Factors related to venous ulceration: a cross-sectional study

Risk factors for venous ulceration in patients with varicose veins of lower extremities

The aim of this case-control study was to explore the potential risk factors for venous ulceration in patients with varicose veins of lower extremities and to establish a simplified diagnostic score model. Seventy subjects with varicose veins of lower extremities and venous ulceration were compared with 1164 controls with varicose veins of lower extremities and no history of venous ulceration. Stepwise multivariate logistic regression analysis was used to identify the risk factors for venous ulceration. The steps in developing the diagnostic score model were based on the Framingham Heart study. The area under the receiver operating characteristic curve (AUC) was calculated to assess the diagnostic ability of the diagnostic score model. Multivariate analysis showed that men, overweight, obesity, longer duration varicose veins, deep venous valve insufficiency, low lymphocyte counts, and high fibrinogen content were independently associated with an increased risk of venous ulceration. The AUC for the diagnostic score model was 0.75, which indicated good discriminatory ability. Special attention should be paid to the high-risk group of patients with lower extremity varicose veins. The diagnostic score model might be a useful screening tool for clinicians, policy makers, and patients.

Venous ulcers: look at the patient, not at the ulcer! Risk factors and comorbid conditions in venous ulcers of lower limbs

BACKGROUND

In venous leg ulcers (VLU), risk factors and comorbidities may affect prognosis and recurrence. Aim of this paper was to assess risk factors and most frequent medical conditions in venous ulcers.

METHODS

This a single center retrospective study from January 2017 to December 2020 on 172 patients with VLU admitted at our Center for Ulcer therapy in San Filippo Neri Hospital in Rome; data about medical history, Duplex scanning results and lifestyle questionnaire were collected in an Excel database and evaluated with Fisher test. Patients with lower limbs arterial insufficiency were excluded.

RESULTS

Incidence of VLU in patients over 65 was twice that in patients under 65 and woman were affected by VLU more than men (59.3% vs. 40.7%; P<0.001); more significant comorbidities were arterial hypertension in 44.19% (P=0.06), heart disease in 35.47% (P<0.001), chronic obstructive pulmonary disease (COPD) in 16.28% (P=0.008). In 33 patients (19% of cases) a trauma caused the ulcer. Diabetes, obesity, chronic renal insufficiency and orthopedic disease do not seem to have a direct influence on VLU.

CONCLUSIONS

Age, female sex, arterial hypertension, heart disease and COPD were significant risk factors. Thinking "globally" to the patient rather than only taking the ulcer into account is the key for a long-lasting therapeutic result; comorbidities are interconnected so weight loss, an exercise program for calf pump and compression must all be part of the VLU therapy, not only to heal the existing ulcer but also to prevent recurrences.

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.

Characteristics of venous leg ulcer patients at a tertiary wound care center

OBJECTIVE

The objective of this study was to assess patient, wound, care, and reflux characteristics of venous leg ulcers (VLUs) to update and improve knowledge of disease etiology, identify barriers to healing, and improve treatment.

METHODS

Patients diagnosed with VLUs treated at the Stanford Advanced Wound Care Center between 2018 and 2019 were identified from the Healogics iHeal database. We identified 327 VLU entries, of which 133 were patients who had multiple or recurring wounds. An additional 27 patients were labeled as misdiagnosis, resulting in a final patient sample of 167. Patient demographics, wound, care, and ultrasound data for these patients were extracted from the Stanford electronic medical records regarding characteristics. The initial data analysis suggested possible differences in VLU characteristics depending on patient age and body mass index (BMI), which was then further analyzed.

