Compression and peri-ulcer skin in outpatients' venous leg ulcers: results of a French survey

Investigating low rates of compliance to graduated compression therapy for chronic venous insufficiency: A systematic review

Chronic venous insufficiency (CVI) is a chronic lower limb progressive disorder with significant burden. Graduated compression therapy is the gold-standard treatment, but its underutilisation, as indicated in recent literature, may be contributing to the growing burden of CVI. The aim of this systematic review is to determine the reasons for poor compliance in patients who are prescribed graduated compression therapy in the management of chronic venous insufficiency. A systematic review of the literature was conducted to identify the reasons for non-compliance in wearing graduated compression therapy in the management of chronic venous insufficiency. The keyword search was conducted through Medline, PubMed, CINAHL, Cochrane library, AMED, and Embase databases from 2000 to April 2023. Qualitative and quantitative studies were included with no study design or language limits imposed on the search. The study populations were restricted to adults aged over 18 years, diagnosed with chronic venous insufficiency. Of the 856 studies found, 80 full-text articles were reviewed, with 14 being eligible for the review. Due to the variability in study designs, the results were summarised rather than subjected to meta-analysis. There are five main overarching themes for non-compliance, which are physical limitations, health literacy, discomfort, financial issues, and psychosocial issues with emerging sub-themes. Graduated compression therapy has the potential to reduce the burden of chronic venous insufficiency if patients are more compliant with their prescription.

Fluorescence-Based Evaluation of Bacterial Load in Perilesional Skin: A Comparison Between Short Stretch Bandage and Zinc Oxide Bandage

Bacterial proliferation plays a well-known role in delayed tissue healing. To date, the presence of microorganisms on the wound bed can be detected by skin swabs or skin biopsies. A novel noninvasive fluorescence imaging device has recently allowed real-time detection of bacteria in different types of wounds through endogenous autofluorescence. The fluorescence signals detected by the device provide health workers with a visual indication of the presence, load, and distribution of bacteria. The aim of our study was to evaluate the level of bacterial colonization in perilesional skin of patients affected by venous leg ulcers treated with 2 different types of bandages: short stretch bandage and zinc oxide bandage. We conducted a monocentric prospective study, enrolling 30 patients with venous leg ulcers, divided into 2 groups: group A was treated with short stretch bandage and group B with zinc oxide bandage. A complete patient's assessment was performed once a week for 3 weeks. Levels of potentially harmful bacteria in perilesional skin were detected using a fluorescent device by 2 experienced operators on the frames taken at individual injuries, while pain was evaluated with the Numerical Rating Scale. After 3 weeks, we observed a reduction in the bacterial colonization levels of the perilesional skin by 68.67% for group A and 85.54% for group B. All the patients had a statistically significant reduction in bacterial load (P < .001), and a statistically significant difference was identified between the 2 groups (P = .043). No statistically significant differences were found between the 2 groups in terms of pain relief (P = .114). Our study demonstrated that the application of zinc oxide bandage provides a higher reduction in bacterial load perilesional skin. On the other hand, we found no difference between the 2 bandages in terms of pain symptom reduction.

Surrounding skin management in venous leg ulcers: A systematic review

OBJECTIVES

Chronic venous insufficiency may lead to the development of venous leg ulcers, the most common form of chronic wounds in the lower extremity. Key to venous leg ulcer care is the maintenance of healthy skin surrounding the ulcer, as failure to maintain skin integrity may influence the healing outcome. We thus reviewed the scientific literature looking for assessment and management instruments regarding this common but often neglected issue.

METHOD

The search included all studies published between 2000 and May 2019. Keywords used were: "peri-wound skin care", "surrounding skin venous ulcers", "surrounding skin management leg ulcers", and "peri-lesional skin management".

