Adjuvant therapies in venous leg ulcer management: A scoping review

Comparison of the therapeutic efficacy of magneto-LED therapy and magnetostimulation applied as the adjuvant treatment of venous leg ulcers - preliminary study

PURPOSE

Venous leg ulcers are chronic wounds that are difficult to cure. The aim of the study was to compare the therapeutic efficacy of two methods of physical medicine - magneto-LED therapy and magnetostimulation, applied as adjuvant treatment in the treatment of venous leg ulcers.

METHODS

The study included 81 patients, 37 male (45.6%) and 44 female (54.3%) ones, age range between 45 and 90 years, with venous leg ulcers. The patients were assigned to two study groups: magneto-LED therapy (group 1) or magnetostimulation (group 2). In both groups, a total of 40 daily procedures were performed. Wound healing was evaluated using computerized planimetry and the pain intensity on numeric rating scale.

RESULTS

After treatment, the decrease in healing rate in group 1 was statistically significantly higher in comparison to group 2 (p < 0.001), while a statistically significant reduction in the surface area of ulcers was obtained, amounting on the average from 6.34 ± 1.29 cm2 to 2.31 ± 1.25 cm2 in group 1 (p < 0.001), and from 6.52 ± 1.20 cm2 to 4.79 ± 1.17 cm2 in group 2 (p < 0.001). The percentage changes of ulcers area in group 1 (64.21 ± 17.94%) were statistically significantly greater as compared to group 2 (25.87 ± 14.07%) (p < 0.001). After treatment, the decrease in pain relief in group 1 was statistically significantly higher in comparison to group 2 (p = 0.006), while pain intensity after treatment decreased statistically significantly in both compared groups of patients (p < 0.001).

CONCLUSIONS

Magneto-LED therapy and magnetostimulation caused significant reduction of surface area of the treated venous leg ulcers and pain intensity, yet magneto-LED therapy was more efficient. Both evaluated methods also significantly reduced pain intensity.

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.

Randomized prospective comparative study of platelet-rich plasma versus conventional compression in treatment of post-phlebitic venous ulcer

OBJECTIVES

to assess the safety and efficacy of platelet-rich plasma (PRP) as adjunctive to compression therapy for post-phlebitic venous ulcers.

METHODS

This is a single-center randomized controlled trial on patients with persistent chronic post-phlebitic lower limb venous ulcers from March 2019 to March 2020. Patients were randomly allocated to one of two equal cohort groups. Patients group in which patients underwent combined PRP with compression therapy versus control group in which patients underwent placebo+ compression therapy alone. The primary endpoint of the study was the improvement in ulcer topographic measurement. Secondary endpoints included ulcer healing parameters, possible healing factors, reduction in pain score (VAS), and the achievement of complete healing.

RESULTS

Forty patients were available equally for randomization and analysis in both groups. The median number of PRP applications for every patient in the patient group was 6 (ranging from 3 to 6). There was a significant decline in the median length, width, and depth of ulcers in the patients group versus control group. Consequently, there was a significant decline of the median ulcer area, in the patient group versus control group (4 (3-9) cm2 vs. 10 (6-14) cm2, p = .036). Also, the median volume of the ulcers showed a significant decline in the patient group versus control group (1 (.7-3) cm3 vs 3 (2-6) cm3, p = .008). Complete healing was achieved in 45% of patient group. There was a significant decline in pain scores at 3- and 6 months from the therapy starting point in both groups (patient group: pre-VAS = 6.5 vs. post(3 months)-VAS = 1 vs. post(6 months)-VAS = 0.5) and (control group: pre-VAS = 6.4 vs. post(3 months)-VAS = 4.5 vs. post(6 months)-VAS = 2.2), (p < .0001 for each). On the other hand, the decline in pain scores between both groups was statistically significant in favor of the patient group, (post (3 months); PRP-VAS = 1 vs. control-VAS = 4.5, and post(6 months); PRP-VAS = 0.5 vs. control-VAS = 2.2), (p < .0001).