RESULTS

Of the 167 VLU patients assessed, 53.9% were male and 46.1% were female. The mean age was 74.7 years, and the average BMI was 30.2 kg/m2, including 41.1% of patients with a BMI over 30 kg/m2. Approximately 50% of wounds were presented in multiples, had cellulitis, or were recurring, and 39.5% were caused by trauma. Most common venous reflux patterns on duplex ultrasound examination were below-knee great saphenous vein reflux and calf perforator reflux, which was identified in 37.7% and 29.3% of the patients, respectively. Axial great saphenous vein reflux was detected in 14.4% of patients. When looking at the patient sample under 60 years of age, 67.7% were male, 61.3% presented with venous skin changes, and 51.6% had diabetes. In the patients older than 60, only 51.9% were male, 37.6% presented with venous skin changes, and 31.6% had diabetes. BMI was greater in the patients under age 60, with an average of 39.2 kg/m2, compared with 28.2 kg/m2 in those above 60. Of the patients with a BMI ≥30 kg/m2, 64.3% had multiple wounds, 61.4% had recurring wounds, and 56.5% had venous skin changes. In contrast, in patients with BMI <30 kg/m2, 47.4% had multiple wounds, 39.2% had recurring wounds, and 32.0% had venous skin changes.

CONCLUSIONS

VLU pathology appears to differ depending on patient demographics and characteristics. Different drivers may influence disease cause, progression, and prognosis, making a standard approach to VLUs difficult. Our findings suggest that identifying different subtypes of VLUs and adapting an algorithm of care with a personalized treatment may help optimize management of these patients.

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

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

Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study

BACKGROUND

Large studies that examine risk factors for first occurrence of venous leg ulcerations are needed to guide management.

OBJECTIVE

To investigate factors associated with development of first occurrence of venous leg ulcerations.

METHODS

A retrospective cohort study using a validated national commercial claims database of patients with venous insufficiency. Subjects were followed to determine whether they developed first occurrence of venous leg ulcerations, and risk and protective factors were analyzed.

RESULTS

Adjusted hazard ratio (AHR) for comorbidities demonstrated an increased risk in men (AHR 1.838; 95% confidence interval [CI] 1.798-1.880), older age (45-54 years: AHR 1.316, 95% CI 1.276-1.358; 55-64 years, AHR 1.596, 95% CI 1.546-1.648), history of nonvenous leg ulceration (AHR 3.923; 95% CI 3.699-4.161), anticoagulant use (AHR 1.199; 95% CI 1.152-1.249), antihypertensive use (AHR 1.067; 95% CI 1.040-1.093), and preexisting venous insufficiency including chronic venous insufficiency (AHR 1.244; 95% CI 1.193-1.298), edema (AHR 1.224; 95% CI 1.193-1.256), and chronic venous hypertension (AHR 1.671; 95% CI 1.440-1.939). Possible protective factors were having venous surgery (AHR 0.454; 95% CI 0.442-0.467), using compression stockings (AHR 0.728; 95% CI 0.705-0.753), using prescribed statin medications (AHR 0.721; 95% CI 0.700-0.743), and using pain medications (AHR 0.779; 95% CI 0.757-0.777).

LIMITATIONS

Risk of misclassification, given the use of International Classification of Diseases, Ninth Revision codes. Possible confounding factors such as body mass index could not be adequately controlled with these codes.

CONCLUSION

The new evidence presented supports a paradigm shift toward venous leg ulceration prevention.

A qualitative study on the patient's narrative in the progression of chronic venous disease into a first venous leg ulcer: a series of events

BACKGROUND

A venous leg ulcer (VLU) has a significant negative impact on quality of life. Prevention of a VLU is not yet imbedded in clinical practice because risk factors for developing a first VLU are not well known.

OBJECTIVES

To explore further the progression of chronic venous disease (CVD) into a first VLU from the patient's perspective.

METHODS

A qualitative study using semistructured interviews was conducted among male and female patients with a VLU. Patients from primary and secondary care, under and over 50 years of age, and with first and recurrent VLUs were included. The interviews were transcribed and analysed using a narrative approach to a thematic analysis. Transcripts were organized in chronological order and an iterative process was used to code the transcripts.

RESULTS

Four key themes and the connections made between them emerged from the 11 narratives on the progression of CVD towards a first VLU: 'comorbidity', 'mobility', 'work and lifestyle' and 'acknowledgment of CVD'. Comorbidity was linked to reduced mobility and late acknowledgment of CVD. Comorbidity also affected work and lifestyle and vice versa. Work and lifestyle affected mobility and was linked to the acknowledgment of CVD.

