Leg ulcers: An Indian perspective

Burden of Chronic Nonhealing Wounds: An Overview of the Worldwide Humanistic and Economic Burden to the Healthcare System

Chronic wounds have long been a significant public health concern, but the true impact of these wounds is unknown since research designs and measuring techniques vary, leading to inconsistent estimates. The definition of a wound is a loss of epithelial continuity caused by damage to the tissue. The following conditions can cause chronic wounds: panniculitis, pyoderma gangrenosum, traumatic, neurological, metabolic, hematologic, neoplastic, or infection-related. The growing global incidence of diabetes and the aging population necessitate greater attention to chronic wounds. Regrettably, it is sad that significant healthcare institutions have overlooked wound research. The study of health-related illnesses and occurrences in particular populations, including their distribution, frequency, and determinants, and the application of this research to control health problems.

Factors associated with health-related quality of life of south indian population with chronic venous leg ulcers - A hospital based pilot study

OBJECTIVE

Venous leg ulcers (VLU) are chronic, recurrent and have a significant impact on the patients' health- related quality of life (HRQoL). This study assessed the association of patient-specific factors on the HRQoL of patients with chronic venous leg ulcers.

MATERIALS AND METHODS

The study included 21 males and 21 females aged 18 years and above, with chronic VLU. Data on demographics, education, occupation, per capita income, duration of ulcer were subjectively recorded. The socio-economic status was scored based on the Modified Kuppuswamy scale 2019, ulcer severity was assessed using M.A.I.D. Scale and the HRQoL of the patients were assessed using the 36-Item Short-Form Health Survey Version 1.0. The differences in the mean HRQoL scores between patients based on their gender and socio-economic class were assessed using an unpaired sample t-test. The association of age, severity, duration of the ulcer with the HRQoL were assessed using Pearson's correlation. A probability value of < 0.05 was considered statistically significant.

RESULTS

There were 21 (50%) males and 21 (50%) females with a mean age of 55.45 ± 7.73 years. The mean duration of ulcers was 7.26 ± 3.34 months and the mean ulcer severity score was 2.16 ± 0.96. Role limitations due to the physical health were found to be most impacted due to the disease condition with the least mean score of 26.78 ± 31.90 %. There were no significant differences in the mean scores of the physical and the mental components of HRQoL based on gender but there were significant differences based on socio-economic status. The lower the socio-economic status, the poorer the HRQoL. Age, severity of ulcers and ulcer duration had a significant negative correlation with HRQoL.

CONCLUSION

The study observed a low HRQoL of patients in physical aspects reflecting on the extensive limitation on the performance of daily physical activities. Patient-specific factors such as age, socio-economic status, severity, and chronicity of ulcers were found to influence HRQoL.

The Efficacy of Platelet-Rich Fibrin in the Management of Chronic Nonhealing Ulcers of the Lower Limb

Introduction

Nonhealing ulcers have a huge burden on the patient, by having high morbidity in terms of chronic pain, partial or complete loss of function, mental health issues, and social isolation, and can have a massive financial burden on the patient. Various novel therapies have been developed to treat nonhealing ulcers. Platelet-rich fibrin (PRF) has been developed in the recent era initially in the dental world for treating oral ulcers. Now, the role of PRF is strongly established in treating nonhealing ulcers. PRF has an aggregate of a myriad of growth factors and cytokines that stimulate healing of the wounds. In this study, we have compared the efficacy of PRF in treating nonhealing ulcers of the lower limb against normal saline dressings.

Aims and objectives

This study aims to determine the efficacy of platelet-rich fibrin over normal saline dressings in the treatment of nonhealing ulcers of the lower limb by comparing the percentage reduction in the surface area of wounds after treatment in both groups.

Methods

Fifty patients with nonhealing ulcers were selected and randomly divided into two groups with 25 patients in each group. Cases were treated with PRF dressings weekly for a period of six weeks. Controls were treated with normal saline dressings weekly for a period of six weeks. The percentage reduction in the size of the ulcer after treatment was recorded in both groups and compared. Patients of age 18-60 with nonhealing ulcers of the lower limb of >12 weeks duration have been included in the study. Patients having wounds with active infection, wound size > 35 cm², uncontrolled diabetes, peripheral vascular disease with Ankle-Brachial Index < 0.9, osteomyelitis of the underlying bone, and immunocompromised state, and patients on antiplatelet drugs have been excluded from the study.

Results

The mean age of the patients included in the study was 42.88 ± 2.73 years. The mean initial surface of the wound​​​ was 14.95 ± 3.08 cm² among cases and 13.28 ± 2.83 cm² among controls. The mean surface area of the wound after six weeks was 1.59 ± 0.78 cm² among cases and 11.08 ± 2.74 cm² among controls. The mean percentage reduction in the wound size after six weeks of treatment was 89.3% among cases and is significantly higher than in the normal saline group (16.5%) (Mdn = 14.63, U = 23, p < 0.00001).

Conclusion

Platelet-rich fibrin is an emerging potential topical agent for the treatment of nonhealing ulcers of the lower limbs and is more effective than normal saline dressings and also has the advantage of being cost-effective.

Transcutaneous Partial Pressure of Oxygen Measurement in Advanced Chronic Venous Insufficiency as a Marker of Tissue Oxygenation

Purpose

Determination of oxygen concentration in tissues affected by chronic venous insufficiency (CVI) has shown inconsistent results over the years and has confounded the pathophysiology of venous diseases. This study measured transcutaneous partial oxygen pressure (TcPO₂) levels in patients with CVI to assess oxygenation and variation in oxygenation according to CVI stage.

Methods

Materials and A prospective study was performed on consecutive patients with unilateral CVI. TcPO₂ of diseased and unaffected limbs was measured in the supine and dependent positions. A single TcPO₂ value was measured at the site of greatest skin change or at the edge of the ulcer. The TcPO₂ values were analyzed and compared according to stage.

Results

A total of 96 patients were included in the study with C4 (24.0%), C5 (19.8%), and C6 (56.3%) disease. The mean age was 44.7 years, and 85 (88.5%) were male. There was a statistically significant (P<0.01) difference in mean TcPO₂ levels between the unaffected limb (supine, 32.1 mmHg; dependent, 50.7 mmHg), C5 diseased limb (supine, 16.6 mmHg; dependent, 35.5 mmHg), and C6 diseased limb (supine, 24.2 mmHg; dependent, 40.4 mmHg). In the supine and dependent positions, the mean TcPO₂ in the affected limb was significantly lower (P<0.01) than that in the unaffected limb.

Conclusion

TcPO₂ in advanced CVI can be used as a marker of oxygenation status. This is the first study in an Indian population looking at the relevance of TcPO₂ in the prognostication of advanced CVI.

Evidence-Based Clinical Practice Points for the Management of Venous Ulcers

Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualised management plan. Venous ulcers generally persist for weeks to many years and are typically recurrent in nature. This consensus aims to present an evidence-based management approach for the patients with venous ulcers. Various management options for venous ulcers include compression therapy, minimally invasive procedures like sclerotherapy and ablation techniques, surgical procedures, debridement and medical management with micronised purified flavonoid fraction (MPFF). Compression therapy is the mainstay treatment for venous ulcer. However, in failure cases, surgery can be preferred. Medical management with MPFF as an adjuvant therapy to standard treatment has been reported to be effective and safe in patients with venous ulcer. In addition to standard therapy, diet and lifestyle modification including progressive resistance exercise, patient education, leg elevation, weight reduction, maintaining a healthy cardiac status and strong psychosocial support reduces the risk of recurrence and improves the quality of life in patients with venous ulcer.