Venous ulcers of the lower extremity: Definition, epidemiology, and economic and social burdens

Association between stroke and venous leg ulcers: A Mendelian randomization study

To investigate any potential bidirectional causal relationships between stroke and venous leg ulcers (VLUs), Mendelian randomization (MR) analyses were carried out in this study. The exposure factor was stroke, the outcome factor was VLUs. The two-sample MR study was carried out based on the online analysis platform (http://app.mrbase.org/). The association of stroke and VLUs was analysed via methods of Inverse Variance Weighted (IVW), Weighted Median, MR-Egger and weighted mode. IVW method suggested no association between stroke and VLUs ((β 1.06; SE 9.321; p = 0.9095)). Weighted median estimator (β 5.906; SE 11.99, p = 0.6223), MR-Egger (β -0.8677; SE 21.89; p = 0.9691) and weighted mode (β 9.336; SE 17.77; p = 0.6089) showed consistent results. Conversely, evidence indicating that the presence of VLUs increased the risk of stroke was lacking. According to this MR study, there is no causal connection between stroke and VLUs, which suggests that therapies targeting stroke may not be effective against VLUs.

Prevention strategies for the recurrence of venous leg ulcers: A scoping review

Venous leg ulcer (VLU) is the most severe manifestations of chronic venous disease, which has characterized by slow healing and high recurrence rates. This typically recalcitrant and recurring condition significantly impairs quality of life, prevention of VLU recurrence is essential for helping to reduce the huge burden of patients and health resources, the purpose of this scoping review is to analyse and determine the intervention measures for preventing recurrence of the current reported, to better inform healthcare professionals and patients. The PubMed, Embase, Web of Science, Cochrane Library databases, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wan Fang Data and Chongqing VIP Information (CQVIP) were accessed up to June 17, 2023. This scoping review followed the five-steps framework described by Arksey and O'Malley and the PRISMA extension was used to report the review. Eleven articles were included with a total of 1503 patients, and adopted the four effective measures: compression therapy, physical activity, health education, and self-care. To conclude, the use of high pressure compression treatment for life, supplementary exercise therapy, and strengthen health education to promote self-care are recommended strategies of VLU prevention and recurrence. In addition, the importance of multi-disciplinary teams to participate in the care of VLU in crucial.

Pathophysiology and Genetic Associations of Varicose Veins: A Narrative Review

Varicose veins (VVs) have a high prevalence worldwide and have become a major medical burden. Their pathophysiology involves a complex interplay of inflammation and tissue remodeling, and current treatment is limited by its impact on the pathophysiological mechanisms. In addition, despite clear environmental factors, family history is an important risk factor, suggesting a genetic component to the risk of developing VVs. Our understanding of the pathogenesis of these diseases has benefited greatly from the expansion of population genetic studies, from pioneering family studies to large genome-wide association studies; we now find multiple risk loci for each venous disease. This review considers the pathophysiology of VVs, highlighting the current state of genetic knowledge. We also propose future directions for research.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Severity of Chronic Venous Insufficiency on Primary Total Knee Arthroplasty Outcomes

BACKGROUND

More than 700,000 people in the United States undergo total knee arthroplasty (TKA) each year. Chronic venous insufficiency (CVI) affects 5% to 30% of adults, sometimes resulting in leg ulceration. These CVI cases in TKAs have been associated with worse outcomes; however, we found no study differentiating CVI severity.

METHODS

This retrospective study analyzed TKA outcomes at one institution from 2011 to 2021 using patient-specific codes. Analyses included short-term complications (< 90 days postoperative), long-term complications (< 2 years), and CVI status (yes/no; simple/complex/unclassified). Complex CVI consisted of pain, ulceration, inflammation, and/or other complications. Revisions within 2 years and readmissions within 90 days post-TKA were assessed. Composite complications included short-term and long-term complications, revisions, and readmissions. Multivariable logistic regressions predicted complication (any/long/short) as a function of CVI status (yes/no; simple/complex) and potential confounding variables. Of 7,665 patients, 741 (9.7%) had CVI. Among CVI patients, 247 (33.3%) had simple CVI, 233 (31.4%) had complex CVI, and 261 (35.2%) had unclassified CVI.

RESULTS

There was no difference in CVI versus control in composite complications (P = .722), short-term complications (P = .786), long-term complications (P = .15), revisions (P = .964), or readmissions (P = .438) postadjustment. Composite complication rates were 14.0% without CVI, 16.7% with complex CVI, and 9.3% with simple CVI. Complication rates differed between simple and complex CVI (P = .035).

CONCLUSION

Overall, CVI did not affect postoperative complications versus control. Patients who have complex CVI are at higher risk for post-TKA complications compared to those who have simple CVI.

A Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Thermal Versus Non-Thermal Endovenous Ablation in Superficial Venous Incompetence

OBJECTIVE

The objective was to compare technical success, complications, and quality of life after thermal vs. non-thermal endovenous ablation for the treatment of superficial venous incompetence.

DATA SOURCES

Electronic bibliographic sources (Google Scholar, Pubmed, Cochrane Database, Scopus, Web of Science, and Embase).

REVIEW METHODS

A systematic review and meta-analysis of randomised controlled trials was conducted using terms to identify relevant studies to be included. The primary outcome was vein occlusion rate at up to four weeks and one to two years from procedure. Secondary outcome measures included peri-procedural pain, nerve injury, endothermal heat induced thrombosis, and quality of life.

RESULTS

Eight randomised controlled trials met the selection criteria. These comprised a total of 1 956 patients, of whom 1 042 underwent endovenous thermal ablation and 915 underwent endovenous non-thermal ablation. There was no statistically significant difference in occlusion rate at all time points. Relative risk at four weeks and one to two years was 0.99 (95% CI 0.96 - 1.02) and 0.95 (95% CI 0.88 - 1.01), respectively. Non-thermal ablation was tolerated better and had less risk of nerve injury. There was no statistically significant difference in risk of endothermal heat induced thrombosis (EHIT). There was improvement in quality of life scores post-procedure but there was no statistically significant difference in thermal vs. non-thermal ablation. The quality of evidence assessed using GRADE methodology showed high quality for occlusion rate at four weeks and one to two years, moderate quality for nerve injury and peri-procedural pain, and low quality for EHIT.

CONCLUSION

Vein occlusion rates after thermal vs. non-thermal endovenous ablation are similar. In the early post-operative period, non-thermal endovenous ablation demonstrated the advantages of less pain and less risk of nerve injury. Improvement in quality of life after both thermal and non-thermal endovenous ablation is similar.

Chronic venous insufficiency and venous leg ulcers: Aetiology, on the pathophysiology-based treatment

The chronic venous disease covers a wide spectrum of venous disorders that are characterized by severely impaired blood return that primarily affects veins in the lower extremities. Morphological and functional abnormalities of the venous system led to chronic venous insufficiency (CVI), and present as leg heaviness/achiness, edema, telangiectasia, and varices. The term 'chronic venous insufficiency' (CVI) refers to a disease of greater severity. Venous dysfunction is associated with venous hypertension and is associated with venous reflux due to poorly functioning or incompetent venous valves, which ultimately reduces venous return, leading to a cascade of morphological, physiological, and histologic abnormalities such as blood pooling, hypoxia, inflammation, swelling, skin changes (lipodermatosclerosis), and in severe cases, venous leg ulcers (VLU). This review summarizes recent knowledge about the aetiology, risk factors, and pathophysiology of VLU and compared the possibilities of their treatment.

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.

Prospective study on the clinical and economic burden of venous leg ulcers in the tropics

OBJECTIVE

Venous leg ulcers (VLUs) are both chronic and recurrent. The treatment of such ulcers often require multiple outpatient visits and dressing changes. Several reports on the costs of treating such VLUs have been reported in the west. We prospectively evaluated the clinical and economic burden of VLUs in a population of Asian patients in the tropics.

METHODS

Patients from a prospective two-center study conducted at two tertiary hospitals in Singapore, as a part of the Wound Care Innovation in the Tropics program, between August 2018 and September 2021 were recruited. The patients were followed up for 12 weeks (visit 1 to visit 12), until index ulcer healing, death, or lost to follow-up (whichever came first). These patients were then followed up 12 weeks later to determine the longer term outcome of the wound (healed, recurrence, remained unhealed). The itemized costs derived from the medical service were retrieved from the relevant departments of the study sites. The patients' health-related quality of life was assessed at baseline and the last visit of the 12-week follow-up period (or until index ulcer healing), using the official Singapore version of the EuroQol five-dimension-5L questionnaire, which also includes a visual analog scale (EQ-VAS).

