Management of leg ulcers

Compression therapy for NHS inpatients with leg ulcers: a literature review

OBJECTIVE

Leg ulcers are common, distressing and painful for patients, and are a significant financial burden to healthcare providers. Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression therapy in the community. However, little is known about the prevalence of leg ulceration and use of compression therapy in acute hospitals. The aim of this study was to explore the published literature on the use of compression therapy for inpatients with leg ulcers in UK National Health Service hospital settings.

METHOD

A literature search was undertaken to identify published papers reporting on inpatient leg ulcer populations and the use of compression therapy in hospitals using the following databases: CINAHL, MEDLINE Complete, Embase and PubMed.

RESULTS

The literature review identified 364 articles, of which three met the eligibility criteria. These studies reported on the prevalence of leg ulceration, the number of Doppler assessments conducted for patients and the use of compression therapy.

CONCLUSION

This review confirmed a lack of information on the prevalence of hospital inpatients with leg ulcers, and identified the need to conduct prevalence audits, establish leg ulcer services to streamline inpatient leg ulcer care and provide staff and patient education programmes.

Clinical Indications of Cultured Epithelial Autografts

ABSTRACT

Cultured epithelial autografts (CEAs) have been used for decades as a treatment for massive burn injuries. Cultured epithelial autografts allow for wounds to heal by taking a small sample and growing a patient's own epithelium in culture to create large, graftable sheets. This technique is especially useful in large wounds where donor sites are limited compared with conventional skin grafting. However, CEAs have a variety of uses in wound healing and reconstruction and have the potential to aid in the closure of several types of defects. Cultured epithelial autografts have shown applicability in large burns, chronic nonhealing wounds, ulcerating wounds of various etiologies, congenital defects, wounds requiring specialized epithelium to replace like by like, and wounds in critically ill patients. Several factors must be considered when using CEAs, such as time, cost, and outcomes. In this article, we detail the various clinical applications of CEAs and how they can be situationally advantageous outside of their original purpose.

Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics

This article explores the impact of combining tissue viability and lymphoedema techniques on optimising time to healing.

AIM

To investigate the healing rates observed in patients who presented to wound and lymphoedema specialist clinics, located in the south eastern region of England, with venous/lymphovenous ulceration of the lower limb during the COVID-19 pandemic in 2020-2022 (30 months in all).

METHODOLOGY

A retrospective analysis of patient outcomes.

RESULTS

1041 patients were referred to the service, with a healing rate of 88.5% over 78 days.

DISCUSSION

When comparing 2013-2019 healing rates/time to healing vs 2020-2022 there was a decrease of 1.5% in the rate of healing and a mean reduction in time to healing of 40 days.

CONCLUSION

Despite the pandemic the service was able to maintain previous levels of outcomes and observed a decrease in the mean time to healing.

Managing the delivery of venous leg ulcer services: A willingness to pay study

Background and Aims

Methods

Results

Conclusions

An Unusual Presentation of a Patient with Leg Ulcers: A Case Report

Leg ulcers have been a common presentation in clinics; disruptions in the mechanism of ulcer healing are vascular insufficiency, anemia, metabolic disturbances, neuropathy, and autoimmunity. The term 'non-transfusion-dependent thalassemia' encompasses the milder forms of thalassemia traits that require intermittent or no transfusion at all, and are mostly associated with leg ulcers.

We present the case of a 19-year-old female with beta-thalassemia major who presented with non-healing leg ulcers and anemia. The clinical findings and lab evidence suggested hemolytic anemia evidenced by pathologic fractures, hepato-splenomegaly, and normal iron studies. Hemoglobin electrophoresis confirmed beta-thalassemia major with its complications including adrenal insufficiency and pathological fractures, all of which remained well compensated till the second decade of life.

Understanding venous leg ulcers

Venous leg ulcers are open lesions between the knee and the ankle joint, which occur in the presence of venous insufficiency. There are theories to explain the causes of venous insufficiency, which ultimately leads to venous hypertension and can result in leg ulceration. Although many patients present with evidence of venous hypertension, others do not, except for the manifestation of the ulcer. There are risk factors associated with venous insufficiency and a holistic approach must be taken in order to influence the management approach of venous leg ulceration. This article discusses venous insufficiency as a disease process, and explores the nursing assessment process, when assessing venous leg ulcers related to venous insufficiency.

