Health-related quality of life and chronic venous leg ulceration: Part 2

Mobility range, level of pain and sleep quality of patients with venous leg ulcers

This study aimed to compare mobility range, level of pain and sleep quality in patients with venous leg ulcers to age- and gender-matched controls without ulcers. Twenty patients with venous leg ulceration and 20 matched controls each answered a questionnaire, completed the short-physical performance battery, filled in a subject diary and wore a smartwatch for 1 week. The median daily step counts of the ulcer group (3622 steps/day) and the control group (5133 steps/day) were significantly different (P = .017). Significant correlations between total step count and age, duration of physical outdoor activities and scores in the short-physical performance battery were observed in the ulcer group. The scores in the short-physical performance battery were significantly different in both groups (P = .005), indicating weaker physical performance in the ulcer group. The greatest difference in the self-reported level of pain between the two groups was stated during movement. On average, the ulcer group slept shorter by 1 h 38 min (P = .002) and had 0.7 wake phases per night (P = .019) more than the control group. Assessing mobility in patients with venous leg ulcers can be used to develop preventive and interventional concepts to improve and individualise physical therapies.

Influence of pain on the quality of life in patients with venous ulcers: Cross-sectional association and correlation study in a brazilian primary health care lesions treatment center

We aimed to verify the association and correlation between pain and QoL in people with VU treated in a Brazilian Primary Health Care (PHC) lesions treatment center. This is an observational, cross-sectional study with a quantitative approach, carried out in a service specialized in the treatment of chronic injuries, linked to 29 PHC units. Sociodemographic and health characterization instruments were used. The Short Form Health Survey-36 (SF-36) and Visual Analogue Pain Scale (VAPS) also were used. The Kruskal-Wallis test verified the association between the scalar variables of QoL and pain intensity. With Spearman's correlation test, we verified the level of correlation between the scales applied. A total of 103 patients participated in the study. Higher QoL scores associated with moderate pain were found, especially in the Physical role functioning, Physical functioning, and Vitality domains. Correlation analysis showed its greatest (moderate) strength in the interaction between the highest scores in the Physical role functioning and Emotional role functioning domains with the lowest pain levels.

nWASP Inhibition Increases Wound Healing via TrKb/PLCγ Signalling

(1) Background: Chronic wounds represent a major burden to patients and healthcare systems and identifying new therapeutic targets to encourage wound healing is a significant challenge. This study evaluated nWASP as a new therapeutic target in human wound healing and determined how this can be regulated. (2) Methods: Clinical cohorts from patients with chronic wounds were tested for the expression of nWASP and cell models were employed to evaluate the influence of nWASP on cellular functions that are key to the healing process following knockdown and/or the use of nWASP-specific inhibitors. (3) Results: nWASP was significantly elevated at transcript levels in human non-healing chronic wounds versus healing tissues. nWASP inhibitors, wiskostatin and 187-1, along with the knockdown of nWASP, modified both HaCaT and HECV cell behaviour. We then identified two signalling pathways affected by nWASP inhibition: TrkB signalling and downstream PLCγ1 phosphorylation were impaired by nWASP inhibition in HaCaT cells. The healing of wounds in a diabetic murine model was significantly improved with an nWASP inhibitor treatment. (4) Conclusions: This study showed that nWASP activity was related to the non-healing behaviour of chronic wounds and together with the findings in the in vivo models, it strongly suggested nWASP as a therapeutic target in non-healing wounds that are regulated via TrkB and PLCγ1 signalling.

What promotes or prevents greater use of appropriate compression in people with venous leg ulcers? A qualitative interview study with nurses in the north of England using the Theoretical Domains Framework

OBJECTIVES

To investigate factors that promote and prevent the use of compression therapy in people with venous leg ulcers.

DESIGN

Qualitative interview study with nurses using the Theoretical Domains Framework (TDF).

SETTING

Three National Health Service Trusts in England.

PARTICIPANTS

Purposive sample of 15 nurses delivering wound care.

RESULTS

Nurses described factors which made provision of compression therapy challenging. Organisational barriers (TDF domains environmental context and resources/knowledge, skills/behavioural regulation) included heavy/increasing caseloads; lack of knowledge/skills and the provision of training; and prescribing issues (variations in bandaging systems/whether nurses could prescribe). Absence of specialist leg ulcer services to refer patients into was perceived as a barrier to providing optimal care by some community-based nurses. Compression use was perceived to be facilitated by clinics for timely initial assessment; continuity of staff and good liaison between vascular/leg ulcer clinics and community teams; clear local policies and care pathways; and opportunities for training such as 'shadowing' in vascular/leg ulcer clinics. Patient engagement barriers (TDF domains goals/beliefs about consequences) focused on getting patients 'on board' with compression, and supporting them in using it. Clear explanations were seen as key in promoting compression use.

