Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool

An overview of systematic reviews of clinical studies of platelet-rich plasma for venous ulcers

To evaluate the clinical evidence of platelet-rich plasma (PRP) in the treatment of venous ulcers (VUs). Electronic searches were conducted through the Cochrane Library, Web of Science, Embase and PubMed. AMSTAR-2 was used to assess the methodological quality. The quality of evidence was assessed using the GRADE system. According to AMSTAR-2, the methodological quality of the included reviews was generally inadequate owing to the limitations of entries 2, 4 and 7. Due to bias risk and imprecision, the evidence quality of the outcome measures was inadequate. In conclusion, PRP may have a therapeutic effect on VUs. However, this conclusion must be treated with caution due to methodological flaws of the included systematic reviews and meta-analyses.

Supporting patients with venous leg ulcers in self-care monitoring: an interview study with primary health care professionals

OBJECTIVE

This study described the experiences and perceptions of how primary health care professionals (PHCPs) support patients with venous leg ulcers (VLUs) in self-care monitoring.

DESIGN

A qualitative approach with reflexive thematic analysis was used, with 24 individual qualitative open interviews.

SETTING

Primary health care clinics and community health care in four southern regions in Sweden.

SUBJECTS

Registered nurses, district nurses and nurse assistants who had experience of caring for patients with VLUs. In total, 24 interviews were conducted with PHCPs in Sweden.

RESULTS

PHCPs have a vital role in promoting patient independence and responsibility, identifying needs and adapting care strategies, while also recognising unmet needs in patients with VLUs.

CONCLUSION

PHCPs actively monitor patients' self-care and establish caring relationships. They see a need for a structured primary health care work routine for ulcer management.

An Evidence Map of Clinical Practice Guideline Recommendations and Quality on Venous Leg Ulcer

Significance: Venous leg ulcers (VLUs) are the most common venous disease, mainly presenting as open skin lesions on the legs or feet and are an important concern in clinical care settings. Recent Advances: Comprehensive tactics were employed to search electronic databases PubMed, Embase, guideline databases, and society websites were searched for Clinical Practice Guidelines (CPGs) on VLU care. The basic information, recommendations for the VLUs, methodological quality, and reporting quality of VLU's CPGs were extracted and captured in Excel. The quality of each CPG was independently assessed by four researchers using AGREE II instrument and the RIGHT checklist. Critical Issues: This study included 19 CPGs with a combined 23 recommendations. The assessment of VLUs was summarized based on the recommendations of VLUs in 11 major items; six on VLU's diagnosis and six on therapeutic strategies of VLUs. The identified CPGs were of mixed quality, and the highest score based on the scope and purpose was 82.85 ± 11.66, whereas the lowest mean score based on the editorial independence by AGREE II was 59.93 ± 21.50. Regarding the RIGHT checklist, field one (basic information) had the highest reporting rate (84.33%), whereas field five (review and quality assurance) had the lowest quality of CPGs (41.11%). Future Directions: This evidence map provided new perspectives in the presentation of evidence. In addition, the evidence map collected and evaluated the characteristics of published CPGs. Thus, the evidence map enhances our knowledge and promotes the development of trustworthy CPGs for VLUs.

Dehydrated human amnion/chorion membrane to treat venous leg ulcers: a cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of dehydrated human amnion/chorion membrane (DHACM) in Medicare enrolees who developed a venous leg ulcer (VLU).

METHOD

This economic evaluation used a four-state Markov model to simulate the disease progression of VLUs for patients receiving advanced treatment (AT) with DHACM or no advanced treatment (NAT) over a three-year time horizon from a US Medicare perspective. DHACM treatments were assessed when following parameters for use (FPFU), whereby applications were initiated 30-45 days after the initial VLU diagnosis claim, and reapplications occurred on a weekly to biweekly basis until completion of the treatment episode. The cohort was modelled on the claims of 530,220 Medicare enrolees who developed a VLU between 2015-2019. Direct medical costs, quality-adjusted life years (QALYs), and the net monetary benefit (NMB) at a willingness-to-pay threshold of $100,000/QALY were applied. Univariate and probabilistic sensitivity analyses (PSA) were performed to test the uncertainty of model results.

RESULTS

DHACM applied FPFU dominated NAT, yielding a lower per-patient cost of $170 and an increase of 0.010 QALYs over three years. The resulting NMB was $1178 per patient in favour of DHACM FPFU over the same time horizon. The rate of VLU recurrence had a notable impact on model uncertainty. In the PSA, DHACM FPFU was cost-effective in 63.01% of simulations at the $100,000/QALY threshold.

CONCLUSION

In this analysis, DHACM FPFU was the dominant strategy compared to NAT, as it was cost-saving and generated a greater number of QALYs over three years from the US Medicare perspective. A companion VLU Medicare outcomes analysis revealed that patients who received AT with a cellular, acellular and matrix-like product (CAMP) compared to patients who received NAT had the best outcomes. Given the added clinical benefits to patients at lower cost, providers should recommend DHACM FPFU to patients with VLU who qualify. Decision-makers for public insurers (e.g., Medicare and Medicaid) and commercial payers should establish preferential formulary placement for reimbursement of DHACM to reduce budget impact and improve the long-term health of their patient populations dealing with these chronic wounds.

