A scoping review on Chronic Venous Disease and the development of a Venous Leg Ulcer: The role of obesity and mobility

Peripheral artery disease mediating the effect of metabolic syndrome related diseases on lower limb ulcers: Mendelian randomization analysis

Background

Previous observational studies have demonstrated a correlation between metabolic syndrome related diseases and an elevated susceptibility to ulcers of lower limb. It has been suggested that this causal relationship may be influenced by the presence of peripheral artery disease (PAD). Nevertheless, the precise contribution of these factors as determinants of ulcers of lower limb remains largely unexplored.

Method

This research incorporated information on hypertension, BMI, hyperuricemia, type 2 diabetes, PAD, and ulcers of lower limb sourced from the GWAS database. Univariate Mendelian randomization (SVMR) and multivariate Mendelian randomization (MVMR) methods were employed to assess the association between metabolic syndrome related diseases, including hypertension, obesity, hyperuricemia, and type 2 diabetes, as well as to investigate whether this association was influenced by PAD.

Results

Univariate Mendelian randomization analysis showed that genetically predicted hypertension, BMI, and type 2 diabetes were associated with an increased risk of PAD and ulcers of lower limb, and PAD was associated with an increased risk of ulcers of lower limb, but there is no causal relationship between hyperuricemia and ulcers of lower limb. The results of multivariate Mendelian randomization showed that PAD mediated the causal relationship between hypertension, obesity and ulcers of lower limb, but the relationship between type 2 diabetes and ulcers of lower limb was not mediated by PAD.

Conclusion

Hypertension, BMI and type 2 diabetes can increase the risk of ulcers of lower limb, and PAD can be used as a mediator of hypertension and obesity leading to ulcers of lower limb, These findings may inform prevention and intervention strategies directed toward metabolic syndrome and ulcers of lower limb.

Associations between self-care advice and healing time in patients with venous leg ulcer- a Swedish registry-based study

BACKGROUND

Venous leg ulcers take time to heal. It is advocated that physical activity plays a role in healing, and so does the patient's nutritional status. Additionally, malnutrition influences the inflammatory processes, which extends the healing time. Therefore, the staff's advising role is important for patient outcomes. Thus, this study aimed to investigate the associations between given self-care advice and healing time in patients with venous leg ulcers while controlling for demographic and ulcer-related factors.

METHODS

The sample consisted of patients registered in the Registry of Ulcer Treatment (RUT) which includes patient and ulcer-related and healing variables. The data was analyzed with descriptive statistics. Logistic regression models were performed to investigate the influence of self-care advice on healing time.

RESULTS

No associations between shorter healing time (less than 70 days) and the staff´s self-care advice on physical activity was identified, whilst pain (OR 1.90, CI 1.32-2.42, p < 0.001) and giving of nutrition advice (OR 1.55, CI 1.12-2.15, p = 0.009) showed an association with longer healing time.

CONCLUSIONS

Neither self-care advice on nutrition and/or physical activity indicated to have a positive association with shorter healing time. However, information and counseling might not be enough. We emphasize the importance of continuously and systematically following up given advice throughout ulcer management, not only when having complicated ulcers.

Association between physical activity levels and healing in people with venous leg ulcers: secondary analysis of prospective cohort data

Aim

To explore the relationship between physical activity levels and wound healing and recurrence in people with venous leg ulcers.

Methods

Questionnaires and medical records were used to collect data, with responses used to group participants into different physical activity groups. The differences in healing and recurrence outcomes of ulcers among different physical activity groups were compared using Chi-square, Kaplan Meier survival analysis, Cox proportional hazards regression analysis, and Kruskal-Wallis test. To measure the strength of the association between physical activity levels and patient outcomes, Spearman's Rho tests were used. We used descriptive analysis to examine how physical activity levels change over 24 weeks.

Results

Participants were classified into four distinct groups based on physical activity levels reported at baseline and week 12. The survival analysis showed higher physical activity level was associated with a shorter time to healing (log-rank test = 14.78, df = 3; p = 0.002). The persistently moderate-to-vigorous group had a 7.3-fold increased likelihood of healing compared to the persistently sedentary group. High levels of physical activity were also associated with a better quality of life score at baseline (ρ = 0.41, p < 0.000), week 12 (ρ = 0.36, p < 0.001), and week 24 (ρ = 0.49, p < 0.000). Most participants (48.5%) reported low levels of physical activity, which remained low for the entire study period.

Conclusion

An increased level of physical activity was linked to a shorter healing time and enhanced quality of life. Low levels of physical activity appeared common among people with venous leg ulcers.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Venous ulcers: look at the patient, not at the ulcer! Risk factors and comorbid conditions in venous ulcers of lower limbs

BACKGROUND

In venous leg ulcers (VLU), risk factors and comorbidities may affect prognosis and recurrence. Aim of this paper was to assess risk factors and most frequent medical conditions in venous ulcers.