CONCLUSIONS

Rising workload pressures present significant challenges to enhancing leg ulcer services. There may be opportunities to develop facilitated approaches to enable community nursing teams to make changes to practice, enhancing quality of patient care. The majority of venous leg ulcers could be managed in the community without referral to specialist community services if issues relating to workloads/skills/training are addressed. Barriers to promoting compression use could also be targeted, for example, through the development of clear patient information leaflets. While the patient engagement barriers may be easier/quicker to address than organisational barriers, unless organisational barriers are addressed it seems unlikely that all people who would benefit from compression therapy will receive it.

Mental Resilience, Mood, and Quality of Life in Young Adults with Self-Reported Impaired Wound Healing

The purpose of this study was to evaluate the impact of self-reported impaired wound healing on quality of life, wellbeing, and mood. It was hypothesized that individuals with impaired wound healing report significantly poorer mood compared to healthy controls. An online survey was conducted among 2173 Dutch young adults (18-30 years old) to investigate mood, neuroticism, and mental resilience. Participants were allocated to a healthy control group (N = 1728) or impaired wound healing groups comprising a wound infection group (WI, N = 76), a slow-healing wounds group (SHW, N = 272), and a group that experienced both WI and SHW (the COMBI group, N = 97). The Kruskal-Wallis test was used to compare outcomes the groups. Compared to the healthy control group, the SHW and COMBI groups, but not the WI group, reported significantly poorer mood, increased neuroticism, reduced mental resilience, and reduced quality of life. An analysis evaluating sex differences found that negative effects on stress, mental resilience, and neuroticism were significantly more pronounced among women than among men. In conclusion, self-reported impaired wound healing is associated with poorer mood and reduced quality of life. To improve future wound care, these findings advocate for an interdisciplinary approach taking into account mood effects accompanying having impaired wound healing.

[Treatment of chronic hard-to-heal wounds with hyaloronic acid ester: a case series of six patients]

The treatment of chronic wounds is usually a major challenge for the involved medical staff. Various different treatment options have to be tested achieving a satisfactory result. In this retrospective case report, we describe successful treatments with hyaluronan acid ester fleece in six patients with chronic wounds of different origins. Furthermore, all patients received compression bandages or compression stockings, two patients were treated additionally with pressure relief devices and all were debrided if necessary. The chronic wounds of five out of the six patients healed completely over a period of 1.5-11 months or only with a minimal residual defect. However, one patient was still resistant to therapy over five months. In summary, the treatment with hyaluronan esters achieved good results especially in patients with complex medical history that makes a successful therapy particularly difficult.

Telemedicine versus face-to-face care for treatment of patients with lower extremity ulcers

OBJECTIVE

Lower extremity ulcers (LEUs) are associated with a decline in patients' quality of life (QoL). Better healthcare availability in remote regions, facilitated by telemedicine (TM), may improve patient wellbeing. The aim of this study was to compare the QoL of patients treated via synchronous video TM with that of patients treated with standard face-to-face (FTF) care.

METHOD

The study was performed in a large health services provider in Israel (Maccabi Healthcare Services). TM was used in four remote locations; the FTF method was applied in two regional clinics. The treatment protocol was performed by a nurse and supervised by the regional physician in both treatment modes. A validated Wound-QoL questionnaire in Hebrew was used to assess patient outcomes.

RESULTS

A total of 83 patients were treated via TM and 94 patients were treated FTF. The mean QoL for patients treated via TM was 0.546±0.249 compared with 0.507±0.238 for the FTF group. A similarity relating to outcomes in both treatment methods was demonstrated by a difference of 0.039 (95% confidence interval -0.33-0.111) and p=0.291. The probability of the difference being within the limits of the interval in a replicated study was 83.4%. The equivalence/non-inferiority was established within the accepted Δ=0.12 range.

CONCLUSION

The results indicated no reduced QoL for patients with LEUs treated with telemedicine versus with standard FTF care.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

Wound cleansing for treating venous leg ulcers

BACKGROUND

Leg ulcers are open skin wounds that occur below the knee but above the foot. The majority of leg ulcers are venous in origin, occurring as a result of venous insufficiency, where the flow of blood through the veins is impaired; they commonly arise due to blood clots and varicose veins. Compression therapy, using bandages or stockings, is the primary treatment for venous leg ulcers. Wound cleansing can be used to remove surface contaminants, bacteria, dead tissue and excess wound fluid from the wound bed and surrounding skin, however, there is uncertainty regarding the effectiveness of cleansing and the best method or solution to use.

OBJECTIVES

To assess the effects of wound cleansing, wound cleansing solutions and wound cleansing techniques for treating venous leg ulcers.

SEARCH METHODS

In September 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including 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 considered randomised controlled trials (RCTs) comparing wound cleansing with no wound cleansing, or RCTs comparing different wound cleansing solutions, or different wound cleansing techniques.

DATA COLLECTION AND ANALYSIS

We screened studies for their appropriateness for inclusion, assessed their risk of bias using the Cochrane 'Risk of bias' tool, and used GRADE methodology to determine the certainty of evidence. Two review authors undertook these tasks independently, using predetermined criteria. We contacted study authors for missing data where possible.

