Venous leg ulceration pathophysiology and evidence based treatment

Sub-ulcer foam sclerotherapy in patients with venous ulceration: A randomized controlled trial

PURPOSE

This trial analyzed the effect of sub-ulcer foam sclerotherapy in patients with venous leg ulcer (VLU).

DESIGN

Randomized controlled trial.

METHODS

This trial recruited patients with VLUs to receive either sub-ulcer foam sclerotherapy and compression therapy (study group) or compression therapy only (control group). The primary outcome of this study was the change in the venous ulcer area at 4 weeks. The feasibility, safety, and complications of the sub-ulcer foam sclerotherapy were recorded.

RESULTS

Of 23 patients included, 12 were randomized to study group and 11 to control group. Preoperatively, the average ulcer areas were 5.8 cm2 in both groups. At 4 weeks, the average reductions in ulcer areas were 4.0 cm2 (SD 3.1) in the study group (95% CI 2.0 to 5.9, p = .001) and 2.0 cm2 (SD 3.1) in the control group (95% CI: -0.1 to 4.1, p = .051). No differences in complications were recorded.

CONCLUSIONS

At 1-month sub-ulcer foam sclerotherapy and compression therapy reduced the ulcer area statistically significantly, whereas compression therapy alone did not. Sub-ulcer foam sclerotherapy could be a good addition to superficial venous insufficiency treatment in patients with VLU.ClinicalTrials.gov identifier NCT03795064.

Associations Among Wound-Related Factors Including Biofilm, Wound-Related Symptoms and Systemic Inflammation in Older Adults with Chronic Venous Leg Ulcers

Objective: The purposes of this observational prospective study were to (1) characterize the wound-related factors (wound area, the presence of biofilm, and total bacteria), wound-related symptoms (fatigue, pain, exudate, itching, and edema or swelling), and systemic inflammation (level of serum C-reactive protein [CRP]), and (2) explore associations between wound-related factors, wound-related symptoms, and systemic inflammation in older individuals with chronic venous leg ulcers (CVLUs) over 8 weeks of wound treatment. Approach: A total of 117 participants who received standardized care (weekly sharp debridement) for chronic venous ulcer were enrolled. We collected clinical data every 2 weeks during the 8 weeks of the study period or until the wound was healed (if healed before 8 weeks). Associations among variables were estimated using a Bayesian approach applied to general linear mixed models. Results: Based on Bayes factor (BF) value, there was extremely strong evidence for the association of biofilm with mean total bacteria (BF >1,000). There was moderate evidence of a direct association between biofilm presence and levels of CRP (BF 4.3) and moderate evidence of direct associations between biofilm and wound-related symptoms, pain and exudate (BF 5.12, 8.49, respectively). Innovation: Wound-related symptoms and the level of systemic CRP were associated with biofilm among patients who were receiving weekly sharp debridement. Symptom severity associated with CVLUs requires assessment and management of wound-related factors and levels of inflammation in addition to symptom assessment. Conclusion: This study is the first to examine associations among biofilm, as wound-related factors, systemic inflammation, wound-related symptoms, and wound healing in clinical settings. Symptom severity, level of systemic CRP, and wound-related factors should be considered as well as assessment of biofilm in CVLU in older individuals with CVLU.

Sub-ulcer Foam Sclerotherapy in Patients with Venous Leg Ulcer, Analysis and Technical Aspects of 134 Consecutive Patients

OBJECTIVE

For this retrospective study, we analyzed the sub-ulcer foam sclerotherapy technique in patients with venous leg ulcer (VLU).

METHODS

This study included 134 patients treated with sub-ulcer foam sclerotherapy at the Oulu University Hospital vascular outpatient clinic from January 2012 to December 2021. All included patients received sub-ulcer foam sclerotherapy as part of the treatment strategy for superficial venous insufficiency. Compression therapy and local wound care were organized for VLU treatment. A follow-up visit was scheduled for one month after the sub-ulcer foam sclerotherapy. Change in ulcer size, local (skin necrosis, infection) or systemic (deep vein thrombosis, pulmonary embolism) complications, and time to ulcer healing were monitored. The occurrence of major limb-related complications (amputation, surgical revision) was monitored for one year postoperatively.

RESULTS

One month after sub-ulcer treatment, ulcers were smaller or completely healed in 108 (81%) patients. Ulcer healing was completed in 123 (92%) patients at one year and 131 (98%) patients at two years. Complications were recorded in four (3%) patients, three (2%) who were diagnosed with erysipelas requiring antibiotic treatment and one (1%) patient diagnosed with local dermatitis. During the one-year follow-up, no major limb-related complications (surgical revisions or amputations) arose.

CONCLUSIONS

Sub-ulcer foam sclerotherapy may be a feasible addition to superficial vein reflux elimination in patients with VLU and a low risk for complications.