RESULTS

A total of 116 patients were enrolled; 63% were men, and the mean patient age was 64.7 years. Of the 116 patients, 85 (73%) had a healed ulcer at 24 weeks (mean duration to ulcer healing, 49 days), and 11 (12.9%) had experienced ulcer recurrence within the study period. Within the 6-month follow-up period, the mean direct healthcare cost per patient was USD$1998. The patients with healed ulcers had significantly lower costs per patient compared with those with unhealed ulcers (USD$1713 vs USD$2780). Regarding health-related quality of life, 71% of the patients had a lower quality of life at baseline, which had improved at 12 weeks of follow-up, with only 58% of the patients reported to have a lower quality of life. Also, the patients with healed ulcers scored higher for both utilities (societal preference weights) and EQ-VAS at follow-up (P < .001). In contrast, patients with unhealed ulcers only scored higher EQ-VAS at follow-up (P = .003).

CONCLUSIONS

The findings from this exploratory study provide information on the clinical, quality of life, and economic burden of VLUs in an Asian population and suggest the importance of healing VLUs to reduce the effects on patients. The present study provides data as a basis for economic evaluation as a consideration for the treatment of VLUs.

Evolution of the Chronic Venous Leg Ulcer Microenvironment and Its Impact on Medical Devices and Wound Care Therapies

Studies have reported that the constituents of the wound microenvironment are likely to have critical roles in the degradation and fate of the polymeric matrix and the compounds dissolved in the wound dressing matrix. Thus, chronic wound assessment and the design of effective medical devices and drug products for wound care partly rely on an in-depth understanding of the wound microenvironment. The main aim of this review is to identify and discuss the different stages of chronic wound progression, focusing on the changes in the biochemical composition of the wound microenvironment, with particular attention given to venous leg ulcers (VLUs), as they are one of the most prevalent chronic wound aetiologies. The pathophysiology of venous ulcers is detailed, followed by a thorough review of what is known about the VLU microenvironment and its changes as a function of the evolution of the VLU. Simulating conditions for VLU are then discussed with the view of highlighting potentially relevant simulating media as a function of VLU evolution for a better assessment of biological safety, in particular medical devices intended to be in contact with these wounds.

A prospective study on the efficacy of sequential treatment of technology Lipido-Colloid Impregnated with Silver and Technology Lipido-Colloid Nano-Oligosaccharide Factor in the management of venous leg ulcers

Background and Aims

Venous leg ulcers (VLUs) are associated with significant morbidity and poor quality of life (QOL). Compression therapy and wound dressing are the mainstay treatment options. Technology Lipido-Colloid Impregnated with Silver (TLC-Ag) reduces bacterial load and Technology Lipido-Colloid Nano-Oligosaccharide Factor (TLC-NOSF) reduces elevated matrix metalloproteinases and improve wound healing. However, evidence is scarce on the role of sequential therapy. This study aims to evaluate if sequential treatment with TLC-Ag and TLC-NOSF improves VLU wound healing and QOL.

Methods

This is a prospective cohort study from May 2020 to October 2021 on patients with VLUs who received sequential therapy, consisting of 2 weeks of TLC-Ag followed by two-layer compression bandage (2LB) with TLC-NOSF until complete wound healing. Participants were followed-up with weekly dressing changes. Our primary outcomes were wound area reduction (WAR) and Pressure Ulcer Scale of Healing (PUSH) score. Our secondary outcomes were QOL measures.

Results

There were 28 patients with 57.1% males (n = 16) with a mean age of 65.3 years. Mean duration of VLU was 13.9 ± 11.7 weeks before the initiation of sequential therapy. Mean baseline wound area was 8.44 cm2. Median time to wound healing was 10 weeks. 57.1% of patients achieved complete wound closure at 3 months. There was significant WAR after 1 month (mean area 8.44-5.81 cm2, 31.2% decrease) and after 3 months (mean area 8.44-2.53 cm2, 70.0% decrease). Mean monthly WAR was 28.9%. PUSH score also decreased at 1 month (16.5% decrease, p < 0.001) and 3 months (63.3% decrease, p < 0.001) marks following the sequential therapy. EuroQol Visual Analog Scale (EQ-VAS) improved following sequential therapy (baseline: 69.0 ± 15.0, week 13: 80.2 ± 13.2, p < 0.001).

Conclusion

Sequential therapy with TLC-Ag followed by TLC-NOSF and 2LB is feasible, with good wound healing and improvement in QOL of patients with VLUs.

Hyperbaric Oxygen Therapy for Nonhealing Wounds-A Long-term Retrospective Cohort Study

OBJECTIVE

To analyze wound healing results of hyperbaric oxygen therapy (HBOT) for a variety of different wound types.

METHODS

This retrospective cohort study included all patients treated with HBOT and wound care at a single hyperbaric center between January 2017 and December 2020. The primary outcome was wound healing. Secondary outcome measures were quality of life (QoL), number of sessions, adverse effects, and treatment cost. Investigators also examined possible influencing factors, including age, sex, type and duration of wound, socioeconomic status, smoking status, and presence of peripheral vascular disease.

RESULTS

A total of 774 treatment series were recorded, with a median of 39 sessions per patient (interquartile range, 23-51 sessions). In total, 472 wounds (61.0%) healed, 177 (22.9%) partially healed, 41 (5.3%) deteriorated, and 39 (5.0%) minor and 45 (5.8%) major amputations were performed. Following HBOT, median wound surface area decreased from 4.4 cm 2 to 0.2 cm 2 ( P < .01), and patient QoL improved from 60 to 75 on a 100-point scale ( P < .01). The median cost of therapy was €9,188 (interquartile range, €5,947-€12,557). Frequently recorded adverse effects were fatigue, hyperoxic myopia, and middle ear barotrauma. Attending fewer than 30 sessions and having severe arterial disease were both associated with a negative outcome.

CONCLUSIONS

Adding HBOT to standard wound care increases wound healing and QoL in selected wounds. Patients with severe arterial disease should be screened for potential benefits. Most reported adverse effects are mild and transient.

Bacterial cellulose biomaterials for the treatment of lower limb ulcers

Chronic ulcers of the lower limbs are common and recurrent, especially in the elderly population, they are disabling injuries that generate a great socioeconomic burden. This scenario encourages the development of new, low-cost therapeutic alternatives. The present study aims to describe the use of bacterial cellulose in the treatment of lower limb ulcers. This is an integrative literature review, carried out in the PubMed and Science Direct databases by associating the descriptors, with the inclusion criteria being clinical studies in the last 5 years, available in full in English, Portuguese and Spanish. Five clinical trials were analyzed and the main therapeutic effects obtained in the experimental groups that used bacterial cellulose dressings were a reduction in the area of the wounds, one of the studies showed a reduction of 44.18cm2 in the area of the wound, the initial lesions measured on average 89.46cm2 and at the end of the follow-up, they had an average of 45.28cm2, since the reduction in pain and the decrease in the number of exchanges were advantages described in all groups that used the BS. It is concluded that BC dressings are an alternative for the treatment of lower limb ulcers, their use also reduces operational costs related to the treatment of ulcers.

Effects of exercise in treating patients with venous leg ulcers: A systematic review and meta-analysis

To determine the effects of exercise on VLU healing and exercise adherence, and to provide evidence for clinical practice and scientific investigation. PubMed, Embase and Scopus were searched from inception to 31st March, 2022. Pooled relative risks (RRs), standardised mean differences (SMDs), adherence rate with respective 95% confidence intervals (CIs) were calculated. Quality assessment of included studies were performed using the Cochrane Collaboration risk of bias evaluation. Heterogeneity between enrolled studies was evaluated. We identified eight randomised control studies (RCTs) that met the inclusion criteria. The pooled RR for healing rate was 1.38 (95% CI: 1.14 to 1.66; P = 0.0008) with no significant heterogeneity between component studies (I2  = 0%, P = 0.96). SMD for differences of total range of ankle joint motion (ROAM) at the end and at the initiation of follow-up in the intervention and control groups was 0.87 (95% CI: 0.22, 1.52; P = 0.0091), no significant heterogeneity was detected (I2  = 59%, P = 0.0622). Pooled adherence rate was 64% (95% CI: 53%, 75%) with no significant heterogeneity. Exercise manifested positive effects on VLU healing, range of ankle mobility compared with the control group. Patients' adherence to the exercise regimens was favourable.