MAIN RESULTS

We included four studies with a total of 254 participants. All studies included comparisons between different types of cleansing solutions, and three of these reported our primary outcomes of complete wound healing or change in ulcer size over time, or both. Two studies reported the secondary outcome, pain. One study (27 participants), which compared polyhexamethylene biguanide (PHMB) solution with saline solution for cleansing venous leg ulcers, did not report any of the review's primary or secondary outcomes. We did not identify any studies that compared cleansing with no cleansing, or that explored comparisons between different cleansing techniques. One study (61 participants) compared aqueous oxygen peroxide with sterile water. We are uncertain whether aqueous oxygen peroxide makes any difference to the number of wounds completely healed after 12 months of follow-up (risk ratio (RR) 1.88, 95% confidence interval (CI) 1.10 to 3.20). Similarly, we are uncertain whether aqueous oxygen peroxide makes any difference to change in ulcer size after eight weeks of follow-up (mean difference (MD) -1.38 cm², 95% CI -4.35 to 1.59 cm²). Finally, we are uncertain whether aqueous oxygen peroxide makes any difference to pain reduction, assessed after eight weeks of follow-up using a 0 to 100 pain rating, (MD 3.80, 95% CI -10.83 to 18.43). The evidence for these outcomes is of very low certainty (we downgraded for study limitations and imprecision; for the pain outcome we also downgraded for indirectness). Another study (40 participants) compared propyl betaine and polihexanide with a saline solution. The authors did not present the raw data in the study report so we were unable to conduct independent statistical analysis of the data. We are uncertain whether propyl betaine and polihexanide make any difference to the number of wounds completely healed, change in ulcer size over time, or wound pain reduction. The evidence is of very low certainty (we downgraded for study limitations and imprecision). The final study (126 participants) compared octenidine dihydrochloride/phenoxyethanol (OHP) with Ringer's solution. We are uncertain whether OHP makes any difference to the number of wounds healed (RR 0.96, 95% CI 0.53 to 1.72) or to the change in ulcer size over time (we were unable to conduct independent statistical analysis of available data). The evidence is of very low certainty (we downgraded for study limitations and imprecision). None of the studies reported patient preference, ease of use of the method of cleansing, cost or health-related quality of life. In one study comparing propyl betaine and polihexanide with saline solution the authors do not report any adverse events occurring. We are uncertain whether OHP makes any difference to the number of adverse events compared with Ringer's solution (RR 0.58, 95% CI 0.29 to 1.14). The evidence is of very low certainty (we downgraded for study limitations and imprecision).

AUTHORS' CONCLUSIONS

There is currently a lack of RCT evidence to guide decision making about the effectiveness of wound cleansing compared with no cleansing and the optimal approaches to cleansing of venous leg ulcers. From the four studies identified, there is insufficient evidence to demonstrate whether the use of PHMB solution compared with saline solution; aqueous oxygen peroxide compared with sterile water; propyl betaine and polihexanide compared with a saline solution; or OHP compared with Ringer's solution makes any difference in the treatment of venous leg ulcers. Evidence from three of the studies is of very low certainty, due to study limitations and imprecision. One study did not present data for the primary or secondary outcomes. Further well-designed studies that address important clinical, quality of life and economic outcomes may be important, based on the clinical and patient priority of this uncertainty.

Factors Associated With the Quality of Life of Patients With Venous Leg Ulcers in Primary Care: Cross-Sectional Study

The presence of venous leg ulcers (VLU) is associated with emotional disorders in individuals who have conditions, such as depression, anxiety, and sleeping problems, which result in a reduced perceived quality of life by these individuals. The study aim was to describe the perceived quality of life and associated factors for individuals with VLU. We conducted a cross-sectional study in 22 primary care health centers with a sample of 93 individuals with VLU. The variables collected were the following: perceived quality of life measured with Spanish version of the Charing Cross Venous Ulcer Questionnaire (CCVUQ-e), ulcer severity measured with the RESVECH 2.0 Score, demographic variables, and those related to the healing process. The results showed a mean CCVUQ-e score of 47.4 ± 11.8 points (Mean ± SD), with the most affected dimension being the emotional status, followed by cosmesis, social interaction, and domestic activities. The mean RESVECH 2.0 score was 11.1 ± 3.7 points. An association was found between ulcer-related pain and poorer quality of life (P < .05, t test) and between erythema in perilesional skin and poorer quality life (P < .05, t test). The signs of infection and inflammation in the VLUs were as follows: increasing exudate, friable tissue, and biofilm-compatible tissue, which were associated with a poorer quality of life (P < .05, t test). The multivariate model was statistically significant and explained a variability of 26% in the CCVUQ-e score. This study confirms that wound severity, pain, and signs of infection in VLU decrease the perceived quality of life of individuals with these wounds.

