Understanding CEAP Classification: Insights from an Italian Survey on Corona Phlebectatica and Recurrent Active Venous Ulcers by Vascular Specialists

Background and Objectives: The clinical relevance of "corona phlebectatica" and the management of risk factors for recurrence of venous ulcers in patients with chronic venous disease may be variable based on vascular specialists in different geographical areas of Italy. The aim of the present survey is to evaluate the management of patients with chronic venous disease by vascular specialists in different areas of the national territory. In particular, this involves ascertaining the clinical/prognostic relevance attributed to the presence of the "corona phlebectatica" as well as to the management of risk factors related to recurrence of venous ulcers. Materials and Methods: The web-based survey aimed at vascular medicine specialists with particular interest in venous disease. A questionnaire was developed, based on 12 questions, in relation to clinical assessment, risk factor management, and therapy in patients with chronic venous disease. Results: Almost all of the specialists involved actively participated in the survey, declaring that they personally manage chronic venous disease overall. There was a strong agreement in the prognostic consideration attributed to the presence of "corona phlebectatica" and to the management of risk factors for venous ulcer recurrence, regardless of the different geographical areas of interest. Conclusions: Accordingly with the results of this self-assessment survey, the skills and experience of the specialists involved appear to be of a good standard, both in the clinical evaluation and in the management of the progression of chronic venous disease. However, the need to reach more cultural insights into the correlations between chronic venous disease and risk factors correlated with disease progression emerges. Moreover, there was the need for a greater and tighter overall clinical control of a patient with chronic venous disease, also in relation to the presence of comorbidities.

Successful Management of Chronic Wounds by an Autophagy-Activating Magnetized Water-Based Gel in Elderly Patients: A Case Series

Chronic wounds pose a significant threat to human health, particularly for the elderly, and require extensive healthcare resources globally. Autophagy, a key molecular player in wound healing, not only offers a defense against infections but also contributes to the deposition of the extracellular matrix during the proliferative phase. Additionally, it promotes the proliferation and differentiation of endothelial cells, fibroblasts, and keratinocytes. We have recently shown that applying magnetized saline water topically can trigger autophagy in intact skin. In this case series, we document the successful management of five non-infected, difficult-to-heal wounds in elderly patients using a topical autophagy-stimulating gel containing 95% magnetized saline water. The treated wounds included pressure ulcers, venous ulcers, and trauma-related injuries that had shown minimal or no improvement with standard wound therapies over a prolonged period. Application of the autophagy-stimulating gel promoted wound healing, as indicated by reduced fibrous and necrotic tissue, granulation tissue formation, re-epithelialization, and partial or complete wound closure. These preliminary case studies suggest that a topical gel containing magnetized saline water, which promotes autophagy, may aid healing of chronic wounds in elderly patients. Further investigation is warranted to explore the potential of this novel approach, as it may offer a valuable addition to the existing arsenal of wound care treatments for the aging population, particularly in addressing difficult-to-heal wounds.

Patterns of use of advanced wound matrices in the Veterans Administration clinics

Chronic wounds are a common and costly health issue affecting millions of individuals in the United States, particularly those with underlying conditions such as diabetes, venous insufficiency, and peripheral artery disease. When standard treatments fail, advanced wound care therapies, such as skin substitutes, are often applied. However, the clinical effectiveness, indications, and comparative benefits of these therapies have not been well established. In this study, we report on the usage of both acellular and cellular, single and bilayer, natural and synthetic, dermal, and epidermal skin substitutes in a VA hospital system. We performed a retrospective chart review to understand the ordering and usage patterns of advanced wound therapies for patients with chronic wounds at the VA Northern California Health Care System. We examined types of products being recommended, categories of users recommending the products, indications for orders, and rate of repeated orders. Neuropathic, venous, or pressure ulcers were the main indications for using advanced wound matrices. Only 15.6% of patients for whom the matrices were ordered had supporting laboratory tests. Exactly 34.3% of the ordered matrices were not applied. And the use of wound matrices resulted in increased costs per patient visit of $1018-$3450. Our study sheds light on the usage patterns of these therapies in a VA healthcare facility and highlights the need for more robust evidence-based studies to determine the true benefits, efficacy, and cost-effectiveness of these innovative treatment options.

Assessing the Application and Effectiveness of Human Amniotic Membrane in the Management of Venous and Diabetic Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This study aimed to assess the efficacy of human amniotic membranes (HAM) in treating venous and diabetic ulcers, which often pose challenges in healing. A systematic review and meta-analysis were conducted, evaluating 10 relevant studies involving 633 participants. Findings revealed that HAM treatment significantly accelerated ulcer closure, demonstrating over 90% complete healing compared to standard care. Despite moderate heterogeneity among studies, the results strongly suggested the effectiveness and safety of HAM therapy for venous and diabetic leg ulcers. Further research with larger study cohorts is recommended to bolster the existing evidence supporting HAM in managing these challenging wounds.