The Influence of Combined Physical Therapy Procedures on Oxygen Partial Pressure in Tissues Surrounding Ulcer in Patients With Venous Leg Ulcers

Venous ulcers in lower legs remain a profound treatment problem in contemporary medicine. Proper healing requires, among other things, sufficient blood supply and provision of suitable amount of oxygen to the treated tissues. The aim of the study was to assess the influence of combined physical therapy applied in patients with chronic venous leg ulcers on the oxygen partial pressure values. Fifty-four patients (25 females and 29 males), in the age range of 38 to 89 years with chronic venous leg ulcers, underwent a cycle of 15 procedures with the use of Laserobaria-S device. During a procedure, the patient's lower limb was simultaneously exposed to oxygen having the pressure of 1.5 ATA, low-frequency magnetic field, and low-energy light radiation. Before procedures, directly after the first procedure, as well as on completion of the entire therapeutic cycle, the patients underwent oxygen partial pressure measurements in the tissues surrounding the ulceration area, by means of transcutaneous oximetry, with the use of Medicap Précise 8008s device. The combined physical therapy shows a statistically significant increase of oxygen partial pressure values in tissues surrounding the ulceration, from the average of 68.63 ± 17.04 mm Hg before commencing the therapeutic cycle, to the average of 74.20 ± 18.92 mm Hg after the first procedure (P < .001) and to the average value of 83.79 ± 20.74 mm Hg (P < .001) after completion of therapeutic cycle. Combined physical therapy procedures cause a statistically significant increase of oxygen partial pressure values in tissues surrounding the ulceration, assessed using the objective method of transcutaneous oximetry, both in women and men.

Effect of Endovenous Laser Ablation Along With Compression Therapy on Chronic Venous Ulcer Healing

Introduction Chronic venous insufficiency is a major cause of morbidity, and there is a paucity of data regarding its epidemiology due to the lack of a central wound registry. In this study, we aimed to study the time for healing of the ulcer and compliance with compression therapy (CT) following endovenous laser ablation (EVLA) ± ultrasound-guided foam sclerotherapy (UGFS) along with CT in patients with chronic venous ulcers. Methods This prospective observational study was conducted from January 2020 to June 2021 after obtaining institutional ethical committee clearance. Patients with chronic venous ulcers (>six weeks to <six months duration) were included in this study. Demographic details, venous duplex findings, and duration of ulceration were noted. All patients underwent EVLA (Biolitec^® 1470 nm) ± UGFS and CT. The patients were followed up weekly till the healing of the ulcer, followed up at one month, three months, and then at six monthly intervals to look for recurrence. Venous clinical severity score (VCSS) at presentation and follow-up, compliance with CT, rate of ulcer healing at six months, and recurrence rates at two years of follow-up were observed prospectively. Results The mean age of the study participants was 45.7±14.2 years, of which 42 (84%) were males. Ulcer size of <2 cm was present in 38%, 2-4 cm in 52%, and >4 cm in 10% of patients. A total of 38% of patients underwent only EVLA, and EVLA+UGFS were done in 62% of participants. The healing rate at six months follow-up was 92%, with the average time taken being 2.55±1.38 months. Those who remained with an unhealed ulcer at six months follow-up had an ulcer size of >5 cm and an age of >50 years. Ninety-six percent of the patients were compliant with CT after an endovenous intervention. The recurrence rate at two years post-ablation was 6%. VCSS was 19.66±3.23 at presentation and 5.5±2.82 at six months of follow-up. Conclusion Endovenous ablation of superficial venous reflux along with CT is associated with a shorter healing time of venous ulcerations and reduced chances of recurrence. There is an improvement in VCSS score over the period of six months follow-up.

VALIDAÇÃO DO CONTEÚDO DE UM INSTRUMENTO PARA CONSULTA DE ENFERMAGEM À PESSOA COM ÚLCERA VENOSA

Objective: To validate the content of an instrument for nursing consultation with people with venous ulcers. Methodology: Methodological study of internal validation of content based on the judgment of enterostomal therapist judges, whose identification occurred through a search on the Lattes Platform. The process occurred in the months of January and February 2019 and 24 experts participated. Data regarding the evaluation of the query were compiled in Microsoft Office Excel spreadsheet and considered according to total and global agreement index, totaling 209 items and 2,400 variables of the query, dichotomous responses being adopted. Results: Regarding the characterization of the judges, a mean age of 36.6 years was obtained. Most were female and located in the state of Ceará. The main qualification observed was Master’s degree (62.5%) and the judges worked in assistance and coordination of enterostomal therapy services. Two thirds had experience with validation of instruments (66.7%). Regarding the validation of the consultation, an overall agreement index of 92% and an alpha of 0.91 were obtained. Conclusion: The consultation has an adequate appearance to be used, is easy to apply, has a logical sequence, and enables a systematic nursing care.

VALIDATION OF THE CONTENT OF AN INSTRUMENT FOR NURSING CONSULTATION FOR PEOPLE WITH VENOUS ULCER

Objective: To validate the content of an instrument for nursing consultation with people with venous ulcers. Methodology: Methodological study of internal validation of content based on the judgment of enterostomal therapist judges, whose identification occurred through a search on the Lattes Platform. The process occurred in the months of January and February 2019 and 24 experts participated. Data regarding the evaluation of the query were compiled in Microsoft Office Excel spreadsheet and considered according to total and global agreement index, totaling 209 items and 2,400 variables of the query, dichotomous responses being adopted. Results: Regarding the characterization of the judges, a mean age of 36.6 years was obtained. Most were female and located in the state of Ceará. The main qualification observed was Master’s degree (62.5%) and the judges worked in assistance and coordination of enterostomal therapy services. Two thirds had experience with validation of instruments (66.7%). Regarding the validation of the consultation, an overall agreement index of 92% and an alpha of 0.91 were obtained. Conclusion: The consultation has an adequate appearance to be used, is easy to apply, has a logical sequence, and enables a systematic nursing care.

The role of podiatry in the early identification and prevention of lower limb venous disease: an ethnographic study

BACKGROUND

Lower limb venous disease can cause significant pain, loss of mobility, and can be detrimental to an individual's quality of life. Manifestations of venous disease often pose a substantially negative impact on patients and place a high demand on finite healthcare resources. Whilst this problem is internationally recognised, most research and discourse has predominantly focussed on treatment of leg ulceration and prevention of recurrence. Prevention of lower limb venous disease progression to the first ulceration has received far less attention. Overall, the care of this condition appears to rest in the domain of medicine and nursing yet podiatry, a profession with responsibility for the lower limb and foot, is conspicuous by its absence from the literature.  METHODS: An ethnographic approach was used to gather data from 26 participants through observation, semi-structured interviews, and a focus group interview. Qualitative analysis was conducted using the framework approach.

RESULTS

The findings revealed an identity crisis within the podiatry profession. Evidence emerged of ritual and routine practices that did not include lower limb venous disease. External control over practice limited the professional autonomy of podiatrists determining their own activities. Inter-professional relationships with nursing, and perceptions of boundaries that venous disease was a nursing role were also found to be limiting factors.

CONCLUSIONS

This research revealed that podiatry does not occupy a substantive role in contributing to the early identification and prevention of lower limb venous disease. Policy, education, research and practice changes are all required to enhance the contribution of podiatry to reduce the burden of this disease.

Levels of secretory leukocyte protease inhibitor expression in acute wounds

OBJECTIVE

Even with our best practices, we are frequently unable to prevent slow and stalled wound healing-particularly in people with impaired circulation and conditions such as diabetes. As a result, greater insight into the nature of wound healing and alternative treatment approaches is needed. An avenue that may be of particular promise is increasing understanding of the role of secretory leukocyte protease inhibitor (SLPI) as there is evidence that it enhances wound healing, its expression increases in response to inflammation and infection, and it exhibits anti-protease, anti-inflammatory, antiviral antibacterial and antifungal activities.

