Health-related quality of life tools for venous-ulcerated patients

Diabetic foot ulcers: Classification, risk factors and management

Diabetic foot ulceration is a devastating complication of diabetes that is associated with infection, amputation, and death, and is affecting increasing numbers of patients with diabetes mellitus. The pathogenesis of foot ulcers is complex, and different factors play major roles in different stages. The refractory nature of foot ulcer is reflected in that even after healing there is still a high recurrence rate and amputation rate, which means that management and nursing plans need to be considered carefully. The importance of establishment of measures for prevention and management of DFU has been emphasized. Therefore, a validated and appropriate DFU classification matching the progression is necessary for clinical diagnosis and management. In the first part of this review, we list several commonly used classification systems and describe their application conditions, scope, strengths, and limitations; in the second part, we briefly introduce the common risk factors for DFU, such as neuropathy, peripheral artery disease, foot deformities, diabetes complications, and obesity. Focusing on the relationship between the risk factors and DFU progression may facilitate prevention and timely management; in the last part, we emphasize the importance of preventive education, characterize several of the most frequently used management approaches, including glycemic control, exercise, offloading, and infection control, and call for taking into account and weighing the quality of life during the formulation of treatment plans. Multidisciplinary intervention and management of diabetic foot ulcers (DFUs) based on the effective and systematic combination of these three components will contribute to the prevention and treatment of DFUs, and improve their prognosis.

Active compression garment prevents tilt-induced orthostatic tachycardia in humans

Compression garments are used by patients with lower extremity edema to help regulate fluid distribution and to prevent orthostatic symptoms. Current compression stockings are often reported as uncomfortable and adherence is poor. The current study was conducted to assess the efficacy of a novel active compression garment on healthy individuals undergoing 60‐degree head‐up tilts for 10 min to induce venous pooling and subsequent physiological responses. During tilts while garments were on, participants’ absolute change in heart rate relative to baseline was lower (16.7 ± 8.7 BPM) compared to control (20.9 ± 11.47 BPM, P = 0.002). There were no differences in changes in mean arterial blood pressure between conditions (P = 0.303). One participant had a pre‐syncopal event which occurred during a tilt without garments. This participant did not experience pre‐syncopal symptoms with the garments on. All together, these data suggest that a novel active compression garment is capable of blunting increases in heart rate during head‐up tilt. While untested thus far in patient populations, these garments may prove efficacious in preventing orthostatic intolerance.

Patient-reported outcome measures for chronic wounds with particular reference to pressure ulcer research: a systematic review

OBJECTIVES

Pressure ulcers are a major health problem, affect patient psychological, physical and social functioning, and cause significant treatment burden. For comprehensive assessment of the benefits of an intervention, patient-reported evidence of the impact of an intervention on important patient outcomes should be made. We systematically reviewed the quality of life literature on chronic wounds to determine the suitability of generic and chronic wound-specific outcome measures for use in evaluating patient outcomes in pressure ulcer research.

DESIGN

A systematic review of the literature.

DATA SOURCES

Searches of eight electronic databases from inception until May 2012 were undertaken.

REVIEW METHODS

Quality of life domains, item content and content relevance were determined for identified outcome measures. The content validity of identified measures was assessed against an empirically derived pressure ulcer-specific conceptual framework.

RESULTS

Three generic and 14 chronic wound measures were identified but no pressure ulcer-specific measures. None of the existing measures cover all quality of life domains important in pressure ulcers. One condition-specific measure, the Venous Leg Ulcer Measure, matched most closely conceptually, but failed to represent three important domains and contained items not specific to pressure ulcers.

CONCLUSIONS

Currently, outcomes important in pressure ulcers are inadequately covered by generic and chronic wound-specific instruments despite similar conceptual models. Highlighted is the need for clear conceptualisation of content as well as determining appropriateness when selecting outcome measures in the future.

Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care

BACKGROUND

Chronic leg ulcers cause long term ill-health for older adults and the condition places a significant burden on health service resources. Although evidence on effective management of the condition is available, a significant evidence-practice gap is known to exist, with many suggested reasons e.g. multiple care providers, costs of care and treatments. This study aimed to identify effective health service pathways of care which facilitated evidence-based management of chronic leg ulcers.

METHODS

A sample of 70 patients presenting with a lower limb leg or foot ulcer at specialist wound clinics in Queensland, Australia were recruited for an observational study and survey. Retrospective data were collected on demographics, health, medical history, treatments, costs and health service pathways in the previous 12 months. Prospective data were collected on health service pathways, pain, functional ability, quality of life, treatments, wound healing and recurrence outcomes for 24 weeks from admission.