RESULTS

Management of moisture-balance with the selection of appropriate dressings is the most important target in surrounding-wound skin care. Moreover, contact dermatitis related to products and the dressings themselves is a neglected problem in patients with chronic leg ulcers which clinicians increasingly have to manage. The literature search revealed that there is an increasing interest in the use of noninvasive assessment tools in the field of wound care, and focusing on the surrounding-wound skin plays a role in assessing the potential of wound healing. Transepidermal water loss measurement (TEWL) and ultrasonography are two of the measurement techniques available.

CONCLUSION

The integrity of the surrounding skin is necessary for wound healing, and appropriate management is needed to address this aspect which is part of an overall approach to treating wounds.

Interface pressures with compression systems: relevance to clinical practice

Interface pressures with compression depend on many factors relating to the science of measurement and intrinsic, patient-related factors, including limb size and tissue texture. While it is important for manufacturers of compression devices to measure pressures, it may not always be relevant to clinical practice where application methods and oedematous limbs may affect final pressures. Accurate performance of any compression system relies on the use of the right technology for the right condition and patient lifestyle. Correct application following training and in accordance with instructions for use may be adapted according to individual patient comfort and needs, including mobility, tissue texture and the stage of management. In order to provide treatment regimens that are safe, effective and well tolerated by patients, as well as being easy to apply and demonstrate sound economic practice, science needs to meet clinical practice. Patient reporting is an important for successful treatment, matching clinical effectiveness with patient acceptance during reassessment and monitoring.

Stress, Illness Perceptions, Behaviors, and Healing in Venous Leg Ulcers: Findings From a Prospective Observational Study

OBJECTIVE

The aim of the study was to investigate the impact of stress, illness perceptions, and behaviors on healing of venous leg ulcers.

METHODS

A prospective observational study of 63 individuals for 24 weeks investigated possible psychosocial predictors of healing. There were two indices of healing: rate of change in ulcer area and number of weeks to heal. Psychological variables were assessed at baseline using self-report measures (Perceived Stress Scale, Hospital Anxiety and Depression Scale, Revised Illness Perception Questionnaire, adapted Summary of Diabetes Self-Care Activities, Adherence Questionnaire, and Short-Form Health Survey).

RESULTS

Controlling for sociodemographic and clinical variables, for the 24 weeks, a slower rate of change in ulcer area was predicted by greater stress (standardized β = -0.61, p = .008), depression (standardized β = -0.51, p = .039), and holding negative perceptions or beliefs about the ulcer (standardized β = -1.4, p = .045). By 24 weeks, 69% of ulcers had closed. A more negative emotional response to the ulcer at baseline (i.e., emotional representation of the ulcer) was associated with a greater number of weeks to heal (hazard ratio [HR] = 0.63, 95% confidence interval [CI] = 0.41-0.95, p = .028). Higher educational attainment (HR = 3.22, 95% CI = 1.37-7.55, p = .007) and better adherence to compression bandaging (HR = 1.41, 95% CI = 1.06-1.88, p = .019) were associated with fewer weeks to heal. No other psychosocial variable (stress, perceptions about the ulcer, health behaviors) predicted weeks to heal.

CONCLUSIONS

Alongside ulcer-related predictors, psychological and sociodemographic factors were associated with healing. Future research should explore mediating mechanisms underlying these associations and develop interventions to target these variables.

[Compression care for venous leg ulcers: Assessment of medical practices in 100 patients]

INTRODUCTION

The etiologic treatment of venous ulcers is based on compression therapy in compliance with the new guidelines promulgated by the French National Authority for Health (HAS) in 2010. Prescriptions often originate from a request by the nurse delivering care in the patient's home. A recent French study demonstrated the positive impact of compression therapy on venous ulcer healing. The objective of this study was to evaluate medical practices in order to target corrective actions.

MATERIALS AND METHODS

We conducted a single-center prospective observational study, using a standardized questionnaire from January to May 2014. Patients with venous ulcers who had an indication for compression therapy were included consecutively. The questionnaire collected demographic and clinical data and also recorded the results of complementary tests and the characteristics of the compression therapy.