Gongying-Jiedu-Xiji recipe promotes the healing of venous ulcers by inhibiting ferroptosis via the CoQ-FSP1 axis

Objective: Gongying-Jiedu-Xiji recipe (DDL, batch number Z01080175) reduces body temperature, detoxifies, activates the blood circulation, reduces swelling, and dispels decay and pus. The aim of this study was to investigate the mechanism of action by which DDL functions in the treatment of venous ulcers (VUs). Methods: Normal tissues as well as VU tissues before and after DDL treatment were collected from nine VU patients in the hospital with ethical approval. These three tissues were subjected to Prussian blue iron staining, immunoblotting, immunohistochemistry, immunofluorescence, and quantitative real-time PCR to detect the expression of ferroptosis suppressor protein 1 (FSP1), coenzyme Q (CoQ), 4-hydroxynonenal (4-HNE), and glutathione peroxidase 4 (GPX4). After successful validation of the heme-induced human foreskin fibroblast (HFF) ferroptosis model, lyophilized DDL powder was added to the cells, and the cells were subjected to viability assays, immunoblotting, flow cytometry, glutathione (GSH) and malonaldehyde (MDA) assays, electron microscopy and qPCR assays. Results: Ferroptosis in VU tissues was stronger than that in normal tissues, and ferroptosis in VU tissues after DDL treatment was weaker than that before treatment. Inhibition of CoQ and FSP1 and transfection of FSP1 influenced the effects of DDL. Conclusion: Our results suggest that DDL may promote healing by attenuating ferroptosis in VUs and that DDL may promote VU healing by modulating the CoQ-FSP1 axis.

Methods for sampling wound fluid from venous leg ulcers for molecular analyses: A scoping review

Determining the precise role of molecular factors present in venous leg ulcer exudate will expedite the identification of biomarkers that can optimally guide treatment. However, there is now no standardized approach for collecting, processing and storing wound fluid samples for molecular analyses. This scoping review was conducted to integrate and summarize the multiple types of methods being used currently in studies of venous leg ulcers for collecting, processing and storing wound fluid prior to analysis. PubMed, CINAHL, EMBASE and Scopus databases were searched for eligible studies between 2012 and 2022. Nineteen studies were selected for this scoping review. Five primary methodological categories for wound fluid sampling were identified. The most commonly used collection method involved extracting the fluid from various absorbent materials, and the majority of studies centrifuged wound fluid before storing it at ultra-low temperatures. This review found the wound fluid sampling methods among the included studies to be heterogeneous. Moreover, the data revealed no definitive patterns. There is a critical need to develop standardized wound fluid sampling methods in research to facilitate accurate comparisons of biomarker data across studies and a more rapid determination of biomarkers that can most effectively guide delivery of tailored venous leg ulcer treatments.

Use of Intralesional and Perilesional Human Recombinant Epidermal Growth Factor (hrEGF) in the Local Treatment of Venous Ulcer - Review Article - Expert Recommendation

Venous Ulcers (VU) represent 60-80% of all leg ulcers and are the final stage of the disease secondary to venous hypertension or valve insufficiency. Conventional treatment that focuses on its etiological factors continues to be the gold standard; however, 30% of ulcers do not heal with this treatment; thus, it has been seen that the use of growth factor can be used as an adjuvant for this pathology. A literature review was carried out to evaluate the evidence from systematic reviews, meta-analyses, case studies, and quantitative studies that respond to the objective of this analysis review in the different databases with specific inclusion criteria with publications between 2002 and 2022, initially finding the topical application of the factor and later, more recently, the intralesional and perilesional application, the latter being an alternative treatment for this type of pathology and generating some recommendations for using the Factor.

Importance of sensitivity to patients' individual background in venous care

In the current era of increasing emphasis on diversity, inclusion, and equity, it is of utmost importance for vascular surgeons to be cognizant of the increasingly diverse population in the United States. We should try our best to ensure the same quality of vascular care to all our patients, regardless of their backgrounds. It is humanly impossible to expect any of us to have a deep understanding of all the cultures, and that is not the point of this essay. The key lesson from this essay is that we should be able to recognize that patients from different backgrounds may have different expectations from us and we should try to meet those expectations to the best of our abilities.

A prospective study on the efficacy of sequential treatment of technology Lipido-Colloid Impregnated with Silver and Technology Lipido-Colloid Nano-Oligosaccharide Factor in the management of venous leg ulcers

Background and Aims

Venous leg ulcers (VLUs) are associated with significant morbidity and poor quality of life (QOL). Compression therapy and wound dressing are the mainstay treatment options. Technology Lipido-Colloid Impregnated with Silver (TLC-Ag) reduces bacterial load and Technology Lipido-Colloid Nano-Oligosaccharide Factor (TLC-NOSF) reduces elevated matrix metalloproteinases and improve wound healing. However, evidence is scarce on the role of sequential therapy. This study aims to evaluate if sequential treatment with TLC-Ag and TLC-NOSF improves VLU wound healing and QOL.

Methods

This is a prospective cohort study from May 2020 to October 2021 on patients with VLUs who received sequential therapy, consisting of 2 weeks of TLC-Ag followed by two-layer compression bandage (2LB) with TLC-NOSF until complete wound healing. Participants were followed-up with weekly dressing changes. Our primary outcomes were wound area reduction (WAR) and Pressure Ulcer Scale of Healing (PUSH) score. Our secondary outcomes were QOL measures.

Results

There were 28 patients with 57.1% males (n = 16) with a mean age of 65.3 years. Mean duration of VLU was 13.9 ± 11.7 weeks before the initiation of sequential therapy. Mean baseline wound area was 8.44 cm2. Median time to wound healing was 10 weeks. 57.1% of patients achieved complete wound closure at 3 months. There was significant WAR after 1 month (mean area 8.44-5.81 cm2, 31.2% decrease) and after 3 months (mean area 8.44-2.53 cm2, 70.0% decrease). Mean monthly WAR was 28.9%. PUSH score also decreased at 1 month (16.5% decrease, p < 0.001) and 3 months (63.3% decrease, p < 0.001) marks following the sequential therapy. EuroQol Visual Analog Scale (EQ-VAS) improved following sequential therapy (baseline: 69.0 ± 15.0, week 13: 80.2 ± 13.2, p < 0.001).