RESULTS

Retrospective data indicated that evidence based guidelines were poorly implemented prior to admission to the study, e.g. only 31% of participants with a lower limb ulcer had an ABPI or duplex assessment in the previous 12 months. On average, participants accessed care 2-3 times/week for 17 weeks from multiple health service providers in the twelve months before admission to the study clinics. Following admission to specialist wound clinics, participants accessed care on average once per week for 12 weeks from a smaller range of providers. The median ulcer duration on admission to the study was 22 weeks (range 2-728 weeks). Following admission to wound clinics, implementation of key indicators of evidence based care increased (p < 0.001) and Kaplan-Meier survival analysis found the median time to healing was 12 weeks (95% CI 9.3-14.7). Implementation of evidence based care was significantly related to improved healing outcomes (p < 0.001).

CONCLUSIONS

This study highlights the complexities involved in accessing expertise and evidence based wound care for adults with chronic leg or foot ulcers. Results demonstrate that access to wound management expertise can promote streamlined health services and evidence based wound care, leading to efficient use of health resources and improved health.

The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial

An increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems are available. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a four-layer compression bandage system and Class 3 compression hosiery on healing and quality of life (QL) in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and QL for 24 weeks. After 24 weeks, 86% of the four-layer bandage group and 77% of the hosiery group were healed (P = 0·24). Median time to healing for the bandage group was 10 weeks, in comparison with 14 weeks for the hosiery group (P = 0·018). The Cox proportional hazards regression found participants in the four-layer system were 2·1 times (95% CI 1·2-3·5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in QL or pain measures. Findings indicate that these systems were equally effective in healing patients by 24 weeks; however, a four-layer system may produce a more rapid response.

Tradução e adaptação cultural do Charing Cross Venous Ulcer Questionnaire - Brasil

CONTEXTO: A tradução e a adaptação cultural são etapas que permitirão que um instrumento criado em determinado idioma e cultura possa ser usado em outro contexto cultural. O Charing Cross Venous Ulcer Questionnaire (CCVUQ) é um questionário de qualidade de vida em portadores de úlceras venosas que para ser utilizado no Brasil é necessária a execução do processo de adaptação transcultural. OBJETIVO: Traduzir e adaptar culturalmente para a população brasileira o CCVUQ. MÉTODOS: O processo consistiu em duas traduções e duas retrotraduções realizadas por tradutores independentes, da avaliação das versões, seguida da elaboração de versão consensual e de pré-teste comentado. RESULTADOS: No processo de tradução, algumas palavras foram modificadas no seu aspecto literal. A análise posterior dos resultados do pré-teste apontou necessidades de modificações de alguns termos para melhor compreensão do respondente. O tempo médio de aplicação do questionário foi de 5 minutos e 23 segundos. CONCLUSÃO: A versão na língua portuguesa do Charing Cross Venous Ulcer Questionnaire foi traduzida e adaptada para uso na população brasileira.

Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study

AIM

The aim of this study was to identify relationships between preventive activities, psychosocial factors and leg ulcer recurrence in patients with chronic venous leg ulcers.

BACKGROUND

Chronic venous leg ulcers are slow to heal and frequently recur, resulting in years of suffering and intensive use of healthcare resources.

METHODS

A prospective longitudinal study was undertaken with a sample of 80 patients with a venous leg ulcer recruited when their ulcer healed. Data were collected from 2006 to 2009 from medical records on demographics, medical history and ulcer history; and from self-report questionnaires on physical activity, nutrition, preventive activities and psychosocial measures. Follow-up data were collected via questionnaires every 3 months for 12 months after healing. Median time to recurrence was calculated using the Kaplan-Meier method. A Cox proportional-hazards regression model was used to adjust for potential confounders and determine effects of preventive strategies and psychosocial factors on recurrence.

RESULTS

There were 35 recurrences in a sample of 80 participants. Median time to recurrence was 27 weeks. After adjustment for potential confounders, a Cox proportional hazards regression model found that at least an hour/day of leg elevation, 6 or more days/week in Class 2 (20-25 mmHg) or 3 (30-40 mmHg) compression hosiery, higher social support scale scores and higher General Self-Efficacy scores remained significantly associated (P < 0·05) with a lower risk of recurrence, while male gender and a history of deep vein thrombosis remained statistically significant risk factors for recurrence.

CONCLUSION

Results indicate that leg elevation, compression hosiery, high levels of self-efficacy and strong social support will help prevent recurrence.