Occurrence and Severity of Pain in Patients with Venous Leg Ulcers: A 12-Week Longitudinal Study

Background: The aim of the study was to analyze the dynamics of pain severity and its predictors in a group of patients with chronic venous leg ulcers. Methods: A 12-week longitudinal study included 754 patients with chronic venous leg ulcers. Subjective severity of pain was measured at weekly intervals with an 11-point visual analogue scale (VAS). Results: A significant decrease in VAS scores has been observed throughout the entire analyzed period. Higher severity of pain during follow-up was independently predicted by the presence of pus and/or unpleasant smell from the ulceration during the first visit, as well as by the occurrence of posterior and/or circumferential ulcers. The presence of ulcer redness during the first visit was associated with lesser pain severity; also, a significant interaction effect between the ulceration redness and warmth was observed. Conclusions: Implementation of complex holistic care may contribute to a substantial decrease in the occurrence and severity of pain in a patient with venous leg ulcers. Pain control seems to depend primarily on clinical parameters and topography of venous ulcers. The predictors of pain severity identified in this study might be considered during the planning of tailored care for patients with venous leg ulcers.

Treatment of venous leg ulcers using bilayered living cellular construct

Background: Venous leg ulcers (VLUs) present a significant economic burden on the US healthcare system and payers (US$14.9 billion). Aim: To evaluate the quality of life (QoL) of patients with VLUs; to analyze the limitations of standard of care (SOC) for VLUs; and to explain how using bilayered living cellular construct (BLCC) with SOC for treatment of VLUs can help heal more VLUs faster (than using SOC alone) as well as help improve QoL and help reduce the burden on the US healthcare system and payers. Materials & methods: This is a review study. The search was conducted in February 2020 by way of electronic databases to find relevant articles that provided information related to QoL of patients with VLUs, limitations of SOC for VLUs and economic analyses of using BLCC for treatment of VLUs. Results: VLUs impact patients' physical, functional and psychological status and reduce QoL. A total 75% of VLU patients who used SOC alone failed to achieve healing in a timely fashion, which led to increased healthcare costs and healthcare resource utilization. Although the upfront cost is high, the greater effectiveness of BLCC offsets the added cost of the product during the time period of the studies. Therefore, BLCC helps to improve the QoL of VLU patients. As an example, for every 100 VLU patients in a healthcare plan, the use of BLCC can create cost savings of US$1,349,829.51. Conclusion: Payers' coverage of BLCC results in reduction of the overall medical cost for treating VLU patients.

Cost of managing patients with venous leg ulcers

The aim of this study was to estimate costs associated with the management of patients with venous leg ulcers (VLUs) from the perspective of the UK National Health Service (NHS). The analysis was undertaken through the Secure Anonymised Information Linkage Databank which brings together and anonymously links a wide range of person-based data from around 75% of general practitioner (GP) practices within Wales (population coverage ~2.5 million). The data covered an 11-year period from 2007 to 2017. All patients linked to the relevant codes were tracked through primary care settings, recording the number of GP practice visits (number of days with an event recorded), and wound treatment utilisation (eg, dressings, bandages, etc.) Resources were valued in monetary terms (£ sterling) and the costs were determined from national published sources of unit costs. This is the first attempt to estimate the costs of managing of VLUs using routine data sources. The direct costs to the Welsh NHS are considerable and represent 1.2% of the annual budget. Nurse visits are the main cost driver with annual estimates of £67.8 million. At a UK level, these costs amount to £1.98 billion. Dressings and compression bandages are also major cost drivers with annual Welsh estimates of £828 790. The direct cost of managing patients with VLUs is £7706 per patient per annum, which translates to an annual cost of over £2 billion, when extrapolated to the UK population. The primary cost driver is the number of district nurse visits. Initiatives to reduce healing times through improving accuracy of initial diagnosis, and improved evidence-based treatment pathways would result in major financial savings.

Translation, cross-cultural adaptation and validation of the "Cardiff wound impact schedule," a wound-specific quality of life instrument, to the native Spanish of Mexican patients

The aim of this study was to translate into Mexican Spanish, cross-culturally adapt and validate the wound-specific quality of life (QoL) instrument Cardiff wound impact schedule (CWIS) for Mexican patients. This instrument went through the full linguistic translation process based on the guidelines of Beaton et al (Beaton DE, Bombardier C, Guillemin F, Ferraz MB, Guidelines for the process of cross-cultural adaptation of self-report measures, Spine Phila Pa, 1976, 2000, 318-391). We included a total of 500 patients with chronic leg ulcers. The expert committee evaluated the Face validity and they agreed unanimously that the instrument was adequate to assess the QoL of these patients, covering all relevant areas presented by them. The content validity index obtained was of 0.95. The construct validity demonstrated moderately significant correlations between related sub-scales of CWIS and SF-36 (P = .010 to P < .001). The instrument was able to discriminate between healed and unhealed ulcers. The instrument obtained an overall Cronbach's alpha of .952, corresponding to an excellent internal consistency (.903-.771 alpha range for domains). The CWIS can be appropriately used to assess the health-related QoL of Mexican patients with chronic leg ulcers.