Conclusion

Sequential therapy with TLC-Ag followed by TLC-NOSF and 2LB is feasible, with good wound healing and improvement in QOL of patients with VLUs.

The association of wound factors and symptoms of fatigue and pain with wound healing in chronic venous leg ulcers

The purpose of this study was: (1) to characterise the association of wound area, wound exudate C-reactive protein (CRP), broad-spectrum matrix metalloprotease protein (MMPs), and symptoms of fatigue and pain in individuals with chronic venous leg ulcers (CVLUs) over time and (2) to identify factors associated with the wound healing trajectory in CVLUs. Seventy four participants with CVLU who received weekly sharp debridement were recruited from a wound care clinic during the 8-week study period. To examine associations among wound CRP, MMPs, pain, fatigue, and wound healing trajectory over time, we calculated Bayes factors (BF) based on a linear mixed model. The mean age of participants was 71.8 (SD = 9.8) and the mean wound area was 2278 mm² (SD = 7085 mm² ) at baseline. Higher fatigue was strongly associated with higher MMPs (BF = 9, 95% HDI: [-.05, .43]), lower CRP (BF = 11, 95% HDI: [-.02, .002]), and large areas of wound (BF = 20, 95% HDI: [-.001, .01]). Higher CRP and MMPs activity in wound exudate and higher fatigue were associated with a larger wound area. To facilitate wound healing, clinicians need to utilise the multifactorial approach, which includes wound treatment and management of symptoms such as pain and fatigue, because of the molecular and psycho-behavioural factors involved in wound healing.

Correlation between Generic and Disease-Specific Quality of Life Questionnaires in Patients with Venous Ulcerations: A Cross-Sectional Study Carried out in a Primary Health Care Setting in Brazil

Venous Ulcers (VU) are a serious health problem that affect the Quality of Life (QoL). They are evaluated by many different scales in the literature. We aimed to analyze the correlation between the Medical Outcomes Short-Form Health QoL (SF-36) and Charing Cross Venous Ulcer Questionnaire (CCVUQ) scales. This is a cross-sectional study conducted in a Brazilian center specializing in chronic VU of the Primary Health Care (PHC) provided to patients with active VU. The general QoL instrument SF-36 and the CCVUQ, specific for people with VU, were used. Spearman's Rho Test determined the correlation between the variables analyzed. Our sample had a total of 150 patients. We found a direct correlation between the domestic activities division (CCVUQ) aspect and the SF-36 Physical role functioning (strong), and Physical functioning (moderate) domains. The Social interaction division (CCVUQ) aspect presented moderate correlation with the domains of the SF-36 Physical role functioning and Physical functioning. The Vitality domain (SF-36) showed moderate correlation with the aspects of CCVUQ Cosmesis division and Emotional status division. The greatest forces of direct correlation were observed between the physical, functional and vitality aspects of SF-36 with those represented by domestic activities and social interaction in the CCVUQ.

Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review

Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.

Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations

OBJECTIVE

An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-).

METHODS

A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs.

RESULTS

A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years.

CONCLUSIONS

Patients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

A Contemporary Comparison of Cyanoacrylate, Radiofrequency, and Endovenous Laser Ablation on Healing of Active Venous Ulceration

BACKGROUND

The goal of this study is to compare the healing rates of active lower extremity venous ulcers for patients receiving one of 3 ablation methods, compare their complications, and identify factors affecting successful healing and prevention of recurrence.

METHODS

For this study, data were collected retrospectively on 146 patients at a single institution, tertiary referral center, with an active venous ulcer who underwent ablation therapy via cyanoacrylate (VenaSeal), radiofrequency (RFA), or endovenous laser ablation (EVLA) from 2010 to 2020.

RESULTS

The study showed a nonsignificant difference in days to ulcer healing postintervention between ablative techniques, with 80.8 days for cyanoacrylate ablation (n = 15), 70.07 for RFA (n = 44), and 67.04 days for EVLA (n = 79). A similar, nonsignificant trend was observed for ulcer recurrence, with a rate of 35.7% (5/14) for cyanoacrylate ablation, 26.7% (20/75) for EVLA, and 23.1% (9/39) for RFA. The same nonsignificant trend occurred with deep venous thrombosis following the procedure in 6.3% (1/16) of cyanoacrylate ablation, 4.8% (4/84) of EVLA, and 2.2% (1/46) of RFA cases. The rate of endovenous glue induced thrombosis was also higher (6.3%) for cyanoacrylate than endovenous heat induced thrombosis in EVLA (3.6%) and RFA (2.2%). Cox proportional hazard was significant for compliance with compression therapy (hazard ratio [HR] 2.12, confidence interval [CI] 95% = 1.10-4.20, P = 0.031) and a lack of working with a wound clinic (HR 0.50, CI 95% = 0.33-0.75, P = 0.001) were associated with the decreased time to healing of ulcer but was not influenced by the presence of other comorbidities of smoking or diabetes mellitus.

CONCLUSIONS

This study indicates a trend toward cyanoacrylate ablation having longer healing times and more complications compared to other ablation methods when used in patients with active venous ulcers. Compliance with compression treatment is predictive of venous ulcer healing and working with a wound clinic had significantly longer healing times.

Red legs: how to differentiate between cellulitis, venous eczema and lipodermatosclerosis

Community nurses often encounter people with red legs. There are a number of reasons why an individual may develop red legs. The most common causes of red legs are cellulitis, venous eczema and lipodermatosclerosis. All have different causes and require different treatments. This article aims to enable readers to differentiate between these conditions which can appear similar, and to offer effective evidence-based care.