Care of chronic wounds in palliative care and end-of-life patients

The aim of this paper was to provide a literature synthesis on current wound care practices for the management of chronic wounds in palliative care and end-of-life patients, focusing on the control of wound-related symptoms for comfort and improved quality of life. These wounds included pressure ulcers, venous and arterial leg ulcers, diabetic ulcers and fungating malignant wounds. Wound-related symptoms included pain, exudate, malodour, infection, bleeding, dressing comfort and negative psychological and social functioning. Best care wound practices were formulated for each wound type to ease suffering based on the literature review. Although symptom management strategies for comfort may work in tandem with healing interventions, it is important to recognise when efforts towards wound closure may become unrealistic or burdensome for the patient at end of life. Thus, unique aspects of palliative wound care feature clinical indicators for early recognition of delayed healing, quality of life measurement tools related to chronic wounds, and comfort care strategies that align with patient wishes and realistic expectations for wound improvement.

Hydrogel sheet dressings and short-stretch cohesive bandaging: case study

Hard-to-heal wounds such as leg ulcers are associated with long duration and a high incidence of complications such as pain, often resulting in considerable financial burden (European Wound Management Association (EWMA), 2008). The financial burden is not just one for the NHS but for the patients as well in lost days from work, taxi fares, prescription charges and even having to take early retirement. The prevalence of venous leg ulcers is approximately 1% in the whole population and this increases with age. Where appropriate research-based treatment protocols and guidelines are in place, about 50% of leg ulcers heal within 4months (EWMA, 2008). The following case study demonstrates that using protocols, national and local guidelines can have a positive effect on the patients wound care journey and promote optimal wound care (Wounds UK, 2008).

The effects of education and training on clinical practice in wound healing

This article considers the effects of two different types of educational programme on community nurse clinical practice in venous ulceration. One group of nurses (the experimental group) attended an educational programme designed to take account of training needs and learning styles. A second group of nurses (the control group) attended a standardised educational programme. A multiple-choice question examination and Objective Structured Clinical Examination were used to measure knowledge and skills. Kolb's Learning Styles Inventory was used to measure learning styles. Findings were that experimental nurses failed to show improved post-intervention clinical practice compared with the control group.

A systematic review on the impact of leg ulceration on patients' quality of life

BACKGROUND

A systematic review was conducted to analyse journal articles that describe or measure the impact of leg ulceration on patients' quality of life (QoL) in order to improve the content of an educational programme that aims to enhance self-care agency in leg ulcer patients.

METHOD

Original articles published in English and German between 1990 and 2006 were included if the findings were analysed at the level of patients. Articles were excluded if (1) they investigated the impact of specific treatments or settings on QoL or (2) focused mainly on arterial ulcers or diabetic foot ulcers.

RESULTS

Twenty-four original research articles met the inclusion criteria; 11 studies used a quantitative, 11 studies a qualitative, and 2 used a mixed method approach. The findings were collapsed into 5 core domains. Quantitative studies commonly investigated the parameters of pain, sleep, social isolation, and physical mobility. Patients had significantly more pain, more restrictions regarding social functioning, less vitality, and limitations with respect to emotional roles compared to the respective controls. Other problem areas identified were restrictions in work capacity, recreation, social interaction, psychological well-being, as well as problems caused by treatment regimes. Inconclusive results were obtained regarding pain intensity, physical restrictions, and gender effects.

LIMITATIONS

Numerous original studies neither undertook a differentiation of participants by ulcer aetiology nor did they analyse the results according to gender differences.

CONCLUSION

As leg ulceration has an impact on QoL, national guidelines on the treatment of leg ulceration need to more specifically address these far-ranging effects identified in this review.

Impact of intravenous drug use on quality of life for patients with venous ulcers

AIM

This paper is a report of a study to examine, from the perspective of patients, the impact of venous leg ulcers on health-related quality of life in current and former intravenous drug users and the general population.

BACKGROUND

Venous ulceration can be caused by intravenous drug use. There has been little examination on how this affects the quality of life of this group of patients and how they compare with other patients who have venous ulcers.

METHOD

A qualitative approach was adopted, using framework analysis. Semi-structured interviews with 19 participants who had a venous leg ulcer were conducted between August 2005 and February 2006. Interview audiotapes were analysed to identify recurring themes relating to the impact of venous leg ulcers on overall quality of life.

FINDINGS

A complex interaction between symptoms, social restriction and attribution of illness influenced the impact of venous leg ulcers. Smell and pain were the symptoms that had the most profound impacts. In addition to the physical and psychological consequences, participants' activities and social interactions were restricted. Intravenous drug users experienced more social isolation and difficulties in accessing treatment for their venous ulcers.