Older patients' experiences and perceptions of having their wounds treated with medical-grade honey

Ancient remedies in wound care have been used for millennia and are now being rediscovered; in particular, the use of honey. The purpose of this study was to capture and explore the meanings that participants assign to their lived experiences when using medical-grade honey to treat wounds. Six participants were recruited from a Lindsey Leg Club support group. Semi-structured interviews were conducted and the verbatim transcriptions were analysed using interpretative phenomenological analysis. Two themes were identified: experiences of using medical-grade honey and perceptions of honey as a natural folkloric medicine. This study revealed the complexity of using medical-grade honey to treat wounds and highlights patients' experiences and perceptions. The findings are reviewed and discussed in relation to the literature and implications for further research and clinical practice are suggested.

Validation of "Wound QoL" Hebrew version disease-specific questionnaire for patients with lower extremity ulcerations

The slow healing process and high recurrence rate of lower extremity ulcerations (LEU) impose a considerable medical and economic burden and affect quality of life (QoL). Analyses of LEU-related QoL in Israel are limited due to lack of a validated Hebrew disease-specific evaluation instrument. The aim of this study was to validate the disease-specific Hebrew "Wound QoL" questionnaire. The validation of the "Wound QoL" disease-specific instrument, translated from English to Hebrew, was based on a comparison with the valid Hebrew version of the SF12v.2 health-related questionnaire. The convenience sample for the "Wound QoL" validation (n = 32) was obtained from patient populations in the Maccabi Health Services' outpatient clinics at the northern and southern parts of Israel. The study was conducted between June and September 2017. Face/construct validity was accepted by specialists' consensus. Internal consistency assessed by Cronbach's α was .893. Concurrent validity reflected by Pearson's correlations between the tools was in the range of 0.830 to 0.950. The Wound QoL Hebrew version is a valid and reliable instrument suitable for implementation in an Israeli cultural environment.

The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

OBJECTIVE

to evaluate pain in individuals with venous ulcers treated with elastic bandage and decongestant physical therapy.

METHODS

we studied 90 patients, divided into three groups with 30 patients each: a group treated with elastic bandage and decongestant physical therapy; a group treated with elastic bandage; and a group treated only with primary dressing according to tissue type and presence of exudate. We used the Pain Numerical Scale to quantify pain intensity and the McGill Pain Questionnaire for pain qualitative assessment.

RESULTS

in the first evaluation, all patients who participated in the study reported intense pain. In the fifth evaluation, the majority of patients treated with elastic bandaging and decongestant physical therapy did not report pain; the majority of patients in the elastic bandage group reported mild pain; and most patients treated only with primary dressing reported mild to moderate pain. During all five assessments using the McGill questionnaire, most patients in the elastic bandaging and primary dressing groups used descriptors of the sensory, affective, evaluative and miscellaneous groups to describe their pain. However, in the fourth and fifth evaluations, most patients who received decongestant physical therapy combined with elastic bandaging treatment did not use any of the descriptors.

CONCLUSION

patients treated with decongestant physical therapy and elastic bandage presented pain improvement from the third evaluation performed on.

Venous leg ulcer management in clinical practice in the UK: costs and outcomes

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to managing venous leg ulcers (VLUs) in clinical practice by the UK's National Health Service (NHS) and the associated costs of patient management. This was a retrospective cohort analysis of the records of 505 patients in The Health Improvement Network (THIN) Database. Patients' characteristics, wound-related health outcomes and health care resource use were quantified, and the total NHS cost of patient management was estimated at 2015/2016 prices. Overall, 53% of all VLUs healed within 12 months, and the mean time to healing was 3·0 months. 13% of patients were never prescribed any recognised compression system, and 78% of their wounds healed. Of the 87% who were prescribed a recognised compression system, 52% of wounds healed. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 30% of all the VLUs may have been clinically infected at the time of presentation, and only 22% of patients had an ankle brachial pressure index documented in their records. The mean NHS cost of wound care over 12 months was an estimated £7600 per VLU. However, the cost of managing an unhealed VLU was 4·5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU). This study provides important insights into a number of aspects of VLU management in clinical practice that have been difficult to ascertain from other studies and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.

Systematic review assessing the measurement properties of patient-reported outcomes for venous leg ulcers

Background

A variety of instruments have been used to assess outcomes for patients with venous leg ulcers. This study sought to identify, evaluate and recommend the most appropriate patient‐reported outcome measures (PROMs) for English‐speaking patients with venous leg ulcers.

Methods

This systematic review used a two‐stage search approach. Electronic searches of major databases including MEDLINE were completed in October 2015, and then updated in July 2016. Additional studies were identified from citation checking. Study selection, data extraction and quality assessment were undertaken independently by at least two reviewers. Evaluation and summary of measurement properties of identified PROMs were done using standard and adapted study‐relevant criteria.

Results

Ten studies with data for four generic PROMS and six condition‐specific measures were identified. No generic PROM showed adequate content and criterion validity; however, the EuroQoL Five Dimensions (EQ‐5D™), Nottingham Health Profile (NHP) and 12‐item Short‐Form Health Survey (SF‐12®) had good acceptability. In general, the EQ‐5D™ showed poor responsiveness in patients with venous leg ulcers. Most condition‐specific PROMs demonstrated poor criterion and construct validity. Overall, there was some evidence of internal consistency for the Venous Leg Ulcer Quality of Life (VLU‐QoL) and the Sheffield Preference‐based Venous Ulcer questionnaire (SPVU‐5D). Test–retest reliability was satisfactory for the Venous Leg Ulcer Self‐Efficacy Tool (VeLUSET).