DECLARATION OF INTEREST

Support for this analysis was provided by MiMedx Group, Inc., US. JLD, and RAF are employees of MiMedx Group, Inc. WHT, BH, PS, BGC and WVP were consultants to MiMedx Group, Inc. VD, AO, MRK, JAN, NW and GAM served on the MiMedx Group, Inc. Advisory Board. MRK and JAN served on a speaker's bureau. WVP declares personal fees and equity holdings from Stage Analytics, US.

A Novel Comprehensive Therapeutic Approach to the Challenges of Chronic Wounds: A Brief Review and Clinical Experience Report

Following the clinical perspective and concept that a healthy body will not develop chronic wounds, the central approach for the treatment described here is based on an understanding of how the body transforms the wound microenvironment from a non-healing to a healing state. As part of a comprehensive treatment regimen that includes OCM™ (complete matrix), wound preparation, and skin protectant formulations, the OCM contains components for complete wound healing by attending to the individual needs required to promote the closure of each unique chronic wound. During application of the comprehensive treatment regimen in independent investigator-led trials, the total wound percentage average reduction over the first 4 weeks of treatment was 60% across multiple wound types; median time to total wound closure was 6.9 weeks. Safety testing of the OCM formulation shows no potential allergenicity, no potential sensitization, and no known product-related adverse events. Clinical trials evaluating the OCM formulation as part of the comprehensive treatment regimen of multiple wound types are underway. Results of clinical trials and real-world experiences will expand current knowledge of the wound-healing potential of this novel product.

Efficacy and safety of platelet-rich plasma in the treatment of venous ulcers: A systematic review and meta-analysis of randomized controlled trials

Considering the substantial impact of venous ulcers on quality of life and healthcare systems, this study evaluated the efficacy and safety of platelet-rich plasma (PRP) in comparison to conventional therapy. A systematic review of four databases identified 16 randomized clinical trials, including 20 study groups. PRP significantly enhanced complete ulcer healing, exhibiting an odds ratio (OR) of 5.06 (95% confidence interval [CI]: 2.35-10.89), and increased the percentage of healed ulcer area by a mean difference of 47% (95% CI: 32%-62%). Additionally, PRP shortened the time required for complete healing by an average of 3.25 months (95% CI: -4.06 to -2.43). Although pain reduction was similar in both groups, PRP considerably decreased ulcer recurrence rates (OR = 0.16, 95% CI: 0.05-0.50) without increasing the risks of infection or irritative dermatitis. These results suggest PRP as a viable, safe alternative for venous ulcer treatment, providing significant improvements in healing outcomes.

Prognostic models for clinical outcomes in patients with venous leg ulcers: A systematic review

OBJECTIVE

The purpose of this review was to identify prognostic models for clinical application in patients with venous leg ulcers (VLUs).

METHODS

Literature searches were conducted in Embase, Medline, Cochrane, and CINAHL databases from inception to December 22, 2021. Eligible studies reported prognostic models aimed at developing, validating, and adjusting multivariable prognostic models that include multiple prognostic factors combined, and that predicted clinical outcomes. Methodological quality was assessed using the CHARMS checklist and PROBAST short form questionnaire.

RESULTS

Thirteen studies were identified, of which three were validation studies of previously published models, four reported derivation and validation of models, and the remainder reported derivation models only. There was substantial heterogeneity in the model characteristics, including 11 studies focused on wound healing outcomes reporting 91 different predictors. Three studies shared similar predicted outcomes, follow-up timepoint and used a Cox proportional hazards model. However, these models reported different predictor selection methods and different predictors and it was therefore not feasible to summarize performance, such as discriminative ability.

CONCLUSIONS

There are no standout risk prediction models in the literature with promising clinical application for patients with VLUs. Future research should focus on developing and validating high-performing models in wider VLU populations.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Entwicklung eines Lokalisations-basierten Algorithmus zur Vorhersage der Ätiologie von Ulcera cruris

Hintergrund

Die diagnostische Abklärung des Ulcus cruris ist zeit‐ und kostenintensiv. Ziel dieser Studie war es, die Ulkuslokalisation als diagnostisches Kriterium zu bewerten und einen diagnostischen Algorithmus zur Unterstützung in der Diagnostik bereitzustellen.

Patienten und Methodik

Die Studie umfasste 277 Patienten mit Ulcera cruris. Es wurden die folgenden fünf Gruppen definiert: Ulcus cruris venosum, arterielle Ulzera, gemischte Ulzera, Arteriolosklerose und Vaskulitis. Mittels computergestütztem Oberflächenrendering wurden die Prädilektionsstellen der verschiedenen Ulkustypen bewertet. Die Ergebnisse wurden in ein multinomiales logistisches Regressionsmodell integriert, um die Wahrscheinlichkeit einer bestimmten Diagnose in Abhängigkeit von Lokalisation, Alter, bilateraler Beteiligung und Anzahl der Ulzera zu berechnen. Zusätzlich wurde eine neuronale Netzwerk‐Bildanalyse durchgeführt.

Ergebnisse

Die Mehrheit der venösen Ulzera fand sich in der medialen Malleolarregion. Arterielle Ulzera waren am häufigsten auf der dorsalen Seite des Vorfußes zu finden. Arteriolosklerotische Ulzera waren zumeist im mittleren Drittel des lateralen Unterschenkels lokalisiert. Vaskulitische Ulzera schienen zufällig verteilt zu sein und waren deutlich kleiner, häufiger multilokulär und bilateral. Das multinomiale logistische Regressionsmodell zeigte eine insgesamt zufriedenstellende Leistung mit einer geschätzten Genauigkeit von 0,68 bei ungesehenen Daten.

