Hydrostatic leg ulcers: a new classification

Determining venous incompetence: a report from a specialised leg ulcer clinic

OBJECTIVE

To analyse the diagnosis, treatment and prognosis in patients attending a specialised leg ulcer clinic at a dermatology department.

METHOD

In total, 345 patients were investigated and 332 registered and followed up prospectively. All patients had their arterial and venous circulation assessed with a hand-held Doppler ultrasound.

RESULTS

The most frequent diagnosis was venous ulceration (153 patients, 46%) followed by hydrostatic ulceration (70 patients, 21%). Venous incompetence was classified as isolated superficial (n=86) or deep venous incompetence (n=57) in 143 out of the 153 patients. Previous deep vein thrombosis (DVT) was more frequent in patients with deep venous incompetence. Of patients with venous ulcers, 38 (25%) healed within 92 days, 77 (50%) within 155 days and 115 (75%) within 329 days. Healing time was influenced by patient age, ulcer duration and ulcer area, but not by type of venous incompetence or ankle brachial pressure index. After healing, 19% of venous patients (28/144), dominated by those with superficial disease, were subject to venous vascular surgery.

CONCLUSION

Classification of venous insufficiency should be mandatory in patients with venous ulcers since it determines suitability for venous surgery.

The rationale for sitting elderly patients in hospital out of bed for long periods is medically unsubstantiated and detrimental to their recovery

The notorious statement by Asher about the dangers of bed rest [Brit Med J 1947; ii: 967-8] which continues to be quoted out of context in leading medical journals today is inapplicable to modern short stay elderly hospital patients and has little medical foundation. 'Blood clotting in the veins' is more likely to result from venous stasis during sitting than from lying down. 'Lime draining from the bones' refers to subjects' spending weeks, not hours, in the horizontal position and similar losses have been shown to occur in healthy people immobilised in chairs for long periods during the day. Constipation is common in sick old people and there is no evidence that 'scybala stacking up the colon' is more likely to occur in bed than in a chair. The 'flesh rotting from the seat', or pressure sores, occur as frequently or more frequently, in sick patients nursed in chairs as in bed. 'Urine leaking from the distended bladder' may be reduced in very debilitated old people sitting in chairs, but at the expense of impaired renal function associated with reduced perfusion in the upright posture and exacerbated incontinence due to a compensatory diuresis at night. The 'spirit evaporating from the soul' today is more likely to afflict old patients who are exhausted by prolonged chair nursing and orthostatic hypotension due to age or illness. Recent studies in intensive care patients have highlighted the hypotension due to vasodilatation which can occur in infection and trauma. There is no evidence that nosocomial pneumonia is reduced by sitting patients out of bed, and lack of sleep is likely to exacerbate infection and delay recovery. Preventing patients from lying down when they feel the need is a violation of their rights and has been shown to be probably as injurious as the Victorian practice of preventing healthy patients from getting up. Physiotherapy is obviously important but patients should be allowed to decide for themselves how long they spend in or out of bed.