leg ulcers on functional status and pain

BACKGROUND

Disability and pain were assessed in patients with venous leg ulcers treated with split-thickness skin grafts to evaluate to what extent skin grafting improves functional status in this population.

METHODS

A prospective, nonrandomized, multicenter case-control study was conducted from July 2008 to December 2010 in two hospitals in Brazil. One hundred patients with venous leg ulcers were divided into two treatment groups of 50 patients each: the control group (conservative treatment) and the surgery group (skin grafting). Patients were assessed at baseline (day 0) and on days 30, 90, and 180. Disability was measured with the Disability Index of the Health Assessment Questionnaire (HAQ-DI). The visual analog scale (VAS) and McGill Pain Questionnaire (MPQ) were used to assess pain.

RESULTS

Surgery group patients reported significantly lower (p = 0.0001) overall HAQ-DI scores (lower disability levels) 180 days postoperatively (HAQ-DI = 0.18) compared with baseline (HAQ-DI = 2.65); mean overall HAQ-DI scores for control patients was 1.70 on day 180, with a significant difference between groups (p = 0.0001). The surgery group showed significant improvement on all HAQ-DI categories and reported significantly lower pain intensity (VAS pain scores) on days 30, 90, and 180 compared with controls (p = 0.0001). The MPQ was used to assess the sensory, affective, evaluative, and miscellaneous dimensions of pain in the two groups; there were significant differences between groups on days 30, 90, and 180 (p = 0.0001).

CONCLUSIONS

Patients with venous leg ulcers treated with split-thickness skin grafts showed improvement in functional status compared with controls.

Falls and balance confidence in persons with and without injection-related venous ulcers

OBJECTIVES

With aging of injection users and the high occurrence of venous disease in their legs, falls are a potential health problem. We examined falls and balance confidence in persons with (VU+) and without (VU-) injection-related venous ulcers (VUs).

METHODS

This study used a cross-sectional, retrospective, comparative design with 31 participants VU+ and 30 VU- recruited in a medical clinic. Participants' legs were assessed for clinical manifestations of venous disease. Participants completed background and fall questionnaires and the Activities-specific Balance Confidence (ABC) Scale.

RESULTS

Participants included 35 men and 26 women (mean age = 54 years); 93% were African American. Falling in the past year was reported by 65% of patients VU+ and 40% VU- (P = 0.048); 29 of these patients fell 2 or more times in the past year. Higher scores on the ABC Scale (N = 61) were significantly related to fewer falls (r = -0.68). Activities-specific Balance Confidence scores were lower/worse for the patients VU+ (P = 0.039). Area under the receiver operating curve for patients VU+ was significant; we found area under the curve of 0.84 and a cutoff score of 80.3% for ABC predictive of recurrent fallers with sensitivity of 84% and specificity of 83%. The ABC test had an internal consistency reliability of 0.97.

CONCLUSIONS

Persons VU+ reported worse balance confidence and more falls than those without these ulcers. The ABC test was related to falls. With aging of injection users and increased occurrence of VUs, examining balance confidence and falls is crucial in long-term patient safety.

E-survey on venous leg ulcer among Dutch dermatologists

Aim: To get insight into the frequency of venous leg ulceration in the Dutch dermato-logic practice, and into how this profession treats this disease.

Design:

Material and Methods: An e-survey was conducted. To all Dutch dermatologists and residents dermatology an email was sent with an online link to a questionnaire on venous leg ulcers.

Results: The overall response was 30 %. 83.5 % of the doctors usually treat their patients according to the guideline. The dermatologic practice consists on average of 73 patients (range 0-500; SD 93) with leg ulceration, and yearly 54 new leg ulcer patients (range 0-300; SD 50) are seen. 65 % of the patients are women, 80 % is more than 45 years of age and 55 % is older than 65. Of all ulcers, 77 % has a venous aetiology, of which 59 % has a primary cause. Mean time to heal is 74 days (range 4-200; SD 39). Per year, dermatologists admit on average 7 patients (range 0-50; SD 11) because of leg ulceration. Eventually, 47 % of the admitted patients are treated by skin transplantation.

Conclusions: This questionnaire gives a good insight in the epidemiology, and the diagnostic and therapeutic regimen for patients with venous leg ulcers in Dutch dermatologic practice.

Effectiveness of apoptotic factors expressed on the wounds of patients with stage III pressure ulcers

PURPOSE

The purpose of this study was to explore the expression of apoptotic factors in stage III pressure ulcers and explain their effects on wound healing.

SUBJECTS AND SETTING

The sample comprised 8 patients with stage III pressure ulcers, along with 4 volunteers with normal skin who were undergoing elective surgical procedures.

METHODS

Eight patient tissue specimens from wound of stage III pressure ulcers were obtained from hospitalized patients. Tissue specimens from 4 volunteer patients were obtained during surgery. All 12 tissue specimens were analyzed for presence of apoptosis-related factors including bax/bcl-2 (B-cell lymphoma 2), Fas/fasL (Fas ligand), and terminal deoxynucleotide transferase-mediated dUTP nick end labeling (TUNEL) as well as immunohistochemical analysis with Fas/FasL.

RESULTS

Bax positive cells were strongly expressed from surrounding zone to center zone in the specimens obtained from stage III pressure ulcers, and Bcl-2 expression staining decreased contrarily (P < .01). Comparison, apoptotic factors bax positive cell and fas/fasL mRNA expression occurred rarely in tissue specimens from the control group. Fas/fasL mRNA-positive granules were detected in epidermal cells and fibroblasts, demonstrating a progressive increase from the margin of the pressure ulcers progressing toward the center of the wound bed. We also found an increased intensity of TUNEL staining in ulcer center as well as wound margin, compared with control skin tissue.