Punch grafts to treat lower limb intractable sores

Lower limb recurrent ulcers, usually caused by prolonged decubitus, trauma, diabetes or burns, may not heal with conventional clinical or surgical treatment. Frequently, laminated skin grafts do not integrate with the recipient layer, and the only alternatives are neighbor microsurgical flaps. These have higher morbidity and create secondary defects, to be corrected with skin grafts, when fasciocutaneous or miocutaneous segments are removed for the treatment of the primary defect. We describe the non-conventional use of punch grafts in the treatment of lower limb ulcers, when conventional skin laminated graft failed, without the use of flaps. Since this is a very successful technique, its use should be considered as a valuable alternative for the treatment of recurrent lower limb ulcers. It is a simple and easy-learned technique that may be used by different surgeons, even in remote places without correct specialized hospital facilities.

Leg Ulcers in the Tropics

Leg ulcers are an important clinical condition and are often difficult to treat. The treatment has to continue for long periods, and the associated morbidity leads to significant loss of work. The successful treatment of leg ulcers or chronic wounds depends upon accurate diagnosis and treatment of the underlying cause. In Western societies, most leg ulcers are due to venous insufficiency, arterial disease, neuropathy (usually diabetic), or some combination of these factors. In tropical countries, however, there have been no large series of leg ulcers reported. The prevalence of leg ulcers and etiology are unknown. In this article, a short review is presented of the etiology and management of lower extremity ulcers as seen in the tropical countries.

Use of dermal injection of activated protein C for treatment of large chronic wounds secondary to pyoderma gangrenosum

BACKGROUND

Pyoderma gangrenosum (PG) is a systemic disease that presents with cutaneous necrotizing ulceration, producing deep necrotic ulcers, usually with a raised, undermined, violaceous border. Treatment typically involves high dose immunosuppressive drugs, but more recently anti-tumour necrosis factor and monoclonal antibodies have been used. Activated protein C (APC) stimulates wound healing in patients with treatment-refractory skin ulcers, possibly by stimulating angiogenesis and re-epithelialization, and preventing inflammation.

AIM

To investigate whether APC may be beneficial as a treatment for ulcers related to cutaneous PG.

METHODS

Two patients were recruited with a clinical history and physical and histopathological evidence of acute PG. A total of 400 μg (1.0 mL) of APC was injected subcutaneously into the dermal edge of necrotic PG ulcers weekly for a total treatment period of 6 weeks. Photographs were taken, and clinical progress, ulcer size and pain score were monitored during this period and after the cessation of treatment, at weeks 8 and 12.

RESULTS

Over the 12 weeks of the trial, APC led to a reduction in wound size from 3.8 cm(2) to 0.8 cm(2) in patient 1 (78.9% decrease) and from 41 cm(2) to 16 cm(2) in patient 2 (70.0% decrease, respectively), and a reduction in pain scores from 10 to 0 (100% decrease) in both patients.

CONCLUSION

Although this study has limited because of its small sample size and lack of a true placebo group, it does indicate that APC has potential as a therapeutic option for patients with chronic skin ulcers from PG.

A clinical study on the efficacy of Panchavalkala cream in Vrana Shodhana w.s.r to its action on microbial load and wound infection

BACKGROUND

The science of wound healing is advancing rapidly, particularly as a result of new therapeutic approaches. The wound healing effect of different herbal ointments have been enormous and are in wide practice these days.

AIM

To evaluate the efficacy of Panchavalkala cream over wound debridement (wound infection and microbial load).

MATERIALS AND METHODS

Ghanasatwa (water extract) of the individual drugs of Panchavalkala was prepared and the extract formulated as herbal ointment. This was used to treat patients of infected chronic non healing wounds. The signs and symptoms of infection were graded before and during the course of treatment. Tissue biopsy to estimate the microbial load prior to and during the course of treatment was done.

RESULTS

The clinical symptoms like Slough, swelling, redness, pain, discharge, tenderness, and malodor in wounds showed statistically significant reduction following treatment. The microbial load of the wounds was also reduced significantly.

