Does leg ulcer treatment improve patients' quality of life?

Dynamic optical coherence tomography of chronic venous ulcers

BACKGROUND

Chronic ulcers, especially venous leg ulcers, are a major burden on the healthcare system. To date there are only few non-invasive established procedures for evaluation of blood perfusion in wounds. Dynamic optical coherence tomography (D-OCT) provides images of the skin's superficial vascularisation.

OBJECTIVES

This study aims to investigate if and how the D-OCT measurement of chronic wounds can provide new information about the vascularisation during the healing process.

METHODS

We examined 16 venous ulcers over 16 weeks and evaluated the vessel morphology and density using D-OCT at the wound bed, borders, two centimetres adjacent to the wound und at non-ulcerated skin on the contralateral leg.

RESULTS

In D-OCT scans clumps were unique and the most common vessel type in the wound area of venous ulcers, whereas lines and serpiginous vessels were the most common in non-ulcerated skin. At the wound border mottle and cluster patterns occurred more frequently. Healthy skin showed a significant increase of mesh pattern. Vessel density significantly increased at the wound area compared to non-ulcerated skin. During the healing process the wound border showed the most vascular changes while only an increase in curves was observed in the wound centre. Non-healing wounds had fewer dots and blobs at the borders, fewer dots, coils, clumps, lines and serpiginous vessels at the centre and fewer dots in adjacent skin. Temperature analysis showed higher temperatures in non-ulcerated skin, followed by the wound margin and centre. Non-healing wounds showed the lowest temperatures in the wound centre.

CONCLUSIONS

These results highlight the non-invasive use of D-OCT for the examination and monitoring of wound healing in chronic venous ulcers. D-OCT imaging of blood vessels may offer the potential to detect disorders of wound healing at an early stage, differentiate ulcers of different genesis and to tailor more individualized, patient-oriented therapy.

Primary Care Disease Management for Venous Leg Ulceration in German Healthcare: Results of the Ulcus Cruris Care Pilot Study

Despite proven effectiveness, compression therapy is applied in only 20-40% of patients with venous leg ulceration, leading to avoidable chronification and morbidity. The Ulcus Cruris Care project was established to develop a new disease-management concept comparable to existing programs for chronic diseases to support evidence-based treatment of venous leg ulceration. This prospective controlled study assessed its first implementation. Interventional elements comprised online training for general practitioner practices, software support for case management, and educational materials for patients. A total of 20 practices and 40 patients were enrolled in a 1:1 ratio to the intervention and control group. Guideline-conform compression therapy was applied more frequently in the intervention group (19/20 [95%] vs. 11/19 [58%]; p = 0.006). For patients with ulcers existing ≤ 6 months, the healing rate at 12 weeks was 8/11 [73%] (intervention) compared to 4/11 [36%] (control; p = 0.087). Patients after intervention had higher scores for self-help and education in the PACIC-5A questionnaire (42.9 ± 41.6 vs. 11.4 ± 28.8; p = 0.044). Treatment costs were EUR 1.380 ± 1.347 (intervention) and EUR 2.049 ± 2.748 (control; p = 0.342). The results of this study indicate that the Ulcus Cruris Care intervention may lead to a significant improvement in care. Consequently, a broader rollout in German healthcare seems warranted.

Axial ablation versus terminal interruption of the reflux source (AAVTIRS): a randomised controlled trial

BACKGROUND

Treatment of superficial venous reflux has been shown to improve ulcer healing time and reduce the risk of ulcer recurrence. Terminal ablation of the reflux source (TIRS) is an alternative to formal endovenous ablation or surgery which can be performed by injecting sclerosant foam into the peri-ulcer plexus of the veins. TIRS has been shown to be successful and in our experience is the option preferred by many patients, when offered as an alternative to axial ablation (AA).

AIM

To determine if the proportion of ulcers healed within 6 months of endovenous treatment differs between patients undergoing AA of varicose veins or TIRS by peri-ulcer foam sclerotherapy.

METHODS

AAVTIRS is an assessor-blinded randomised controlled trial. Patients will be recruited from a dedicated ulcer clinic in Roscommon University Hospital and from the vascular surgical clinics in University Hospital Galway. All patients attending the ulcer clinic will be screened for eligibility.

RANDOMISATION

Random computer-generated sequence is stratified by ulcer size. Allocation will be concealed using sealed opaque envelopes.

BLINDING

Assessors reviewing wounds at follow -p visits will be blinded to patient allocation.

PRIMARY ENDPOINT

The proportion of ulcers healed within 6 months of enrolment.