METHODS

This a single center retrospective study from January 2017 to December 2020 on 172 patients with VLU admitted at our Center for Ulcer therapy in San Filippo Neri Hospital in Rome; data about medical history, Duplex scanning results and lifestyle questionnaire were collected in an Excel database and evaluated with Fisher test. Patients with lower limbs arterial insufficiency were excluded.

RESULTS

Incidence of VLU in patients over 65 was twice that in patients under 65 and woman were affected by VLU more than men (59.3% vs. 40.7%; P<0.001); more significant comorbidities were arterial hypertension in 44.19% (P=0.06), heart disease in 35.47% (P<0.001), chronic obstructive pulmonary disease (COPD) in 16.28% (P=0.008). In 33 patients (19% of cases) a trauma caused the ulcer. Diabetes, obesity, chronic renal insufficiency and orthopedic disease do not seem to have a direct influence on VLU.

CONCLUSIONS

Age, female sex, arterial hypertension, heart disease and COPD were significant risk factors. Thinking "globally" to the patient rather than only taking the ulcer into account is the key for a long-lasting therapeutic result; comorbidities are interconnected so weight loss, an exercise program for calf pump and compression must all be part of the VLU therapy, not only to heal the existing ulcer but also to prevent recurrences.

No More Venous Ulcers-What More Can We Do?

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

Effect of obesity on venous blood flow in the lower limbs

BACKGROUND AND OBJECTIVES

Although obesity is a recognized risk factor for the development of lower limb venous disease, less attention has been paid to objectively measuring the effect of centripetal obesity on blood flow in the lower limbs.

PATIENTS AND METHODS

The diameter of lower limb veins and venous blood flow were measured in 44 patients (65.6 ± 12.5 years, 25 females, 19 males) with centripetal obesity and chronic venous disease.

RESULTS

The mean diameter of both common femoral veins (CFV) increased significantly in the semi-supine position following elevation of the panniculus (right: ∆0.73 ± 1.21 mm; p ≤ 0.001, left: ∆1.16 ± 1.42 mm; p ≤ 0.001). Moreover, there was a significant increase in venous flow volume in the left CFV (∆62.96 ± 117.85 ml/min; p  =  0.001). Similarly, there was an increase in the diameter of left great saphenous vein (∆0.24 ± 0.41 mm; p  =  0.002), measured at the mid-thigh, when the patient lifted their abdominal panniculus. Finally, the grade of obesity correlated with the extent of the venous disease.

CONCLUSIONS

These data provide preliminary evidence that centripetal obesity results in both structural and hemodynamic changes in the lower limb veins, even in the absence of classical reflux.

Post-treatment course of acute lipodermatosclerosis

OBJECTIVES

We aimed to clarify whether acute lipodermatosclerosis (LDS) progress to chronic LDS without continued compression therapy.

METHODS

Between April 2015 and November 2021, 30 patients with acute/subacute LDS, which was diagnosed clinically by presence of isolated, poorly demarcated, tender erythema, and induration limited to the lower leg(s), visited our clinic and were able to be followed up for longer than a year. We reviewed their treatment results and the post-treatment courses.

RESULTS

In all cases, the symptoms in the acute phase subsided with compression bandages. After the discontinuation of compression therapy, 18 legs (56%) progressed to chronic LDS, and 14 legs (44%) did not. In the legs without progression, subcutaneous tissue in the affected leg was thicker compared with that in the contralateral leg (median 19.1 mm vs. 13.4 mm, p < 0.05) on the initial visit. In the legs with progression, the difference in subcutaneous tissue thickness between the affected and unaffected legs was not significant (10.0 mm vs. 7.6 mm).

CONCLUSIONS

Our findings suggest that in legs which later progress to chronic LDS, subcutaneous tissue contraction due to panniculitis is already present during the acute phase; therefore, long-term compression therapy is unlikely to improve the prognosis.