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.

Chronic Venous Insufficiency With Emphasis on the Geriatric Population

The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.

Venous, Arterial, and Neuropathic Leg Ulcers With Emphasis on the Geriatric Population

Leg ulcers are a common and often serious problem in older adults. Underlying conditions that increase risk include age-related increases in chronic venous insufficiency, peripheral artery disease, connective tissue and autoimmune conditions, reduced mobility, and diabetes mellitus (DM). Geriatric patients have a higher risk of multiple wound-related complications including infection, cellulitis, ischemia, and gangrene, any of which may lead to further complications including amputation. The very presence of these lower extremity ulcers in the elderly negatively impacts their quality of life and ability to function. Understanding and early identification of the underlying conditions and wound features are important for effective ulcer healing and complication mitigation. This targeted review focuses on the three most common types of lower extremity ulcers: venous, arterial, and neuropathic. The goal of this paper is to characterize and discuss the general and specific aspects of these lower extremity ulcers and their relevancy and impact on the geriatric population. The top five main results of this study can be summarized as follows. (1) Venous ulcers, caused by inflammatory processes secondary to venous reflux and hypertension, are the most common chronic leg ulcer in the geriatric population. (2) Arterial-ischemic ulcers are mainly due to lower extremity vascular disease, which itself tends to increase with increasing age setting the stage for an age-related increase in leg ulcers. (3) Persons with DM are at increased risk of developing foot ulcers mainly due to neuropathy and localized ischemia, both of which tend to increase with advancing age. (4) In geriatric patients with leg ulcers, it is important to rule out vasculitis or malignancy as causes. (5) Treatment is best made on a case-by-case basis, considering the patient's underlying condition, comorbidities, overall health status, and life expectancy.

Clinical validation of a smartphone application for automated wound measurement in patients with venous leg ulcers

Chronic wounds are associated with significant clinical, economic and quality-of-life burden. Despite the variety of wound imaging systems available in the market for wound assessment and surveillance, few are clinically validated among patients of Asian ethnicity. We aimed to clinically validate the accuracy of a smartphone wound application (Tissue Analytics [TA], Net Health Systems Inc, Florida, USA), versus conventional wound measurements (visual approximation and paper rulers), in patients of Asian ethnicity with venous leg ulcers (VLU). A prospective cohort study of patients presenting with VLU to a specialist wound nurse clinic over a 5-week duration was conducted. Each patient received seven wound measurements: one by a trained wound nurse clinician, and three separate wound measurements using TA on each of the iOS and Android operating systems. Inter-rater and intra-rater reliability between clinical and TA-based measurements were analysed using intra-class correlation statistics, with values of <0.5, 0.5 to 0.75, 0.75 to 0.9, and >0.9 indicating poor, moderate, good and excellent reliability, respectively. 82 patients (51% males), with a mean age at 65.8 years, completed the 5-week study duration. 25 (30%) had underlying diabetes mellitus. Chinese, Malay and Indian ethnicity comprised 68%, 12% and 11%, respectively. The VLU healed in 26 (32%) of patients within the study period. In total, 358 wound episodes with 2334 wound images were analysed. Inter-rater reliability for length, width and area between wound nurse measurements and TA application measurements was good (range 0.799-0.919, P < 0.001). Separate measurements of intra-rater reliability for length, width and area within the iOS or Android systems were excellent (range 0.967-0.985 and range 0.977-0.984 respectively, P < 0.001). Inter-rater reliability between TA used on the iOS and Android systems was also excellent (0.987-0.989, P < 0.001). Tissue Analytics, a smartphone wound application, is a useful adjunct for wound assessment and surveillance in VLU patients of Asian ethnicity.

Radiofrequency ablation of varicose veins in combination with ultrasonic-assisted wound debridement and platelet-rich plasma as well as platelet-rich fibrin technologies in treatment of lower extremity venous ulcers in office-based surgery

INTRODUCTION

for the treatment of varicose ulcer performed clinical and laboratory reasoning of the use of ultrasonic-assisted venous ulcer debridement and Platelet-rich plasma with radiofrequency ablation in an outpatient setting, was carried out.

METHODS

ultrasonic-assisted debridement of trophic ulcer were performed for 50 patients with lower extremity varicose veins at decompensation stage. The effectiveness of ultrasonic-assisted debridement was evaluated by indicators of bacteriological, morphological, cytological study and assessment of trophic ulcers according to the MEASURE system. After ultrasonic-assisted debridement, the patients were divided into two groups: 30 patients, who underwent combined Platelet-rich plasma to stimulate wound regeneration and 20 patients, for whom the Granuflex hydrocolloid bandage was applied for the same purpose.