CONCLUSION

In most of the cases, there was a progressive reduction in the microbial load with time, during the course of treatment indicating the efficacy of the formulation in reducing the microbial load and thus controlling infection, facilitating wound healing.

Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management

Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress. The condition affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and greatly reduce patients' quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases. As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment. A correct diagnosis is essential to avoid inappropriate treatment that may cause deterioration of the wound, delay wound healing, or harm the patient. The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.

Manejo clínico de úlceras venosas na atenção primária à saúde

OBJETIVO: Discutir o manejo clínico de úlceras venosas realizado na atenção primária à saúde, com base na visão dos usuários que convivem com esta afecção. MÉTODOS: Estudo de natureza qualitativa exploratório, descritivo, realizado com 25 usuários adultos em tratamento nas Unidades de Saúde da Família. Os dados foram coletados no segundo semestre de 2008, utilizando-se um formulário estruturado com questões de caracterização sociodemográfica, tipo de limpeza, coberturas, uso de terapia compressiva, medicamentos e orientações prescritas. RESULTADOS: São usados para a limpeza produtos que agridem o tecido de granulação, como coberturas com várias substâncias, dentre elas o óleo de girassol e pomadas antibióticas; a maioria dos usuários não utiliza medidas para controle do edema. CONCLUSÃO: fazem-se necessárias a elaboração e a adoção de protocolos clínicos para o cuidado com úlceras venosas, bem como a capacitação permanente dos profissionais de saúde.

Surgical management of Diabetic foot ulcers: A Tanzanian university teaching hospital experience

Background

Diabetic foot ulcers (DFUs) pose a therapeutic challenge to surgeons, especially in developing countries where health care resources are limited and the vast majority of patients present to health facilities late with advanced foot ulcers. A prospective descriptive study was done at Bugando Medical Centre from February 2008 to January 2010 to describe our experience in the surgical management of DFUs in our local environment and compare with what is known in the literature.

Findings

Of the total 4238 diabetic patients seen at BMC during the period under study, 136 (3.2%) patients had DFUs. Males outnumbered females by the ratio of 1.2:1. Their mean age was 54.32 years (ranged 21-72years). Thirty-eight (27.9%) patients were newly diagnosed diabetic patients. The majority of patients (95.5%) had type 2 diabetes mellitus. The mean duration of diabetes was 8.2 years while the duration of DFUs was 18.34 weeks. Fourteen (10.3%) patients had previous history of foot ulcers and six (4.4%) patients had previous amputations. The forefoot was commonly affected in 60.3% of cases. Neuropathic ulcers were the most common type of DFUs in 57.4% of cases. Wagner's stage 4 and 5 ulcers were the most prevalent at 29.4% and 23.5% respectively. The majority of patients (72.1%) were treated surgically. Lower limb amputation was the most common surgical procedure performed in 56.7% of cases. The complication rate was (33.5%) and surgical site infection was the most common complication (18.8%). Bacterial profile revealed polymicrobial pattern and Staphylococcus aureus was the most frequent microorganism isolated. All the microorganisms isolated showed high resistance to commonly used antibiotics except for Meropenem and imipenem, which were 100% sensitive each respectively. The mean hospital stay was 36.24 ± 12.62 days (ranged 18-128 days). Mortality rate was 13.2%.

Conclusion

Diabetic foot ulceration constitutes a major source of morbidity and mortality among patients with diabetes mellitus at Bugando Medical Centre and is the leading cause of non-traumatic lower limb amputation. A multidisciplinary team approach targeting at good glycaemic control, education on foot care and appropriate footware, control of infection and early surgical intervention is required in order to reduce the morbidity and mortality associated with DFUs. Due to polymicrobial infection and antibiotic resistance, surgical intervention must be concerned.