Schlussfolgerungen

Der vorgestellte Algorithmus auf Grundlage der Ulkuslokalisation kann als unterstützendes Instrument zur Eingrenzung potenzieller Differenzialdiagnosen und als Hilfestellung für die Einleitung diagnostischer Maßnahmen dienen.

Development of a localization-based algorithm for the prediction of leg ulcer etiology

BACKGROUND

Diagnostic work-up of leg ulcers is time- and cost-intensive. This study aimed at evaluating ulcer location as a diagnostic criterium and providing a diagnostic algorithm to facilitate differential diagnosis.

PATIENTS AND METHODS

The study consisted of 277 patients with lower leg ulcers. The following five groups were defined: Venous leg ulcer, arterial ulcers, mixed ulcer, arteriolosclerosis, and vasculitis. Using computational surface rendering, predilection sites of different ulcer types were evaluated. The results were integrated in a multinomial logistic regression model to calculate the likelihood of a specific diagnosis depending on location, age, bilateral involvement, and ulcer count. Additionally, neural network image analysis was performed.

RESULTS

The majority of venous ulcers extended to the medial malleolar region. Arterial ulcers were most frequently located on the dorsal aspect of the forefoot. Arteriolosclerotic ulcers were distinctly localized at the middle third of the lower leg. Vasculitic ulcers appeared to be randomly distributed and were markedly smaller, multilocular and bilateral. The multinomial logistic regression model showed an overall satisfactory performance with an estimated accuracy of 0.68 on unseen data.

CONCLUSIONS

The presented algorithm based on ulcer location may serve as a basic tool to narrow down potential diagnoses and guide further diagnostic work-up.

Effect of hyperbaric oxygen therapy on the patients with venous leg ulcer: A systematic review and meta-analysis

This systematic review and meta-analysis aim to explore the adjuvant effect of hyperbaric oxygen therapy (HBOT) in patients with venous leg ulcer (VLU) undergoing surgeries and non-surgeries. Literatures were searched from Web of Science, Cochrane Library, Embase, Pubmed, Wan fang, China National Knowledge Infrastructure (CNKI), and VIP from inception to November 15, 2022. The risk ratio (RR) and weighted mean difference (WMD) were used as effect size for categorical variables and continuous variables, respectively, with 95% confidence interval (95%CI). The heterogeneity was assessed using Q-test and quantified as I2. Sensitivity analysis was performed for all outcomes. A total of 11 studies were finally included in this study, with a total of 617 patients (313 in the HBOT group and 304 in the control group). Results showed that HBOT in combination with surgeries was associated with shorter ulcer healing time (WMD: -13.76, 95%CI: -20.42 to -7.10), lower VAS score (WMD: -0.95, 95% CI: -1.83 to -0.07), and smaller ulcer area (WMD: -2.64, 95%CI: -3.86 to -1.42). HBOT in combination with non-surgeries was associated with higher ulcer PAR (WMD: 20.82, 95%CI: 5.86 to 35.79), but no statistical significance was found in the improvement of ulcer area (WMD: 0.79, 95% CI: -1.54 to 3.12). Our results indicating that HBOT had a good adjuvant effect in surgeries to treat VLU, and its effect in non-surgeries needed further studies.

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.

Patient experiences of people with leg ulcers during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic affected the care of people with chronic leg ulcers (CLUs).

AIMS

To understand how people with CLUs perceived illness, health care and the public health emergency during the second wave of the COVID-19 pandemic.

METHODS

Twenty people attending a wound care clinic in Northern Italy participated in semi-structured interviews and a thematic analysis was conducted using the software Atlas.ti 9.

FINDINGS

Results show that most of the participants evaluated their healthcare experience as positive but differed in their perceptions of the changes brought about by the pandemic according to their varied illness experiences and perceived social support. Participants were grouped in four trajectories that provided insight into the construction of personalised support strategies for people with CLUs.

CONCLUSION

These results may help inform healthcare interventions and policies in the care of long-term conditions such as CLUs during a widespread emergency in future.

Is the Area Under Curve Appropriate for Evaluating the Fit of Psychometric Models?

In the literature of modern psychometric modeling, mostly related to item response theory (IRT), the fit of model is evaluated through known indices, such as χ2, M2, and root mean square error of approximation (RMSEA) for absolute assessments as well as Akaike information criterion (AIC), consistent AIC (CAIC), and Bayesian information criterion (BIC) for relative comparisons. Recent developments show a merging trend of psychometric and machine learnings, yet there remains a gap in the model fit evaluation, specifically the use of the area under curve (AUC). This study focuses on the behaviors of AUC in fitting IRT models. Rounds of simulations were conducted to investigate AUC's appropriateness (e.g., power and Type I error rate) under various conditions. The results show that AUC possessed certain advantages under certain conditions such as high-dimensional structure with two-parameter logistic (2PL) and some three-parameter logistic (3PL) models, while disadvantages were also obvious when the true model is unidimensional. It cautions researchers about the dangers of using AUC solely in evaluating psychometric models.