CONCLUSION

Platelet-rich plasma as an adjunct to compression therapy for chronic post-phlebitic venous ulcers is safe and effective as regards the ulcer healing and improvement of pain score. PRP may be useful adjunct in treatment of post-phlebitic venous ulcer. However, larger trials are warranted.

The effectiveness of nursing interventions in adherence to self-care for preventing venous ulcer recurrence: A systematic literature review

Venous ulcers affect up to 3% of the global population, with a high impact on economies and quality of life. This is exacerbated by its recurrence rates, which reach 70% at 12 months after healing. The perpetuation of these cycles of healing and recurrence is not interrupted or even attenuated by the self-care activities recommended and directed toward their prevention. In this context, we sought to identify the effectiveness of interventions that promote adherence to self-care to prevent venous ulcer recurrence. In August 2022, we conducted a literature search via EBSCO in the following databases: CINAHL Complete, MEDLINE Complete, Cochrane Database of Systematic Reviews, Scopus, and Web of Science. The inclusion criteria were researched in the form of randomised controlled trials or systematic literature reviews, and 99 studies were identified. During the different times of selection, four studies met the defined inclusion criteria and were included. As the main conclusions, the emphasis goes to the importance of the use of compression and the greater effectiveness of higher compression classes for the prevention of recurrence. Different educational methodologies seem to be important to increase knowledge about prevention, specifically regarding the aetiology of recurrence and the implementation of prevention measures.

The effect of wound electrical stimulation in venous leg ulcer healing-a systematic review

OBJECTIVE

The benefit of using electric stimulation therapy (EST) to heal venous leg ulcers (VLUs) is not well established. The main aim of this systematic review was to evaluate the effects of ulcer EST in VLU healing.

METHODS

A systematic search of the literature was conducted using the databases PubMed, Scopus, and Web of Science and included original studies that reported VLU healing after EST. The inclusion criteria were at least two surface electrodes placed on or near the wound or a planar probe covering the ulcer area to be treated. The Cochrane risk of bias tool for randomized control trials (RCTs) and Joanna Briggs Institute critical appraisal checklist for case series were used to evaluate the risk of bias.

RESULTS

This review included eight RCTs and three case series involving a total of 724 limbs in 716 patients with VLUs. The mean patient age was 64.2 years (95% confidence interval, 62.3-66.2), and 46.2% (95% confidence interval, 41.2%-50.4%) were men. The active electrode was placed on the wound with the passive electrode placed on healthy skin (n = 6), the two electrodes were placed on either side of the wound edges (n = 4), or a planar probe was used (n = 1). The pulsed current was the most used waveform (n = 9). The change in the ulcer size was the main method used to determine ulcer healing (n = 8), followed by the ulcer healing rate (n = 6), exudate levels (n = 4), and the time to healing (n = 3). Five RCTs detected a statistically significant improvement in at least one VLU healing outcome, after EST compared with the control group. In two of these, EST was better than the control but only for patients who had not undergone surgical treatment of VLU.

CONCLUSIONS

The findings from the present systematic review support the use of EST to accelerate wound healing of VLUs, especially for patients who are not surgical candidates. However, the significant variation in electric stimulation protocols represents an important limitation to its use and should be addressed in future studies.

Knowledge assessment among subjects with chronic venous leg ulcer in outpatient setting: Translation and adaptation of a tool to identify subjects at risk of poor understanding

Promotion of self-care is an important issue in the treatment of chronic diseases such as venous leg ulcers, as adequate self-care can prevent complications and ulcer recurrence. However, only a few tools have been developed and tested to assess the knowledge of patients with venous leg ulcers. This study aimed to translate, adapt and validate in an Italian language and context a questionnaire to assess the knowledge of patients with venous leg ulcers about their disease (pathophysiology, risk factors, lifestyle changes due to ulcer) and the proper management of the ulcer to prevent recurrence. This is a cross-sectional study divided into two phases: (1) translation and cross-cultural adaptation of the 'Educational Interventions in Venous Leg Ulcer Patients' tool in a six-stage process and (2) validation and reliability study with patients with active ulceration. There was great agreement for the English-to-Italian translation. In content validation, the tool showed good applicability among experts. Adjustments were made to improve semantic equivalence, and the questionnaire was made to be easy and quick to administer. The results of the target population showed a low level of knowledge among the patients. Knowing the deficiencies of the patients makes it possible to create educational projects to improve their abilities. Now more than ever, it is necessary to improve self-care and patient knowledge, allowing home care, improving autonomy, and avoiding hospital care that results in higher costs and risks. This questionnaire could be used in future studies to identify topics that need to be reinforced through education and to improve the awareness and self-care of these patients.