METHOD

The response of SLPI levels to wounding and skin injury was assessed by taking punch skin biopsies from healthy volunteers and assessing the levels of SLPI at the site of injury at the time of wounding (baseline) as well as one, two, three, four, seven, nine and 12 weeks later.

RESULTS

A total of 35 volunteers took part in the study. Significant elevations were found: levels of SLPI were greatly increased, 12 times that at baseline, and remained elevated at three weeks despite re-epithelialisation having occurred.

CONCLUSION

These findings not only suggest that levels of SLPI rise rapidly following wounding, but that these elevations are sustained, and continue to increase even when re-epithelialisation has occurred. These results suggest that the role and potential benefits of this protease inhibitor deserve further exploration.

Concurrent optical and magnetic stimulation therapy in patients with lower extremity hard-to-heal wounds

OBJECTIVE

The treatment of patients with hard-to-heal wounds represents a major multidisciplinary challenge. Therefore, the development and clinical validation of new technologies remains extremely important. The novel application of concurrent optical and magnetic stimulation (COMS) offers a promising noninvasive approach to support physiological wound healing processes, especially in hard-to-heal wounds.

METHOD

In a multicentre, prospective, comparative, clinical trial, patients with hard-to-heal wounds on lower extremities of different aetiologies were treated with COMS as an adjunct to standard of care (SOC). The primary endpoint was safety; secondary endpoints were wound healing, pain and wound-specific quality of life (Wound-QoL).

RESULTS

A total of 40 patients were enrolled in this study (intention to treat population (ITTP), n=40). Of these patients, 37 were included in the analysis of the primary endpoint (primary endpoint population, (PEP), n=37). A further subgroup of 30 patients was included in the analysis of the secondary endpoint (secondary endpoint population (SEP), n=30). Finally, the SEP was stratified regarding patients' responsiveness to SOC in an SOC non-responder subgroup (NRSG), n=21, and in an SOC responder subgroup (RSG), n=9. A total of 102 adverse events (AEs) were recorded, of which 96% were 'mild' or 'moderate', and 91% were either a singular or transient event. Only 11 AEs were serious and associated with inpatient treatments unrelated to the studied intervention. In the NRSG, reductions in wound size were found to be statistically significant within the different study periods. Additionally, an acceleration of the healing rate was detected between the baseline and the first four weeks of COMS treatment (p=0.041). The rate of near-complete and complete wound closure in the SEP after 12 weeks were 60% and 43%, respectively. Pain reduction across the treatment group was statistically significant (p≤0.002 for both the SEP and NRSG). The Wound-QoL score improved by 24% during the study (p=0.001).

CONCLUSION

In this study, COMS treatment for patients with hard-to-heal wounds on lower extremities was a safe and effective novel treatment option, especially for patients who did not respond to SOC.

Safety and efficacy of acellular human amniotic fluid and membrane in the treatment of non-healing wounds in a patient with chronic venous insufficiency

Chronic, non-healing venous ulcers of the lower extremity are often limb-threatening conditions. Their management is characterized by a prolonged and frequently frustrating clinical course that represents an economic burden to both the patient and healthcare system. During the last two decades, thermal ablation of underlying incompetent venous systems has been extensively utilized to treat chronic venous insufficiency. Despite successful correction of venous hypertension, a substantial subgroup of patients remain affected by non-healing venous ulcers, thus posing a significant clinical challenge. In this case report, we detail quantitative and qualitative wound treatment course in a patient refractory to standard interventions, by treatment with a combination of cell-free amniotic fluid and dehydrated amniotic membrane following successful thermal ablation of refluxing veins.

Development of a Consensus-Based Cross-Domain Protocol for the Management of Elastic Compression Stocking Therapy in Patients With Deep Venous Thrombosis and Chronic Venous Disease: A Modified Delphi Study

Objective

Elastic compression stocking (ECS) therapy is commonly used in patients with deep venous thrombosis (DVT) and chronic venous disease (CVD). The provision of ECS therapy is complex, and studies indicate a lack of practical guidance and suboptimal collaboration among health care professionals. We aimed to reach consensus on critical issues of ECS therapy among the involved health care professionals and patients.

Methods

A three-round modified Delphi analysis was performed in the Netherlands in which 56 health care professionals (internists, dermatologists, general practitioners, emergency room nurses, home care nurses, medical stocking suppliers, and occupational therapists) and seven patients were invited. The 21 statements included in this analysis were based on information collected from a previously conducted Functional Resonance Analysis Method and Realist Evaluation. We used 7-point Likert scale questions and a 75% threshold for consensus.

Results

Of the 63 persons invited for this study, 59 (94%) agreed to participate and responded in the first questionnaire round; of whom 52 were health care professionals and seven were patients (five DVT and two CVD). The overall response rate for the three questionnaire rounds was 91%. After completion of the rounds, full consensus was achieved on 19 out of 21 statements. No consensus was reached on the need for a follow-up appointment for CVD patients and who should be responsible to determine the ECS type (custom-made or standard).

Conclusion

We identified 19 consensus-driven recommendations on treatment decisions and collaboration in ECS therapy among an interdisciplinary panel of health care professionals and patients. These recommendations form a basis for consensus-driven optimization of ECS therapy and should ideally be incorporated in a general cross-domain protocol for ECS therapy in patients with DVT and CVD.

Faster Than Projected Healing in Chronic Venous and Diabetic Foot Ulcers When Treated with Intact Fish Skin Grafts Compared to Expected Healing Times for Standard of Care: An Outcome-Based Model from a Swiss Hospital

Purpose: Inadequate response to wound management is defined as a reduction in the wound area of <40-50% following four weeks of standard of care (SOC) and should be managed with a skin substitute product. We set out to evaluate a novel outcome-based model focusing on the management of hard-to-heal venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs) using SOC treatment or intact fish skin grafts (FSGs) in a regional hospital. Methods: We built an outcome-based model applying surrogate markers and endpoints of wound healing for VLU and DFU to determine the healing trajectory with SOC treatment. We could predict if VLU and DFU would heal by weeks 20 and 24, respectively, after four weeks of evaluating the initial wound area reduction. 51 patients were recruited (26 VLUs and 25 DFUs) and 42 wounds were randomized. 17 wounds deemed unlikely to heal by week 8 received management with FSG as per the Swiss Society for Dermatology and Venereology (SGDV) and the Swiss Association for Woundcare (SAfW) guidelines for the use of skin replacement products, and 26 wounds continued SOC for weeks 5-8. Results/Discussion: 12 wounds managed with FSG beat the modeled SOC healing predictions, with the majority healed >50% sooner and as early as <10% of the time than was predicted. Of these 17, five wounds failed to achieve the required size reduction in Week 4-8 (over 25% improvement in wound area vs. SOC). The FSG were assigned to treatment-resistant VLU and DFUs and were still able to heal these wounds most of the time and even changed the wound's healing trajectory that increased in size in the initial four weeks. Conclusion: This pilot study showed that management with FSG results in faster healing wounds than SOC predicted, while SOC-treated wounds mostly followed model predictions.

Healing outcomes and predictors among patients with venous leg ulcers treated with compression therapy

OBJECTIVE

This study aimed to compare the healing outcomes between three types of compression therapy-two-layer bandage (2LB), four-layer bandage (4LB), and compression stockings, and to identify the predictors of venous leg ulcer (VLU) healing.

METHOD

A retrospective review of the medical records of patients diagnosed with VLU between 2011 and 2016 in Singapore was conducted. Univariate and multivariate analyses were done between healed and unhealed VLU patients at three and six months, based on potential factors, ranging from demographic profile to comorbidities and treatment-related variables.

RESULTS

Data from 377 patients' medical records were analysed. The healing rates with the three types of compression system, 4LB, 2LB and compression stockings, were 22.3%, 34.9% and 8.7% respectively at three months; at six months they were 44.2%, 41.9% and 34.8% respectively. Patients on 2LB reported a significantly higher proportion of healed ulcers at three months (p=0.003) but at six months there was no difference in healing rates between the three types of therapy. At three and six months, the duration of compression therapy was found to be an independent predictor of healing (p<0.001).

CONCLUSION

In this study, the 2LB appeared to show the most favourable healing outcome in the short-term but as VLUs persisted beyond the months, the type of compression system used did not make a difference in the healing outcome. Our findings suggested that, as the duration became more prolonged, VLUs became more resistant to healing despite compression therapy. Therefore, it may be necessary for clinicians to consider adjuvant therapies for hard-to-heal ulcers at an earlier stage.