RESULTS

One hundred patients were included (61 women and 39 men). The average age was 76 years. Patients were recruited during consultations (n = 69), with a majority of patients living at home (n = 80) and receiving home care delivered by a nurse (n = 81). Thirteen patients were seen for the first time and 87 patients were receiving long-term care. The ulcers evolved for 5.7 years on average. Patients presented peri-lesional edema (n = 58), ankle ankylosis (n = 49), autonomous mobilization (n = 40) and walking problems (n = 60). Physical therapy was prescribed for 39 patients and was effectively carried out for 24. The two main causes were venous varices (n = 66) and post-phlebitis disease (n = 18). Compression therapy was prescribed for 97 patients and the products delivered by the pharmacy were consistent with the prescription for 74 patients. Compliance with compression therapy was faulty for 28 patients because of poor tolerance, misunderstanding, manipulation problems, or inappropriate footwear. At assessment, 66 patients were wearing the bands, but not always correctly (starting at the base of the toes [n = 61], heel included [n = 43], proper stretching [n = 43] up to below the knee [n = 57]). Proper footwear was noted in 70 patients.

CONCLUSION

Data are scarce on compliance with compression banding. This study shows that further efforts are needed to ensure proper patient education and professional training for physicians and allied profession concerning the installation of compression therapy. Total compliance was observed in only 35% of patients. In addition, the products delivered by the pharmacy were not consistent with the prescription in 26% of cases. Many discrepancies were observed between what was prescribed and what the patients achieved. Patient adherence is a crucial issue for compression therapy.

Donning devices (foot slips and frames) enable elderly people with severe chronic venous insufficiency to put on compression stockings

OBJECTIVE/BACKGROUND

Compression therapy is highly effective in the treatment of post-thrombotic syndrome and venous leg ulcer. On average, 50-60% of the patients cooperate with compression therapy. Therefore, it is necessary to improve the user-friendliness. This prospective study investigated whether the use of donning devices can contribute to improving user-friendliness.

METHODS

Forty patients aged >65 years with severe chronic venous insufficiency (CVI; C4-C6) successively donned compression stockings in a randomized order: one 40 mmHg (CS40) or two superimposed 20 mmHg (CS20+20), each with open toe (CS-o-t) and closed toe (CS-c-t), using donning devices (three foot slips for CS-o-t; two foot slips and three frames for CS-c-t). The study endpoint was that the stocking was completely donned and correctly positioned on the patient's leg. The success rate and its association with age, sex, first time versus second time user, body mass index, abdominal circumference, ability to reach the forefoot with the hand, and hand grip strength were analyzed. Additionally, subjective evaluation by the patients was performed.

RESULTS

Without donning devices, success with CS40-c-t was 60% (24/40 patients) and with CS20+20-c-t 70% (28/40 patients) (p = .220). Using donning devices increased success rates significantly. With CS40-o-t the success rate was 88% (35/40 patients; p = .001) and with CS40-c-t it was 90% (36/40 patients; p = .002). With CS20+20-o-t and CS20+20-c-t, the success rate was 88% (35/40 patients; p = .016). The proportion of patients who successfully used either CS40 or CS20+20 increased from 73% to 93%. Relevant for the patients' success was the ability to reach the forefoot with the hand, and hand grip strength. Subjectively, donning with a device was rated significantly better than without.

CONCLUSION

Donning devices significantly improve the ability of elderly patients with CVI to don compression stockings successfully. However, there are differences in user-friendliness among the devices..

Evaluation of two fibrous wound dressings for the management of leg ulcers: results of a European randomised controlled trial (EARTH RCT)

OBJECTIVE

To evaluate the performance (efficacy, safety and acceptability) of a new micro-adherent absorbent dressing (UrgoClean®) compared with a hydrofiber dressing (Aquacel®) in the local management of venous leg ulcers, in the debridement stage.