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.

Planning exercise interventions as an adjunct treatment in managing venous leg ulcers: A qualitative study of nurses’ perspectives

OBJECTIVE

To explore clinicians' perspectives regarding strategies to support exercise interventions for people with venous leg ulcers.

DESIGN

1:1 interview was guided by the Behaviour Change Wheel (BCW) to collect thoughts from clinicians with experiences in managing venous leg ulcers.

SETTINGS

Clinical nurses in metropolitan/regional Victoria, Australia.

PARTICIPANTS

A convenience sample of 21 nurses (mean clinical experience 14 years) was recruited.

METHODS

We conducted semi-structured remote interviews. Transcripts were coded and analysed using a theory-driven thematic analysis, and interventions to support the implementation of exercise interventions were mapped across the BCW.

RESULTS

Strategies related to capability, opportunity and motivation components from the BCW were identified. The strategies reported to be important included: i) education of patients and family members; ii) the provision of consistent and clear exercise advice; iii) setting realistic and meaningful goals in light of challenges encountered by patients; iv) flexibility in how exercise programmes were organised/structured, particularly to facilitate rapid adoption; and v) clinician education.

CONCLUSIONS

In-depth qualitative interviews of nurses working with people with venous leg ulcers in Australia revealed multifactorial issues that potentially affect prescription of care regarding physical exercise. In order to improve and standardise future clinical practice, a clear focus of future research should address such issues.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Randomized Controlled Trial on the Effect of Local Insulin Glargine on Venous Ulcer Healing

INTRODUCTION

To determine whether the local administration of insulin glargine compared with placebo in nondiabetic patients with venous ulcers (VUs) leads to increased wound healing.

METHODS

A randomized controlled trial using a split-plot design was performed in 36 adults with leg VUs >25 cm² and more than 3 mo of evolution. Each hemi-wound received either 10 UI insulin glargine or saline solution once a day for 7 d. Size of the wounds, thermal asymmetry, the number of blood vessels, and the percentage area of collagen content in wound biopsies were assessed at baseline and after 7 d of treatment. Blood capillary glucose was monitored once a day after the insulin injection.

RESULTS

After 7 d of treatment, the hemi-wounds treated with insulin glargine were significantly smaller, had less thermal asymmetry, more blood vessels, and more collagen content than the saline-treated side. Correlation between thermal asymmetry and the number of blood vessels was also found (r² = 66.2, P < 0.001). No patient presented capillary glucose levels ≤3.3 mmol/L nor any adverse effects.

CONCLUSIONS

In nondiabetic patients with chronic VUs, the topical administration of insulin glargine seems to be safe and promotes wound healing and tissue repair after 7 d of treatment.

Effects of physical activity as an adjunct treatment on healing outcomes and recurrence of venous leg ulcers: A scoping review