Barriers and enablers to physical activity participation in patients with venous leg ulcers: a systematic review protocol of qualitative evidence

OBJECTIVE

The objective of this review is to synthesize available qualitative evidence to provide an overview of the barriers and enablers that influence physical activity participation in patients with venous leg ulcers.

INTRODUCTION

Management of venous leg ulcers is a costly and time-consuming process in clinical settings due to the protracted healing process. Physical activity may be a useful adjuvant treatment to improve healing outcomes. However, a low level of physical activity is still observed in patients with venous leg ulcers and the reasons are multifactorial. A comprehensive understanding of the barriers and enablers to physical activity participation from different perspectives is crucial to develop workable interventions and achieve desired healing outcomes.

INCLUSION CRITERIA

The review will consider qualitative studies that focus on evidence concerning the barriers and enablers influencing physical activity level in adults diagnosed with venous leg ulcers in all settings.

METHODS

Relevant studies will be searched in MEDLINE, CINAHL Plus, PsycINFO, and Emcare databases. Only studies published in English will be considered, with no date limits. Two independent reviewers will perform title and abstract screening and the full text of potential eligible studies will be retrieved and assessed against the inclusion criteria. All eligible studies will be appraised for methodological quality. Qualitative data will be extracted manually by two independent reviewers. A meta-aggregation approach will be used to pool and categorize findings from the included studies. The ConQual approach will be used to grade the final synthesized findings to determine confidence in the analysis findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021238579.

Potential predictors of quality of life in patients with venous leg ulcers: A cross-sectional study in Taiwan

Internationally, the impact of venous leg ulcers (VLUs) on the quality of life is well recognised; however, in Taiwan, the focus is only on chronic wound management. This cross‐sectional correlational study conducted at the cardiovascular and plastic surgery clinics of a regional teaching hospital between August 2019 and June 2020 investigates venous clinical severity, pain, fatigue, depression, sleep quality, quality of life, and related factors among 167 patients with VLUs. The potential predictors of the quality of life in terms of activities were venous clinical severity (P < 0.001), pain (P = 0.004), and fatigue (P < 0.001) after adjusting for covariates. The potential predictors of the quality of life in terms of the psychological domain were marital status (single/divorced) (P = 0.016), marital status (widowed) (P = 0.027), venous clinical severity (P < 0.001), pain (P = 0.001), and fatigue (P = 0.002). The potential predictors of the quality of life with regard to symptoms were venous clinical severity (P < 0.001), pain (P < 0.001), fatigue (P = 0.001), and depression (P = 0.038). These potential predictors can serve as the basis of interventions for patients with VLUs, such as those related to nutrition or training in wound dressing.

Multidimensional Pain Characteristics in Older Adults with Chronic Venous Leg Ulcers

Objective: Pain affects wound healing, treatment, and quality of life because it has significant impacts on physical, psychological, and social well-being. Despite the fact that more than half of chronic venous leg ulcer (CVLU) patients experience mild-to-moderate pain, the multidimensional characteristics of CVLU pain are not well documented. The objective of this study was to describe the multidimensional pain characteristics, including the sensory, affective, cognitive, and behavioral dimensions, of CVLU before debridement. Approach: Participants (N = 40) were recruited from a wound clinic. We conducted a descriptive analysis of clinical data, including pain, wound, and demographic characteristics, collected at the first visit. Results: The mean age of participants was 70.8 ± 9.1 years, 22 (55%) participants were female, and 35 (87.5%) were white. Participants reported mean current pain intensity (2.9 ± 2.7), least (1.2 ± 2.2) and worst (4.8 ± 3.4) pain intensity in 24 h, and tolerable pain level (4.9 ± 2.64) on a 0-10 scale. They described pain as periodic (66.7%, n = 26) with multiple pain quality descriptors (5.4 ± 2.9). Their past pain treatments provided some pain relief (65%, n = 25). For 68% (n = 27), their pain was the same as they expected. Nearly all had a tendency not to tell others about their pain (95%, n = 38). Innovation: This study is the first to describe the multidimensional pain characteristics of patients with CVLU as measured with PAINReportIt. Conclusion: Patients with CVLU reported willingness to tolerate a relatively high level of pain and experience the level of pain they anticipate. Multidimensional pain assessment will assist clinicians to select individualized therapies to manage pain and improve quality of life for these patients.

Disease acceptance and social support in patients with peripheral vascular diseases treated in the surgical ward

Aim

The purpose of this study is a comparative analysis of the degree of disease acceptance and social support in patients with peripheral vascular diseases and other medical conditions treated in surgery ward.

Design

A cross‐sectional study.

Methods

This cross‐sectional study compares disease acceptance and social support in a group of 212 patients with peripheral vascular diseases and other conditions treated in surgery ward. A standardized Acceptance of Illness Scale (AIS) and Social Support Scale were used to collect the research data.

Results

Overall, on the AIS, 14% of patients with surgical diseases and 34% of patients with vascular diseases had a low disease acceptance rate. A high level of support was demonstrated in 41% of study participants with surgically treated diseases and in 17% of participants with vascular diseases.

β-acetoxyisovaleryl alkannin (AAN-II) from Alkanna tinctoria promotes the healing of pressure-induced venous ulcers in a rabbit model through the activation of TGF-β/Smad3 signaling

Alkannin-based pharmaceutical formulations for improving wound healing have been on the market for several years. However, detailed molecular mechanisms of their action have yet to be elucidated. Here, we investigated the potential roles of AAN-II in improving the healing of pressure-induced venous ulcers using a rabbit model generated by combining deep vein thrombosis with a local skin defect/local skin defect. The extent of healing was evaluated using hematoxylin and eosin (HE) or vimentin staining. Rabbit skin fibroblasts were cultured for AAN-II treatment or TGFB1-sgRNA lentivirus transfection. ELISA was used to evaluate the levels of various cytokines, including IL-1β, IL-4, IL-6, TNF-α, VEGF, bFGF, TGF-β and PDGF. The protein levels of TGF-β sensors, including TGF-β, Smad7 and phosphor-Smad3, and total Smad3, were assayed via western blotting after TGF-β knockout or AAN-II treatment. The results show that, for this model, AAN-II facilitates ulcer healing by suppressing the development of inflammation and promoting fibroblast proliferation and secretion of proangiogenic factors. AAN-II enhances the activation of the TGF-β1-Smad3 signaling pathway during skin ulcer healing. In addition, the results demonstrate that AAN-II and TGF-β have synergistic effects on ulcer healing. Our findings indicate that AAN-II can promote healing of pressure-induced venous skin ulcers via activation of TGF-β-Smad3 signaling in fibroblast cells and provide evidence that could be used in the development of more effective treatments.

Clinical and cost efficacy of advanced wound care matrices in the treatment of venous leg ulcers: a systematic review

BACKGROUND

Venous leg ulcers (VLUs) are hard-to-heal, recurrent and challenging to treat. Advanced wound care matrices (AWCMs) have been developed to supplement conventional therapies. These costly AWCMs warrant careful comparison as healthcare expenditures are subjected to increasing scrutiny.

AIM

This study was designed to compare AWCMs in their ability to heal VLUs and their cost efficacy through a systematic review of randomised controlled trials (RCTs).

METHOD

An organised search of Medline, Cochrane Library, Central and CINAHL databases identified RCTs that compared AWCMs to standard compression therapy in the healing of VLUs. Bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Eight studies analysing bilayered skin substitute (BSS) (Apligraf), dehydrated human amnion/chorion membrane (dHACM) (Epifix), human fibroblast-derived dermal substitute (HFDDS) (Dermagraft), extracellular wound matrix (ECM) (Oasis), advanced matrix (AM) (Talymed) and matrix wound dressing (MWD) (Promogran) met the inclusion criteria.

RESULTS

Four studies reported significant improvement over standard therapy: BSS, dHACM, ECM and AM. Incremental cost per additional successful treatment was determined for each trial, ranging from $2593 (MWD) to $210,800 (HFDDS).

CONCLUSION

Our consolidated analysis of eight major RCTs of AWCMs in the treatment of VLUs revealed a great variation in clinical and cost efficacy among these products. The included trials were inconsistent in methodology, and these limitations should be noted, but, in the absence of RCTs to compare these products, our systematic review may serve as a guide for practitioners who seek to optimise wound healing while considering cost efficacy.