Healing Process, Pain, and Health-Related Quality of Life in Patients with Venous Leg Ulcers Treated with Fish Collagen Gel: A 12-Week Randomized Single-Center Study

The aim of the study was to assess the effectiveness of fish skin collagen and its impact on healing, pain intensity, and quality of life in patients with venous leg ulcers (VLUs). This study included 100 adults with VLUs. Eligible patients were randomized to either tropocollagen gel treatment (group A, n = 47) or placebo alone (group B, n = 45). We applied the gel to the periwound skin for 12 weeks. All groups received standard wound care, including class 2 compression therapy and wound hygiene procedures. We assessed the healing rate (cm2/week) and quality of life (QoL) using the Skindex-29 and CIVIQ scales. In group A, more ulcers healed, and the healing rate was faster. In both study groups, patients showed a significant improvement in quality of life after the intervention, but there was a greater improvement in the tropocollagen group. In group A, the greatest improvement was related to physical symptoms and the pain dimension. This study showed that the application of fish collagen gel to the periwound skin improves the healing process and QoL in patients with VLUs. The 12-week treatment with collagen reduced the severity of physical complaints, pain, and local skin symptoms, which determined the quality of life in patients with VLUs to the greatest extent.

Patient and clinician experiences and opinions of the use of a novel home use medical device in the treatment of peripheral vascular disease - a qualitative study

BACKGROUND

Peripheral vascular diseases have a significant impact on functional quality of life. Previous research has demonstrated the complex, limiting and costly economic implications of these conditions such as lower limb ulceration chronicity and ischaemic amputation. These complex, limb and life threatening conditions demand the development of novel interventions with objective research as part of that development. Hence, a novel intermittent negative pressure medical device in the form of a wearable boot (FlowOx™) was developed. As part of the development process, this study aimed to explore patient and clinician opinions of the boot.

METHODS

A qualitative approach was used to collect patient and clinician experiences in Norway. An advisory group informed the semi-structured questions used in seven patient interviews and one clinician focus group (n = 5). The data were recorded digitally and transcribed verbatim. Patient and clinician data were analysed as distinct groups using a thematic process.

RESULTS

Data analysis resulted in five themes from the patients which gave insight into; the impact of the disease process; practicalities of using the boot, positive experiences of use; perceived outcomes; reflecting on use. Six themes were created from the clinicians. These gave insight into; ideal outcomes and how to measure them; ways to potentially use the boot; using research in healthcare; positives of the device; observed effects and next steps; potential improvements to the device.

CONCLUSION

This study provides insight into the experiences and opinions of FlowOx™. Patients and clinicians were positive about the device due to its ease of use. Those patients with peripheral arterial disease experienced significantly more benefit, especially for ischaemic ulceration than those with a chronic venous condition. Clinicians placed value on the patient reported outcomes in the treatment decision-making process. This preliminary study into experiences of FlowOx™ use provides valuable feedback that will inform design modification and ongoing research into implementation points and prospective user groups. FlowOx™ demonstrates potential as a conservative therapy offering users a convenient, home use, self-care management solution for improving symptomatic peripheral arterial disease and quality of life.

New Insights on the Effects of Dietary Omega-3 Fatty Acids on Impaired Skin Healing in Diabetes and Chronic Venous Leg Ulcers

Long-chain Omega-3 polyunsaturated fatty acids (Omega-3 PUFAs) are widely recognized as powerful negative regulators of acute inflammation. However, the precise role exerted by these dietary compounds during the healing process is still largely unknown, and there is increasing interest in understanding their specific effects on the implicated cells/molecular factors. Particular attention is being focused also on their potential clinical application in chronic pathologies characterized by delayed and impaired healing, such as diabetes and vascular diseases in lower limbs. On these bases, we firstly summarized the current knowledge on wound healing (WH) in skin, both in normal conditions and in the setting of these two pathologies, with particular attention to the cellular and molecular mechanisms involved. Then, we critically reviewed the outcomes of recent research papers investigating the activity exerted by Omega-3 PUFAs and their bioactive metabolites in the regulation of WH in patients with diabetes or venous insufficiency and showing chronic recalcitrant ulcers. We especially focused on recent studies investigating the mechanisms through which these compounds may act. Considerations on the optimal dietary doses are also reported, and, finally, possible future perspectives in this area are suggested.

Pressure-Measuring Devices for Compression Therapy in Venous Leg Ulcers: A Comprehensive Review

OBJECTIVE

To investigate the evolution of pressure-measuring devices used in compression treatment for venous leg ulcers and assess the most practical and effective devices to determine optimal pressure in compression therapy.

DATA SOURCES

Relevant information was retrieved from databases including Google Scholar, PubMed, Wiley Online, and ScienceDirect without publication date restrictions. The keywords included venous leg ulcer, compression therapy, pressure measuring device, pressure sensor, and wireless system.

STUDY SELECTION

Studies included in the review had to be published in English and discuss or compare pressure-measuring devices/sensors for compression therapy, the development of alternative sensors, and the applications of wireless technologies. Veterinary studies, conference proceedings, and unpublished articles were excluded. Applicable studies and articles were critically evaluated and synthesized.

DATA EXTRACTION

After abstract review, 39 studies were identified. During full-text review, study details were collected using a data extraction form and organized into tables. Device attributes, accuracy, price, and limitations were categorized and analyzed.