Leg ulcers associated with Klinefelter's syndrome: a case report and review of the literature

We present the case of a young man with type II diabetes, stage III chronic kidney disease, hypertension, obstructive sleep apnea and diabetes who presented to the Georgetown University Hospital Center for Wound Healing with refractory lower extremity ulcers. Autoimmune work-up was negative. However, chromosome analysis showed a genetic variant of Klinefelter's syndrome (48 XXYY). Lower extremity ulceration is a recognised complication of Klinefelter's syndrome. The pathogenesis of ulcers in this endocrinopathy is unclear, but associations with abnormalities of fibrinolysis and prothrombotic states are reported. This case emphasises the importance of considering Klinefelter's syndrome in the differential diagnosis of a sterile male patient with non healing lower extremity ulcers.

The use of Matriderm and autologous skin grafting in the treatment of diabetic ulcers: a case report

The aim of our case report was to analyse the results obtained with the Matriderm system and autologous skin grafting for the surgical treatment of diabetic ulcers. We recruited one patient with diabetic ulcers admitted at the Department of Plastic and Reconstructive Surgery, University of Rome 'Tor Vergata'. The patient underwent Matriderm system and autologous skin grafting for diabetic ulcer treatment. After just a single treatment, we obtained reduction in ulcer after 15 days from the surgical treatment. We achieved a reduction in pain and exudate secretion of the ulcer. We noticed an almost complete restoration of the missing volume and good quality of skin. Matriderm system and autologous skin grafting is a simple, safe and feasible technique. This method, when compared with other methods of treatment, is simple, cheap, less time consuming and does not require sophisticated laboratory facilities.

Improvement of wound healing by water-filtered infrared-A (wIRA) in patients with chronic venous stasis ulcers of the lower legs including evaluation using infrared thermography

BACKGROUND

Water-filtered infrared-A (wIRA) is a special form of heat radiation with a high tissue-penetration and with a low thermal burden to the surface of the skin. wIRA is able to improve essential and energetically meaningful factors of wound healing by thermal and non-thermal effects.

AIM OF THE STUDY

prospective study (primarily planned randomised, controlled, blinded, de facto with one exception only one cohort possible) using wIRA in the treatment of patients with recalcitrant chronic venous stasis ulcers of the lower legs with thermographic follow-up.

METHODS

10 patients (5 males, 5 females, median age 62 years) with 11 recalcitrant chronic venous stasis ulcers of the lower legs were treated with water-filtered infrared-A and visible light irradiation (wIRA(+VIS), Hydrosun radiator type 501, 10 mm water cuvette, water-filtered spectrum 550-1400 nm) or visible light irradiation (VIS; only possible in one patient). The uncovered wounds of the patients were irradiated two to five times per week for 30 minutes at a standard distance of 25 cm (approximately 140 mW/cm(2) wIRA and approximately 45 mW/cm(2) VIS). Treatment continued for a period of up to 2 months (typically until closure or nearly closure of the ulcer). The main variable of interest was "percent change of ulcer size over time" including complete wound closure. Additional variables of interest were thermographic image analysis, patient's feeling of pain in the wound, amount of pain medication, assessment of the effect of the irradiation (by patient and by clinical investigator), assessment of feeling of the wound area (by patient), assessment of wound healing (by clinical investigator) and assessment of the cosmetic state (by patient and by clinical investigator). For these assessments visual analogue scales (VAS) were used.

RESULTS

The study showed a complete or nearly complete healing of lower leg ulcers in 7 patients and a clear reduction of ulcer size in another 2 of 10 patients, a clear reduction of pain and pain medication consumption (e.g. from 15 to 0 pain tablets per day), and a normalization of the thermographic image (before the beginning of the therapy typically hyperthermic rim of the ulcer with relative hypothermic ulcer base, up to 4.5 degrees C temperature difference). In one patient the therapy of an ulcer of one leg was performed with the fully active radiator (wIRA(+VIS)), while the therapy of an ulcer of the other leg was made with a control group radiator (only VIS without wIRA), showing a clear difference in favour of the wIRA treatment. All mentioned VAS ratings improved remarkably during the period of irradiation treatment, representing an increased quality of life. Failures of complete or nearly complete wound healing were seen only in patients with arterial insufficiency, in smokers or in patients who did not have venous compression garment therapy.