Hyperbaric Oxygen Therapy for Venous Leg Ulcers: A 6 Year Retrospective Study of Results of a Single Center

Background: Venous leg ulcers (VLUs) are common and have a large impact on healthcare budgets worldwide. Hyperbaric oxygen therapy (HBOT) may improve healing of these ulcers. Methods: Retrospective, single-center cohort study between 2013 and 2019. All patients with a VLU from an outpatient clinic providing HBOT and wound care were included. The primary outcome measure was wound healing, determined at discharge from the center. Other outcome measures were improvement in patient related outcome measures (PROMs), as assessed by the EQ-5D-3L questionnaire and including quality of life (QoL) and pain score. Results: Fifty patients were included, 53% female, with a mean age of 73.4 (±12.2). Most wounds (83%) had existed longer than 3 months before starting treatment. Patients received an average of 43 (±20) sessions of HBOT. After treatment, 37 patients (63%) achieved complete or near-complete wound healing. Wound size decreased from a median of 14 cm² [interquartile range (IQR) 32 cm²] to 0.5 cm² (IQR 5.3 cm²), a median decrease of 7.5 (IQR 16.2 cm²) in cm² (94%). Patients mostly reported improvement for all health aspects on the questionnaire. Pain score decreased from 5.7 (±2.5) to 2.1 (±2.2) (p < 0.0001) and health score increased from 57.2 (±15.6) to 69.9 (±18.9) (p = 0.02). Conclusions: Patients with non-healing VLUs may benefit from HBOT to achieve complete or substantial wound healing. We recommend a well-designed randomized clinical trial with a number of patients allowing enough statistical power, and of a reasonable duration, to establish the potential of additional HBOT on hard-to-heal venous ulcers.

Physical Activity as an Adjunct to Compression Therapy on Healing Outcomes and Recurrence in Patients With Venous Leg Ulcers: A Scoping Review Protocol

Background: Chronic venous leg ulceration is a common and costly clinical issue across the world, affecting up to 3 in 1,000 people. Compression therapy is recommended as the gold standard treatment in clinical practice, although a large number of venous leg ulcers remain unhealed after several years. Physical activity may improve healing although there is limited evidence on the effects of physical activity as an adjuvant treatment to compression to improve venous leg ulcers healing and prevent recurrence. Objectives: This scoping review protocol aims to systematically search, appraise, and synthesize quantitative research evidence to assess the effect of physical activity interventions applied in conjunction with compression therapy on venous leg ulcer healing and recurrence. Methods and Analysis: We will use the methodology framework suggested by Arksey and O'Malley, Levac et al., the JBI as a guide. We will also follow the three-step search strategy recommended by the JBI to systematic search for relevant published research, ongoing clinical trials, and grey literature. Two review authors will independently screen titles and abstracts followed by full-text review to determine final eligibility for inclusion. The search process will be reported using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. Characteristics of physical activity interventions, primary outcomes related to ulcer healing and recurrence, and secondary outcomes of interest included quality of life, pain level, adverse effects, and economic costs will be extracted and summarized. The review will provide a descriptive account of the findings from included studies. Where appropriate, data will be pooled for a meta-analysis using a random effects model. Discussion: Physical activity interventions represent a low-cost, potentially useful adjuvant treatment to compression therapy for the management of venous leg ulcers. Several gaps in knowledge remain that are answerable via a targeted scoping review. This protocol outlines the rationale, objectives, and the planned methodology for conducting the study. Ethics and Dissemination: The scoping review will use data from publicly available sources and ethical approval is not required. Findings from this review will be submitted to a peer-reviewed journal, presented at relevant conferences and disseminated via social media.

Thermal imaging potential and limitations to predict healing of venous leg ulcers

Area analysis of thermal images can detect delayed healing in diabetes foot ulcers, but not venous leg ulcers (VLU) assessed in the home environment. This study proposes using textural analysis of thermal images to predict the healing trajectory of venous leg ulcers assessed in home settings. Participants with VLU were followed over twelve weeks. Digital images, thermal images and planimetry of wound tracings of the ulcers of 60 older participants was recorded in their homes by nurses. Participants were labelled as healed or unhealed based on status of the wound at the 12th week follow up. The weekly change in textural features was computed and the first two principal components were obtained. 60 participants (aged 80.53 ± 11.94 years) with 72 wounds (mean area 21.32 ± 51.28cm2) were included in the study. The first PCA of the change in textural features in week 2 with respect to week 0 were statistically significant for differentiating between healed and unhealed cases. Textural analysis of thermal images is an effective method to predict in week 2 which venous leg ulcers will not heal by week 12 among older people whose wounds are being managed in their homes.

Single ALA-PDT irradiation induces increase in mast cells degranulation and neuropeptide acute response in chronic venous ulcers: A pilot study

BACKGROUND

The behavior of mast cells, their interaction with neuronal cells or nerve fibers, the expression of neuropeptides and the distribution of skin neuronal cells or nerve fibers after ALA-PDT treated vs untreated chronic wounds were investigated.

METHODS

Nineteen patients suffering from chronic venous ulcers (CVU) were enrolled in this study. Skin samples from wound bed before and after irradiation with ALA-PDT were taken. All specimens were anonymized and analyzed by immunohistochemistry.

RESULTS

After completion of ALA-PDT, mast cells showed an increase of degranulation index and expression of NGF and VIP. Amongst all the neuronal mediators tested, all except for SP showed an increase of cellular expression after ALA-PDT therapy.

CONCLUSION

Our study shows preliminary evidences that ALA-PDT induces rapid recruitment of mast cells around dermal fibers in chronic venous ulcers. This finding is also associated with increase in expression of multiple peripheral neuropeptides except SP by skin neuronal cells. ALA-PDT may promote healing of chronic venous ulcers via stimulation of quiescent peripheral nerves, possibly after release of inflammatory molecules by degranulating mast cells.

Study protocol for a multicentre, randomised controlled trial to compare the use of the decellularised dermis allograft in addition to standard care versus standard care alone for the treatment of venous leg ulceration: DAVE trial

INTRODUCTION

Venous leg ulceration (VLU), the most common type of chronic ulcer, can be difficult to heal and is a major cause of morbidity and reduced quality of life. Although compression bandaging is the principal treatment, it is time-consuming and bandage application requires specific training. There is evidence that intervention on superficial venous incompetence can help ulcer healing and recurrence, but this is not accessible to all patients. Hence, new treatments are required to address these chronic wounds. One possible adjuvant treatment for VLU is human decellularised dermis (DCD), a type of skin graft derived from skin from deceased tissue donors. Although DCD has the potential to promote ulcer healing, there is a paucity of data for its use in patients with VLU.

METHODS AND ANALYSIS

This is a multicentre, parallel group, pragmatic randomised controlled trial. One hundred and ninety-six patients with VLU will be randomly assigned to receive either the DCD allograft in addition to standard care or standard care alone. The primary outcome is the proportion of participants with a healed index ulcer at 12 weeks post-randomisation in each treatment arm. Secondary outcomes include the time to index ulcer healing and the proportion of participants with a healed index ulcer at 12 months. Changes in quality of life scores and cost-effectiveness will also be assessed. All analyses will be carried out on an intention-to-treat (ITT) basis. A mixed-effects, logistic regression on the outcome of the proportion of those with the index ulcer healed at 12 weeks will be performed. Secondary outcomes will be assessed using various statistical models appropriate to the distribution and nature of these outcomes.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Bloomsbury Research Ethics Committee (19/LO/1271). Findings will be published in a peer-reviewed journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN21541209.

Evaluation of timolol maleate gel for management of hard-to-heal chronic venous leg ulcers. Phase II randomised-controlled study

BACKGROUND

Venous leg ulcers (VLUs) often take a very long time to heal. Timolol maleate has been reported as displaying efficacy in healing of VLUs.

OBJECTIVES

To evaluate the efficacy of timolol maleate gel in the management of hard-to-heal VLUs and to assess its safety as a topical agent during 12 weeks of use in combination with conventional treatment.