METHOD

A non-inferiority European randomised controlled clinical trial (RCT) was conducted in 37 centres, on patients presenting with venous or predominantly venous, mixed aetiology leg ulcers at their sloughy stage (with more than 70% of the wound bed covered with slough at baseline). Patients were followed over a 6-week period and assessed weekly. The primary judgement criteria was the relative regression of the wound surface area after the 6-week treatment period. Secondary endpoints were the relative reduction of sloughy tissue and the percentage of patients presenting with a debrided wound.

RESULTS

Altogether, 159 patients were randomised to either UrgoClean (test group; n=83) or Aquacel (control group; n=76) dressings. Regarding the wound healing process predictive factors (wound area, duration, ABPI value, recurrence), at baseline, the two groups were well balanced, for both wound and patient characteristics. Compression therapy was administered to both groups and after a median 42-day treatment period, the percentage of relative reduction of the wound surface area was very similar (-36.9% vs -35.4% in the UrgoClean and control groups, respectively). When considering the secondary criteria at week 6, the relative reduction of sloughy tissue was significantly higher in the UrgoClean group than in the control group (-65.3% vs -42,6%; p=0.013). The percentage of debrided wounds was also significantly higher in the test group (52.5% vs 35.1%; p=0.033).

CONCLUSION

This 'EARTH' RCT confirmed that the UrgoClean dressing has similar efficacy and safety compared to Aquacel. However, UrgoClean also showed better autolytic properties than the control group in the management of venous leg ulcers at the sloughy stage. The new UrgoClean dressing therefore represents a promising therapeutic option within the current range of autolytic dressings available.

DECLARATION OF INTEREST

This study was sponsored by a grant from the pharmaceutical company Laboratoires Urgo. S. Bohbot and O. Tacca are employees of Laboratoires Urgo. S. Meaume, J. Dissemond and G. Perceau have received monetary compensation as presenters for Laboratoires Urgo. Data management and statistical analyses were conducted independently by Vertical (Paris, France).

Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence

Moffatt Christine, Kommala Dheerendra, Dourdin Nathalie, Choe Yoonhee. Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence. ABSTRACT This study aimed to review available data on the reasons attributed to patient non concordance with compression therapy for the treatment of venous leg ulcers (VLUs), the frequency of non concordance and its effects on clinical outcomes. The biomedical literature was searched for publications on VLUs, compression therapy and concordance over the past 20 years. Physical, aesthetic and cosmetic factors, patient lack of education about VLUs, cost of therapy and issues with treatment by clinicians were all reported to influence concordance with compression therapy. The search identified 10 studies reporting patient concordance with compression stockings or bandages; while non concordance ranged from 2% to 42% of patients in three randomised controlled trials, it was generally higher in real-world studies, ranging from 9.7% to 80%. Another set of six studies indicated that the healing rate was half and the median time to complete healing was twice as long when patients were not concordant. Further, recurrence rates were 2-20 times greater when patients did not comply with the use of stockings following VLU healing. In conclusion, published biomedical literature has documented that non concordance with compression therapy negatively impacts the outcome of VLUs, highlighting the need to improve patient concordance to maximise therapeutic benefits.

Cohesive short-stretch vs four-layer bandages for venous leg ulcers

Nurses today are employing more and more evidence base within their practice. This must be carefully balanced with their ability to offer patients choice about treatment options for venous leg ulceration. Knowledge of only one particular compression bandage system is inadequate for nurses working within this area. This article aims to examine the evidence base for the use of compression bandaging in the treatment of leg ulceration. It explores results of current randomised controlled trials in this area pertaining to four-later bandage (4LB) and cohesive short-stretch bandage (CSSB) systems. The advantages and disadvantages of the 4LB and CSSB are explored and application method of CSSB is explained. Concordance is and important issue that affects successful leg ulcer management (Moffatt, 2004a): if this can be achieved through offering patients choice of treatment bandages, then more successful treatment will be achieved for patients.