CONCLUSION

While leg ulcer services remain focused on the needs of older people, services for young intravenous drug users are unlikely to improve. A more coherent and earlier intervention, when the ulcers are not as difficult to treat, would decrease time and costs to the health service. The challenge is to find new ways of providing effective and accessible care to this growing population.

Dressings for healing venous leg ulcers

BACKGROUND

Venous leg ulcers, sometimes called varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. Venous ulcers are characterised by a cyclical pattern of healing and recurrence. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound in order to achieve a 'moist wound environment'. There are a large number of dressing products and types available. It is unclear whether particular dressings aid healing of leg ulcers.

OBJECTIVES

To assess the effectiveness of wound dressings for the treatment of venous leg ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (April 2006) and CENTRAL (issue 1, 2006) and several other electronic databases (up to April 2005). Manufacturers of dressing products were contacted for unpublished studies.

SELECTION CRITERIA

Randomised controlled trials that evaluated dressings for the treatment of venous leg ulcers. There was no restriction in terms of source, date of publication or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Data from eligible studies were extracted and summarised using a data extraction sheet by two authors independently.

MAIN RESULTS

42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). In none of the comparisons was there evidence that any one dressing type was better than others in terms of number of ulcers healed. Current evidence does not suggest that hydrocolloids are more effective than simple low adherent dressings used beneath compression (9 trials; relative risk for healing with hydrocolloid 1.09 (95% CI 0.89 to 1.34)). For other comparisons there was insufficient evidence.

AUTHORS' CONCLUSIONS

The type of dressing applied beneath compression has not been shown to affect ulcer healing. For the majority of dressing types there was insufficient data to allow us to draw strong conclusions except for hydrocolloid compared with a low adherent dressing. The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression. Decisions regarding which dressing to apply should be based on local costs of dressings and practitioner or patient preferences.

Preventing venous ulcer recurrence: a review

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

Health-Related Quality of Life in Diabetic Patients With Foot Ulcers

Foot ulcers are a common, serious, and costly complication of diabetes, preceding 84% of lower extremity amputations in diabetic patients and increasing the risk of death by 2.4-fold over diabetic patients without ulcers. Health-related quality of life (HRQOL) is worse among individuals with diabetes than individuals without diabetes, and complications of diabetes, including foot ulcers, have a major negative effect on HRQOL. Diabetic foot ulcers are associated with reduced mobility and deficits related to activities of daily living that adversely affect HRQOL. Qualitative studies have confirmed clinical observations that diabetic foot ulcers have a huge negative psychological and social effect, including reduction in social activities, increased family tensions for patients and their caregivers (spouses or partners), limited employment, and financial hardship. Quantitative studies confirm the findings of qualitative studies that diabetic foot ulcers exert a negative effect on physical functioning, psychological status, and social situation. Recent advances include the development and validation of disease-specific HRQOL surveys for diabetic patients with foot ulcers. Disease-specific surveys may improve the evaluation of HRQOL as a function of ulcer healing, the effect of different treatment methods on HRQOL, and the relationship between treatment-specific HRQOL, patient compliance, and treatment efficacy.

Quality of life and leg ulceration from the patient's perspective

Chronic leg ulceration can have a profound impact on a patient's quality of life. Studies have shown that pain, and general interference with normal activities of living, are the major themes emerging which are often not dealt with in a consistent manner by healthcare professionals. A literature review of this subject shows that although a number of studies have been carried out on quality of life related to chronic leg ulceration, there is little evidence that these findings are being addressed in daily management of these often complex leg ulcer patients. The aim of this article is to examine the research relating to quality of life and leg ulceration, and to attempt to determine what the most important issues are from the patient's perspective, in an effort to improve the way nurses manage their care.

Acceptability to patients of a honey dressing for non-healing venous leg ulcers

OBJECTIVES

This four-centre feasibility study was undertaken to determine whether Medihoney, a proprietary blend of honeys, is an acceptable treatment for patients with leg ulcers in terms of pain relief, odour control and overall patient satisfaction.

METHOD

Forty patients whose leg ulcers had not responded to 12 weeks of compression therapy were recruited. Medihoney dressings were applied on their ulcers for the 12-week study period. All other aspects of their care, including the use of compression bandaging, remained unchanged. Their leg ulcers were assessed every two weeks. This included the use of a patient questionnaire.

RESULTS

Overall, ulcer pain and size decreased significantly and odorous wounds were deodorised promptly. This had a positive impact on patient satisfaction with the Medihoney treatment.

CONCLUSION

The results support the previously reported positive effects of honey and revealed a high patient acceptance for this treatment. Following these results, comparative clinical trials, which should also consider pain, are now recommended.