METHODS

A prospective, phase-II randomised-controlled trial with a sample size based on Fleming's one-stage design (P0=0.25, P1=0.45, alpha=0.1, beta=0.2) was planned. Patients with VLUs present for ≥24 weeks and with ≥50% granulation tissue were included. One drop of sustained-release timolol gel (Timoptol® LP 0.5%, Santen, Tampere, Finland) per 6 cm² VLU area was applied every 2 days for 12 weeks in timolol-treated patients, as adjuvant therapy to the standard care protocol (interface dressing and multilayer venous compression). Controls received standard care alone. The primary endpoint was to obtain ≥40% reduction in ulcer area at week 12 (W12).

RESULTS

Forty-three patients were randomised to the study, with 40 receiving at least one treatment and included in the analysis: 21 timolol-treated patients and 19 controls (females: 70%; median age: 72.5 [range 35-93] years). At W12, ≥40% ulcer-area reduction was achieved in 14/21 (67%) timolol-treated patients vs. 6/19 (32%) controls. No serious adverse events occurred. Local wound infections not requiring systemic antibiotics occurred in 5 cases in the timolol group and in one case in the controls.

CONCLUSIONS

These results support the benefit and safety of using timolol maleate to manage hard-to-heal VLUs, but confirmation is required in a larger multicentre randomised phase-III study.

A randomised controlled clinical trial comparing the effectiveness of bandaging compared to the JuxtaCures™ device in the management of people with venous ulceration: Feasibility study

INTRODUCTION

The mainstay of treatment for venous ulceration remains compression therapy. Velcro Wrap devices are being increasingly used in these patients despite limited evidence. This feasibility study aimed to compare standard bandaging to the JuxtaCures™ Velcro wrap device.

METHODS

A single centre, unblinded RCT compared participants with venous ulceration randomised to either the JuxtaCures™ device or short stretch bandaging. Participants were followed up for 26 weeks.

RESULTS

160 participants were screened with 40 randomised. 3 participants in bandaging and 1 in JuxtaCures™ didn't complete the study. 60% in JuxtaCures™ healed v 55% in bandaging despite larger ulcers in the JuxtaCures™ arm (9.33 cm² v 6.97 cm²). There was no significant difference in time to healing (12.17 v 13.64 weeks). JuxtaCures™ showed improved ulcer reduction for those that didn't heal (14.91-5.00 cm² v 14.20-8.62 cm²; P = 0.06). JuxtaCures™ had more consistent sub-bandage pressure dropping from 39-36 mmHg versus 41-25 mmHg in bandaging between application and removal (P < 0.001). Quality of life (EQ5D) was improved in JuxtaCures at 3 months (mean difference 0.14, p = 0.04), but not at 1 and 6 months, or in disease specific quality of life. Cost was lower in JuxtaCures™ £842.47 v £1064.68. Duration of appointment was significantly shorter in JuxtaCures™ (41 minutes v 53 minutes; P = 0.003).

CONCLUSION

This study has shown the feasibility and necessity of running a multicentre trial to evaluate the use of Velcro wrap devices for venous ulceration. It highlights the potential benefits of more consistent pressure, increased self-care, and potential with regards to ulcer healing, cost, nursing resource and quality of life.

Ten years of experience with first-visit foam sclerotherapy to initiate venous ulcer healing

OBJECTIVE

We evaluated the effect of first-visit foam sclerotherapy compared with scheduled treatment for patients with venous ulceration.

METHODS

The study design was a retrospective comparative study. From December 2009 to October 2019, a total of 245 venous ulcers in 214 patients (including recurrent ulcers) were treated at Oulu University Hospital. Of these 245 venous ulcers, 143 were treated with first-visit foam sclerotherapy (group A) and 102 with scheduled treatment (group B). All patients received endovenous ablation (foam sclerotherapy and/or endothermal ablation) and compression therapy to promote venous ulcer healing. The primary outcome was the interval to ulcer healing, determined by Kaplan-Meier survival analysis. The secondary outcomes included the time to ulcer healing from the receipt of referral and ulcer recurrence.

RESULTS

The median time to ulcer healing was 2.3 months for group A and 3.2 months for group B (P = .002). The estimated median ulcer healing times after referral for a first session of endovenous ablation were 2.7 months with a delay of <1 month from the referral, 3.3 months with a delay of 1 to 2 months, and 5.0 months with a delay of >2 months (P = .002). In group A, recurrent ulcers were recorded for 11 patients (7.7%). In group B, recurrent ulcers were recorded for 12 patients (11.8%; P = .281).

CONCLUSIONS

The results of the present retrospective comparative study support first-visit foam sclerotherapy as an effective method to initiate endovenous ablation to promote venous ulcer healing. In venous ulcers, delays to endovenous ablation should be avoided whenever possible.

Wound Care During the COVID-19 Emergency in Padua Hospital, Italy

Chronic vascular wounds have a significant economic and social impact on our society, calling for the allocation of a great deal of attention and resources. The coronavirus disease (COVID-19) outbreak has represented a difficult challenge to face for health care providers and fragile patients, such as for outpatients and Day-Hospital patients needing continuous care at the Angiology Unit of the University Hospital of Padova in Italy, one of the most crucial areas worldwide. The project consisted of a critical revision of all the procedures from the patients’ arrivals to their discharge after completing the entire course of treatment. The previous standard of practice was modified according to the current evidence-based guidelines and the national and local government’s indications. The new standard of practice allowed our unit to protect every patient and staff member from the coronavirus infection, providing the same high standard of care as before the COVID-19 outbreak.

Standing and sitting postures at work and symptoms of venous insufficiency - results from questionnaires and a Doppler ultrasound study

Chronic venous insufficiency is the most common vascular disease. One of the major risk factors for its development is long-term sitting or standing in the same position and the nature of the work performed. This study aimed to evaluate the incidence of chronic venous insufficiency in a group of persons employed in workplaces with a predominance of standing or sitting positions, and to determine work-related and non-work risk factors. The research used two tools: questionnaires and medical examinations. The survey comprised 500 people, including 238 men (47.6%) and 262 women (52.4%), aged 25-60 years, 39.75 ± 10.80 years old on average. In addition, a group of 100 randomly selected people was subjected to medical examinations to confirm or exclude chronic venous insufficiency symptoms in the study group. The study showed a statistically significant correlation between postures adopted at work and the symptoms of chronic venous insufficiency of the lower limbs.

Type I collagen matrix plus polyhexamethylene biguanide antimicrobial for the treatment of cutaneous wounds

Aim: Determine the effectiveness of purified native type I collagen matrix plus polyhexamethylene biguanide antimicrobial (PCMP) on cutaneous wounds. Materials & methods: A prospective cohort study of 307 patients (67 venous leg ulcers, 62 diabetic foot ulcers, 45 pressure ulcers, 54 post-surgical wounds and 79 other wounds) was conducted. Results: Cox wound closure for PCMP was 73% at week 32. The median time to wound closure was 17 weeks (Kaplan-Meier). The incidence of PCMP-treated wounds showing >60% reductions in areas, depths and volumes were 81, 71 and 85%, respectively. Conclusion: PCMP demonstrated clinically meaningful benefits to patients with various types of cutaneous wounds. Clinical Trial registration number: NCT03286452.

Clinical and economic burden of wound care in the tropics: a 5-year institutional population health review

The aim of this study is to evaluate the clinical and economic burden of wound care in the Tropics via a 5-year institutional population health review. Within our data analysis, wounds are broadly classified into neuro-ischaemic ulcers (NIUs), venous leg ulcers (VLUs), pressure injuries (PIs), and surgical site infections (SSIs). Between 2013 and 2017, there were a total of 56 583 wound-related inpatient admissions for 41 461 patients, with a 95.1% increase in wound episodes per 1000 inpatient admissions over this period (142 and 277 wound episodes per 1000 inpatient admissions in 2013 and 2017, respectively). In 2017, the average length of stay for each wound episode was 17.7 days, which was 2.4 times that of an average acute admission at our institution. The average gross charge per wound episode was USD $12 967. Among the 12 218 patients with 16 674 wound episodes in 2017, 71.5% were more than 65 years of age with an average Charlson Comorbidity Index (CCI) of 7.2. Half (51.9%) were moderately or severely frail, while 41.3% had two or more wound-related admission episodes. In 2017, within our healthcare cluster, the gross healthcare costs for all inpatient wound episodes stand at USD $216 million within hospital care and USD $596 000 within primary care. Most NIU patients (97.2%) had diabetes and they had the most comorbidities (average CCI 8.4) and were the frailest group of patients (44.9% severely frail). The majority of the VLU disease burden was at the specialist outpatient setting, with the average 1-year VLU recurrence rate at 52.5% and median time between healing and recurrence at 9.5 months. PI patients were the oldest (86.5% more than 65 years-old), constituted the largest cohort of patients with 3874 patients at an incidence of 64.6 per 1000 admissions in 2017, and have a 1-year all-cause mortality rate of 14.3%. For SSI patients, there was a 125% increase of 14.2 SSI wound episodes per 1000 inpatient admissions in 2013 to 32.0 in 2017, and a 413% increase in wound-related 30-day re-admissions, from 40 in 2013 (4.1% of all surgeries) to 205 (8.3% of all surgeries) in 2017. The estimated gross healthcare cost per patient ranges from USD $15789-17 761 across the wound categories. Similar to global data, there is a significant and rising trend in the clinical and economic burden of wound care in Tropics.