Healing time is protracted and ulcer recurrence is common in patients with venous leg ulcers. Although compression is the mainstay treatment, many patients do not heal timely. Physical activity may be a clinically effective adjunct treatment to compression to improve healing outcomes. This scoping review provides a broad overview of the effect of physical activity as an adjunct treatment to compression on wound healing and recurrence. We followed the six-step framework developed by Arksey and O'Malley. We searched electronic databases and trial registration websites for relevant studies and ongoing trials. Two authors independently screened and selected articles. Findings were presented in a descriptive statistical narrative summary. We consulted and presented our findings to the wound consumer group to ensure the relevance of our study. Physical activity interventions in 12 out of the 16 eligible studies consisted of only one component, eight studies were resistance exercises, three studies reported ankle and/or foot range of motion exercises, and one study reported aerobic/walking exercises. The remaining four studies involved multicomponent exercise interventions. Resistance exercise combined with ankle and/or foot range of motion exercise minimised ulcer size on day 12 (intervention group: 4.55 ± 1.14 cm² vs. control group: 7.43 ± 0.56 cm² ) and improved calf muscle pump performance on day 8 (ejection fraction: 40%-65%; residual volume fraction: 56%-40%). We identified one study that reported ulcer recurrence rate with no clinical difference in the intervention group versus the control group (i.e., 12% in intervention vs. 5% in control). Our review identified that resistance exercise was the most common type of physical activity intervention trialled in the published literature. Resistance exercise combined with ankle and/or foot range of motion exercise appears to be effective adjunct treatments; however, the overall evidence is still relatively weak as most programmes had a short intervention period which limited clinical outcomes.

[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.

Adipose-Derived Stem Cell Conditioned Medium and Wound Healing: A Systematic Review

Adipose-derived stem cells (ASCs) have been growing in popularity for their potential in wound healing and tissue engineering. Stem cell therapies are limited in application, with the need to maintain cell viability and function as well as safety concerns. It has been increasingly reported that the effects of ASCs are predominantly attributable to the paracrine effects of the secreted factors, which can be collected in conditioned medium (CM). The goal of this systematic review is to investigate the effects on wound healing of CM collected from ASC culture. Original articles relevant to ASC-CM and wound healing (in vitro: dermal fibroblast, epidermal keratinocytes and their equivalent cell lines; in vivo: full-thickness wound models) were included. The agreement level of selections between two investigators were calculated by the kappa scores. And the information concerning to the publications, CM preparation and its application and effects were extracted and reported in a systematic way and summarized in tables. In total, 121 publications were initially identified through a search of the PubMed/MEDLINE database with a specific search algorithm, and 36 articles were ultimately included after two screenings. Nineteen were in vitro studies that met the search criteria and 17 were in vivo studies with or without in vitro data. In summary, based on the included articles, treatment with ASC conditioned medium (ASC-CM), to a large extent, resulted in positive effects on wound healing in vitro and in vivo. Modulation of the culture conditions of ASCs producing the CM, including hypoxic conditions, alternative substrates, medium supplementation, as well as genetic modification of cells, favorably promoted the effects of ASC-CM. Finally, a discussion of the future perspectives and therapeutic potential of ASC-CM, which also addresses the limitations of the field, is presented. A limitation of the evidence is the inconsistency in CM preparation methods among included articles. In conclusion, ASC-CM is a promising novel cell-free therapy for wound healing in regenerative medicine and warrants further exploration.

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.

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.

Nurse-led patient education for persons suffering from a venous leg ulcer in outpatient's clinics and homecare settings: A scoping review

AIM OF THIS STUDY

To provide an overview of the available nurse-led individualized educational interventions, for persons with Venous Leg Ulcer (VLUs) in an outpatient or homecare settings.

MATERIALS AND METHODS

For this scoping review, a search was performed between December 2019 and January 2020. To identify sources of evidence a systematic search was conducted in PubMed, CINAHL, Embase, PsychINFO, Web of Science and LiSSa as well as in clinical trial registers to identify sources of evidence. All types of evidence associated with a nurse led-intervention were included.

RESULTS

Fifteen sources of evidence met the inclusion criteria. Educational sessions varied in modality, content and duration. Education sessions were face to face and supported by written materiel. The content focused on compression therapy and exercises. The duration and numbers of sessions varied. The most reported health related outcomes was wound healing.

CONCLUSION

This scoping review provides a broad overview of the available evidence and ongoing research for individualized nurse-led education persons with VLUs. Variability in the literature was found, which suggests that more intervention studies are needed to test and evaluate efficacy of nurse-led patient education.

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.

