The profile of patients with venous leg ulcers: A systematic review and global perspective

Treating Infected Non-Healing Venous Leg Ulcers with Medical-Grade Honey: A Prospective Case Series

Venous leg ulcers (VLUs) are hard-to-heal wounds and are prone to microbial colonization. Innovative and improved therapies are thus required to resolve local infection and enhance the wound healing process. The objective of this study was to evaluate the effectiveness of medical-grade honey (MGH) for the treatment of clinically infected and non-healing VLUs. This prospective case series included nine patients with an average age of 83.4 years (range: 75-91 years) with a total of eleven VLUs, previously ineffectively treated with various products. Major risk factors for the appearance of VLUs were chronic venous insufficiency, advanced age, multiple comorbidities (particularly cardiovascular diseases), and impaired mobility. All wounds presented with local signs of infection. Upon presentation, treatment was commenced with a range of MGH-based products (L-Mesitran®). Clinical signs of infection were eliminated by MGH after 2.2 weeks on average (range: 1-4 weeks), and wounds were completely healed after 7 weeks on average (range: 3-18 weeks). No further complications or recurrences were observed. MGH has a broad-spectrum antimicrobial activity and promotes rapid healing, thus improving patients' quality of life. Moreover, MGH-based products are safe, easy to use, cost-effective, and can effectively treat VLUs alone or in combination with standard-of-care therapies.

Methods for sampling wound fluid from venous leg ulcers for molecular analyses: A scoping review

Determining the precise role of molecular factors present in venous leg ulcer exudate will expedite the identification of biomarkers that can optimally guide treatment. However, there is now no standardized approach for collecting, processing and storing wound fluid samples for molecular analyses. This scoping review was conducted to integrate and summarize the multiple types of methods being used currently in studies of venous leg ulcers for collecting, processing and storing wound fluid prior to analysis. PubMed, CINAHL, EMBASE and Scopus databases were searched for eligible studies between 2012 and 2022. Nineteen studies were selected for this scoping review. Five primary methodological categories for wound fluid sampling were identified. The most commonly used collection method involved extracting the fluid from various absorbent materials, and the majority of studies centrifuged wound fluid before storing it at ultra-low temperatures. This review found the wound fluid sampling methods among the included studies to be heterogeneous. Moreover, the data revealed no definitive patterns. There is a critical need to develop standardized wound fluid sampling methods in research to facilitate accurate comparisons of biomarker data across studies and a more rapid determination of biomarkers that can most effectively guide delivery of tailored venous leg ulcer treatments.

Acts of negotiation: toward a grounded theory of nursing practice in chronic wound care in Austria

BACKGROUND

Demographic change and the rise of diabetes mellitus are leading to a projected increase in the prevalence of chronic wounds. People suffering from chronic wounds experience significant losses in their health-related quality of life. Health systems struggle to meet the needs of these persons, even in high-income countries. This paper explores wound nurses' perspectives on their professional practice in Austria. They play a key role as they do much of the treatment work, contribute to advancing the field, and enable interprofessional coordination. Their perspectives enable insights into how a health system provides care for elderly and chronically ill people.

METHODS

We used the Constructivist Grounded Theory framework to analyse transcripts of 14 semi-structured qualitative interviews with nurses who work in different treatment settings.

RESULTS

We identified three themes. Firstly, the interviewees characterise working with patients as a balancing act between offering enough support to build a trustful relationship while protecting themselves against the overwhelming situation of caring for a chronically ill person. Secondly, the interviewees compensate for nonexistent care pathways by building informal networks with doctors, which requires delicate relationship work. Thirdly, the study participants must prove their competence in every new professional encounter. Their need for professional autonomy clashes with the traditional doctor-nurse hierarchy. Based on these insights, we propose a grounded theory that conceives of nursing practice in terms of 'acts of negotiations'.

CONCLUSION

Our results demonstrate that wound nurses in Austria operate in an institutional environment whose outdated imagination of the nursing role is at odds with the care demands that arise from a growing number of elderly and chronically ill people. We detailed the 'acts of negotiation' nurses deploy to compensate for this situation. We identify areas for policy intervention to strengthen the autonomy of wound nurses, including access to statutory health insurance billing.

Nursing students' skills in applying short-stretch compression bandages using the control of compression bandaging score

AIM

To assess the feasibility using the Control of Compression Bandaging (CCB) score to measure skills development on short-stretch compression therapy during a second-year nursing students' workshop.

DESIGN

A quasi-experimental pilot study with one group.

METHOD

All students followed a blended learning unit comprising an e-learning unit on leg ulcers and compression therapy including videos, followed by hands-on workshops where they could exercise how to apply short-stretch compression bandages. Clinical nurse specialists in wound care collected pre- and post-workshop measures. Data collection included feasibility, absolute pressure under compression bandages and the CCB score.