A multi-task convolutional neural network for classification and segmentation of chronic venous disorders

Chronic Venous Disorders (CVD) of the lower limbs are one of the most prevalent medical conditions, affecting 35% of adults in Europe and North America. Due to the exponential growth of the aging population and the worsening of CVD with age, it is expected that the healthcare costs and the resources needed for the treatment of CVD will increase in the coming years. The early diagnosis of CVD is fundamental in treatment planning, while the monitoring of its treatment is fundamental to assess a patient's condition and quantify the evolution of CVD. However, correct diagnosis relies on a qualitative approach through visual recognition of the various venous disorders, being time-consuming and highly dependent on the physician's expertise. In this paper, we propose a novel automatic strategy for the joint segmentation and classification of CVDs. The strategy relies on a multi-task deep learning network, denominated VENet, that simultaneously solves segmentation and classification tasks, exploiting the information of both tasks to increase learning efficiency, ultimately improving their performance. The proposed method was compared against state-of-the-art strategies in a dataset of 1376 CVD images. Experiments showed that the VENet achieved a classification performance of 96.4%, 96.4%, and 97.2% for accuracy, precision, and recall, respectively, and a segmentation performance of 75.4%, 76.7.0%, 76.7% for the Dice coefficient, precision, and recall, respectively. The joint formulation increased the robustness of both tasks when compared to the conventional classification or segmentation strategies, proving its added value, mainly for the segmentation of small lesions.

Correlation of Clinical Class with Duplex Ultrasound Findings in Lower Limb Chronic Venous Disease

Background

This study investigated the distribution of valve incompetence in patients with chronic venous disease (CVD) and its correlation with the clinical category of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.

Methods

In total, 1,386 limbs with clinically suspected CVD were categorized according to the CEAP classification and consecutively underwent duplex ultrasonography between April 2017 and December 2020.

Results

There were 362 limbs in male patients and 1,024 limbs in female patients. The limbs were classified as C0s–C1 (608 limbs, 43.8%), C2 (727 limbs, 52.5%), or C3–C6 (51 limbs, 3.7%). The prevalence of saphenous vein incompetence in CEAP C0s–C1 limbs was 43.6%. The saphenofemoral junction (SFJ) was competent in 37% of CEAP C2–C6 limbs. The CEAP C3–C6 category was not correlated with reflux patterns of the saphenous vein system (Cramer’s V=0.07), incompetent SFJ (Cramer’s V=0.07), deep vein reflux (Cramer’s V=0.03), or the distribution of incompetent segments in the great saphenous vein (GSV) (Cramer’s V=0.11).

Conclusion

Duplex ultrasonography is necessary to formulate a proper treatment plan for limbs categorized as CEAP C0s–C1. The SFJ was competent in more than one-third of CEAP C2–C6 limbs with GSV reflux; as such, flush ligation of the GSV may be unnecessary in these patients. The CEAP C3–C6 category showed no correlations with reflux patterns of the saphenous vein system, SFJ reflux, deep vein reflux, or the distribution of incompetent segments in the GSV.

Incidence of Recurrent Venous Ulcer in Patients Treated at an Outpatient Clinic: Historical Cohort

The recurrence of venous ulcers is the wound reopening after a period of completed epithelisation of a previous ulcer due to exposure to causal factors and lack of prevention. Venous ulcers have a high recurrence rate that may increase through the years. Epidemiological evidence on its incidence and risk factors is scarce due to the lack of patient follow-up in outpatient clinics and adherence to treatment after healing. The objective was to analyze the incidence of venous ulcers recurrency in outpatients and the risk factors for its occurrence. It is an observational historical cohort with retrospective data collection, performed through electronic medical records. Setting: private health insurance outpatient clinic. The participants were adult patients with healed venous ulcers. Incidence of venous ulcer recurrence was calculated within individuals with healed ulcers from 2014 and 2018 with a follow-up of at least one year. Bivariate analysis and logistic regression were used to explore risk factors considering demographic, clinical, and wound-related variables. As a result, sixty-five (65) of the 134 patients with healed venous ulcers had a recurrence, leading to an incidence of 48.5%, with a mean onset time of 230.1 (SD 267) days. Patients with recurrent venous ulcers were primarily women (39/48.1%), with a mean age of 64 (SD 15.5) years, 57 (50.8%) had some comorbidity, with systemic arterial hypertension as the most frequent (47/51%). Obesity (15/88.2%) increased the risk of venous ulcers recurrence by 8.7 (OR 95% CI 2.1-60.8; P = .009) times. In conclusion, venous ulcers recurrence incidence was 48.5%, with obesity as a risk factor. This study demonstrates that the clinical approach of people with venous ulcers should not finish when the wound is healed. For ulcer recurrence prevention interventions addressing systemic factors, besides topical management of the wound, are essential.

An evaluation of quality of life, physical activity level and symptoms in patients with early stages of chronic venous disease

BACKGROUND

Chronic venous disease (CVD) is a common, long-term disease that has a variety of symptoms, signs and decreases the patients' quality of life (QoL) of the patients. The aim of this study was to evaluate QoL, symptoms, and physical activity level of CVD patients with early stages (C₁ and C₂ classes).

METHODS

The sample of this study composed of 40 patients diagnosed with CVD. The data were collected by face-to-face interview method in the cardiovascular surgery outpatient clinic. Participants were diagnosed with duplex ultrasound (DUS). A personal information form, venous insufficiency epidemiological and economic study-quality of life/symptoms (VEINS-QOL/Sym), and international physical activity questionnaire were used to assess the participants.