RESULTS

a comparative analysis of ulcer regeneration in two groups of patients proved that in cases of platelet rich plasma the time of transition from inflammatory-regenerative type to regenerative one is much shorter than when using a hydrocolloid dressing. In 28 patients undergoing Platelet-rich plasma (PRP) and Platelet-rich fibrin (PRF), the radiofrequency ablation of the principal superficial and perforating veins was performed. Another 22 patients performed autodermoplasty of trophic ulcers after radiofrequency ablation.

CONCLUSION

our experience has shown that in a one-day inpatient surgical clinic such a multidisciplinary approach to treatment of venous ulcers, including ultrasonic-assisted debridement that is stimulation of wounded process by Platelet-rich plasma with further surgeries to remove the causes of decompensated chronic insufficiency, is promising regarding low costs of treatment and rehabilitation of these patients.

Chronic venous insufficiency: a comprehensive review of management

Chronic venous insufficiency is an extensive progressive disease in need of public health attention. This insidious disease is a growing burden on patient quality of life and the health economy. Chronic venous insufficiency has become more pronounced in global populations, especially in regions exhibiting a higher rate of risk factors. It is critical for healthcare providers to recognise and intervene early to prevent ongoing and debilitating complications. This article provides a comprehensive review of chronic venous insufficiency outlining the anatomy, pathophysiology, clinical presentation, assessment and management options.

Proteus mirabilis resistant to carbapenems isolated from a patient with a venous leg ulcer: a case report

OBJECTIVE

The aim of the study was to phenotypically investigate the expression of the enzyme Klebsiella pneumoniae carbapenemase (KPC) in a Proteus mirabilis sample resistant to carbapenems, isolated from the wound of a patient with a venous leg ulcer (VLU) treated at an outpatient referral service.

METHOD

This was a case study conducted with a patient who had a VLU on the lower left limb. Samples were taken for the examination of microbiological material from the patient's wound, using an aseptic technique. The colonies extracted were submitted to Gram staining and biochemical tests to identify the strain. In addition, an antimicrobial susceptibility test, E-test and a modified Hodge test were performed.

RESULTS

The identified microorganism was Proteus mirabilis, which showed resistance to cefuroxime and the carbapenems imipenem and meropenem. As well as the minimum inhibitory concentration (MIC) of 3.0μg/ml for imipenem, demonstrating resistance, there was no KPC production by the tested isolate, which presented a negative modified Hodge test.

CONCLUSION

The results highlight the importance of microbiological surveillance, aimed at reducing morbidity and mortality rates associated with infection by multiresistant bacteria.

Growth factors for treating chronic venous leg ulcers: A systematic review and meta-analysis

Chronic venous leg ulcers (VLU) are wounds that commonly occur due to venous insufficiency. Many growth factors have been introduced over the past two decades to treat VLU. This systematic review and meta-analysis evaluates the impact of growth factor treatments of VLU in comparison to control for complete wound healing, percent reduction in wound area, time to wound healing, and adverse events. A systematic review and meta-analysis of randomised trials was conducted. MEDLINE and EMBASE were searched up to December 2020. Studies were included if they compared a growth factor versus placebo or standard care in patients with VLU. From 1645 articles, 13 trials were included (n = 991). There was a significant difference between any growth factor and placebo in complete wound healing (P = 0.04). Any growth factor compared to placebo significantly increased the likelihood of percent wound reduction by 48.80% (P = <0.00001). There was no difference in overall adverse event rate. Most comparisons have low certainty of evidence according to Grading of Recommendations, Assessment, Development, and Evaluation. This meta-analysis suggests that growth factors have a beneficial effect in complete wound healing of VLU. Growth factors may also increase percent reduction in wound area. The suggestion of benefit for growth factors identified in this review is not a strong one based on the low quality of evidence.