Leg Ulcer Pathway Acceleration (LUPA) study

BACKGROUND

Leg ulcers are common, costly, and significantly impair quality of life, but their management is variable and associated with considerable delays in healing. The aim of this study was to design an accelerated leg ulcer care pathway in a community and hospital setting to improve patient outcomes.

METHODS

A new referral pathway was developed using a series of healthcare professional and patient interviews, focus groups, and stakeholder workshops. The referral pathway, investigation and treatment protocols were further informed by clinical guidelines to develop the Leg Ulcer Pathway Acceleration care pathway. The outcomes of a consecutive series of patients enrolled in the Leg Ulcer Pathway Acceleration care pathway were compared with the outcomes of patients from a historical leg ulcer cohort from the same community and hospital setting.

RESULTS

A total of 110 eligible patients were enrolled and followed prospectively through the Leg Ulcer Pathway Acceleration care pathway. Their outcomes were compared with those of 183 patients with venous leg ulcers identified from existing hospital and community ulcer centres, and acting as the historical control group. The 110 patients in the Leg Ulcer Pathway Acceleration group consisted of 73 (66 per cent) men, had a mean(s.d.) age of 55.7(17.2) years, and had a median initial ulcer duration of 14.5 (i.q.r. 6-30) months. The 183 patients in the historical control group consisted of 119 (65 per cent) men, had a mean(s.d.) age of 56.4(17.2) years, and had a median initial ulcer duration of 13.5 (i.q.r. 6-47) months. Venous disease was treated in 67/110 (61 per cent) and deep venous disease was treated in 33/110 (30 per cent) of patients in the Leg Ulcer Pathway Acceleration cohort. In contrast, only 16/183 (8 per cent) of patients in the control group were treated for superficial venous insufficiency and 4/183 (2 per cent) of patients in the control group were treated for deep venous disease. Ulcer healing rates at 12 months were 80 and 20 per cent in the Leg Ulcer Pathway Acceleration group and the control group respectively (P < 0.001). Adjusted for baseline characteristics, the OR for a healed ulcer at 12 months was 21.21 (95 per cent c.i.. 11.32 to 42.46) (P < 0.001).

CONCLUSION

The introduction of an accelerated leg ulcer care pathway significantly improves ulcer healing when compared with historical controls.

Venous, Arterial, and Neuropathic Leg Ulcers With Emphasis on the Geriatric Population

Leg ulcers are a common and often serious problem in older adults. Underlying conditions that increase risk include age-related increases in chronic venous insufficiency, peripheral artery disease, connective tissue and autoimmune conditions, reduced mobility, and diabetes mellitus (DM). Geriatric patients have a higher risk of multiple wound-related complications including infection, cellulitis, ischemia, and gangrene, any of which may lead to further complications including amputation. The very presence of these lower extremity ulcers in the elderly negatively impacts their quality of life and ability to function. Understanding and early identification of the underlying conditions and wound features are important for effective ulcer healing and complication mitigation. This targeted review focuses on the three most common types of lower extremity ulcers: venous, arterial, and neuropathic. The goal of this paper is to characterize and discuss the general and specific aspects of these lower extremity ulcers and their relevancy and impact on the geriatric population. The top five main results of this study can be summarized as follows. (1) Venous ulcers, caused by inflammatory processes secondary to venous reflux and hypertension, are the most common chronic leg ulcer in the geriatric population. (2) Arterial-ischemic ulcers are mainly due to lower extremity vascular disease, which itself tends to increase with increasing age setting the stage for an age-related increase in leg ulcers. (3) Persons with DM are at increased risk of developing foot ulcers mainly due to neuropathy and localized ischemia, both of which tend to increase with advancing age. (4) In geriatric patients with leg ulcers, it is important to rule out vasculitis or malignancy as causes. (5) Treatment is best made on a case-by-case basis, considering the patient's underlying condition, comorbidities, overall health status, and life expectancy.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Risk factors for the recurrence of venous leg ulcers in adults: A systematic review protocol

BACKGROUND

Venous leg ulcers are slow to heal, and recurrence is frequent. Living with venous leg ulcers can affect physical and psychological health, and result in financial burden for individuals. Physiological and psychosocial factors are associated with venous leg ulcer recurrence. As over 50% of venous leg ulcers will recur within 12 months of healing, a comprehensive knowledge of holistic risk factors associated with recurrence is required by health professionals involved in the care of the person with venous leg ulcers.

AIM

To develop a systematic review protocol to determine the risk factors for recurrence of venous leg ulcers in adults.

METHOD AND ANALYSIS

This protocol was developed according to the Preferred Reporting Items Form Systematic Review and Meta-Analysis Protocols (PRISMA-P). The inclusion criteria will be based on the PICOS mnemonic-adults with a history of venous leg ulcer/s (participants), risk factor/s under physiological (general/medical), clinical, demographics, psychosocial categories (I (intervention) or E (exposure), venous leg ulcer non-recurrence (comparison group), venous leg ulcer recurrence (outcomes to be measured) and will include study designs of original qualitative, quantitative and mixed method studies (study designs to be included). Methodological quality will be assessed using the Mixed Methods Appraisal Tool. This Systematic Review Protocol was registered in PROSPERO [CRD42021279792].

RESULTS

If meta-analysis is not possible, a narrative review of results will be presented.