DISCUSSION

This will be the first time that TIRS has been evaluated with a properly powered randomised trial in the setting of venous ulcer management. Streamlining the management of venous ulcers has broad health economic benefits. If it is found that TIRS is superior or non-inferior to AA, then a less expensive, less invasive injection can be offered as an alternative to AA in an attempt to encourage the healing of venous ulcers. If AA is found to be superior to TIRS, then this would suggest that all patients undergoing ablation in the management of venous ulcers should have their superficial reflux fully treated, building on the evidence of the EVRA trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04484168. Registered on 23 July 2020.

24-hour interval compression: a plan to balance effectiveness and tolerability for chronic oedema

As one of the mainstays for the management of chronic oedema, compression is unquestionably an efficacious and important element in treatment pathways during the intensive acute, transition and maintenance phases. Despite the variety of compression technologies on the market, devices to aid application and innovative methods employed by caregivers to encourage adherence to treatment, concordance remain a challenge. Balancing clinical effectiveness and patient comfort, the 24-hour interval plan considers wearer lifestyle and treatment options to tailor types of compression and times during the day and night when compression is worn. This article reviews previously published theories and evidence on which the 24-hour compression plan has been based (Bock et al, 2022).

[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.

Clinical performance and quality of life impact of an absorbent bacteria-binding foam dressing

The aim of this prospective multicentre observational study was to assess the clinical performance and safety of Cutimed® Siltec® Sorbact® absorbent bacteria-binding foam dressing in wound healing and its impact on patients' quality of life (QoL). The study was conducted under routine clinical conditions in 5 study sites in Germany and Poland. Each patient with a venous leg ulcer (VLU) or a diabetic foot ulcer (DFU) was observed for 28 days (initial visit and close-out visit, as well as 3 control visits). An assessment of QoL of the patient was undertaken before and after the study. Sixty-two patients were included in the statistical analysis. Clinicians rated the following assessment parameters in relation to Cutimed Siltec Sorbact dressings as 'very good' to 'good': wearing comfort (rated by the patient), application and removal, exudate absorption with or without compression and fluid retention capacity with or without compression and infection management. The use of Cutimed Siltec Sorbact dressing was beneficial in absorbing wound exudate (chi-square=28.45, P value<0.001), reduction of the viscosity of wound exudate (chi-square=25.63, P value<0.001), and there were more intact, less macerated, red and oedematous wound surroundings. There was also a 9% decrease in the number of infected wounds at the close-out visit. Analysis of the Wound-QoL measures demonstrated a reduction in the perception of performance parameters associated with wound infection. It can therefore be deduced that the use of Cutimed Siltec Sorbact was effective in wound management and had positive implications for patients' QoL.

DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers

BACKGROUND

Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy.

METHODS

This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates.

DISCUSSION

This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence.

ETHICAL COMMITTEE REFERENCE

C.A. 2111 Galway Clinical Research Ethics Committee REGISTRATION: Clinical Trials.gov registration NCT03640689 , Registered on 21 August 2018.

Quality of life in patients with leg ulcers: results from CHALLENGE, a double-blind randomised controlled trial

OBJECTIVE

We recently showed the superiority of a matrix metalloproteinase (MMP) modulating dressing (foam impregnated with NOSF, nano-oligosaccharide factor) compared with a lipidocolloid matrix (TLC) control dressing in median wound area reduction (WAR). Here we report the results from the same study assessing the performance and safety of TLC-NOSF in the local management of venous leg ulcers (VLUs) or mixed leg ulcers and determining its impact on the patient's health-related quality of life (HRQoL).

METHOD

A superiority randomised double-blind controlled trial was conducted on patients presenting with a non-infected leg ulcer (VLUs or mixed leg ulcers) of predominantly venous origin (ABPI >0.8), with a surface area ranging from 5 to 50cm² and a duration of 6 to 36 months. Patients were randomly allocated to either the TLC-NOSF matrix foam (UrgoStart) dressing group or to the neutral TLC foam dressing group (UrgoTul Absorb). All received appropriate compression therapy and the wounds were assessed blindly (clinical examination, wound area tracing and photographic record) every 2 weeks for a period of 8 weeks, or until complete closure. A secondary endpoint, described here, was the patient's HRQoL, documented by the patient, through the EuroQol 5D tool (EQ-5D) questionnaire and visual analogue scale (VAS).

RESULTS

In total, 187 patients were randomised to either the TLC-NOSF group (n=94) or the control dressing group (n=93). The two groups were well balanced at baseline with regard to wound and patient characteristics. In the HRQoL questionnaire (EQ-5D), the pain/discomfort and anxiety/depression dimensions were significantly improved in the TLC-NOSF group versus the control one (pain/discomfort: 1.53±0.53 versus 1.74±0.65; p=0.022, and anxiety/depression: 1.35±0.53 versus 1.54±0.60, p=0.037). The VAS score was better in the test group compared with the control group (72.1±17.5 versus 67.3±18.7, respectively), without reaching significance (p=0.072). Acceptability and tolerance of the two products were similar in both groups.