Correlation of Venous Clinical Severity Score With Dermatology Life Quality Index Among Patients With Chronic Venous Insufficiency: A Cross-Sectional Study

Introduction Chronic venous insufficiency (CVI) is characterized by inadequate functioning of venous valves in the lower limb. CVI is associated with a significant reduction in patient's quality of life (QOL). The severity of CVI was determined by CEAP (clinical, etiological, anatomical, pathophysiological) classification and venous clinical severity score (VCSS). The study is aimed to evaluate and correlate Dermatology Life Quality Index (DLQI) with VCSS, CEAP in patients with CVI. Methods A cross-sectional study of 57 patients with CVI was conducted over a period of 12 months. A sociographic survey, clinical and severity grading using CEAP classification, and VCSS were done for all venous doppler confirmed patients. QOL was evaluated by validated DLQI questionnaires using English and native languages Hindi and Marathi. Results A total of 57 patients with a male to female ratio of 6.1:1 and a mean age of 51.68 years were included in the study. CEAP grading in patients showed 49.12% (C4a), 21.05% (C6), 15.7% (C4b), 7.01% (C3), 3.50% (C2 and C5). Mean VCSS and DLQI were 11.47 and 10.12, respectively; 49.12%, 40.35%, 10.53% of patients had a moderate, very large, and small impact on DLQI respectively, positively correlating to VCSS (P < 0.001). Conclusion From this study, it was observed that VCSS and CEAP positively correlated with DLQI, and the impact increases in proportion with the seriousness of the disease.

Innovative biodegradable dibutyrylchitin dressing for the treatment of ulcers occurring during chronic venous insufficiency in patients with type 2 diabetes

The aim of this study was to assess the course of the healing process following the use of dibutyrylchitin (DBC) dressing, a fully degradable material used in the treatment of ulcers which occur during chronic venous insufficiency common in patients suffering from type 2 diabetes. These diseases have a significant impact on the patients' standard of living, including the potential employment, and on the declining attendance at the current workplace. The implementation of this innovative therapeutic solution may positively affect the above-mentioned difficulties. An analysis of the healing process, following the application of the DBC dressing, was performed. Once the dressing was positioned on the wound, the analysis indicated that it underwent a process of degradation facilitated by the enzymes occurring naturally in the wound. When fully degraded, a further layer was applied. This process was repeated until the wound was fully healed. The study group consisted of 4 patients previously diagnosed with type 2 diabetes. During the observation period, the ulcers in all 4 cases had healed. The examined wound dressings adhered well to the wound surface and degraded within it. No side effects or adverse effects of the applied innovative therapy were observed. An addition of the biodegradable DBC dressing to the standard therapy procedure of ulcers occurring during chronic venous insufficiency among patients with type 2 diabetes indicate safe and effective treatment, which may have a direct reflection in the patient's professional capacity enhancement. It resulted in the complete healing of all ulcers in each of the observed cases. Int J Occup Med Environ Health. 2021;34(4):565-73.

Neuromuscular stimulation of the common peroneal nerve increases arterial and venous velocity in patients with venous leg ulcers

Activation of the venous muscle pumps by neuromuscular stimulation of the common peroneal nerve has been previously shown to increase venous and arterial flow in the legs of healthy subjects. The aim of this study is to determine whether a similar effect is observed in patients with chronic venous leg ulcers. 1 Hz intermittent electrostimulation of the common peroneal nerve was applied to 14 patients with ulcers between 1 and 10 cm in diameter, eliciting a small, painless, regular, muscular twitch of the leg. Flow was measured using Duplex ultrasound in the popliteal vein and the popliteal artery. Peak arterial velocity increased from 57 to 78 cm/s (P = .001) in sitting position, and from 79 to 98 cm/s in recumbent position (P = .001). Peak venous velocity increased from 10 to 33 cm/s (P = .001) sitting, and from 14 to 47 cm/s (P = .001) recumbent. Significant increases were observed in both venous and arterial blood flow in the lower limb. This suggestsed that activation of the venous muscle pump and improvement of arterial flow assisted oxygen delivery at the wound site. Moreover this may be a worthwhile intervention to assist in the healing of venous leg ulcers, and may provide a mechanistic explanation for the increased healing rates previously reported with neuromuscular stimulation of the common peroneal nerve.

Prevalence and awareness of varicose veins among teachers in Abha, Saudi Arabia

Background:

Teachers, compelled by the nature of their profession, are required to stand for a significant amount of time. This prolonged standing, being one of the risk factors for venous insufficiency, puts them at risk to develop varicose veins. Hence, as there is a need to educate and sensitize the teachers. This study was carried out to investigate the prevalence and awareness regarding varicose veins in school teachers.

Methods:

A cross sectional, questionnaire based study was carried out on 391 school teachers of the Aseer region, KSA, after obtaining ethical committee clearance and informed consent. Questions included personal, occupational, and varicose vein based questions. Responses were collected and analyzed using SPSS version 25.0 software. Frequencies and percentages were calculated.

Results:

Forty two percent of the teachers were found to have varicose veins most of which were females. Around 62% of the teachers suffering from varicose veins were between 36 and 45 years of age. Participants who did regular exercises were less prone to varicose than irregularly exercising participants (P = 0.0001). No association was observed between smoking and varicose veins (odds ratio 0.15, 95% confidence interval 0.05–0.44).