RESULTS

Six clinical nurse specialists (CNSs) collected data and 16 students participated in this pilot study. The mean application time was 8.02 minutes (min=2, max=20) pre and 9.25 minutes (min=5, max=17) post workshop. Pressure under compression bandages increased at the forefoot (P=0.01) and the calf muscle base (P=0.03) post workshop. One extreme outlier was observed. In addition, the CCB score increased from 3.57 to 4.47 (P=0.16). Using pressure measuring devices was described as essential by all the CNSs and the CCB score was easy to use.

CONCLUSION

Using the CCB score and pressure measuring devices were feasible during an undergraduate education session. Recruitment procedure and modality of data collection were satisfactory. This score may be a valuable way to assess students' skills in short-stretch compression therapy. If used for formal assessment, a passing score should be defined.

Can Thermal Imaging Technique be Used to Predict the Healing Status of a Venous Leg Ulcer?

Venous leg ulcers (VLUs) are the most common chronic wound types in older populations, with many wounds not healing in the normal trajectory. Many older people with wounds are treated in their homes, currently assessed by monitoring the wound area over weeks to ascertain the potential for healing. A noncontact method using thermal imaging has been shown to predict the healing trajectory of diabetes-related foot ulcers, although has not been tested in VLU or the home setting. This project investigated the effectiveness of using thermal imaging to predict VLU healing in the homes of participants. Images of 78 ulcers were collected weekly using a thermal camera from 67 participants in their homes, at 5 consecutive time points. Final follow-up calls were undertaken at 12 weeks to ascertain healing status (healed/unhealed). Images were preprocessed and segmented and the area of the region of the wound was extracted. Kruskal-Wallis tests were performed to test the association of the change of areas over the 5 consecutive weeks with the healing status of the ulcers at 12 weeks. The 95% confidence interval plots were obtained to study the distribution of the area in the healed and unhealed cases. This study found that the difference in the imaged areas between unhealed ulcers at 12 weeks did not reach statistical significance using thermal imaging. Therefore, thermal images could not predict healing progression in VLUs when the images were taken in the homes of participants. Future research to improve the prediction of venous leg ulcer healing should include developing a protocol to standardize conditions, improve imaging process methods, and use machine learning.

How health literacy relates to venous leg ulcer healing: A scoping review

BACKGROUND

The level of personal health literacy of patients with venous leg ulcers is likely to affect their ability to self-manage their condition impacting on their adherence to treatment and influences healing and recovery outcomes.

OBJECTIVES

To scope existing research that examined the level of health literacy in venous leg ulcer patients, to identify how this may link to self-management behaviours (particularly physical activity and compression adherence), and venous leg ulcer healing outcomes.

METHODS

This scoping review was based on the PRISMA-ScR six-stage framework. We searched MEDLINE, EMBASE, the Cochrane Library, PsycInfo and Health, Open Grey, and Google Scholar for publications examining general and specific health literacy in those with venous leg ulcers and for those examining any potential links of health literacy with self-management/healing generally, published between 2000-2020. This search was guided by a published protocol; studies that described other types of ulcers or did not examine health literacy were excluded. After applying inclusion and exclusion criteria the initial search identified 660 articles.

RESULTS

We included five articles. Four studies used randomised controlled trials or experimental designs to test the effect of specific health literacy interventions on venous leg ulcer knowledge, compression therapy use, or healing outcomes. One study was a cross- sectional survey with qualitative elements, assessing health literacy in venous leg ulcer patients. Broadly, the research suggested that health literacy was suboptimal amongst those with venous leg ulcers, and health literacy interventions had limited effects on improving key venous leg ulcer specific outcomes.

CONCLUSION

This review provides a synthesis of extant literature examining health literacy in patients with venous leg ulcers. We identified a dearth of literature investigating the value of general and specific health literacy interventions in this space. Most importantly, no recent research on general health literacy and venous leg ulcers was identified, despite strong theoretical utility to do so. The few studies identified largely indicated that targeting health literacy of patients with venous leg ulcers is a viable area of research and intervention, encouraging future researchers and clinicians to consider patient health literacy in venous leg ulcer management.

Daily life after healing of a venous leg ulcer: A lifeworld phenomenological study

Purpose

Venous leg ulcer is a recognized condition, affecting people globally. Ulcers mainly affect the elderly and recurrences are not uncommon. There is knowledge about life with venous leg ulcers, but the situation after healing is unexplored. This paper explores and describes meanings of experiences of daily life after healing of a hard-to-heal venous leg ulcer.

Methods

Lived experiences of 15 individuals with healed hard-to-heal venous leg ulcers generated data for this study. Interviews were recorded for analysis using a reflective lifeworld research approach. An essence emerged, further described by its constituents.

Results

Memories of a difficult time with leg ulcer were ever present, in a way becoming part of the self. A striving for control in daily life entailed a struggle to do what was best for the own body. After healing, a new normal emerged in daily life, a reality that encompassed the risk for a new ulcer. The body had changed physically, with marks alongside those from ageing, in a life that still went on.