RESULTS

According to DUS results, 23 participants had unilateral CVD, 17 participants had bilateral CVD. Thirty-six of these limbs were stage C₂ according to CEAP, twenty one were stage C_3. The patients with CVD had low QoL and physical activity level, also moderate pain intensity. Pain, swelling, restless leg, heavy legs, night cramps, and itching were more common symptoms. There was no statistical difference between unilateral/bilateral CVD patients in QoL scores, physical activity level, and pain intensity (p˃0.05).

CONCLUSION

There was no difference between the extent and severity of the disease and QoL, physical activity level, variety of symptoms. To increase the physical activity level and to evaluate the quality of life may be important for the management of the disease from the early stages of the disease (C₁ and C₂ classes).

Hyperbaric Oxygen Therapy Is an Effective Adjunctive Therapy to Manage Treatment-Resistant Venous Leg Ulcers

We report five cases of venous leg ulcers (VLU) that were resistant to conservative therapy for 22–119 months and were eventually healed via hyperbaric oxygen therapy (HBOT). In one patient, VLU recurred four times and was managed using HBOT, each time. The VLU sizes ranged from 18 to 68 cm² before HBOT. HBOT was administered at 2.0 atmospheres absolute with 100% oxygen for 60 min per session, five sessions a week during hospitalization. All VLUs healed after 17–66 sessions of HBOT.

Patient Explanation of Adherence and Non-Adherence to Venous Leg Ulcer Treatment: A Qualitative Study

The aim of this study was to understand which factors influence patients’ adherence to venous leg ulcer treatment recommendations in primary care. We adopted a qualitative study design, conducting phone interviews with 31 people with venous leg ulcers in Melbourne, Australia. We conducted 31 semi-structured phone interviews between October and December 2019 with patients with clinically diagnosed venous leg ulcers. Participants recruited to the Aspirin in Venous Leg Ulcer Randomized Control Trial and Cohort study were invited to participate in a qualitative study, which was nested under this trial. We applied the Theoretical Domains Framework to guide the data analysis. The following factors influenced patients’ adherence to venous leg ulcer treatment: understanding the management plan and rationale behind treatment (Knowledge Domain); compression-related body image issues (Social Influences); understanding consequences of not wearing compression (Beliefs about Consequences); feeling overwhelmed because it’s not getting better (Emotions); hot weather and discomfort when wearing compression (Environmental Context and Resources); cost of compression (Environmental Context and Resources); ability to wear compression (Beliefs about Capabilities); patience and persistence (Behavioral Regulation); and remembering self-care instructions (Memory, Attention and Decision Making). The Theoretical Domains Framework was useful for identifying factors that influence patients’ adherence to treatment recommendations for venous leg ulcers management. These factors may inform development of novel interventions to optimize shared decision making and self-care to improve healing outcomes. The findings from this article will be relevant to clinicians involved in management of patients with venous leg ulcers, as their support is crucial to patients’ treatment adherence. Consultation with patients about VLU treatment adherence is an opportunity for clinical practice to be targeted and collaborative. This process may inform guideline development.

Health literacy in people with venous leg ulcers: a protocol for scoping review

INTRODUCTION

Chronic venous leg ulcer (VLU) healing is a complex clinical problem. It requires intervention from skilled, costly, multidisciplinary wound-care teams, working with patients to manage their care. Compression therapy has been shown to help heal venous ulcers and to reduce recurrence, with some evidence suggesting the value of exercise as well. These activities require health education and health literacy (HL) as patients must process, understand and consistently apply health information for successful self-management. Research suggests that those most vulnerable to VLUs also tend to have limited HL, but there have been no reviews examining the state of HL in patients with previous or active VLUs. This scoping review aims to examine the level of HL in VLU patients and how HL may link to self-management behaviours (particularly exercise and compression adherence), and their VLU healing generally.

METHODS AND ANALYSIS

We will use Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review guidelines and the Levac methodology framework to explore eligible papers that examine the effect of HL on their exercise and compression adherence. Electronic databases will be searched (MEDLINE, EMBASE, the Cochrane Library, PsycInfo and Health, OpenGray), examining for all papers on these subjects published between 2000 and 2020. All studies describing compression and or exercise during VLU management will be included. Study characteristics will be recorded; qualitative data will be extracted and evaluated. Quantitative data will be extracted and summarised.

ETHICS AND DISSEMINATION

We will disseminate results through peer-reviewed publications. We will use data (ie, journal articles) from publicly available platforms; so, this study does not require ethical review. The consultation step will be carried out with patients, carers and health professionals as part of an established wound consumer group.