DISCUSSION AND CONCLUSIONS

wIRA can alleviate pain considerably (with an impressive decrease of the consumption of analgesics) and accelerate wound healing or improve a stagnating wound healing process and diminish an elevated wound exudation and inflammation both in acute and in chronic wounds (in this study shown in chronic venous stasis ulcers of the lower legs) and in problem wounds including infected wounds. In chronic recalcitrant wounds complete healing is achieved, which was not reached before. Other studies have shown that even without a disturbance of wound healing an acute wound healing process can be improved (e.g. reduced pain) by wIRA. wIRA is a contact-free, easily used and pleasantly felt procedure without consumption of material with a good penetration effect, which is similar to solar heat radiation on the surface of the earth in moderate climatic zones. Wound healing and infection defence (e.g. granulocyte function including antibacterial oxygen radical formation of the granulocytes) are critically dependent on a sufficient energy supply (and on sufficient oxygen). The good clinical effect of wIRA on wounds and also on problem wounds and wound infections can be explained by the improvement of both the energy supply and the oxygen supply (e.g. for the granulocyte function). wIRA causes as a thermal effect in the tissue an improvement in three decisive factors: tissue oxygen partial pressure, tissue temperature and tissue blood flow. Besides this non-thermal effects of infrared-A by direct stimulation of cells and cellular structures with reactions of the cells have also been described. It is concluded that wIRA can be used to improve wound healing, to reduce pain, exudation, and inflammation and to increase quality of life.

Biologic therapeutics and molecular profiling to optimize wound healing

Non-healing wounds represent a significant cause of morbidity and mortality for a large portion of the adult population. Wounds that fail to heal are entrapped in a self-sustaining cycle of chronic inflammation leading to the destruction of the extracellular matrix. Among cancer patients, malnutrition, radiation, physical dehabilitation, chemotherapy, and the malignancy itself increase the likelihood of chronic wound formation, and these co-morbidity factors inhibit the normal wound healing process. Current wound treatments are aimed at some, but not all, of the underlying causes responsible for delayed healing of wounds. These impediments block the normal processes that allow normal progression through the specific stages of wound healing. This review summarizes the current information regarding the management and treatment of complex wounds that fail to heal normally and offers some insights into novel future therapies [Menke N, Ward KR, Diegelmann R. Non-healing wounds. Emerg Med Rep 2007; 28(4).,Menke NB, Ward KR, Witten TM, Bonchev DG, Diegelmann RF. Impaired wound healing. Clin Dermatol 2007;25:19-25].

Bioactive glass-derived hydroxyapatite-coating promotes granulation tissue growth in subcutaneous cellulose implants in rats

Granulation tissue was induced in hydroxyapatite-coated cellulose sponges with subcutaneous implantation in rats. A massive inflammatory reaction with an intense foreign body reaction and an increased invasion of fibrovascular tissue was observed by days 1-3 post-operation, whereas tissue growth into the uncoated control implants was much slower and took place mainly on their surfaces. The foreign body reaction in apatite-coated sponges declined after post-operative day 14, and no obvious differences were seen between the two cellulose sponges from 1 month up to 1 year after implantation. The apatite-coated implants attracted macrophages and fibroblasts, and favored angiogenesis. The excessive connective tissue formation was histologically normal, synthesized the major extracellular matrix molecules in a normal ratio and did not seem to disturb the animals in any way. These results warrant further investigations on clinical applicability of hydroxyapatite-coated cellulose sponges, when fast proliferation of connective tissue is desirable.

Venous leg ulcer treatment and practice--part 1: the causes and diagnosis of venous leg ulcers

This article, the first of a series of four on venous leg ulceration, discusses theories relating to the pathophysiology underlying the condition, and the range of diagnostic procedures undertaken to establish that ulceration is of venous origin.

Etiology and incidence of chronic ulcers in Blantyre, Malawi

BACKGROUND

Little information is available on the incidence and etiology of chronic ulcers in the tropics. Therefore, the incidence and etiology of chronic skin ulcers were assessed in out-patients at the Department of Dermatology and in in-patients at the Departments of Dermatology, Surgery, Medicine, and Pediatrics, Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi.

METHOD

In a 10-week study period, 44 patients (31 males, 70%) with chronic skin ulcers were diagnosed from 6292 patients seen by the departments involved.