CONCLUSIONS

This systematic review on recurrence of venous leg ulcers can provide evidence-based information for preventive strategies for recurrence of a healed venous leg ulcer. The standardised approach outlined in this systematic review protocol offers a rigorous and transparent method to conduct the review.

Photobiomodulation, as additional treatment to traditional dressing of hard-to-heal venous leg ulcers, in frail elderly with municipality home healthcare

The main objectives of the study were to explore whether laser Photobiomodulation (PBM) in addition to traditional dressing of hard-to-heal venous leg ulcer, reduced healing time of the ulcer and if the duration of the ulcer before PBM impacted the treatment time with PBM to healing. The intervention group was frail, elderly patients with home healthcare in the municipality of Skellefteå, registered in the Swedish quality registry RiksSar for ulcer treatment with hard-to-heal venous leg ulcer. The control group with equivalent physical conditions was obtained from the same quality registry. Definition of hard-to-heal ulcer was six weeks duration or more. The PBM was performed two times per week with laser type infrared GaAs, 904nm, 60mW, and 700Hz, targeting lymphatic area and ulcer area. Laser type red visible, GaAllnp, 635nm, 75mW and 250Hz, targeting ulcer area. The intervention group treated with PBM in addition to traditional dressing healed significantly faster than the control group with a mean of 123 days (p = 0.0001). Duration of the ulcer before PBM did not impact the healing time. To conclude, the findings indicate that using PBM in addition to dressing may have multiple benefits on hard-to-heal venous leg ulcer, saving valuable time and resources for patients, healthcare providers, and institutions.

Impact of Educational Nursing Intervention on Compression Therapy Adherence and Recurrence of Venous Leg Ulcers: A Quasi-Experimental Study

Following the healing of venous leg ulcers, the primary problems for nursing and patients are adhering to compression therapy and preventing ulcer recurrence. As a result, it is important that patients comprehend their situation. The purpose of this study is to see how an educational nursing intervention affected compression therapy adherence and recurrence of venous leg ulcers in patients with chronic venous leg ulcers. A quasi-experimental design was used, including an intervention, a control group, and before and after assessments. This study was conducted in one of Egypt's largest teaching hospitals associated with Menoufia University. The 20-month study included 80 adult patients with healed venous leg ulcers. Each participant was randomized to either a control (got regular leg ulcer information) or study (received educational interventions) group. The following tools were used in the study: bio-sociodemographic variables, knowledge evaluation, compression therapy adherence scale, and recurrence follow-up, after 3, 6, and 12 months of implementation. Furthermore, there is a statistically significant difference between the study groups during the pretest (r = 0.885, 0.774, and 0.477, p = 0.002). The use of nursing education increased patients' understanding and adherence to compression treatment substantially. As a consequence, those with chronic venous leg ulcers may be able to avoid recurrent venous leg ulcers.

[Modern concept about trophic venous ulcers]

Venous trophic ulcer is a common complication of chronic venous diseases that have a negative impact on the quality of life and result negative socio-economic consequences. There are three main theories of development of venous trophic ulcers. The criterion is visible trophic changes of skin (CEAP class C4). If correction of etiological factor of ulcer is impossible, local management is preferred. There are various wound coverings which can be used for the treatment of trophic ulcers. However, data on their effectiveness are sometimes unavailable. Therefore, it is necessary to systematize knowledge about modern measures and methods of exposure to trophic ulcers. The authors also discuss current understanding of pathophysiology, symptoms and diagnosis of venous trophic ulcers.

Topically administered purified clinoptilolite-tuff for the treatment of cutaneous wounds: a prospective, randomized phase I clinical trial

In an ageing society, chronic ulcers pose an increasingly relevant healthcare issue associated with significant morbidity and an increasing financial burden. Hence, there is an unmet medical need for novel, cost‐effective therapies that improve healing of chronic cutaneous wounds. This prospective, randomised, open‐label, phase I trial investigated the safety and tolerability of topically administered purified clinoptilolite‐tuff (PCT), mainly consisting of the naturally occurring zeolite‐mineral clinoptilolite, in artificial wounds in healthy male volunteers compared to the standard of care (SoC). We found that topically administered PCT was safe for therapeutic application in acute wounds in healthy male volunteers. No significant differences in wound healing or wound conditions were observed compared to SoC‐treated wounds. However, we found a significantly higher proportion of CD68‐positive cells and a significantly lower proportion of α‐smooth muscle actin‐positive cells in PCT‐treated wounds. Scanning electron microscopy revealed PCT particles in the restored dermis in some cases. However, these did not impede wound healing or clinical symptoms. Hence, purified PCT could represent an attractive, cost‐effective wound treatment promoting the process of healing.

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

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

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

AIM

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

METHODS

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Microbiological Status of Venous Leg Ulcers and Its Predictors: A Single-Center Cross-Sectional Study

Venous leg ulcers are frequently colonized by microbes. This can be particularly devastating if the ulcer is infected with alert pathogens, i.e., highly virulent microorganisms with well-developed mechanisms of antibiotic resistance. We analyzed the microbiological status of venous leg ulcers and identified the clinicodemographic predictors of culture-positive ulcers, especially in ulcers with colonization by alert pathogens.

METHODS

This study included 754 patients with chronic venous leg ulcers. Material for microbiological analysis was collected by swabbing only from patients who did not receive any antibiotic treatment.