Conclusions

For those who had healed from a venous leg ulcer, life had changed. Even if they referred to life as normal, it was not the same normal as before.

Investigating Quality of Life Instrument Measurement Properties for Adults with Active Venous Leg Ulcers: A Systematic Review

The primary objective of this systematic review was to identify which quality of life instruments have been applied in published studies of patients with active venous leg ulcers. Our secondary objective was to map the measurement properties of each identified quality of life instrument and to inform future recommendations for clinical practice and research. We searched CINAHL, Ovid Medline, Ovid Emcare and ProQuest to identify studies published from 1 January 2000 to 31 July 2021. Eleven studies that utilised quality of life instruments in adults with active venous leg ulcers met the inclusion criteria. Thirteen quality of life instruments were identified as some studies utilised both generic and condition‐specific quality of life instruments. Six out of nine (6/9) instruments were rated ‘very good’ of methodological quality on internal consistency; 1/7 studies rated ‘adequate’ on reliability; 2/4 rated ‘adequate’ on content validity; 3/6 studies rated ‘adequate’ on structural validity; 5/6 rated ‘adequate’ on hypotheses testing for construct and 2/6 studies rated ‘adequate’ on responsiveness. There is limited evidence of measurement properties of quality of life instruments for people with active venous leg ulcers. The Venous Leg Ulcer Quality of Life Questionnaire (VLU‐QoL) could be provisionally recommended for use although from our review it is clear further studies to assess VLU‐QoL measurement properties are needed to inform future recommendations for clinical practice and research.

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.

Decreased mobility, lack of social support, haemosiderosis and use of antidepressant medications may predict recurrent venous leg ulcers within 12 months of healing: A prospective longitudinal study

AIM

To identify clinical, medical and psychosocial predictors of venous leg ulcer recurrence within 12 months of healing.

METHODS

A multi-site study was conducted in Australia in community and hospital outpatient settings. Adults with venous leg ulcers were recruited within 4 weeks of healing and data were collected on preventative treatments and health, medical, clinical and psychosocial factors. Follow-up data on recurrences were collected every 3 months until ulcer recurrence, or until 12 months after healing pending which occurred first. Factors associated with time to recurrence were analysed using a Cox proportional hazards regression model.

DESIGN

Secondary data analysis of a multi-site, prospective longitudinal study to validate a risk assessment tool for recurrence.

RESULTS

A sample of 143 participants was recruited (51% male, M^age = 73 years, SD 13.6). Almost half (49.6%) had an ulcer recurrence within 12 months, with a mean time to ulcer recurrence of 37 weeks (SE 1.63, 95% CI 33.7-40.1). Factors measured at the time of healing that were significant independent predictors of recurrence were: prescribed antidepressant medications (p = .035), presence of haemosiderosis (p = .006), decreased mobility (longer sitting times) (p = .007) and lower social support scale scores (p = .002). Participants who wore compression systems providing 20 mmHg or higher for at least 5 days/week were less likely to recur, although not reaching statistical significance (p = .06).

CONCLUSION

Results provide evidence that antidepressant medications, haemosiderosis, decreased mobility and lack of social support are risk factors associated with ulcer recurrence; therefore, these variables are modifiable and could guide early intervention.

Topical cannabis-based medicines - A novel adjuvant treatment for venous leg ulcers: An open-label trial

Venous leg ulcers are highly prevalent lower limb integumentary wounds that remain challenging to heal despite the use of evidence-based compression therapies. A multitude of adjuvant treatments has been studied but none have demonstrated enough efficacy to gain adoption into treatment guidelines. Global attention on Cannabis-Based Therapies is increasing and has been driven by quantum scientific advancements in the understanding of the endocannabinoid signalling system. Topical Cannabis-Based Medicines represent a novel treatment paradigm for venous leg ulcers in terms of promoting wound closure. Fourteen complex patients with sixteen recalcitrant leg ulcers were treated with Topical Cannabis-Based Medicines in conjunction with compression bandaging, every second day, to both wound bed and peri-wound tissues. The cohort had a mean age of 75.8 years and was medically complex as reflected by a mean M3 multimorbidity index score of 2.94 and a mean Palliative Performance Scale score of 67.1%. Complete wound closure, defined as being fully epithelialized, was achieved among 11 patients (79%) and 13 wounds (81%) within a median of 34 days. All three remaining patients demonstrated progressive healing trends but were lost to follow-up. The treatments were well tolerated, and no significant adverse reactions were experienced. The rapid wound closure of previously non-healing venous leg ulcers among elderly and highly complex patients suggests that Topical Cannabis-Based Medicines may become effective adjuvants in conjunction with compression therapy. This may also indicate that they may have an even broader role within integumentary and wound management. Therefore, this treatment paradigm warrants being subjected to controlled trials.