DATA SYNTHESIS

Studies disagree on the effectiveness and user-friendliness of existing pressure-measuring devices. These devices often impact user comfort and convenience, which are crucial factors in the adoption and use of wearable devices. Potential solutions for pressure-measuring devices with promising technologies were proposed: four feasible alternative sensors are described that could improve comfort and facilitate prolonged use under bandages. Advanced communication technologies may provide more convenience for users and practitioners.

CONCLUSIONS

Conventional pressure-measuring devices used in compression therapy are not designed for the user's comfort and convenience. The use of flexible and stretchy pressure sensors (e-skin) provides good biocompatibility, conformability, and comfort and when integrated with near-field communication technology could address the drawbacks of current pressure-measuring devices.

Review of the Current Evidence for Topical Treatment for Venous Leg Ulcers

OBJECTIVE

The development of a venous leg ulcer (VLU) represents the most severe clinical manifestation of a chronic venous disease. Despite major progress, there is a limited understanding of VLU pathogenesis and wound healing biology. Treatment of VLUs remains a serious challenge for physicians of different specialties. This communication focuses on describing the rationale and scientific basis for topical wound care in the management of VLUs.

METHODS

A literature review was performed to summarize methods with proven efficacy in VLU management. A systematic literature search was also performed to identify new evidence from the randomized controlled trials published within 2014-2021. The scientific challenges, clinical practice concerns, economic obstacles, and possible directions for further research have been discussed.

RESULTS

Hundreds of topical products have been advertised for the treatment of VLUs. Published data on topical treatment of venous ulcers is insufficient, scattered, weak, and has significant methodological flaws. Forty-three randomized controlled trials on topical treatment of VLUs have been published within 2014-2021. Clinical practice guidelines need to be updated. Major gaps in knowledge have been identified, and suggestions for future research directions have been provided.

CONCLUSIONS

The American Venous Forum Research Committee would like to bring attention to topical wound care for VLUs as a critical gap in knowledge, and encourage scientists, practitioners, and industry to collaborate to fill this gap.

Structure, processes, and initial outcomes of The Ottawa Hospital Multi-Specialist Limb-Preservation Clinic and Programme: A unique-in-Canada quality improvement initiative

In 2017, The Ottawa Hospital initiated a unique-in-Canada quality improvement initiative by opening a novel, multi-specialist limb-preservation clinic. We sought to describe the structure, processes, and initial outcomes of the clinic and evaluate whether it is achieving its mandate of providing high-quality wound clinical care, education, and research. We conducted a descriptive prospective cohort study alongside a nested study of 162 clinic patients requiring serial assessments. There have been 1623 visits, mostly (72.2%) from outpatients. During 17.8% of visits, patients were evaluated by >1 specialist. Therapies provided most often included negative-pressure wound therapy (32.7%), biological wound dressings (21.6%), and total contact casting (18.5%). Furthermore, 1.2% underwent toe/ray amputations or skin grafting in clinic and 22.8% were initiated on antimicrobials. Mixed-effects models suggested that mean wound volumes for those requiring serial assessments decreased by 1.6 (95% confidence interval = -0.86 to -2.27) cm³ between visits. The clinic provided seven rotations to vascular surgery, infectious diseases, dermatology, and palliative care physicians; three nursing preceptorships; and two educational workshops. It also initiated provincial and national vascular health and wound care research initiatives. This study may be used to guide development of other limb-preservation clinics and programmes. Findings support that our programme is achieving its mandate.

Effectiveness of different types of skin grafting for treating venous leg ulcers: A protocol for systematic review and network meta-analysis

BACKGROUND

Venous leg ulcers (VLUs) are the most common ulcer on the lower extremity, with 4% of patients over the age of 65 suffering from VLUs worldwide. As a recurrent, chronic, disabling disease, VLUs are associated with prolonged disability, substantial socioeconomic impact, and significant psychosocial morbidity. At present, Skin grating is one of the most effective treatments for non-healing ulcers. However, there are still no new studies based on the latest research and new research methods to evaluate and compare the effect of different types of skin grafts for treating venous leg ulcers. Therefore, a Bayesian network meta-analysis (NMA) will be conducted to systematically assess skin grafting efficacy for VLUs.

METHODS

We will include randomized controlled trials (RCTs) involving patients with VLUs treated by skin grafts. Electronic databases and clinical trials registries will be searched from their inception until June 2021, without language or publication restrictions on status. The search strategy mainly includes Medical Subject Headings (MeSH) and free-text terms. Two review authors will independently perform data extraction and assessment of study quality. And We will use Bayesian NMA to evaluate all available evidence in STATA 14.0 and WinBUGS software.

RESULTS

This protocol will use Bayesian NMA to assess the effectiveness of different types of skin grafting for treating venous leg ulcers.

CONCLUSION

This study aims to synthesize the available evidence from RCTs in a network meta-analysis to summarize the best research available and provide consistency among treatment protocols given to patients, resulting in improved efficacy and the quality of care and reduced cost.

Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment

Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.

Eczema and the older person

Age-related changes lead to an increase in skin problems, and around 70% of older people have a treatable skin condition. However, ageing and poor physical health can make it difficult for older people to care for their skin. Eczema, a chronic inflammatory skin condition, where the skin becomes red, inflamed, itchy and scaly, can develop easily in older adults. This can, in turn, become infected and cause discomfort and health problems. This article explains how ageing affects the skin, how eczema can develop and how it can be treated, also touching upon the different types of eczema. It aims to equip community nurses with knowledge about this common condition and how to recognise and manage it.