Conclusion:

Due to high prevalence of varicose veins among teachers, it is necessary to spread awareness regarding varicose veins among them and sensitize them with the methods to prevent its formation.

Kikuhime Device in the Management of Venous Leg Ulcers

The effectiveness of compression therapy in the treatment of venous leg ulcers has been confirmed in many scientific studies. The healing process depends on many of its parameters, such as the type of compression bandages, their elastic properties and sub-bandage pressure. However, there is no standard protocol that would ensure success for all patients. A pressure of about 83 mmHg provides complete compression for both superficial and deep veins; however, applying compression bandages under such high pressure is a difficult task, even for experienced therapists. Here, we present the case of a 61-year-old woman with approximately 2.5-year-old venous ulcer in her left leg due to chronic venous insufficiency (CVI). Our study aimed to show that routine pressure control at each bandage renewal using the Kikuhime device, as well as their twice daily application in the first week of therapy reduced the healing time of a venous leg ulcer with an area of about 20 cm² to four weeks.

The Effectiveness of Advanced Practice Nurses with Respect to Complex Chronic Wounds in the Management of Venous Ulcers

This study aims to evaluate the effectiveness of advanced practice nurses with respect to complex chronic wounds (APN-CCWs) in the care of patients with venous ulcers. A multicentric, quasi-experimental pre-post study was conducted without a control group in the sanitary management areas where the APN-CCW program is being piloted. The intervention consisted of a mass training of clinical nurses from the participating districts on the proper management of injuries and the use of compression therapy. The data were collected through a specifically constructed questionnaire with questions regarding descriptive variables of injuries and their treatment. A total of 643 professionals responded (response rate of 89.1%), attending to a total population of 707,814 inhabitants. An increase in multilayer bandage use by 15.67%, an increase in elastic bandage use by 13.24%, and a significant decrease in the referral of patients to consultation with hospital specialists was achieved, from 21.08% to 12.34%. The number of patients referred to the APNs was 13.25%, which implied a resolution rate of 94.08% of their injuries. In conclusion, the coordination by the APN-CCWs in patients with venous ulcers was effective in improving the continuity of care, in the optimization of resources, and in their care role.

Measurement of transcutaneous oxygen pressure in patients with post-thrombotic syndrome: Findings and possible clinical applications

Objectives

Post-thrombotic syndrome is the commonest long-term sequela of deep venous thrombosis. Severe post-thrombotic syndrome reduces importantly the quality of life of patients and tissue hypoxia is associated with ulceration. Transcutaneous oxygen pressure (tcPO2) provides information on the delivery of oxygen through the microvascular circulation and measuring tcPO2 might detect values at which patients with post-thrombotic syndrome might ulcerate. The aim of our study is to determine tcPO2 in post-thrombotic syndrome patients and compare the values with a control group.

Methods

A cross-sectional study was performed. Periflux 5000 monitor (Perimed) was used to measure tcPO2 in patients with mild-moderate, severe post-thrombotic syndrome and control groups. In patients with ulceration, two measurements were obtained, the first around the ulcer and the second 10 cm away from the lesion. Categorical data were analyzed with Fisher’s exact test and a p value <0.05 was considered statistically significant.

Results

Twelve patients with post-thrombotic syndrome and 13 patients (control group) were enrolled. Post-thrombotic syndrome patients’ mean age was 58 years (47–72 years) and eight (67%) patients were males. The overall mean tcPO2 measurement in post-thrombotic syndrome group was 35.5 mm Hg (SD ± 11), while in the severe post-thrombotic syndrome was 23.2 mm Hg (SD ± 9). All severe post-thrombotic syndrome patients had measurements <40 mm Hg, tcPO2 value in control group was >50 mm Hg (SD ± 4) in all patients, with a mean value of 58.2 mm Hg. During comparison of severe post-thrombotic syndrome subgroup versus control group, we found that patients with venous ulcers had <40 mm Hg in tcPO2 measurement and all control group patients had >50 mm Hg ( p < 0.0001).

Conclusions

Our results demonstrate that severe post-thrombotic syndrome patients have significantly lower TcPO2 values compared to a healthy control group and non-severe post-thrombotic syndrome ( p = 0.0001). Further research is necessary to establish cut-off point values of tcPO2 in this debilitating disease for possible clinical applications and determination of ulcer healing predictors.