CONCLUSIONS

A reduction in mobility as a result of comorbidity and work and lifestyle occurred before the VLU developed. Patients did not recognize symptoms of CVD and did not acknowledge the chronicity of CVD. Healthcare professionals should be aware of reductions in mobility and the knowledge deficit in patients with CVD. What's already known about this topic? Not all patients with chronic venous disease (CVD) develop a venous leg ulcer (VLU). A patient's quality of life decreases significantly when a VLU develops. Risk factors for the development of a first VLU in patients with CVD are not well known, unlike risk factors for other chronic wounds like diabetic foot ulcer and pressure ulcers. What does this study add? The patient's narrative towards the development of a first VLU, a series of events. Insight into the events (comorbidity, mobility, work and lifestyle) that patients themselves link to the development of a VLU. Insight into the patients' acknowledgment of CVD in the progression of CVD towards a first VLU. What are the clinical implications of this work? More awareness is needed of CVD symptoms among patients and healthcare providers, as well as more awareness for prevention of a VLU in clinical practice. New insights (for further studies) are needed into the concept of mobility and the development of a VLU. Improved patient education and follow-up are needed for patients with CVD.

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

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

A scoping review on Chronic Venous Disease and the development of a Venous Leg Ulcer: The role of obesity and mobility

OBJECTIVE

The risk factors obesity and reduced mobility are not well known in the development of a Venous Leg Ulcer (VLU). The aim of this scoping review is to explore the mechanisms by which obesity and reduced mobility contribute the development of a VLU in patients with Chronic Venous Disease (CVD).

METHODS

For this scoping review a search was performed in May 2019 in the Cochrane Library and Pubmed to identify studies on the working mechanisms of obesity and mobility in developing a VLU. Hand searches were performed to find additional studies explaining the working mechanisms (indirectly related to the VLU). Two reviewers independently reviewed the abstracts and full-text articles.

RESULTS

Twenty-eight studies met our eligibility criteria. Disturbed range of ankle motion and gait can lead to a reduced Calf Muscle Pump (CMP) function which leading to a venous outflow disorder. Increased abdominal pressure due to obesity can lead to a venous outflow obstruction and increased adipose tissue mass results in an increase in adipokine secretion. The venous outflow disorder, outflow obstruction and increased adipokine secretion can all lead to chronic systemic inflammation, increased endothelial permeability and hence microcirculatory dysfunction. This alone can result in a VLU.

CONCLUSION

Obesity and reduced mobility can lead to a reduction of the CMP function, an increase in abdominal pressure and an increase in adipose tissue mass. This can simultaneously lead to haemodynamic changes in the macro- and microcirculation of the lower extremities and eventually in a VLU. In patients with obesity and reduced mobility the microcirculation alone can lead to skin changes and eventually a VLU. Therefore, early recognition of CVD symptoms in patients with obesity and reduced mobility is crucial to diagnose and treat CVD to prevent a VLU.

Correlation between chronic venous ulcer exudate proteins and clinical profile: A cross-sectional study

Chronic venous ulcers affect the quality of life of patients around the world. The aims of this study were to identify the proteins expressed in chronic venous ulcer exudates, to categorize them according to their roles and to correlate them with the clinical and epidemiological aspects of the disease. The study population consisted of 37 ulcers from 28 patients, and the inflammatory exudates of these thirty-seven ulcers were subjected to tryptic digestion and mass spectrometry analysis. Twenty-three patients were female (62.2%), and five (37.8%) were male. The patients had a mean age of 70 (±10.1) years. Of the patients, 73% adhered to compression and rest, 81.1% reported a history of primary varices, 54.1% reported a history of systemic arterial hypertension, 54.1% reported a history of devitalized tissue in the wound bed and 64.9% reported ulcers with more than ten years of evolution. Seventy-six proteins were identified, and they were grouped according to their primary role in the healing process. Eight correlations between clinical and epidemiological data and protein expression were noteworthy: diabetes mellitus vs. Ig gamma-2 and apolipoprotein-A1 and albumin; congestive heart failure vs. Ig lambda-2; colonization vs. actin; compressive therapy vs. Ig kappa; systemic arterial hypertension vs. alpha-2-macroglobulin and apolipoprotein-A1; area of ulcer vs. apolipoprotein-A1; race vs. heavy chain Ig and Ig γ-1 chain; age and race vs. Ig γ-1 chain. These associations may help to elucidate the prognosis and chronicity of chronic venous ulcers based on secreted proteins.