Conclusion

The NHP and VLU‐QoL questionnaire seemed the most suitable PROMs for use by clinicians. However, a valid condition‐specific PROM is still required.

The Effectiveness of EMLA as a Primary Dressing on Painful Chronic Leg Ulcers: Effects on Wound Healing and Health-Related Quality of Life

This study aimed to evaluate the effect of EMLA 5% cream applied to painful chronic leg ulcers (CLUs) as a primary dressing on wound healing and health-related quality of life (HRQoL). A pilot, parallel-group, nonblinded, randomized controlled trial was conducted in 6 community nursing procedure clinics in New South Wales, Australia. A total of 60 participants with painful CLUs of varied etiology were randomly assigned to the intervention (EMLA daily for 4 weeks as a primary dressing, followed by usual care) or usual care only. Wound size and HRQoL were measured at baseline, end of the intervention period (week 4), and week 12. At baseline, wound sizes were similar for both the intervention and control groups. During the intervention period, there was no significant difference in wound sizes between groups (intervention group: median (cm²) = 2.4, IQR = 1.3-12.7; control group: median (cm²) = 5.0, IQR = 2.5-9.9; P = .05). Mean HRQoL scores for all subscales at baseline and weeks 4 and 12 were similar between groups except for Wellbeing, which was significantly higher in the intervention group at the end of the 4-week intervention period (intervention group: mean = 52.41, SD = 24.50; control group: mean = 38.15, SD = 21.25; P = .03; d = 0.62). The trial findings suggest that daily applications of EMLA as a primary dressing do not inhibit wound healing and may improve patient well-being. Studies with larger samples are required to more comprehensively evaluate the impact of this treatment on wound healing and HRQoL.

Social-demographics, health behaviors, and telomere length in the Mexican American Mano a Mano Cohort

In the current study, we examined cross-sectional associations among social-demographics, lifestyle behaviors, and relative telomere length (RTL) in peripheral blood leukocytes, as well as longitudinal relationships among major chronic diseases, weight gain, and RTL, among 12,792 Mexican Americans aged 20 to 85 years in the Mano-A-Mano, the Mexican American Cohort. As expected, RTL was inversely correlated with age (ρ=-0.15, ρ<0.001). In the multivariate analysis, we found that RTL was positively correlated with levels of education (ρ=0.021), self-insurance (ρ=0.041), body mass index (BMI) (ρ<0.001), and sleeping time per day (ρ for trend<0.001), and RTL was inversely correlated with sitting time per day (ρ for trend =0.001). In longitudinal analysis, we found that longer RTL was modestly but positively associated with increased risks of overall cancer (adjusted hazard ratio (adj.HR)=1.05, 95% conference interval (95%CI)=1.02-1.09). In quartile analysis, 4^th quartile (longest RTL) was associated with 1.53-fold increased risk of overall cancer (adj.HR=1.53, 95%CI=1.11-2.10), compared to 1^st quartile (shortest RTL). RTL was reversely associated with the risk of type-2 diabetes (adj.HR=0.89, 95%CI=0.82-0.94). In quartile analysis, 4^th quartile (longest RTL) was associated with 48% decreased risk of typle-2 diabetes (adj.HR=0.52, 95%CI=0.32-0.70), compared to 1^st quartile (shortest RTL). In addition, longer RTL was a positive predictor of at least 10% weight gain (adj.HR=1.03, 95%CI=1.00-1.05). In summary, our results in Mexican Americans support the notion that telomere length is a biological mechanism by which social demographics and health behaviors “get under the skin” to affect health.

Health-related quality of life at healing in individuals with chronic venous or mixed-venous leg ulceration: a longitudinal assessment

AIMS

To identify factors associated with longitudinal changes in health-related quality of life in community-dwelling individuals with venous or mixed-venous leg ulcers.

BACKGROUND

Most care focuses primarily on healing; this research may additionally lead to strategies to improve quality of life.

DESIGN

Data from four studies (2000-2009) were combined (2012) to examine quality of life in community-dwelling individuals referred for care of chronic leg wounds.

METHODS

Data collection occurred at baseline, 3, 6, 9 and 12 months or at healing and included a comprehensive clinical assessment and measures of pain (McGill), functional autonomy (EQ-5D^™ ) and quality of life (SF-12^TM ). Physical Component Summary and Mental Component Summary scores (SF-12^TM ) were categorized by whether or not there was an improvement (≥3 points) over time. Multivariable logistic regression modelling was used to identify factors associated with improvement.

RESULTS/FINDINGS

Mean age of this sample (n = 519) was 67·5 years, 55·9% were women. Median time to healing was 70 days. Mean Physical Component Summary score increased from 37·0-41·5; factors associated with improvement included independent mobility, family history, problems with usual activities, fewer comorbidities and higher baseline pain. Mean Mental Component Summary score improved from 50·5-53·7; factors associated with improvement included anxiety or depression at baseline and living with others.