An overview of the relationship between anaemia, iron, and venous leg ulcers

The factors preventing healing in venous leg ulcers are still not fully understood. Iron-mediated tissue damage has been hypothesised, yet anecdotally anaemia is also thought to have a negative effect on wound healing. This article summarises the current evidence for these theories and their likely effects in the context of venous ulceration. A comprehensive search of the literature was conducted. Studies suggest that a number of forms of iron including haemosiderin and ferritin are implicated in progression of venous disease, ulcer formation, and impaired healing, which is thought to be primarily free radical mediated. There is a paucity of evidence for the role of iron deficiency and anaemia on ulcer healing; however, there is likely to be a highly complex interplay between the damaging effects of iron on local tissues and the negative effects of anaemia-mediated tissue hypoxia. Studies looking at options to increase local oxygen delivery such as topical haemoglobin suggest that this may have an impact on some aspects of healing, but findings are generally inconclusive. There is growing evidence that locally elevated iron levels may have a detrimental effect on ulcer healing and formation; however, more robust research is needed.

Influences of sodium and glycosaminoglycans on skin oedema and the potential for ulceration: a finite-element approach

Venous ulcers are chronic transcutaneous wounds common in the lower legs. They are resistant to healing and have a 78% chance of recurrence within 2 years. It is commonly accepted that venous ulcers are caused by the insufficiency of the calf muscle pump, leading to blood pooling in the lower legs, resulting in inflammation, skin oedema, tissue necrosis and eventually skin ulceration. However, the detailed physiological events by which inflammation contributes to wound formation are poorly understood. We therefore sought to develop a model that simulated the inflammation, using it to determine the internal stresses and pressure on the skin that contribute to venous ulcer formation. A three-layer finite-element skin model (epidermis, dermis and hypodermis) was developed to explore the roles in wound formation of two inflammation identifiers: glycosaminoglycans (GAG) and sodium. A series of parametric studies showed that increased GAG and sodium content led to oedema and increased tissue stresses of 1.5 MPa, which was within the reported range of skin tissue ultimate tensile stress (0.1-40 MPa). These results suggested that both the oedema and increased fluid pressure could reach a threshold for tissue damage and eventual ulcer formation. The models presented here provide insights to the pathological events associated with venous insufficiency, including inflammation, oedema and skin ulceration.

The role of compression therapy in the treatment of venous leg ulcers

Epidemiological data regarding venous leg ulcers, specifically low healing rates and frequent recurrences (occurring in 20-70% of the cases), seems surprising regarding recent progress in the management of this complication. The aim of this review is to present the current state of knowledge on venous leg ulcer management, especially compression therapy. Treatment of venous ulcers should be comprehensive and wellorganized, based on modern standards and up-to-date, and should involve elaborated treatment strategies. A thorough diagnostic process followed by adequate treatment may result in marked improvement of the outcomes, with up to 67% healing rate at 12 weeks and up to 81% within 24 weeks. Continuation of therapeutic activities after the ulceration has been healed is reflected by a marked decrease in the recurrence rates, down to 16% whenever the patient is actively involved in the therapeutic process. Furthermore, early diagnosis and appropriate causal treatment may prevent progression of the illness.

Vein Size and Disease Severity in Chronic Venous Diseases

Given the high prevalence of chronic venous diseases (CVD), defining criteria to screen patients who are in need for intervention is attaining primacy. An important clinical criterion for treating CVD is incompetence of larger veins. We have assessed the association of size of afflicted veins with disease severity in patients with CVD to define an acceptable criterion to identify patients who need intervention. Demographic characteristics and risk factors were recorded from 6350 patients. Based on physical examination and venous duplex ultrasound study, patients were classified into clinical severity, etiology, anatomy, and pathophysiology (CEAP) classes and grouped according to the size of the veins which had varicosities. Patients with reflux in smaller veins (vein size <4 mm diameter) were considered as type I and those with varicosities in truncal veins (>4 mm diameter) as type II. Risk ratio was determined by multivariate regression analysis. About 47.67% of patients in this study were found to have CEAP class 3 disease. Compared with varicose veins of large truncal veins, patients with varicosities in smaller superficial veins had 2.85-fold ( p  < 0.01) more risk of edema and 5.71-fold ( p  < 0.01) higher prevalence of hyperpigmentation. Varicosities in small superficial veins were associated with higher risk of ulceration (odds ratio 3.93, 95% confidence interval 2.51-6.18) compared with truncal vein reflux. Our study reveals that presence of small varicose veins in patients without truncal saphenous reflux involvement is associated with severe manifestations of venous insufficiency such as edema and skin lesions even in the absence of varicosities in truncal saphenous veins.