Factors related to the size of venous leg ulcers: A cross-sectional study

Venous leg ulcers (VLUs) are an important health problem, and the size of ulcers often affects patient care, healing time, and quality of life. However, the risk factors associated with ulcer size have been rarely reported. The aim of this study was to establish the risk factors for the size of venous ulceration by analyzing the patient demographics and the results of duplex ultrasonography.This study was an in-patient population-based cross-sectional study conducted at a single center during the period from 2013 to 2017. Men and women aged >18 years, who consecutively presented to our hospital with VLU, were included. According to the size of the ulcer, patients were divided into two groups, those with ulcers≤2 cm and those with ulcers >2 cm. Demographic, anthropometric, and clinical data were collected. For the analysis, univariate and multivariate logistic regressions were used.A total of 232 patients with VLUs were admitted to our hospital from 2013 to 2017, including 117 patients (50.4%) with ulcer diameters ≤2 cm and 115 patients (49.6%) with ulcer diameters >2 cm. According to the results of the multivariate analysis, the ulcer duration (P = .001), the diameter of perforating veins (PVs) around the ulcers (P = .025), the reflux time of common femoral veins (CFVs) (P = .013), the reflux time of great saphenous veins (GSVs) (P = .021), and the reflux time of PVs around the ulcers (P = .001) were independent risk factors for VLUs.These findings provide evidence that the size of VLU was significantly related to the ulcer duration, the diameter of PV around the ulcers, the CFV reflux time, the GSV reflux time, and the PV reflux time.

Protocol for a longitudinal cohort study: determination of risk factors for the development of first venous leg ulcer in people with chronic venous insufficiency, the VEINS (venous insufficiency in South Florida) cohort

INTRODUCTION

Chronic venous insufficiency (CVI) affects up to one-third of the adult population yet venous leg ulcers (VLU), a significant complication of CVI, only affect 1%-2% of adults in the USA. Why some develop VLU and others do not is unclear. VLU have a significant impact on quality of life and are extremely costly and difficult to treat. Moreover, VLU prevalence is increasing, doubling in the last 20 years. In order to characterise the differences between people with CVI and those who ultimately develop VLU, we aim to set up the unique venous insufficiency in South Florida cohort.

METHODS AND ANALYSIS

Subjects will be recruited from the University of Miami Hospital and Clinic's vascular laboratory database, which began in July 2011. Any adult age 18-95 who has had venous reflux detected on duplex ultrasound of the lower extremities is included. Approximately 2500 patients are already in the database that meet these criteria, with an estimated 2500 additional potential subjects to be recruited from the vascular laboratory database over the next 5 years. Subjects with a history of VLU prior to the duplex study date will be excluded. Data will be collected via review of the Doppler study report, patient phone interview and review of the electronic medical record. Subjects will be contacted for follow-up every 3 months for at least 5 years until the study endpoint, development of first VLU (fVLU), is reached. In order to estimate the time from reflux documentation to fVLU, Kaplan-Meier survival curves will be constructed. Cox proportional hazard regression models will be constructed to investigate possible risk factors.

ETHICS AND DISSEMINATION

This study is approved by the University of Miami's Institutional Review Board. We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals.

Protease activity as a prognostic factor for wound healing in venous leg ulcers

BACKGROUND

Venous leg ulcers (VLUs) are a common type of complex wound that have a negative impact on people's lives and incur high costs for health services and society. It has been suggested that prolonged high levels of protease activity in the later stages of the healing of chronic wounds may be associated with delayed healing. Protease modulating treatments have been developed which seek to modulate protease activity and thereby promote healing in chronic wounds.

OBJECTIVES

To determine whether protease activity is an independent prognostic factor for the healing of venous leg ulcers.

SEARCH METHODS

In February 2018, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and CINAHL.