Cathelicidin Host Defense Peptides and Inflammatory Signaling: Striking a Balance

Host-defense peptides (HDPs) are vital components of innate immunity in all vertebrates. While their antibacterial activity toward bacterial cells was the original focus for research, their ability to modulate immune and inflammatory processes has emerged as one of their major functions in the host and as a promising approach from which to develop novel therapeutics targeting inflammation and innate immunity. In this review, with particular emphasis on the cathelicidin family of peptides, the roles of natural HDPs are examined in managing immune activation, cellular recruitment, cytokine responses, and inflammation in response to infection, as well as their contribution(s) to various inflammatory disorders and autoimmune diseases. Furthermore, we discuss current efforts to develop synthetic HDPs as therapeutics aimed at restoring balance to immune responses that are dysregulated and contribute to disease pathologies.

Comparison of the Hemodynamic Performance of Two Neuromuscular Electrical Stimulation Devices Applied to the Lower Limb

Currently, 1% of the population of the Western world suffers from venous leg ulcers as a result of chronic venous insufficiency. Current treatment involves the use of moist wound healing, compression bandages, and intermittent pneumatic compression. Neuromuscular electrical stimulation is a novel potential new therapeutic method for the promotion of increased lower limb hemodynamics. The aim of this study was to measure the hemodynamic changes in the lower limb with the use of two neuromuscular electrical stimulation devices. Twelve healthy volunteers received two neuromuscular stimulation device interventions. The Geko^TM and National University of Ireland (NUI) Galway neuromuscular electrical stimulation devices were randomized between dominant and non-dominant legs. Hemodynamic measurements of peak venous velocity (cm/s), the time average mean velocity (TAMEAN) (cm/s), and ejected volume (mL) of blood were recorded. Peak venous velocity was significantly increased by the Geko^TM and the NUI Galway device compared to baseline blood flow (p < 0.0001), while only the voluntary contraction produced significant increases in TAMEAN and ejected volume (both p < 0.05). Neuromuscular muscular electrical stimulation can produce adequate increases in lower limb hemodynamics sufficient to prevent venous stasis. Greater use of neuromuscular stimulation devices could be considered in the treatment of conditions related to chronic venous insufficiency but requires further research.

Impact of omega-3 fatty acid oral therapy on healing of chronic venous leg ulcers in older adults: Study protocol for a randomized controlled single-center trial

Background

This trial addresses the global problem of chronic venous leg ulcers (CVLUs), wounds that cause significant infirmity for an estimated 9.7 million people annually, mainly older adults with comorbidities. Advanced therapies are needed because standard topical therapies are often ineffective or yield only short-term wound healing. Thus, we are testing a new oral therapy containing the bioactive elements of fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for targeting and reducing the high numbers of activated polymorphonuclear leukocytes (PMN) in wound microenvironments that keep CVLUs “trapped” in a chronic inflammatory state.

Methods

This double-blind RCT will include 248 eligible adults ≥ 55 years of age with CVLUs receiving standard care at a large Midwest outpatient wound clinic. Participants are randomized to two groups: 12 weeks of daily oral therapy with EPA + DHA (1.87 g/day of EPA + 1.0 g/day of DHA) or daily oral therapy with placebo. At 0, 4, 8, and 12 weeks, across the two groups, we are pursuing three specific aims: Aim 1. Compare levels of EPA + DHA-derived lipid mediators, and inflammatory cytokines in blood and wound fluid; Subaim 1a. Compare inflammatory cytokine gene expression by PMNs in blood; Aim 2. Compare PMN activation in blood and wound fluid, and PMN-derived protease levels in wound fluid; Aim 3. Compare reduction in wound area, controlling for factors known to impact healing, and determine relationships with lipid mediators, cytokines, and PMN activation. Subaim 3a. Compare frequency of CVLU recurrence and levels of study variables in blood between the randomly assigned two subgroups (continuing EPA + DHA therapy versus placebo therapy beyond week 12) within the EPA + DHA group with healed CVLUs after 3 months of therapy. Subaim 3b. Compare symptoms of pain at all time points and quality of life at first and last time points across the two groups and two subgroups.

Discussion

This trial will provide new evidence about the effectiveness of EPA + DHA oral therapy to target and reduce excessive PMN activation systemically and locally in patients with CVLUs. If effective, this therapy may facilitate healing and thus be a new adjunct treatment for CVLUs in the aging population.

Trial registration

ClinicalTrials.gov, NCT03576989; Registered on 13 June 2018.

Periulcer Foam Sclerotherapy Injection in Chronic Venous Leg Ulcers Using Near-Infrared Laser for Vein Visualization

High recurrence and high costs of treatment are the main problems with venous ulcer management. Therefore, it is of utmost importance to target the exact pathological cause. The role of cutaneous microvalves reflux in the pathogenesis of these ulcers has been confirmed. In this study, 20 chronic venous leg ulcers were prospectively subjected to foam sclerotherapy injection into periulcer veins using direct visualization by AccuVein AV400. Patients having infected ulcers, acute deep vein thrombosis, hypercoagulability, Ankle-Brachial Index <0.9, pregnancy, and/or allergy to the sclerosant were excluded. Endpoints included rates of ulcer size reduction, complete healing, ulcer recurrence, and procedure-related complications. Aethoxysklerol 1% was used in all cases to produce foam employing the double-syringe system. The mean reduction in ulcer surface area, postinjection, was 75% after 8 weeks and 91% after 12 weeks. Nineteen ulcers (95%) healed in a median time of 8 weeks, range 3 to 17 weeks. At 1 year of follow-up, 18 patients (90%) were still ulcer-free, while 1 patient's ulcer (5%) recurred 19 weeks postinjection. No major complications were encountered. Periulcer foam sclerotherapy injection, guided by vein visualization technology, should be one of the main lines of treatment of venous leg ulcers. It offers good results with regard to rapid ulcer healing and low recurrence rate without major risk. Randomized controlled trials are needed to establish these conclusions.