CONCLUSION

Chronic leg ulceration has a substantial, negative impact on health-related quality of life. Ascertaining characteristics associated with changes in quality of life will contribute to the development of comprehensive strategies for prevention, care and improved quality of life.

Cultural adaptation and validation of the Freiburg Life Quality Assessment--Wound Module to Brazilian Portuguese

Objectives:

to adapt the Freiburg Life Quality Assessment - Wound Module to Brazilian Portuguese and to measure its psychometric properties: reliability and validity.

Method:

the cultural adaptation was undertaken following the stages of translation, synthesis of the translations, back translation, committee of specialists, pre-test and focus group. A total of 200 patients participated in the study. These were recruited in Primary Care Centers, Family Health Strategy Centers, in a philanthropic hospital and in a teaching hospital. Reliability was assessed through internal consistency and stability. Validity was ascertained through the correlation of the instrument's values with those of the domains of the Ferrans and Powers Quality of Life Index - Wound Version and with the quality of life score of the visual analog scale.

Results:

the instrument presented adequate internal consistency (Cronbach alpha =0.86) and high stability in the test and retest (0.93). The validity presented correlations of moderate and significant magnitude (-0.24 to -0.48, p<0.0001).

Conclusion:

the results indicated that the adapted version presented reliable and valid psychometric measurements for the population with chronic wounds in the Brazilian culture.

Correlation between health-related quality of life and venous leg ulcer's severity and characteristics: a cross-sectional study

This study aims to determine health-related quality of life (HRQoL) in patients suffering with venous ulceration and to correlate wound's severity status with HRQoL loss as well as identify the aspects of HRQoL most negatively affected by the presence of venous ulcers. In this observational, cross-sectional, descriptive, analytical multi-centre study, data was compiled over a period of 3·5 months. Thrity-four patients with venous ulceration were recruited. The RESVECH 2·0 scale was used to monitor wounds. The MAID scale was used to measure wound's severity. The Charing Cross Venous Ulcer Questionnaire (CCVUQe) (Spanish version) was used to evaluate quality of life. The mean CCVUQe score was 60·58 ± 16·04. The HRQoL dimension most affected was 'Emotional state' (mean score = 77. 67 ± 17·34). The average RESVECH 2.0 score for the wounds was 13·15 ± 5·07. A statistically significant association between total CCVUQ-e score and total RESVECH 2.0 score was detected [Pearson correlation coefficient r = 0·546 (P ≤ 0·001)]. Venous ulcers affect patients' HRQoL, particularly their emotional status. There is a relationship between the severity of the wound and loss of HRQoL. The presence of non-viable tissue, poor exudate control and infection all determine loss of HRQoL. New studies are needed to confirm these findings.

Influence of psychosocial factors on coping and living with a venous leg ulcer

This clinical focus and literature review describe the effect of psychosocial factors on coping and living with a venous leg ulcer (VLU). The associated stressors of living with a VLU include: pain, loss of self-esteem, and social isolation, with subsequent negative emotions that could potentially lead to anxiety and depression. The ability to cope with a VLU depends upon the individual, with some patients employing negative coping strategies such as denial, depending on the stage of the illness and level of acceptance reached (Husband, 2001; Brown, 2014). Psychosocial interventions by health professionals have been shown to reduce the stress of living with a VLU, to improve a patient's coping ability, and subsequently enhance wound healing. This article highlights the importance of holistic assessment and joint treatment planning, to incorporate patients' psychosocial needs and individual coping methods in order to reduce the associated stress of living with a VLU.

The impact of skin grafting on the quality of life and self-esteem of patients with venous leg ulcers

BACKGROUND

The assessment of health-related quality of life in patients with venous leg ulcers provides important information for clinical decision making, evaluation of therapeutic benefits, and prediction of survival probabilities.

METHODS

Health-related quality of life and self-esteem were assessed using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Rosenberg self-esteem (RSE) scale, respectively, in patients with venous leg ulcers treated with split-thickness skin grafts. One hundred patients with venous leg ulcers and indication for skin grafting were divided into two groups of 50 patients each: the control group (patients who received conservative treatment) and surgery group (patients who received split-thickness skin grafts).

RESULTS

Patients in the surgery group reported significantly higher SF-36 scores (better health status) than controls one month after surgery, as well as 90 and 180 days postoperatively (p < 0.002). The mean total RSE score was significantly lower (indicating higher self-esteem) in the surgery group (mean RSE score, 17.54) than in the control group (mean RSE score, 24.22).

CONCLUSIONS

Split-thickness skin grafting resulted in better health-related quality of life and self-esteem in patients with venous leg ulcers than did compression therapy with Unna's boot.

Quality of life assessment of patients with and without venous ulcer

OBJECTIVES

to compare the quality of life of patients with chronic venous disease with and without ulcer and to identify the most affected aspects.

METHOD

cross-sectional study with a sample of 204 patients with chronic venous disease. The quality of life was assessed with the help of the SF-36 questionnaire. To compare the scores between the groups, the Mann-Whitney test was used, considering a statistically significant difference when p<0.05.