SELECTION CRITERIA

We included prospective and retrospective longitudinal studies with any follow-up period that recruited people with VLUs and investigated whether protease activity in wound fluid was associated with future healing of VLUs. We included randomised controlled trials (RCTs) analysed as cohort studies, provided interventions were taken into account in the analysis, and case-control studies if there were no available cohort studies. We also included prediction model studies provided they reported separately associations of individual prognostic factors (protease activity) with healing. Studies of any type of protease or combination of proteases were eligible, including proteases from bacteria, and the prognostic factor could be examined as a continuous or categorical variable; any cut-off point was permitted. The primary outcomes were time to healing (survival analysis) and the proportion of people with ulcers completely healed; the secondary outcome was change in ulcer size/rate of wound closure. We extracted unadjusted (simple) and adjusted (multivariable) associations between the prognostic factor and healing.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage, and undertook data extraction, assessment of risk of bias and GRADE assessment. We collected association statistics where available. No study reported adjusted analyses: instead we collected unadjusted results or calculated association measures from raw data. We calculated risk ratios when both outcome and prognostic factor were dichotomous variables. When the prognostic factor was reported as continuous data and healing outcomes were dichotomous, we either performed regression analysis or analysed the impact of healing on protease levels, analysing as the standardised mean difference. When both prognostic factor and outcome were continuous data, we reported correlation coefficients or calculated them from individual participant data.We displayed all results on forest plots to give an overall visual representation. We planned to conduct meta-analyses where this was appropriate, otherwise we summarised narratively.

MAIN RESULTS

We included 19 studies comprising 21 cohorts involving 646 participants. Only 11 studies (13 cohorts, 522 participants) had data available for analysis. Of these, five were prospective cohort studies, four were RCTs and two had a type of case-control design. Follow-up time ranged from four to 36 weeks. Studies covered 10 different matrix metalloproteases (MMPs) and two serine proteases (human neutrophil elastase and urokinase-type plasminogen activators). Two studies recorded complete healing as an outcome; other studies recorded partial healing measures. There was clinical and methodological heterogeneity across studies; for example, in the definition of healing, the type of protease and its measurement, the distribution of active and bound protease species, the types of treatment and the reporting of results. Therefore, meta-analysis was not performed. No study had conducted multivariable analyses and all included evidence was of very low certainty because of the lack of adjustment for confounders, the high risk of bias for all studies except one, imprecision around the measures of association and inconsistency in the direction of association. Collectively the research indicated complete uncertainty as to the association between protease activity and VLU healing.

AUTHORS' CONCLUSIONS

This review identified very low validity evidence regarding any association between protease activity and VLU healing and there is complete uncertainty regarding the relationship. The review offers information for both future research and systematic review methodology.

The Significance of Pain in Chronic Venous Disease and its Medical Treatment

Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies. Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.

Alcohol Consumption, High-Density Lipoprotein Cholesterol, Antithrombin III, and Body Mass Index Are Associated with Great Saphenous Vein Reflux in the Thigh

BACKGROUND

Venous valvular reflux is the main cause of chronic venous dysfunction. However, the etiology of valvular reflux is not completely understood. We conducted this study to investigate new risk factors for venous reflux of the great saphenous vein (GSV) in the thigh.

METHODS

We studied 139 consecutive patients (278 legs) who underwent Doppler ultrasonography at our hospital between March 2015 and February 2016 for leg discomfort with visible varicosities, edema, skin changes, or venous ulcer in the legs. Continuous variables included age, body mass index (BMI), hematological and blood chemistry parameters, smoking (pack-years), and alcohol consumption (days). Nominal variables included sex, comorbidities, smoking status, alcohol drinking status, and specific antibodies. The relationship of GSV reflux with pregnancy and number of children was investigated in 184 legs of 92 patients among 96 female patients.

RESULTS

On logistic regression analysis, independent factors determining GSV reflux were BMI (B = 0.126, P = 0.012), high-density lipoprotein (HDL) cholesterol level (B = 0.029, P = 0.025), duration of alcohol consumption (B = 1.237 E^-4, P = 0.016), and antithrombin III level (B = -0.036, P = 0.011).

CONCLUSIONS

In this study, the factors determining GSV reflux were higher HDL cholesterol level, longer duration of alcohol consumption, lower antithrombin III level, and higher BMI.