First-Line Interactive Wound Dressing Update: A Comprehensive Review of the Evidence

Wound management is a significant and growing issue worldwide. Knowledge of dressing products and clinical expertise in dressing selection are two major components in holistic wound management to ensure evidence-based wound care. With expanding global market of dressing products, there is need to update clinician knowledge of dressing properties in wound care. Optimal wound management depends on accurate patient assessment, wound diagnosis, clinicians’ knowledge of the wound healing process and properties of wound dressings. We conducted a comprehensive review of the physical properties of wound dressing products, including the advantages and disadvantages, indications and contraindications and effectiveness of first-line interactive/bioactive dressing groups commonly used in clinical practice. These include semipermeable films, foams, hydroactives, alginates, hydrofibers, hydrocolloids, and hydrogels. In making decisions regarding dressing product selection, clinicians need to ensure a holistic assessment of patient and wound etiology, and understand dressing properties when making clinical decisions using wound management guidelines to ensure optimal patient outcomes. This review has highlighted there is lack of high quality evidence and the need for future well designed trials.

Vascular assessment in venous leg ulcer diagnostics and management in Australian primary care: Clinician experiences

AIM

In this article, we focus on primary health clinicians' experiences of vascular assessment in venous leg ulcer (VLU) diagnostics and management, including ankle brachial pressure index (ABPI) measurements using Doppler ultrasonography.

METHODS

We conducted semi-structured face-to-face and telephone interviews with general practitioners [15] and practice nurses [20] from primary health care settings in Australia. Twenty-one participants were recruited from practices located in Melbourne metropolitan settings and 14 from rural Victoria. We used the theory driven thematic analysis as a method of data analysis. The Theoretical Domains Framework informed this analysis.

RESULTS

Five domains were identified as relevant, including Environmental Context and Resources, Motivation and Goals, Skills, Knowledge, and Beliefs about Capabilities. Although the Australian and New Zealand clinical practice guideline for prevention and management of venous leg ulcers recommend that vascular assessment is conducted for all patients with suspected VLUs, findings from our study indicate vascular assessments are not routinely performed in many primary care settings. Our study also found that a lack of awareness of clinical practice guidelines among clinicians might be one of the main issues for not following the latest clinical recommendations for vascular assessment in venous leg ulcer diagnostics and wound management practice.

CONCLUSION

We recommend development of theory-informed interventions for clinicians in primary health care settings to optimise VLU management and healing outcomes for patients with VLUs. Implementation and evaluation of these interventions have the potential to reduce the evidence-practice gap in VLU management and optimise healing outcomes.

A conceptual framework of patient-reported outcomes in people with venous leg ulcers

Venous leg ulcers (VLUs) are a common chronic often undertreated condition, which affects individual's health-related quality of life (HRQoL). Numerous patient-reported outcome measures (PROMs) have been validated to capture HRQoL in patients with VLUs. However, available instruments contain many items, are hard to use in clinical practice, and present with weak responsiveness. This study aims to determine clinical utility of an existing VLU-QoL instrument and to develop a comprehensive PROs assessment framework to guide clinical practice treatment in people with VLUs in Australia. Semi-structured qualitative interviews were conducted with VLU patients (N = 13) and their managing clinicians (N = 6) in Victoria, Australia. Interview topics covered content and face validity, appropriateness, and acceptability of the VLU-QoL instrument to determine suitable and appropriate for use in clinical practice. Clinicians and patients agreed that a VLU-QoL instrument was needed in clinical practice. Both clinicians and patients agreed it would be appropriate to answer PROMs questions prior to consultation with clinicians every 3-6 months. However, patients considered that some of the questions are ambiguous and too technical. Patients reported that it would be useful to include additional items relating to daily wound care, compression bandaging, and dressings. Clinicians reported that the VLU-QoL instrument was too long and required restructuring to facilitate utility in practice. A conceptual framework for HRQoL in VLUs included traditional HRQoL components and VLU-specific issues. Overall, the VLU-QoL was well accepted, although changes to make it more concise, comprehensive, and to clearly reflect consumers' perspectives were lacking. The proposed conceptual framework will inform the development of a new PROM for use by clinicians and patients in clinical settings.

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.