CONCLUSION

The double-blind clinical trial has demonstrated that the TLC-NOSF matrix dressing promotes faster healing of VLUs and mixed leg ulcers and significantly reduces the pain/discomfort and anxiety/depression experienced by the patients. These results suggest that acceleration of VLU healing could improve the HRQoL of the patients and reduced the emotional and social burden of these chronic wounds.

The comparative impact of conservative treatment versus superficial venous surgery, for the treatment of venous leg ulcers: A systematic review of the impact on patients’ quality of life

Objectives

Leg ulcers are known to have a profound effect on patients’ quality of life; however, the influence of different treatment approaches is unclear. This review aims to evaluate the comparative impact of conservative treatments and superficial venous surgery, for venous leg ulcers, on patients’ Quality of Life.

Data sources

Three electronic databases (PsycInfo, Medline and CINAHL), and reference lists of relevant articles, were searched. A total of 209 articles were initially identified, and 16 articles were included in the review.

Results

The results lend cautious support to the suggestion that all treatments have a positive effect on quality of life, regardless of type, whilst wound status also appears to be an important factor.

Conclusions

Some evidence suggests that surgical treatment methods may lead to greater improvements in patients’ quality of life than compression bandaging alone; however, future research may focus on the psychological mechanisms underlying such changes.

Randomised controlled trial comparing European standard class 1 to class 2 compression stockings for ulcer recurrence and patient compliance

The aim of this study was to determine the rate of venous ulcer recurrence and the level of compliance in patients wearing European class 1 or class 2 compression stockings. A total of 100 patients with healed venous leg ulcers were recruited, and were randomised to either class 1 (n = 50) or class 2 (n = 50) compression stockings. Follow-up was at 1 week, 3, 6, 9 and 12 months to monitor ulcer recurrence and compliance. Patients had a duplex scan to identify the source of venous incompetence. The rate of ulcer recurrence after 12 months was 16·1%, and the difference in recurrence rate between classes was not statistically significant (P = 0·287) although greater numbers in class 1 developed a recurrence. Participants (88·9%) were compliant; non-compliant patients were at a significantly greater risk of recurrence (P≤ 0·0001). Thirteen patients had both superficial and deep incompetence; those randomised to class 1 stockings (n = 4) developed ulcer recurrence. Patients with a history of multiple episodes of ulceration were more likely to develop a recurrence (P = 0·001). The lowest venous ulcer recurrence rates were seen in patients who were compliant with hosiery regardless of the compression level. Patients with both superficial and deep incompetence had a lower rate of recurrence with class 2 compression.

Prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility

OBJECTIVE

To assess whether a difference in venous reflux pattern, ulcer size or duration, regular medications or the daily use of walking aids can predict the healing of a chronic venous leg ulcer (VLU).

METHOD

In this prospective, randomised, single-centre study, 110 consecutive patients with chronic leg ulcers were assessed. Ninety-nine patients met the inclusion criteria and a controlled, conservative 3-month treatment period was initiated, in which 90 patients were managed with standardised local treatment combined with compression therapy. In this group, 62 VLUs healed within 12 weeks and 28 were still open after 12 weeks. The study group consisted of 22 patients with non-healed ulcers and a control group (n=28), which was selected randomly from the healers. In both groups, venous reflux profiles were assessed using colour-flow duplex imaging.

RESULTS

The study and control groups did not differ in smoking habits, age, gender or daily oral medications. On average, the healing wounds were 5cm² before starting controlled treatment (range 1-80cm²) and had been open for 7 months (range 2-48 months); the non-healing wounds were on average 11.2cm² (range 1-31cm²) and had been open for 26 months (range 8-106 months). Venous disease severity scores were similar for both groups (12.6 vs. 13.4). Five patients (18%) with healed ulcers regularly used walking aids, the use of which was more frequent (36%) among non-healers (p<0.001). Venous reflux profiles differed significantly between the groups, with isolated superficial reflux noted in 64% of healers, compared with 36% of non-healers. In addition, isolated deep reflux was found in 14% of the healers, compared with 41% of non-healers (p=0.0002). The rate of popliteal reflux was significantly higher in non-healers (59% versus 21%; p=0.0004).

CONCLUSION

Long duration of a chronic venous ulcer may predict a poor outcome. The presence of deep venous reflux, especially in the popliteal vein, is typically found in those legs with non-healed ulcers. .