A case-control study of risk factors of chronic venous ulceration in patients with varicose veins

Background/objectives

Venous ulcers carry psychological and high financial burden for patients, causing depression, pain, and limitation of mobility. The study aimed to identify factors associated with an increased risk of venous ulceration in patients with varicose veins in Armenia.

Methods

A case-control study design was utilized enrolling 80 patients in each group, who underwent varicose treatment surgery in two specialized surgical centers in Armenia during 2013–2014 years. Cases were patients with varicose veins and venous leg ulcers. Controls included patients with varicose veins but without venous leg ulcers. Data were collected using interviewer-administered telephone interviews and medical record abstraction. Multiple logistic regression analysis was used to identify the risk factors of venous ulceration.

Results

There were more females than males in both groups (72.5% of cases and 85.0 % of controls). Cases were on average older than controls (53.9 vs. 39.2 years old, p ≤ 0.001). After adjusting for potential confounders, the estimated odds of developing venous ulcer was higher in patients with history of post thrombotic syndrome (odds ratio = 14.90; 95% confidence interval: 3.95–56.19; p = 0.001), with higher average sitting time (odds ratio = 1.32 per hour of sitting time; 95% confidence interval: 1.08–1.61; p = 0.006), those with reflux in deep veins (odds ratio = 3.58; 95% confidence interval: 1.23–10.31; p = 0.019) and history of leg injury (odds ratio = 3.12; 95% confidence interval: 1.18–8.23; p = 0.022). Regular exercise in form of walking (≥5 days per week) was found to be a protective factor from venous ulceration (odds ratio = 0.26; 95% confidence interval: 0.08–0.90; p = 0.034).

Conclusion

We found that reflux in deep veins, history of leg injury, history of post thrombotic syndrome, and physical inactivity were significant risk factors for venous ulceration in patients with varicose veins, while regular physical exercise mitigated that risk. Future studies should investigate the relationships between the duration and type of regular exercise and the risk of venous ulceration to make more specific recommendations on preventing ulcer development.

Protease-modulating matrix treatments for healing venous leg ulcers

BACKGROUND

Venous leg ulcers (VLUs) are open skin wounds on the lower leg that occur because of poor blood flow in the veins of the leg; leg ulcers can last from weeks to years, and are both painful and costly. Prevalence in the UK is about 2.9 cases per 10,000 people. First-line treatment for VLUs is compression therapy, but around 60% of people have unhealed ulcers after 12 weeks' treatment and about 40% after 24 weeks; therefore, there is scope for further improvement. Limited evidence suggests non-healing leg ulcers may have persisting elevated levels of proteases, which is thought to deter the later stages of healing; thus, timely protease-modulating matrix (PMM) treatments may improve healing by physically removing proteases from the wound fluid.

OBJECTIVES

To determine the effects of protease-modulating matrix (PMM) treatments on the healing of venous leg ulcers, in people managed in any care setting.

SEARCH METHODS

In September 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We searched for published or unpublished randomised controlled trials (RCTs) that evaluated PMM treatments for VLUs. We defined PMM treatments as those with a purposeful intent of reducing proteases. Wound healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included 12 studies (784 participants) in this review; sample sizes ranged from 10 to 187 participants (median 56.5). One study had three arms that were all relevant to this review and all the other studies had two arms. One study was a within-participant comparison. All studies were industry funded. Two studies provided unpublished data for healing.Nine of the included studies compared PMM treatments with other treatments and reported results for the primary outcomes. All treatments were dressings. All studies also gave the participants compression bandaging. Seven of these studies were in participants described as having 'non-responsive' or 'hard-to-heal' ulcers. Results, reported at short, medium and long durations and as time-to-event data, are summarised for the comparison of any dressing regimen incorporating PMM versus any other dressing regimen. The majority of the evidence was of low or very low certainty, and was mainly downgraded for risk of bias and imprecision.It is uncertain whether PMM dressing regimens heal VLUs quicker than non-PMM dressing regimens (low-certainty evidence from 1 trial with 100 participants) (HR 1.21, 95% CI 0.74 to 1.97).In the short term (four to eight weeks) it is unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (very low-certainty evidence, 2 trials involving 207 participants).In the medium term (12 weeks), it is unclear whether PMM dressing regimens increase the probability of healing compared with non-PMM dressing regimens (low-certainty evidence from 4 trials with 192 participants) (RR 1.28, 95% CI 0.95 to 1.71). Over the longer term (6 months), it is also unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (low certainty evidence, 1 trial, 100 participants) (RR 1.06, 95% CI 0.80 to 1.41).It is uncertain whether there is a difference in adverse events between PMM dressing regimens and non-PMM dressing regimens (low-certainty evidence from 5 trials, 363 participants) (RR 1.03, 95% CI 0.75 to 1.42). It is also unclear whether resource use is lower for PMM dressing regimens (low-certainty evidence, 1 trial involving 73 participants), or whether mean total costs in a German healthcare setting are different (low-certainty evidence, 1 trial in 187 participants). One cost-effectiveness analysis was not included because effectiveness was not based on complete healing.