Use of a National Electronic Health Record Network to Describe Characteristics and Healing Patterns of Sickle Cell Ulcers

Objective: Sickle cell ulcers affect as many as 15% of patients with sickle cell disease in the United States and severely impact quality of life. An understanding of baseline healing patterns is important to inform study design for future trials that test therapies for this disease. Approach: In this study, an electronic wound management system was leveraged to analyze retrospective data on 133 unique sickle cell patients who were treated across 114 wound healing centers, and to describe their characteristics and healing patterns as compared with those of venous ulcer patients. The data included 198 care episodes for 427 wounds. Results: Patients with sickle cell ulcers were younger and had fewer comorbid diseases than those with venous ulcers. Larger size and longer duration were predictors of poor healing. Between the first and fourth assessments, mean change in area for sickle cell ulcers showed a 58% increase, compared with a 13% decrease for venous ulcers. Kaplan-Meier curves showed poorer healing in sickle cell ulcers than in venous ulcers across all categories of size and duration. Patients with sickle cell ulcers had longer care episodes and were more likely to re-present for care. Innovation: This study reports on the largest data set of sickle cell ulcer patients analyzed to date in the published literature to provide a more detailed understanding of wound healing patterns of this disease. Conclusion: A national network of electronic health records can effectively identify a large number of patients with sickle cell ulcers to support analysis of epidemiology, healing patterns, and health care utilization.

Exercise fidelity and progression in a supervised exercise programme for adults with venous leg ulcers

Despite exercise being included in the recommended advice for patients with venous leg ulcers, there is a fear shared by clinicians and patients that exercise may be either inappropriate or harmful and actually delay rather than promote healing. Therefore, before implementing a larger-scale study exploring the effects of a supervised exercise programme in patients with venous ulcers being treated with compression therapy, it is important to assess exercise safety as well as fidelity and progression in a feasibility study. Eighteen participants randomised in the exercise group were asked to undertake 36 (3 times/week for 12 weeks) 60-min exercise sessions, each comprising moderate-intensity aerobic, resistance, and flexibility exercise components. For the purposes of this paper, we analysed the data collected during the exercise sessions. The overall session attendance rate was 79%, with 13 of 18 participants completing all sessions. No in-session adverse events were reported; 100% aerobic components and 91% of resistance components were completed within the desired moderate-intensity target. Similarly, 81% of aerobic components and 93% of flexibility components were completed within the prescribed duration targets. Our data showed that patients with venous ulcers could safely follow a supervised exercise programme incorporating moderate-intensity aerobic, resistance, and flexibility components.

Recommendations for the medical management of chronic venous disease: The role of Micronized Purified Flavanoid Fraction (MPFF)

Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index < .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.

Comparison of Efficacy of Autologous Platelet-rich Fibrin versus Saline Dressing in Chronic Venous Leg Ulcers: A Randomised Controlled Trial

BACKGROUND

Venous leg ulcer is a chronic condition, and various treatment modalities are available. Platelet-rich fibrin (PRF) is one of the newer modalities and it contains fibroblast growth factor (GF), vascular endothelial GF, angiopoitin and platelet-derived GF which enhances the wound healing. Hence, we conducted a randomised controlled trial to compare the efficacy of PRF versus saline dressing in chronic venous leg ulcers.

AIM

This study aims to compare the efficacy of autologous PRF with saline dressing in patients with chronic venous leg ulcer and to compare the mean reduction in ulcer area at the end of 4 weeks.

MATERIALS AND METHODS

Fifteen patients with chronic venous leg ulcers of >6 months duration having an ulcer area of 1 cm × 1 cm to 5 cm × 5 cm were taken into the study and were randomly divided into two groups. Group 1: Patients received PRF dressing. Ten millilitres of patient's blood was taken and centrifuged at 3000 rpm for 15 min. A fibrin clot obtained in the middle of the tube was removed and used for dressing over the wound surface. It was repeated every week for 4 weeks. Group 2: Patients received saline dressings once a week for 4 weeks. The assessment of the ulcer size was done with the help of photographs, and ulcer area was measured.

RESULTS

The mean reduction in the area of the ulcer size in PRF group was 85.51%, and the mean reduction in the area of the ulcer size in Saline group was 42.74% which was statistically significant with a P < 0.001 and t = 4.11.

CONCLUSION

We conclude that PRF dressing can be used as it is effective, inexpensive, safe and an outpatient procedure.

Clinical and Economic Benefits of Autologous Epidermal Grafting

Chronic wounds are an increasingly prevalent disease with a significant healthcare burden. These wounds often do not respond to standard of care therapy alone, requiring the use of adjuvant therapies. Epidermal grafting, previously utilized primarily for correction of leukoderma, is increasingly being recognized as a beneficial therapy for wounds, both acute and chronic. Epidermal grafting has been shown to be effective in the management of chronic wounds, with successful healing in refractory patients. It has not only been shown to be effective, but it is also associated with lower cost and morbidity than traditional skin grafting techniques as well as improved donor site healing. Through the use of a novel epidermal harvesting system, the CelluTome™ Epidermal Harvesting System (KCI, an Acelity company, San Antonio, TX), this treatment modality has become more standardized, reproducible, and easy to use as well as less time consuming, making its use in the clinical setting more convenient and beneficial. Epidermal grafting, therefore, represents a promising, efficacious, and cost-effective option for treatment of refractory non-healing wounds.