RESULTS

A total of 636 (84.3%) patients presented with culture-positive ulcers. Alert pathogens, primarily Pseudomonas aeruginosa, were detected in 28.6% of the positive cultures. In a logistic regression model, culture-positive ulcers were predicted independently by age > 65 years, current ulcer duration > 12 months, and ulceration area greater than 8.25 cm². Two of these factors, duration of current ulcer > 12 months and ulceration area > 8.25 cm², were also identified as the independent predictors of colonization by alert pathogens.

CONCLUSIONS

Colonization/infection is particularly likely in older persons with chronic and/or large ulcers. Concomitant atherosclerosis was an independent predictor of culture-negative ulcers.

A service evaluation to examine the use of compression strapping for the management of patients with retromalleolar leg ulcers in a specialist community setting

Leg ulcers are costly to the NHS, and they have a significant impact on patients' physical, social, and psychological well-being. Compression therapy is traditionally the "gold-standard" treatment for the management of venous leg ulcers and can be beneficial for those individuals with mixed ulcer aetiology. Evidence suggests that the application of standard, strong, graduated compression bandaging does not apply therapeutic compression to the retromalleolar fossa. The addition of compression strapping has been found to increase sub-bandage pressure, promote healing, reduce pain and increase quality of life in patients with retromalleolar leg ulcers. This service evaluation aimed at evaluating the use of compression strapping with patients with retromalleolar leg ulcers. The service evaluation included 24 patients with 41 ulcers treated with compression strapping by a specialist team. Patients treated with CS had multiple comorbidities and shared common characteristics including foot and ankle oedema, previous ulceration, reduced mobility, and failure to heal despite the application of "gold-standard" compression therapy. Following application of compression strapping, 17 patients (n = 27/41 ulcers) healed, mean pain scores decreased, and mean quality of life scores increased. The compression strapping was tolerated well, and patients reported a positive experience. This service evaluation has contributed towards a growing evidence base that supports the use of CS for the management of patients with retromalleolar leg ulcers.

An estimate of the economic burden of venous leg ulcers associated with deep venous obstruction

Introduction:

Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of chronic venous disease. Approximately 40% of patients with VLU present with the underlying deep venous disease (DVD). Although the data are scarce, these deep venous disease-related VLU (DRV) are thought to have higher recurrence rates and a substantial economic burden. The objective of this study was to assess the economic burden of DRV across Australia, France, Germany, Italy, Spain, the UK, and the USA.

Methods:

A comprehensive literature review was undertaken to identify publications documenting the incidence and prevalence of VLU and DRV, medical resource utilization, and associated costs of DRV. Findings from this literature review were used to estimate the economic burden of illness, including direct medical costs over a 12-month interval following initial presentation of a newly formed DRV.

Results:

Total annual incidence of new or recurrent DRV in Australia, France, Germany, Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000, 253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019. Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated annual direct medical costs for patients managed conservatively in these geographies total ~ $10.73 billion (USD) or $5527 per person per year.

Conclusion:

The availability of published data on the costs of VLU care varies widely across countries considered in this analysis. Although country-specific VLU practice patterns vary, there is a uniform pattern of high-cost care.

Wounds in chronic leg oedema

Wounds and chronic oedema are common disorders, but rarely studied together. The objective of this cross-sectional study was to investigate the point-prevalence and risk factors of wounds on the leg, in chronic leg oedema. Forty sites in nine countries were included. Of 7077 patients with chronic leg oedema, 12.70% had wounds. Independent risk factors were: peripheral arterial disease (odds ratio (OR) 4.87, 95% confidence intervals (CI) 3.63-6.52), cellulitis within the past 12 months (OR 2.69, 95% CI 2.25-3.21), secondary lymphoedema (OR 2.64, 95% CI 1.93-3.60), being male (OR 2.08, 95% CI 1.78-2.44), being over 85 years of age (OR 1.80, 95% CI 1.23-2.62), underweight (OR 1.79, 95% CI 1.14-2.79), bed bound (OR 1.79, 95% CI 1.01-3.16), chair bound (OR 1.52, 95% CI 1.18-1.97), diabetes (OR 1.47, 95% CI 1.23-1.77), and walking with aid (OR 1·41, 95% CI 1.17-1.69). 43.22% of those with wounds had clinically defined well-controlled oedema, associated with a significantly lower risk of wounds (OR 0.50, 95% CI 0.42-0.58, P < .001). Hard/fibrotic tissue (OR 1.71, 95% CI 1.19-2.48), and a positive Stemmers sign (OR 1.57, 95% CI 1.05-2.35) were associated with wounds. The study reinforces the importance of measures to control oedema, as controlled swelling was associated with a 50% lower risk of wounds.

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

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

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

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Cooling Intervention (MUSTCOOL) for Prevention of Lower Extremity Ulcer Recurrence: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to test our MUSTCOOL cooling patch intervention on the incidence of venous leg (VLU) and diabetic foot ulcer (DFU) recurrence over a previously healed wound.

DESIGN

A 6-month randomized controlled trial.

SUBJECTS AND SETTING

The target population was individuals with previously healed ulcers receiving care in outpatient wound centers in the Southeastern region of the United States. The sample comprised 140 individuals with recently healed ulcers; their average age was 62.4 years (SD = 12 years); 86 (61.4%) were male; and 47 (33.6%) were Black or African American.