AUTHORS' CONCLUSIONS

The evidence is generally of low certainty, particularly because of risk of bias and imprecision of effects. Within these limitations, we are unclear whether PMM dressing regimens influence venous ulcer healing relative to dressing regimens without PMM activity. It is also unclear whether there is a difference in rates of adverse events between PMM and non-PMM treatments. It is uncertain whether either resource use (products and staff time) or total costs associated with PMM dressing regimens are different from those for non-PMM dressing regimens. More research is needed to clarify the impact of PMM treatments on venous ulcer healing.

Successful Treatment of Chronic Venous Ulcers With a 1,320-nm Endovenous Laser Combined With Other Minimally Invasive Venous Procedures

BACKGROUND

Venous ulcers are very common with few curative treatment options.

OBJECTIVE

To report the closure rate and clinical characteristics of active venous ulcers in a vein clinic using endovenous laser ablation (EVLA) with a 1,320-nm laser.

METHODS AND MATERIALS

A prospective database was kept consisting of patients with an active venous ulcer at the time of consultation in a single-practitioner academic vein clinic from March 2007 to May 2014. A database was maintained and charts were reviewed with attention to the length of time the patient reported having the ulcer, procedures performed, and time to ulcer healing.

RESULTS

Thirty-one patients were identified at consultation with venous ulceration. One patient's ulcer was healed with conservative medical management before receiving treatment. The remaining 30 patients were treated with a combination of EVLA of the great and/or short saphenous veins, foam sclerotherapy of insufficient varicose and reticular veins, and phlebectomy as appropriate. Two patients were lost to follow up after partial treatment. Ulcer healing occurred in more than 93% (27/29) of patients with a median healing time of 55 days from the time of first treatment. The median follow-up time after treatment was 448 days.

CONCLUSION

Endovenous laser ablation with a 1,320-nm laser in combination with foam sclerotherapy and phlebectomy as appropriate is effective treatment of chronic venous ulcers and should be considered as a treatment option for patients with C6 venous insufficiency. To the authors' knowledge, this is the largest, prospective series of chronic venous ulcers treated with EVLA. Further randomized controlled studies are needed to confirm these findings.

Ankle fractures in the elderly: an overlooked burden

Ankle fractures in the elderly are a complex under-recognized burden which require a multidisciplinary approach to management. This article discusses the holistic approach required, including the up-to-date surgical management options and the areas for future development.

Chronic Venous Disease and Comorbidities

We report the relations between comorbidities and chronic venous disease. In this cross-sectional study, information was gathered from 1679 Serbian patients. The majority (65.0%) of patients were women. Mild forms of chronic venous disease (clinical, etiologic, anatomic and pathophysiologic [CEAP] classification; C0s-C1) were more frequent in women (11.6%), while severe forms (CEAP C4-C6) were more commonly encountered in men (42.1%). The most frequent comorbidity was emphysema/chronic obstructive pulmonary disease in both groups (74.3% in males and 70.6% in females). For females, diabetes mellitus ( P < .005), arterial hypertension ( P < .000), and skeletal/joint diseases ( P < .042) were more commonly found in the C4 to C6 category. Both males and females, with severe form of chronic venous disease, may benefit from additional screening for comorbidities. Further studies are needed to clarify the nature of association among comorbidities and chronic venous disease.

Venous leg ulceration pathophysiology and evidence based treatment

Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.