The effect of natural matrix biopolymer membrane on hard-to-heal venous leg ulcers: a pilot randomised clinical trial

OBJECTIVE

The aim of this study was to evaluate the therapeutic effects of natural matrix biopolymer membrane (NMBM) in the treatment of venous leg ulcers (VLUs).

METHOD

Patients exhibiting one or more VLU were assigned to a test group receiving NMBM or to a control group receiving conventional treatment. Patients exhibiting venous insufficiency-related ulcers within 0.1-170cm² were included. Efficacy was assessed based on ulcer size and visual analogue scale (VAS) pain scores at baseline and at weeks one, two and four. Ulcer size and pain were compared between groups using a two-way ANOVA.

RESULTS

In this study, 25 patients with 32 VLUs (NMBM group: 14 patients with 17 ulcers; control group: 11 patients with 15 ulcers) were included in the final analysis. At four weeks after baseline measurements, the mean percentage change in VLU area of patients in the NMBM group was 61.6% (95% CI: 40.3-82.9) compared with 84.1% (95% CI: 56.5-111.7) for control group patients. Additionally, the mean percentage change in VLU volume of NMBM group patients was 51.2% (95% CI: 31.8-70.6) compared with 84.0% (95% CI: 57.0-121.0) for control group patients. The NMBM group patients exhibited a mean decrease of 0.38 (95% CI: -0.85-1.61) in VAS pain score over four weeks, compared with a mean decrease of 0.13 (95% CI: -1.32-1.58) for control group patients. No significant differences in VLU area (p=0.210), volume (p=0.122) or VAS pain score (p=0.460) were shown between groups.

CONCLUSION

NMBM was found to be as effective and safe as the control group treatments. This pilot study suggests NMBM can be used safely to promote ulcer healing.

Nanomaterials for Angiogenesis in Skin Tissue Engineering

Damage to skin tissue, which causes the disorder of the patient's body homeostasis, threatens the patient's life and increases the personal and social treatment burden. Angiogenesis, a key step in the wound healing process, provides sufficient oxygen and nutrients to the wound area. However, traditional clinical interventions are not enough to stabilize the formation of the vascular system to support wound healing. Due to the unique properties and multiple functions of nanomaterials, it has made a major breakthrough in the application of medicine. Nanomaterials provide a more effective treatment to hasten the angiogenesis and wound healing, by stimulating fundamental factors in the vascular regeneration phase. In the present review article, the basic stages and molecular mechanisms of angiogenesis are analyzed, and the types, applications, and prospects of nanomaterials used in angiogenesis are detailed. Impact statement Wound healing (especially chronic wounds) is currently a clinically important issue. The long-term nonhealing of chronic wounds often plagues patients, medical systems, and causes huge losses to the social economy. There is currently no effective method of treating chronic wounds in the clinic. Angiogenesis is an important step in wound healing. Nanomaterials had properties that are not found in conventional materials, and they have been extensively studied in angiogenesis. This review article provides readers with the molecular mechanisms of angiogenesis and the types and applications of angiogenic nanomaterials, hoping to bring inspiration to overcome chronic wounds.

Factors that influence venous leg ulcer healing and recurrence rate after endovenous radiofrequency ablation of incompetent saphenous vein

OBJECTIVE

Endovenous radiofrequency ablation (RFA) is one of the most popular techniques for correcting superficial vein reflux. However, the effectiveness of RFA of superficial vein reflux in patients with active or healed venous leg ulcer (VLU) is unknown. Accordingly, the objective of this study was to evaluate the healing rate, the recurrence rate, and the factors significantly associated with healing and recurrence in patients with active or healed VLU who had superficial venous reflux treated with RFA.

METHODS

We retrospectively reviewed all healed VLU or active VLU patients treated with RFA at the Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January 2011 to December 2017 to evaluate the rate of VLU healing and recurrence. Time to healing and time to ulcer recurrence were determined by Kaplan-Meier survival analysis. Risk factors were assessed to determine their association with VLU healing and recurrence by Cox regression survival analysis.

RESULTS

RFA of the great saphenous vein (n = 56), anterior accessory saphenous vein (n = 5), or both (n = 1) was performed on 62 limbs with active (n = 32) or healed (n = 30) VLUs. The mean age of patients was 65.4 ± 9.8 years, and 80% were female. Deep venous insufficiency was present in 10 limbs (16%). Pathologic perforating vein was found in 17 patients (27%). Concomitant ultrasound-guided foam sclerotherapy (UGFS) of the pathologic perforating vein was performed in 12 limbs (19%). Concomitant phlebectomy was performed in 19 limbs (31%). The median follow-up time was 753 days after RFA. VLU healed in 31% of patients at 3 months, in 56% at 6 months, and in 66% at 1 year after RFA. Concomitant UGFS of the pathologic perforating vein was the only factor significantly associated with VLU healing (hazard ratio, 2.84; 95% confidence interval, 1.07-7.55; P = .037). VLU recurrence was found in 8% of patients at 1 year, in 14% at 2 years, and in 23% at 3 years after RFA. Deep vein reflux was the only identified risk factor for VLU recurrence (hazard ratio, 3.72; 95% confidence interval, 1.05-13.21; P = .042).

CONCLUSIONS

UGFS of the pathologic perforating vein at the time of RFA of saphenous vein reflux improved VLU healing. VLU recurrence was more frequent in patients with concomitant deep vein reflux. The authors suggest performing UGFS of the pathologic perforating vein at the time of RFA to improve VLU healing and monitoring of patients with associated deep vein reflux for ulcer recurrence.

Prothrombotic clot properties can predict venous ulcers in patients following deep vein thrombosis: a cohort study

Venous ulcers are the most severe manifestation of post-thrombotic syndrome (PTS). We have previously demonstrated that formation of compact fibrin clots resistant to lysis is observed in patients following deep-vein thrombosis (DVT) who developed PTS. The current study investigated whether unfavourable fibrin clot properties can predict post-thrombotic venous ulcers. In a cohort study on 186 consecutive patients following DVT, we determined plasma fibrin clot characteristics, including clot permeability and lysability, inflammatory markers, thrombin generation, fibrinolysis proteins at 3 months since the index event. Occurrence of PTS and venous ulcers was recorded during follow-up (median, 53; range 24 to 76 months). Fifty-seven DVT patients (30.6%) developed PTS, including 12 subjects (6.45%) with a venous ulcer (4 individuals with recurrent ulcers). Patients who developed ulcers compared with the remainder had at enrolment 13.0% lower clot permeability (Ks), 17.4% longer clot lysis time (CLT), 13.1% longer lag phase of clot formation, and 5.0% higher maximum absorbance, with no difference in fibrinogen, C-reactive protein, and thrombin generation. The baseline prothrombotic fibrin clot phenotype (Ks ≤ 6.5 × 10-9 cm2 and CLT > 100 min) was associated with a higher risk of ulcers [hazard ratio (HR), 5.37; 95% confidence interval (CI), 1.3-21.5]. A multivariate model adjusted for age, sex, and fibrinogen showed that independent predictors of the ulcer occurrence were body mass index (HR 1.53; 95% CI 1.30-1.86), CLT (HR 1.43; 95% CI 1.04-2.05), and α2-antiplasmin (HR 0.95; 95% CI 0.90-0.99). This study suggests that formation of denser fibrin clots with impaired fibrinolysis predisposes to post-thrombotic venous ulcers.