RESULTS

The mean age of patients with ulcers was 38 years (range, 9 months to 82 years). The most frequent cause of ulcers was bacterial infection (n=22), followed by malignancy (n=11) and trauma (n=7).

CONCLUSION

In contrast with developed countries, venous and diabetic ulcers were uncommon. In addition to bacterial infections, a surprisingly large number of malignancies were found in this study. We speculate that human immunodeficiency virus (HIV) infection, which is seen with a high prevalence at QECH, is a contributing factor. Because of the large number of malignancies, we recommend early histopathologic investigation of chronic ulcers in this part of Africa.

Preventing venous ulcer recurrence: a review

This review article examines the available evidence on both the primary and secondary prevention of venous ulceration, exploring both the individual, social and financial implications of system failures that allow patients to remain at increased risk of recurrent ulceration. The role of both venous disease assessment and corrective superficial venous surgery are discussed in the light of recently published randomised controlled studies on the role of superficial venous surgery as both an adjunct to ulcer healing and ulcer prevention.

Comparison of elastic versus nonelastic compression in bilateral venous ulcers: a randomized trial

BACKGROUND

There is controversy regarding the effectiveness of elastic vs nonelastic compression in the healing of venous leg ulcers. To gain insight into this controversy, we randomly compared a four-layer elastic bandage with a nonelastic garment (CircAid) in patients with venous leg ulcers.

METHODS

Twenty-four extremities of 12 patients with bilateral leg ulcers were randomized to have a four-layer elastic bandage in 1 extremity and a nonelastic compression garment CircAid in the contralateral limb. The CEAP classification in 22 extremities was C(6 S); ES; A(D6,14,15,P18); PR; 1 extremity in 2 patients was C(6 S); E(S); A(D 6,14,15,P18); PRO. There were seven men and five women. Age ranged from 45 to 82 years, with a mean of 61 years. All patients had postthrombotic leg ulcers diagnosed clinically by duplex ultrasonography (n = 8) or by phlebography (n = 4). Every 4 weeks, patients had the ulcer area measured in square centimeters by a computerized scanning method and had the limb girth measured in centimeters at the foot, ankle, and calf. The ankle-brachial index was determined in all cases. Color photographs of the ulcer areas were taken monthly to assess healing progress. All patients were compliant. Results were assessed at 12 weeks. A patient satisfaction sheet was filled out by the patient, who circled one of the following scores: 3, very satisfied; 2, moderately satisfied; and 1, not satisfied. Cox proportional hazards models or paired t tests were used for comparison.

RESULTS

The 24 limbs were randomized and divided into 2 groups of 12 each. Group A received CircAid, and group B, a four-layer elastic bandage. Duplex scanning showed a pattern of reflux in 11 limbs of each group. One limb in each group had a pattern of obstruction documented by air plethysmography (n = 2). Phlebography demonstrated the anatomic site in both limbs. The initial ulcer area in group A was 48.98 +/- 14.13 cm2 and was 50.08 +/- 18.30 cm2 in group B (P = .9285). The ulcer healing rate was significantly faster in group A compared with group B (hazard ratio, 0.56; 95% confidence interval, 0.33-0.96; P = .0173). Ulcers with hemodynamic obstruction had a protracted course when compared with the contralateral limbs with reflux. There was no significant difference in girth reduction between groups A and B (hazard ratio, 2.36; 95% confidence interval, 0.30-18.52; P = .3580). The ankle-brachial index was normal (> or = 1.0) in all patients.

CONCLUSIONS

In compliant patients, venous leg ulcers randomized to nonelastic compression had a significantly faster healing rate per week than ulcers treated by the conventional four-layer compression system.

An Indian community-based epidemiological study of wounds

OBJECTIVE

To establish the prevalence of wounds in a community, with an emphasis on chronic lower extremity wounds, and to identify the various aetiological factors involved.

METHOD

A cross-sectional study was conducted to screen the population of two nearby communities (one urban and one rural) in India for wounds. This involved conducting a door-to-door survey between July 2001 and February 2003.

RESULTS

The prevalence of wounds in the population studied (n = 6917) was 15.03 per 1000. The prevalences of acute and chronic wounds were 10.55 and 4.48 per 1000 of the population respectively.