A prospective, randomized, controlled clinical trial on the efficacy of a single-use negative pressure wound therapy system, compared to traditional negative pressure wound therapy in the treatment of chronic ulcers of the lower extremities

Multicenter, phase‐4, randomized, comparative‐efficacy study in patients with VLUs or DFUs comparing for noninferiority the percentage change in target ulcer dimensions (area, depth, and volume) a single‐use negative pressure wound therapy (s‐NPWT) system versus traditional NPWT (t‐NPWT) over a 12‐week treatment period or up to confirmed healing. Baseline values were taken at the randomization visit. Randomized by wound type and size, 164 patients with non‐infected DFUs and VLUs were included. The ITT population was composed of 161 patients (101 with VLUs, 60 with DFUs) and 115 patients completed follow‐up (64 in the s‐NPWT group and 51 in the t‐NPWT group) (PP population). The average age for all patients was 61.5 years, 36.6% were women, and treatment groups were statistically similar at baseline. Primary endpoint analyses on wound area reduction demonstrated statistically significant reduction in favor of s‐NPWT (p = 0.003) for the PP population and for the ITT population (p < 0.001). Changes in wound depth (p = 0.018) and volume (p = 0.013) were also better with s‐NPWT. Faster wound closure was observed with s‐NPWT (Cox Proportional Hazards ratio (0.493 (0.273, 0.891); p = 0.019) in the ITT population. Wound closure occurred in 45% of patients in the s‐NPWT group vs. 22.2% of patients in the t‐NPWT group (p = 0.002). Median estimate of the time to wound closure was 77 days for s‐NPWT. No estimate could be provided for t‐NPWT due to the low number of patients achieving wound closure. Device‐related AEs were more frequent in the t‐NPWT group (41 AEs from 29 patients) than in the s‐NPWT group (16 AEs from 12 patients). The s‐NPWT system met noninferiority and achieved statistical superiority vs. t‐NPWT in terms of wound progression toward healing over the treatment period. When NPWT is being considered for the management of challenging VLUs and DFUs, s‐NPWT should be considered a first choice over other types of NPWT.

Compression therapy: Unna boot applied to venous injuries: an integrative review of the literature

OBJECTIVE

To analyze the literature related to the types of therapies for venous injuries with emphasis on use of the Unna boot, and to investigate and discuss the main aspects related to its use compared to other techniques.

METHOD

Integrative review of the literature of the last five years through searches in the following databases: VHL, LILACS, BDENF, SciELO, MEDLINE/PubMed.

RESULTS

Twenty-two publications were identified, with 15,931 cases among adult or elderly individuals, whose mean age was 60 (35-78) years or greater with no sex differences. The Unna boot presented a shorter healing time than the single and two-layer elastic bandage.

CONCLUSION

Although other compression techniques may prove to be more efficient than the Unna boot by adding more technology, the boot stands out as a traditional low-cost dressing. Multilayer bandage is a gold standard technique. This review demonstrated the best option may not be the Unna boot, because it requires a higher healing time compared to the multilayer bandage, but it meets the expectation with a high rate of treatment efficiency, also when compared to simple dressing, single or two-layer bandage.

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.

The evidence supporting treatment of reflux and obstruction in chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.

Diagnosis of stenosis within the popliteal-femoral venous segment upon clinical presentation with a venous ulcer and subsequent successful treatment with venoplasty

This case study reports the diagnosis and treatment of a lower limb venous ulcer with abnormal underlying venous pathology. One male patient presented with bilateral varicose veins and a right lower limb ulcer. Upon investigation, full-leg duplex ultrasonography revealed total incompetence of the great saphenous vein in the left leg. In the right leg, duplex ultrasonography showed proximal incompetence of the small saphenous vein, and dilation of the anterior accessory saphenous vein, which remained competent. Incidentally, two venous collaterals connected onto the distal region of both these segments, emerging from a scarred, atrophic popliteal–femoral segment. An interventional radiologist performed venoplasty to this popliteal–femoral venous segment. Intervention was successful and 10 weeks post procedure ulceration healed. Popliteal–femoral venous stenosis may be associated with venous ulceration in some cases and may be successfully treated with balloon venoplasty intervention.

Prediction of venous wound healing with laser speckle imaging

Introduction Laser speckle imaging is used for noninvasive assessment of blood flow of cutaneous wounds. The aim of this study was to assess if laser speckle imaging can be used as a predictor of venous ulcer healing. Methods After generating the flux speckle images, three regions of interest (ROI) were identified to measure the flow. Sensitivity, specificity, negative predictive value, and positive predictive value for ulcer healing were calculated. Results In total, 17 limbs were included. A sensitivity of 92.3%, specificity of 75.0%, PPV of 80.0%, and NPV 75.0% were found in predicting wound healing based on laser speckle images. Mean flux values were lowest in the center (ROI I) and showed an increase at the wound edge (ROI II, p = 0.03). Conclusion Laser speckle imaging shows acceptable sensitivity and specificity rates in predicting venous ulcer healing. The wound edge proved to be the best probability for the prediction of wound healing.