RESULTS

the quality of life score of patients with ulcer was lower when compared to that of patients without ulcer, in all domains and dimensions of the SF-36, particularly in the domains physical aspect and functional capacity, with very low scores.

CONCLUSION

all aspects of quality of life were more compromised in people with ulcers. These findings can contribute towards a better understanding of the effects of chronic venous disease on the quality of life and towards a better orientation of therapeutic interventions in this population.

Cost-effective use of silver dressings for the treatment of hard-to-heal chronic venous leg ulcers

AIM

To estimate the cost-effectiveness of silver dressings using a health economic model based on time-to-wound-healing in hard-to-heal chronic venous leg ulcers (VLUs).

BACKGROUND

Chronic venous ulceration affects 1-3% of the adult population and typically has a protracted course of healing, resulting in considerable costs to the healthcare system. The pathogenesis of VLUs includes excessive and prolonged inflammation which is often related to critical colonisation and early infection. The use of silver dressings to control this bioburden and improve wound healing rates remains controversial.

METHODS

A decision tree was constructed to evaluate the cost-effectiveness of treatment with silver compared with non-silver dressings for four weeks in a primary care setting. The outcomes: 'Healed ulcer', 'Healing ulcer' or 'No improvement' were developed, reflecting the relative reduction in ulcer area from baseline to four weeks of treatment. A data set from a recent meta-analysis, based on four RCTs, was applied to the model.

RESULTS

Treatment with silver dressings for an initial four weeks was found to give a total cost saving (£141.57) compared with treatment with non-silver dressings. In addition, patients treated with silver dressings had a faster wound closure compared with those who had been treated with non-silver dressings.

CONCLUSION

The use of silver dressings improves healing time and can lead to overall cost savings. These results can be used to guide healthcare decision makers in evaluating the economic aspects of treatment with silver dressings in hard-to-heal chronic VLUs.

Methodological recommendations for comparative research on the treatment of chronic wounds

OBJECTIVE

To provide specific recommendations to product developers and clinical researchers on the design of comparative effectiveness studies for the treatment of chronic wounds, specifically those pertaining to arterial and venous-disease related ulcers, diabetic foot ulcers, pressure ulcers and burn wounds.

METHOD

The recommendations were developed based on a process defined by the Center for Medical Technology Policy (CMTP). After selecting the subject area, semi-structured phone interviews were conducted by one of the authors (SSS) with representatives of payers, manufacturers, clinicians, clinician/researchers and patient advocates. Next, a broad range of stakeholders participated in a meeting convened by CMTP to determine their needs. A technical working group comprising key stakeholders then participated in clarifying recommendations developed by CMTP staff and adding important considerations for their implementation. The resulting draft document was finalised based on public and solicited comment from individual manufacturers; a consortium of product developers and manufacturers; and an alliance of physicians, providers, manufacturers and patient organisations. This article is a summary of the full effectiveness guidance document.

RESULTS

To address the needs of patients, clinicians, guideline developers, payers and other post-regulatory decision makers, this work makes ten recommendations to guide comparative effectiveness research for chronic wound care. These recommendations fall into four categories: study design, population, comparators and outcomes.

CONCLUSION

This paper suggests that using the recommendations outlined to conduct comparative effectiveness research on treatments for chronic wound therapies would facilitate trials that provide patients, clinicians, and payers with the information they need to make optimal treatment decisions. These recommendations focus on design changes that would have the largest impact in improving the usability of the results by decision makers and provide specific guidance on the design of prospective studies intended to inform decision making by patients, clinicians and payers.

DECLARATION OF INTEREST

There were no external sources of funding for these recommendations. The Value Institute and the Center for Medical Technology Policy (CMTP) are both private, non-profit organisations. The authors have no financial, commercial or social conflicts of interest to declare with respect to the article or its content.

Venous leg ulcer in the context of chronic venous disease

Objectives

Chronic venous disease (CVD) is a frequent disorder with a high socioeconomic impact. Little is known about the possible differences between healed ulcer (C5 group) and active ulcer (C6 group) in terms of disease severity and quality of life (QoL). Our aim was to determine the possible differences in severity disease and QoL between the C5–C6 and C1 (control) group.

Methods

Data from a national, multicentre, observational and cross-sectional study ( n = 1598) were used to compare three groups of CVD: C1 ( n = 243), C5 ( n = 136) and C6 ( n = 70). CVD severity was assessed with the Venous Clinical Severity Score (VCSS) and QoL with the Short Form 12 Health Survey (SF-12) and Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ-20).

Results

Patients with active ulcers had a higher mean total VCSS than patients with healed ulcers ( P < 0.05). Both SF-12 and CIVIQ-20 QoL questionnaires indicated a poorer QoL in patients with ulcers than in those with C1 ( P < 0.05). Compared with the C5 group, patients with active ulcers (C6) had lower QoL scores, but the differences were not statistically significant.

Conclusions

Patients with venous leg ulcers (C5–C6) are associated with high severity and poor QoL. However, the healing of a leg ulcer did not contribute to improvement of QoL.