CONCLUSION

The most common site for both acute and chronic wounds was the lower extremity. In contrast to Western studies, the most common aetiology for a chronic lower extremity wound was an untreated acute traumatic wound. This in turn highlights the need to establish community-based wound-care teams in India.

An evaluation of the leg and foot ulcer treatment provided in Oslo

OBJECTIVE

This study set out to gather more information about the treatment of leg and foot ulcers in the community in Oslo, Norway.

METHOD

A structured questionnaire on leg and foot ulcer treatment was sent to 173 community nurses in Oslo, of whom 102 responded with data on 145 patients.

RESULTS

Of the sample, 55.9% had leg ulcers, 32.2% had foot ulcers and 11.9% both; 26.2% had diabetes. Thirty-four per cent of the patients had not had a diagnosis of leg ulceration. Saline was the preferred cleansing solution. Compression therapy was used on all types of ulcer. Pain was a problem for 52.9% of the patients, of whom 9% did not receive analgesia.

CONCLUSION

Nurses and doctors working in this community need to update their knowledge of wound treatments.

Humic acid induces oxidative DNA damage, growth retardation, and apoptosis in human primary fibroblasts

Humic acid (HA) has been implicated as an etiological factor of Blackfoot disease endemic in the southwest coast of Taiwan. Dysfunction of endothelial cells and vasculopathy have been proposed to explain the onset of ulcerous changes at extremities. However, little is known about the effect of HA on activities of cells in these nonhealing wounds. In the present study, we demonstrate that HA adversely affects the growth properties of fibroblasts, one of the key players in wound repair. HA treatment caused growth arrest and apoptosis in human foreskin fibroblasts (HFF). This was accompanied by a significant increase in the level of 8-hydroxy-2'-deoxyguanosine (8-OHdG) in cellular DNA. The increased fluorescence in dichlorofluorescin (H2DCF)-stained and HA-treated cells suggests the involvement of reactive oxygen species (ROS) in HA-induced biological effects. Conversely, vitamin E pretreatment, which significantly reduced the 8-OHdG formation in HA-treated cells, alleviated the growth-inhibitory and apoptosis-inducing effects of HA. These results indicate that HA initiates oxidative damages to fibroblasts, and leads to their dwindling growth potential and survival. The present study suggests that HA-induced growth retardation and apoptosis of fibroblasts may play a role in the pathogenesis of Blackfoot disease.

A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers

INTRODUCTION

As part of a reconsideration of coverage policy, the Centers for Medicare and Medicaid Services requested a systematic review of the evidence on the use of pneumatic compression devices in the home environment for treatment of chronic venous insufficiency (CVI) and venous ulcers.

METHODS

Articles were found with a systematic literature search of MEDLINE, EMBASE, and AMED (Allied and Complementary Medicine) databases, hand searches of reference lists, and suggestions of experts.

RESULTS

Eight trials that met the inclusion criteria, including several randomized control trials, were found. Most studies were small and may have been underpowered. However, several were well-designed randomized controlled trials. Three studies showed that the devices could alleviate symptoms of CVI. No studies directly measured whether the devices could prevent the occurrence of venous ulcers. Some studies on the treatment of venous ulcers did not show a benefit for pneumatic compression, but other studies showed a benefit for the devices in healing long-standing chronic ulcers that had not healed with other methods. No studies directly compared single-chamber and multiple-chamber devices or studied whether the effectiveness of the pump was dependent on types of treatment used concurrently with the pump. Few adverse events were reported in the trials. Patients generally expressed satisfaction with the pneumatic compression devices, and several studies reported higher compliance than with other compression methods.

CONCLUSION

The available data cannot be relied on to inform the optimal choice of compression therapy or optimal protocol for patients with CVI or venous ulcers. Methodologically rigorous research designed to answer these questions would be useful for treatment decisions. The Centers for Medicare and Medicaid Services considered the results of this study and issued a decision that pneumatic compression will only be covered for patients with refractory edema with significant ulceration of the lower extremities after a 6-month trial of standard therapies, such as compression stockings, has failed.