Outcomes of Foam Sclerotherapy plus Ligation versus Foam Sclerotherapy Alone for Venous Ulcers in Lower Extremities

BACKGROUND

Foam sclerotherapy (FS) is a safe and effective approach for managing patients with varicose veins and venous ulcers in lower extremities. But, recanalization of the ablated varicose veins and phlebitis are common postoperative complications that jeopardize its clinical effects. We hypothesize that ligation of the ablated varicose veins after FS will improve the outcomes of patients with varicose veins and venous ulcer. This study was aimed to evaluate the clinical efficacy of ligation after FS in comparison with FS alone for the management of patients with varicose veins and venous ulcers in lower extremities.

METHODS

Eighteen patients underwent FS plus ligation (FSL) and 15 patients received FS alone. Aberdeen varicose veins questionnaire (AVVQ) and the revised venous clinical severity score (rVCSS), venous disability scores (VDSs), duplex sonography, ulcer healing rate, and ulcer healing time were documented to compare the outcomes in both groups.

RESULTS

The ulcer healing time in patients treated with FSL was shorter than that in patients who received FS (P = 0.022; log-rank test). The average healing time was significantly shorter in FSL group than in FS group (35.67 ± 24.62 days vs. 62.86 ± 47.43, P = 0.042). The mean rVCSS, VDS, and AVVQ at 3 months after treatment in both groups decreased significantly in comparison with baseline, respectively. There were no severe complications or side effects in both groups.

CONCLUSIONS

Ligation of the treated varicose veins after FS can improve the outcomes of patients with venous ulcers in comparison with FS alone. FSL is a safe, effective, and technically feasible procedure and can be used as a day surgery.

Healing of an arterial leg ulcer by compression bandaging: a case report

This case report demonstrates that arterial ulcers may heal with compression therapy. The patient was a 72-year-old woman with elevated blood pressure and type II diabetes mellitus, who underwent angiography because of a painful, non-healing ulcer over the shin. The angiography showed multisegment arterial occlusive disease, not amenable to surgical revascularisation. After 4 months of wearing inelastic bandages, with increased pressure over the ulcer area and hypertension and diabetes under control, the patient was pain-free and the ulcer had healed. The ankle-brachial pressure index (ABPI) increased from 0.54 at the start of treatment to 0.70. In patients with arterial leg ulcers, properly applied compression therapy using increased pressure over the wound may lead to an improvement of the arterial flow and to complete healing.

Self-Care-Based Treatment Using Ordinary Elastic Bandages for Venous Leg Ulcers

Objective: We aimed to study venous leg ulcer (VLU) healing and recurrence rates of VLU using a self-care-based treatment strategy. Methods: The study included 36 patients (43 legs) who visited our clinic between April 2009 and June 2015 because of non-healing VLUs and who had been treated by us for more than a year (until June 2016). Patients or their caregivers were first provided instructions for performing the "no-intentional-stretch" bandaging technique using ordinary elastic bandages. Wounds were cleansed with tepid water daily, and bandages were re-applied by patients or their caregivers; this was continued until VLUs were healed. Compression was discontinued after healing, but was restarted if persistent swelling and/or dermatitis was noticed on their legs. Results: The median ulcer size was 6.5 cm² (range, 1-105 cm²). The median number of clinic visits until healing was six (range, 3-35). The 6- and 12-month healing rates were 67% and 86%, respectively. Twenty (44%) legs required compression therapy after VLU healing. The cumulative recurrence-free rate at 60 months was 86%. Conclusion: Reasonable healing and recurrence rates were achieved by applying a self-care-based VLU treatment strategy.

News in Pathogenesis of Chronic Venous Insufficiency

This review article is concentrating on the news in the pathophysiology of chronic venous insufficiency (CVD). Despite ongoing progress in understanding the molecular aspects of CVD the exact mechanism of its development remains unclear. Many different factors may play role in the pathogenesis of CVD, including changes in hydrostatic pressure, valvular incompetence, increased capillary permeability, endothelial dysfunction, activation of leukocytes, deep venous obstruction, capillary microthrombosis, ineffective function of calf muscle pump, biochemical and structural changes in the vessel wall, extracellular matrix alteration, and several other mechanisms. A better understanding of the pathophysiology is an important step in the finding of new potential treatment.

Pathophysiology of wound healing and alterations in venous leg ulcers-review

Venous leg ulcer (VLU) is one of the most common lower extremity ulcerated wound, and is a significant healthcare problem with implications that affect social, economic, and the well-being of a patient. VLU can have debilitating related problems which require weekly medical care and may take months to years to heal. The pathophysiology of VLU is complex, and healing is delayed in many patients due to a persistent inflammatory condition. Patient genetic and environmental factors predispose individuals to chronic venous diseases including VLU. Changes in shear stress affecting the glycocalyx are likely initiating events, leading to activation of adhesion molecules on endothelial cells, and leukocyte activation with attachment and migration into vein wall, microcirculation, and in the interstitial space. Multiple chemokines, cytokines, growth factors, proteases and matrix metalloproteinases are produced. The pathology of VLU involves an imbalance of inflammation, inflammatory modulators, oxidative stress, and proteinase activity. Understanding the cellular and biochemical events that lead to the progression of VLU is critical. With further understanding of inflammatory pathways and potential mechanisms, certain biomarkers could be revealed and studied as both involvement in the pathophysiology of VLU but also as therapeutic targets for VLU healing.