CONCLUSION

These results suggest that molecular regulators of apoptosis are involved in pressure ulcer wound healing. Results also suggest that differences in the expression and distribution of the apoptotic related factors in stage III pressure ulcers play an important role in the delayed wound healing characteristic of these complex wounds.

Acute and impaired wound healing: pathophysiology and current methods for drug delivery, part 1: normal and chronic wounds: biology, causes, and approaches to care

This is the first installment of 2 articles that discuss the biology and pathophysiology of wound healing, review the role that growth factors play in this process, and describe current ways of growth factor delivery into the wound bed. Part 1 discusses the latest advances in clinicians' understanding of the control points that regulate wound healing. Importantly, biological similarities and differences between acute and chronic wounds are considered, including the signaling pathways that initiate cellular and tissue responses after injury, which may be impeded during chronic wound healing.

Successful and safe use of 2 min cold atmospheric argon plasma in chronic wounds: results of a randomized controlled trial

Background  The development of antibiotic resistance by microorganisms is an increasing problem in medicine. In chronic wounds, bacterial colonization is associated with impaired healing. Cold atmospheric plasma is an innovative promising tool to deal with these problems.

Objectives  The 5‐min argon plasma treatment has already demonstrated efficacy in reducing bacterial numbers in chronic infected wounds in vivo. In this study we investigated a 2‐min plasma treatment with the same device and the next‐generation device, to assess safety and reduction in bacterial load, regardless of the kind of bacteria and their resistance level in chronic wounds.

Methods  Twenty‐four patients with chronic infected wounds were treated in a prospective randomized controlled phase II study with 2 min of cold atmospheric argon plasma every day: 14 with MicroPlaSter alpha device, 10 with MicroPlaSter beta device (next‐generation device) in addition to standard wound care. The patient acted as his/her own control. Bacterial species were detected by standard bacterial swabs and bacterial load by semiquantitative count on nitrocellulose filters. The plasma settings were the same as in the previous phase II study in which wounds were exposed for 5 min to argon plasma.

Results  Analysis of 70 treatments in 14 patients with the MicroPlaSter alpha device revealed a significant (40%, P < 0·016) reduction in bacterial load in plasma‐treated wounds, regardless of the species of bacteria. Analysis of 137 treatments in 10 patients with the MicroPlaSter beta device showed a highly significant reduction (23·5%, P < 0·008) in bacterial load. No side‐effects occurred and the treatment was well tolerated.

Conclusions  A 2‐min treatment with either of two cold atmospheric argon plasma devices is a safe, painless and effective technique to decrease the bacterial load in chronic wounds.

Venous ulcers of the lower limb: Where do we stand?

Venous ulcers are the most common ulcers of the lower limb. It has a high morbidity and results in economic strain both at a personal and at a state level. Chronic venous hypertension either due to primary or secondary venous disease with perforator paucity, destruction or incompetence resulting in reflux is the underlying pathology, but inflammatory reactions mediated through leucocytes, platelet adhesion, formation of pericapillary fibrin cuff, growth factors and macromolecules trapped in tissue result in tissue hypoxia, cell death and ulceration. Duplex scan with colour flow is the most useful investigation for venous disease supplying information about patency, reflux, effects of proximal and distal compression, Valsalva maneuver and effects of muscle contraction. Most venous disease can be managed conservatively by leg elevation and compression bandaging. Drugs of proven benefit in venous disease are pentoxifylline and aspirin, but they work best in conjunction with compression therapy. Once ulceration is chronic or the patient does not respond to or cannot maintain conservative regime, surgical intervention treating the underlying venous hypertension and cover for the ulcer is necessary. The different modalities like sclerotherapy, ligation and stripping of superficial varicose veins, endoscopic subfascial perforator ligation, endovenous laser or radiofrequency ablation have similar long-term results, although short-term recovery is best with radiofrequency and foam sclerotherapy. For deep venous reflux, surgical modalities include repair of incompetent venous valves or transplant or transposition of a competent vein segment with normal valves to replace a post-thrombotic destroyed portion of the deep vein.

Effective use of negative pressure wound therapy provides quick wound-bed preparation and complete graft take in the management of chronic venous ulcers

Venous ulcers are characterised by longstanding and recurrent loss of skin integrity. Once occurred, healing is slow and recurrence is high because of inappropriate conditions of the wound bed. This study involves 20 patients with chronic venous ulcers at least 6 weeks of duration treated with negative pressure wound therapy (NPWT). Patients underwent a radical debridement of all devitalised tissues in the first operation. After adequate haemostasis, silver-impregnated polyurethane foam was applied. Once the wounds were determined to be clean and adequate granulation tissue formation was achieved, split-thickness skin grafts were applied. Black polyurethane foam was applied over them. All wounds completely healed without the need for further debridement or regrafting. The mean number of silver-impregnated foam dressing changes prior to grafting was 2·9 (one to eight changes). The mean number of NPWT foam changes was 2·6 after skin grafting (two to five changes). Two patients who did not use conservative treatments for chronic venous insufficiency (CVI) after discharge from the hospital had recurrence of venous ulcers in the follow-up period. Application of NPWT provides quick wound-bed preparation and complete graft take in venous ulcer treatment.

Venous leg ulcerations: a treatment update

OPINION STATEMENT

Selecting the appropriate treatment for venous leg ulcerations is essential for optimal wound healing and patient quality of life. Compression therapy remains the mainstay of treatment for these wounds. Compression methods should be carefully selected and tailored for compatibility with patients' daily life. Pain management should not be neglected. When response to compression therapy is limited, adjuvant therapy such as medication, débridement, or surgical procedures should be considered on an individual basis.