Quality of life in patients with diabetic foot ulcers: validation of the Cardiff Wound Impact Schedule in a Canadian population

The purpose of this study was to evaluate and validate the Cardiff Wound Impact Schedule (CWIS), a disease-specific quality-of-life measure, in a diabetic foot ulcer (DFU) population. Patients with DFUs have restrictions as part of their treatment and rehabilitation, which can affect health-related quality of life (HRQoL). Because of the high number of comorbidities experienced in diabetes, a disease-specific quality-of-life measure is needed to best assess the affect of a foot ulcer on HRQoL. Patients with DFUs completed the CWIS and a World Health Organization generic quality-of-life questionnaire. Validity was assessed by comparing domains of the questionnaires. Patients were categorised using the University of Texas wound classification system. Mean CWIS scores were compared between categories to assess the questionnaire's ability to differentiate wound severity. Patients with open ulcers scored significantly lower on the CWIS than those with healed ulcers. Correlations between questionnaire domains were as follows: Social Life with Social Functioning (r = 0·641, P < 0·001); Well-Being with General Health (r = 0·533, P < 0·01); Physical Symptoms and Daily Living with Physical Functioning (r = 0·631, P < 0·01) and Health-Related Quality of Life with Vitality (r = 0·425, P < 0·01). However, there was no significant difference in mean CWIS scores between categories of wound severity. We have demonstrated the ability of the CWIS in assessing HRQoL in a DFU population and its ability to differentiate between healed and non healed states.

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

Leg ulceration is a debilitating condition which compromises the quality of life of the sufferer, owing to factors such as pain, exudate, odour and social isolation. As nurses, much of the daily care provided for such patients focuses on the provision of wound care; often failing to fully address the wide ranging effects that the ulceration is having on the life of the sufferer. This article reviews the quantitative studies that have explored the health-related quality of life of patients with chronic venous leg ulceration and presents a synthesis of their findings.

Impact of lower extremity venous ulcers due to chronic venous insufficiency on quality of life

Lower extremity venous ulcers comprise a complex medical and social issue. The conservative and/or surgical management of venous ulcers is often inadequate. In addition, the psychosocial aspect of the disease is often overlooked and most often undertreated. Common symptoms such as pain, low self-esteem and patient isolation are usually not recognized and therefore not adequately managed.This mini-review summarizes the current data on the management of lower extremity venous ulcers and their impact on the quality of life of these patients.

Chronic wound pain: a conceptual model

PURPOSE

To present the wound care practitioner with a model for the assessment and treatment of wound-related pain.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in wound care and related disorders.

OBJECTIVES

After reading this article and taking this test, the reader should be able to: 1. Discuss the pathophysiology of chronic pain and the wound pain model. 2. Describe the patient's wound-related pain perspective. 3. Identify aspects of local wound care and their relationship to pain.

Leg ulceration in Portugal: quality of life

This study was undertaken to examine the impact of chronic leg ulceration on patients' health-related quality of life in an audit of practice in Lisbon, Portugal, and to observe the changes following 12 weeks of treatment. A questionnaire was administered at entry into an observational study and following 12 weeks of treatment. Patients entering the study were asked to complete the Nottingham Health Profile (NHP), Euroqol and visual analogue (VA) pain questionnaires at entry and after 12 weeks. Principal analysis compared final scores with those found at baseline and compared results with Portuguese normative data. In total, 98 patients entered the study and completed the initial questionnaire, with 68 (69.3%) patients completing the follow-up questionnaire. There were significantly (P < 0.001) higher scores for the patients compared with normative data for all domains of the NHP (all P < 0.001). Improvements were noted for all NHP scores after 12 weeks, although only bodily pain showed a significant improvement [mean difference (d) = 10.5, P = 0.003], with significant improvement also in Euroqol (d = 0.10, P = 0.027). Energy and social isolation improved substantially in the eight (11.8%) patients whose ulcers healed, but did not achieve statistical significance, although VA pain score did (d = 4.85, P < 0.001). Patients suffering from leg ulceration show modest improvements in perceived health following 12 weeks of usual care in Portugal. Improvements in practice may enhance the magnitude of these improvements.

Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial

OBJECTIVE

To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression.

DESIGN

Randomised controlled trial.

SETTING

Specialist nurse led leg ulcer clinics in three UK vascular centres.

PARTICIPANTS

500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux.

INTERVENTIONS

Compression alone or compression plus saphenous surgery.

MAIN OUTCOME MEASURES

Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time.

RESULTS

Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test).

CONCLUSION

Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07549334 [controlled-trials.com].

Venous ulcers

Veneous ulcers are extremely common, accounting for a large proportin of all lower extremity ulcers. Due to their chronicity and relatively high prevalence, their impact on the cost of healthcare and the lives of the patients affected is quite significant. There has been progress in understanding the pathophysiology, clinical features, and diagnosis of these ulcers, but the basic principles of care have remained consistent for almost a half century. To allow for optimal healing, it is important to maintain a clean moist wound bed, treat any clinically significant infection, and decrease surrounding edema.

Skin cooling, pain and chronic wound healing progression

There are many areas of wound care where theory does not always match the practical experiences of the patient. This article discusses the effects of two factors--skin cooling and pain--on chronic wound healing, and the role of pain and inflammation on the overall wound healing process.