A large Italian observational multicentre study on vascular ulcers of the lower limbs (Studio Ulcere Vascolari)

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.

Sulodexide for Diabetic-Induced Disabilities: A Systematic Review and Meta-Analysis

INTRODUCTION

Micro- and macrovascular complications of diabetes are leading morbidities in the world population. They are responsible not only for increased mortality but also severe disabilities, which jeopardize quality of life (e.g., blindness, walking limitations, and renal failure requiring dialysis). The new antidiabetic agents (e.g., glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter inhibitors) are increasingly recognized as breakthrough agents in the treatment of diabetes and prevention of diabetic complications. However, drugs effective in preventing and treating diabetic disabilities are still needed and sulodexide could be one of those able to address the unmet clinical needs of the new antidiabetic agents.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal. We also manually searched potentially relevant journals, conference proceedings, and journal supplements. Any study monitoring any effect of sulodexide in subjects with diabetes, in relation to renal, vascular, and ocular complication, was considered. Treatment effects were estimated using standardized mean differences (SMDs), mean differences (MDs), and risk ratios (RRs), as appropriate. We calculated 95% confidence interval (CIs) and heterogeneity (Q, tau, and I²).

RESULTS

The search found 45 studies with 2817 participants (mean age 57 years; 63% male). The 26 randomized controlled studies included 2074 participants (mean age 58.8 years; 66% male). Sulodexide reduced the impact of diabetic retinopathy; increased the pain-free and maximal walking distance in peripheral arterial disease; accelerated the healing of diabetes-associated trophic ulcers; and decreased the rate of albumin excretion in subjects with nephropathy. The risk of adverse events (AEs) was not different between sulodexide and controls.

CONCLUSION

Sulodexide has a beneficial effect on the ocular, peripheral arterial disease, trophic ulcers, and renal complications of diabetes without increasing the risk of AEs.

Anthropometric, Biochemical, and Food Consumption Parameters are Associated with Venous Leg Ulcer Area and Duration

OBJECTIVE

To describe the dietary habits and anthropometric and biochemical parameters of patients with active venous leg ulcers and to verify the association of these variables with wound duration and area.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study conducted with 33 participants diagnosed with venous leg ulcers in outpatient care.

MAIN OUTCOME MEASURES

Socioeconomic data, anthropometric parameters, biochemical parameters, food consumption, and wound characteristics were analyzed by an interprofessional team.

MAIN RESULTS

Participants were an average of 58 ± 13 years, 57.6% women, 84.8% overweight, and had a median wound duration of 10 months (range, 1-192 months) and an average wound area of 5 cm (range, 0.22-61.1 cm). Diets were typically hypocaloric and hypoproteic, with a low amount of vitamin A and magnesium. Wound duration was negatively associated with polyunsaturated fat intake (P = .032), whereas wound area was significantly associated with lipid intake (P = .002) and C-reactive protein (P = .040).

CONCLUSIONS

Patients with active venous leg ulcers were overweight (leading to systemic inflammation) and had low consumption of calories, protein, and micronutrients that could support cicatrization. Wound area was associated with a high-fat diet, whereas wound duration was negatively associated with polyunsaturated fat intake.

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

BACKGROUND

A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes.

OBJECTIVES

To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area.

METHODS

A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting.

RESULTS

twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm²; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together.

CONCLUSION

a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.

Sulodexide for the Symptoms and Signs of Chronic Venous Disease: A Systematic Review and Meta-analysis

INTRODUCTION

Chronic venous disease (CVD) is a common condition associated with valvular dysfunction, venous hypertension and endothelial inflammation. Sulodexide facilitates the healing of venous ulcers and is frequently used in patients with CVD without ulcer. This review assessed the efficacy and safety of sulodexide for treatment of signs and symptoms of lower extremity CVD.

METHODS

We searched MEDLINE, EMBASE, CINAHL and AMED as well as the Cochrane Central Register of Controlled Trials and the World Health Organisation (WHO) International Clinical Trials Registry Platform Search Portal. We also manually searched potentially relevant journals, conference proceedings and journal supplements. Any study monitoring any effect of sulodexide in patients with CVD at any stage of the disease, classified or non-classified, was considered. Treatment effects were estimated using standardised mean differences (SMDs), mean differences (MDs) and risk ratios (RRs), as appropriate. We calculated 95% confidence intervals (CIs) and heterogeneity (Q, tau and I²).

RESULTS

The search found 64 studies, but only 23 provided data on 7153 participants (mean age 55 years; 68% female). The 13 studies providing extractable quantitative information included 1901 participants (mean age 55.2 years; 65% female). Sulodexide decreased the intensity of pain, cramps, heaviness, oedema and total symptom score and reduced inflammatory mediators in patients with CVD. The risk of adverse events (AEs) was not different between sulodexide and placebo or heparan sulphate (RR 1.31, 95% CI 0.74-2.32; I² = 0%; 270 participants). The overall risk of AEs with sulodexide was low: 3% (95% CI 1-4%) estimated from 3656 participants.

CONCLUSION

Sulodexide was found to have a beneficial venoactive effect on the major signs and symptoms of CVD such as pain, cramps, heaviness and oedema without increasing the risk of AEs. It is also likely to exert a systemic effect on the course of CVD by interfering with inflammatory chemokines.