METHODS

Participants were randomized to the MUSTCOOL or placebo patch. Both groups received instructions to apply the patch 3 times per week, and engage in standard of care including compression and leg elevation (VLU) or therapeutic footwear and hygiene (DFU). Demographic data were collected at baseline, and incidence measures taken at 1, 3, and 6 months. We also studied whether new ulcers developed on the adjacent leg or foot. Data were reported in frequencies/percentages.

RESULTS

One hundred seventeen participants (84%) were analyzed who completed 6 months of study participation. Thirteen percent (9/69) and 17% (12/69) developed a recurrent or new VLU, respectively; 29% (14/48) and 13% (6/48) developed a recurrent or new DFU, respectively. One person in the DFU group developed both a recurrent and new ulcer. For 9 recurrent VLUs, 6 (66.7%) recurred in the MUSTCOOL group and 3 (33.3%) receiving the placebo. Of the 15 recurrent DFUs (includes individual who developed both a recurrent and new ulcer), 10 (66.7%) recurred in the MUSTCOOL group and 5 (33.3%) receiving the placebo.

CONCLUSIONS

While the incidence of ulcer recurrent was slightly higher in the MUSTCOOL group, this finding was not considered clinically relevant. Overall ulcer recurrence during the 6-month study period was lower than reports in the literature, the time frame in which recurrence rates are highest.

TRIAL REGISTRATION

The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156)-https://clinicaltrials.gov/ct2/show/NCT02626156.

Rationale for participation in venous leg ulcer clinical research: Patient interview study

Recruitment to wound care clinical trials is challenging and a better understanding of patient decisions to participate has the potential to influence recruitment success. We conducted 31 semi-structured telephone interviews of patients who participated in the Aspirin in Venous Leg Ulcer (ASPiVLU) randomised controlled trail (RCT) or ASPiVLU cohort study. Data were coded and analysed using thematic analysis. We identified four key themes: (a) "I participated to help others"; (b) "I participated in research to thank those who cared for me"; (c) "I participated to receive better care"; and (d) "I participated to have a say on what works." These themes became basic elements for the Rationale for Research Participation Framework that we have developed to improve the participant recruitment process for clinical trials in wound care.

Association of autologous punch grafting, TLC-NOSF dressing and multitype compression therapy to rapidly achieve wound closure in hard-to-heal venous leg ulcers

OBJECTIVE

To document the efficacy of a combined therapeutic strategy in achieving rapid wound healing in patients with long-standing ulcers.

MATERIALS AND METHODS

Outpatients with hard-to-heal venous leg ulcers were included in an interventional, prospective, single-arm, mono-centre study and treated with autologous punch grafting, TLC-NOSF dressing and multi-type compression therapy. The primary outcome was the percentage of healed wounds by week 12. Secondary outcomes included time-to-reach wound closure, wound area reduction, treatment acceptability and safety.

RESULTS

From November 2018 to October 2019, 42 patients with 51 ulcers were included (23 males, 70.6±40.8 years old, with multiple comorbidities). Despite poor wound healing prognosis at baseline (47% of recurrent ulcers, with a mean duration of 15 months and a mean area of 12.6cm²), wound healing was achieved in 47 ulcers (92%) after a mean period of treatment of 25±13 days. A relative wound area reduction>75% was also reached in three additional ulcers by the last evaluation visit. No adverse event related to the procedure was reported throughout the study period. The associated treatment were very well tolerated and accepted by the patients.

CONCLUSIONS

The evaluated procedure induced fast re-epithelisation of the treated ulcers. Based on our experience, this simple and successful reparative strategy may be considered as an interesting option in the treatment of venous leg ulcers of poor prognosis.

Venous leg ulcer management in Australian primary care: Patient and clinician perspectives

BACKGROUND

Venous leg ulcers are the most common chronic wound seen in Australian primary care. Healing outcomes are protracted due to suboptimal use of clinical practice guideline recommendations. A better understanding of the differences between patients and clinicians may optimise management in primary care and improve healing and health outcomes for patients and healthcare spend in society.

OBJECTIVE

We explored venous leg ulcer management from patients' and primary care clinicians' perspective, including assessment, diagnosis, treatment, referral, and health education as outlined in the clinical practice guidelines.

DESIGN

We conducted a qualitative secondary analysis of data obtained from the qualitative face-to-face and telephone interviews with the primary care clinicians and telephone interviews with patients with venous leg ulcers.

SETTING

Clinicians were recruited from urban and rural primary health practices across Victoria, Australia. Patients were recruited from two specialist care wound clinics in Victoria.

PARTICIPANTS

We analysed data from interviews with 66 participants, including 31 patients with venous leg ulcers, 15 general practitioners and 20 practice nurses.

METHODS

Secondary analysis of qualitative data was carried out using thematic analysis. Interview transcripts were coded and analysed for common themes.

RESULTS

We found patients and clinicians reported differing perspectives related to venous leg ulcer management. Patients reported the need for earlier referral to specialist wound care clinics from primary care, emphasizing the need for vascular assessment and compression therapy. Clinicians discussed clinical judgements about when to refer rather than follow guideline recommendations. Clinicians frequently discussed managing venous leg ulcers using only topical dressing treatments, without compression therapy. Patients reported inadequate pain management for wound pain. Meanwhile, clinicians reported that they generally did not discuss wound pain management as part of overall venous leg ulcer management. Clinicians reported patients lacked an understanding about the role of compression in management of and subsequent healing outcomes. Patients stated they wanted more information about how to care for venous leg ulcers and how best to prevent recurrence, and needed more information than was already provided by clinicians. Conversely, clinicians reported less information is given to ensure patients were not overwhelmed with health information.