Effects and associations of nutrition in patients with venous leg ulcers: A systematic review

AIMS

To identify the associations and effects of nutritional characteristics and interventions on ulcer outcomes in adult patients with venous leg ulcers.

BACKGROUND

Venous leg ulcers are the most prevalent type of lower limb ulcer; however, little evidence exists regarding the relationship between nutritional status and ulcer healing.

DESIGN

A systematic search of English language articles was conducted using the Cochrane Collaboration Handbook for Systematic Reviews of Interventions.

DATA SOURCES

A search of databases Ovid MEDLINE, EMBASE, Cochrane, CINAHL and Scopus was performed for studies published between January 2004 - May 2017.

REVIEW METHODS

Quality of the included studies was assessed using the Cochrane Collaboration's Risk of Bias Assessment tool and the relevant Joanna Briggs Institute quality appraisal checklists.

RESULTS

Twenty studies met the inclusion criteria. All participants had Clinical Aetiology Anatomy Pathophysiology classification C5 (healed) or C6 (active) ulcers. Studies were conducted in a range of clinical settings with relatively small sample sizes. The majority of patients were overweight or obese. Increased body mass index was associated with delayed wound healing. Vitamin D, folic acid and flavonoids were associated with some beneficial effects on ulcer healing. Dietary intakes of omega-3 fatty acids, vitamin C and zinc were low for some patients.

CONCLUSION

Current evidence suggests that venous leg ulcer patients are more likely to be overweight or obese. However, evidence for weight management improving wound healing is lacking. Micronutrients, including vitamin D and folic acid, may improve wound healing in at-risk patients.

May-Thurner syndrome: an often overlooked cause for refractory venous leg ulcers

We report a 53-year-old female patient presenting with a refractory venous leg ulcer and unremarkable findings in the doppler Ultrasound venous mapping of the leg veins. Further comprehensive diagnostics demonstrated an underlying May-Thurner syndrome. After resolution of the primary mechanical obstruction, rapid wound healing in the following 3 weeks was documented. Iliac vein compression syndrome, commonly known as May-Thurner syndrome, is a distinguishable anatomical variant that results from an external compression over the left iliac vein exerted by the overriding adjacent right common iliac artery. It is mostly seen among young, healthy female patients and can easily be under-diagnosed. Lower extremities duplex ultrasonography remains the gold standard in diagnosing venous insufficiency, but it should not solely depend on it. Instead, clinicians should consider other possibilities, assessing the patency within the truncal veins, which in turn might contribute to the venous insufficiency along the lower limbs. An active early diagnostic approach can prevent significant overall morbidity and help patients to ease back into their daily-life activities. Therefore, it is recommended that all patients with suspected venous insufficiency and normal lower limbs duplex findings should undergo further evaluation of the truncal venous system pattern. May-Thurner syndrome, along with other causes of iliac veins compression, should be considered in the differential diagnosis in unclear persistent cases of unilateral venous symptoms.

Impact of optimal anticoagulation therapy on chronic venous ulcer healing in thrombophilic patients with post-thrombotic syndrome

OBJECTIVE

Post-thrombotic syndrome (PTS) is the long-term sequelae of deep venous thrombosis (DVT). PTS clinical manifestations include chronic leg pain, oedema, lipodermatosclerosis and ulcers. The objective of this study is to determine in patients with documented history of thrombophilias and DVT whether the number of previous thrombotic events and optimal anticoagulation therapy are associated with the time to venous ulcer healing following the start of compression therapy.

METHOD

Retrospective analysis performed in thrombophilic patients under the age of 50 years old with chronic venous ulcers secondary to DVT at the wound clinic in the National Institute of Medical Sciences and Nutrition 'Salvador Zubirán ' in Mexico City. Variables such as the number or episodes of thrombotic events, type of hypercoagulable disorder, optimal anticoagulation therapy with Warfarin monitored by therapeutic International Normalised Ratio (INR) (2-3) and compliance to compression therapy were examined. Patients that underwent superficial or perforator vein interruption or endovascular recanalisation of deep veins were excluded from the study.

RESULTS

From a database of 29 patients with chronic venous ulcers followed in our clinic from January 1992 to September 2012, only 13 patients (61% female) met the inclusion criteria. Mean age±standard deviation (SD) was 32±12 years old. Of these, seven (54%) patients with suboptimal INR presented with an average of two previous thrombotic events and the remaining six (46%) patients with optimal INR only one event (p=0.28), the mean time to the clinical manifestation of a venous ulcer after the first episode of DVT was 39 months (range: 12-72) for patients with suboptimal INR and 82 months (range: 12-216) for those with optimal anticoagulation therapy (p=0.11). During the mean follow-up period of 52 months, all patients in optimal anticoagulation healed their ulcer; their mean time for wound healing was 44 months (range: 4-102). In the suboptimal INR group, only four healed the ulcers with an mean of 72 months (range: 2-204) (p=0.94).

CONCLUSION

There seems to be an association between an optimal anticoagulation therapy with Warfarin monitored by INR and wound healing rates in thrombophilic patients with chronic venous ulcers. Further research is warranted.

DECLARATION OF INTEREST

The authors have no conflict of interest.