CONCLUSION

There are discrepancies between what patients want and what clinicians do. These data suggest that patients' preferences are aligned with venous leg ulcer clinical practice guideline recommendations. Greater awareness of the guidelines by health professional may not only reduce discrepancies they may improve health and healing outcomes. Tweetable abstract: Patients and primary care clinicians have different perspectives about venous leg ulcer management.

Understanding factors influencing venous leg ulcer guideline implementation in Australian primary care

The aim of this study was to gain a better understanding of the venous leg ulcer (VLU) management in primary health care settings located in Melbourne metropolitan and rural Victoria, Australia. We explored health professionals' perspective on the use of the Australian and New Zealand Venous Leg Ulcer Clinical Practice Guideline (VLU CPG) to identify the main challenges of VLU CPG uptake in clinical practice. We conducted semi-structured interviews with 15 general practitioners (GPs) and 20 practice nurses (PNs), including two Aboriginal health nurses. The Theoretical Domains Framework guided data collection and analysis. Data were analysed using a theory-driven analysis. We found a lack of awareness of the VLU CPGs, which resulted in suboptimal knowledge and limited adherence to evidence-based recommendations. Environmental factors, such as busy nature of clinical environment and absence of handheld Doppler ultrasound, as well as social and professional identity factors, such as reliance on previous experience and colleague's advice, influenced the uptake of the VLU CPGs in primary care. Findings of this study will inform development of interventions to increase the uptake of the VLU CPG in primary care settings and to reduce the evidence-practice gap in VLU management by health professionals.

Barriers and enablers to the use of venous leg ulcer clinical practice guidelines in Australian primary care: A qualitative study using the theoretical domains framework

BACKGROUND

Venous leg ulcers represent the most common chronic wound problem managed in Australian primary care. Despite the prevalence of the condition, there is an evidence-practice gap in both diagnosis and management of venous leg ulcers.

OBJECTIVE

We used the Theoretical Domains Framework to identify barriers and enablers perceived by primary care practitioners in implementing venous leg ulcer guidelines in clinical practice.

DESIGN

We collected data to explore the experiences of practice nurses and general practitioners related to their use of clinical practice guidelines in management of venous leg ulcers.

SETTING(S)

We recruited participants from primary care settings located in metropolitan and rural areas across Victoria, Australia.

PARTICIPANTS

We recruited general practitioners (15) and practice nurses (20).

METHODS

We conducted 35 semi-structured face-to-face and telephone interviews. Content analysis of health practitioners' statements was performed and barriers to implementing clinical practice guidelines were mapped across the Theoretical Domains Framework theoretical domains.

RESULTS

Six main domains from the Theoretical Domains Framework (Environmental context and resources, Knowledge, Skills, Social influences, Social/Professional Role and Identity and Belief about Capabilities) best explained these barriers and enablers. Many participants were not aware of venous leg ulcer clinical practice guidelines. Those that were aware, stated that finding and accessing guidelines was challenging and most participants relied on other sources of information. Venous leg ulcer management was greatly influenced by professional experience and suggestions from colleagues. Other barriers included busy clinical practice, absence of handheld Doppler ultrasonography, insufficient skills and a lack of confidence related to the use of technology to rule out arterial involvement prior to compression application, a particular skill related to venous leg ulcer management that will impact on healing outcomes.

CONCLUSIONS

We identified a number of barriers and the lack of enablers that influence the uptake of venous leg ulcer clinical practice guidelines in primary care. This paper adds a theoretically sound, systematic approach for understanding and addressing the behaviour change required to improve translation of venous leg ulcer clinical practice guidelines in clinical practice. Tweetable abstract: The need to optimise venous leg ulcer clinical practice guidelines (CPG) has never been greater as the current estimate of health cost is AUD3billion and increasing due to rising epidemics of diabetes and obesity. We found most primary care health practitioners are unaware of CPG and this will impact on health and healing outcomes in Australian primary care.

Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool

The aim of this study was to validate a newly developed tool for predicting the risk of recurrence within 12 months of a venous leg ulcer healing. Performance of the tool to predict recurrence within a 12-month period was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Multi-site retrospective and prospective longitudinal studies were undertaken to validate a risk assessment tool for the recurrence of venous leg ulcers within 12 months. In the retrospective study (n = 250), 55% of venous leg ulcers recurred within 12 months, and the risk assessment total score had excellent discrimination and goodness of fit with an AUC of 0.83 (95% CI, 0.76-0.90, P < .001). The prospective study (n = 143) observed that 50.4% (n = 63) of venous leg ulcers recurred within 12 months of healing. Participants were classified using the risk assessment tool as being at low risk (28%), moderate risk (59%), and high risk (13%); the proportion of wounds recurring at 12 months was 15%, 61%, and 67% for each group, respectively. Validation results indicated good discrimination and goodness of fit, with an AUC of 0.73 (95% CI, 0.64-0.82, P < .001). Validation of this risk assessment tool for the recurrence of venous leg ulcers provides clinicians with a resource to identify high-risk patients and to guide decisions on adjunctive, tailored interventions to address the specific risk factors to decrease the risk of recurrence.