Subjective and objective assessment of patients' compression therapy skills as a predicator of ulcer recurrence

AIMS AND OBJECTIVES

To verify whether the subjectively and objectively assessed patient's skills in applying compression therapy constitute a predicting factor of venous ulcer recurrence.

BACKGROUND

Systematic implementation of compression therapy by the patient is a core of prophylaxis for recurrent ulcers. Therefore, patient education constitutes a significant element of care. However, controversies remain if all individuals benefit equally from education.

DESIGN

A retrospective analysis.

METHODS

The study included medical records of patients with venous ulcers (n = 351) treated between 2001 and 2011 at the Clinic for Chronic Wounds at Bydgoszcz Clinical Hospital. We compared two groups of patients, (1) with at least one episode of recurrent ulcer during the five-year observation period, and (2) without recurrences throughout the analysed period in terms of their theoretical skills and knowledge on compression therapy recorded at baseline and after one month.

RESULTS

Very good self-assessment of a patient's compression therapy skills and weak assessment of these skills by a nurse proved significant risk factors for recurrence of the ulcers on univariate analysis. The significance of these variables as independent risk factors for recurrent ulcers has been also confirmed on multivariate analysis, which also took into account other clinical parameters.

CONCLUSIONS

Building up proper compression therapy skills among the patients should be the key element of a properly construed nurse-based prophylactic program, as it is the most significant modifiable risk factor for recurrent ulcers. Although the development of compression skills is undeniably important, also other factors should be considered, e.g. surgical correction of superficial reflux.

RELEVANCE TO CLINICAL PRACTICE

Instruction on compression therapy should be conducted by properly trained nursing personnel - the nurses should have received both content and psychological training. The compression therapy training should contain practical instruction with guided exercises and in-depth objective assessment of the effects of the training.

Endovenous laser ablation of the great and short saphenous veins with a 1320-nm neodymium:yttrium-aluminum-garnet laser: retrospective case series of 1171 procedures

BACKGROUND

Venous insufficiency is a common medical condition affecting up to 50.5% of women and 30.1% of men. Endovenous laser ablation is a minimally invasive procedure that safely and effectively treats reflux involving the great and short saphenous veins.

OBJECTIVE

We sought to present safety and efficacy data of 1171 endovenous laser ablations using the Scripps Clinic endovenous laser therapy (EVLT) protocol.

METHODS

We conducted an institutional review board-approved, retrospective chart analysis of 1171 endovenous laser ablations performed from March 2007 until February 2011 treated at Scripps Clinic with the 1320-nm neodymium:yttrium-aluminum-garnet laser with 1-month, 6-month, 1-year, and 2-year follow-up data.

RESULTS

Our current overall experience is greater than 2000 EVLT procedures. The mean follow-up for this case series of 1171 EVLT procedures (1066 great saphenous veins and 105 short saphenous veins) is 11.4 months with an overall closure success rate of 99.9% for patients not lost to follow-up. There has been no incidence of deep vein thrombosis, permanent nerve damage, or pulmonary embolism related to laser ablation.

LIMITATIONS

Retrospective chart analysis, investigator bias, patients lost to follow-up, and lack of quality-of-life assessment are limitations.

CONCLUSION

EVLT using a 1320-nm neodymium:yttrium-aluminum-garnet laser appears to be a viable option for venous insufficiency and venous ulceration unresponsive to conservative treatment.

Autologous platelet rich plasma in chronic venous ulcers: study of 17 cases

Background:

Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs. They are the major cause of chronic wounds, occurring in 70% to 90% of chronic wound cases. The treatment of venous ulcers also entails substantial costs. Autologous platelet rich plasma (PRP) is a simple office based procedure which helps in enhancing the wound healing by releasing many growth factors like platelet derived growth factors, fibroblast derived growth factors and epidermal growth factors.

Aim:

To study the efficacy of autologous platelet rich plasma in the management of chronic venous ulcer.

Methodology:

12 patients with 17 venous ulcers were treated with PRP and treatment outcome was measured by percentage of improvement in area and volume of the ulcer.

Results:

12 patients with 17 ulcers were treated with PRP. The mean age of the patients was 33.5 years (SD 9.82). 10 were males and 2 were females. The mean duration of the healing of the ulcers was in 5.1 weeks (SD 3.1). The mean percentage improvement in the area and volume of the ulcer was 94.7% (SD 11.12) and 95.6% (SD 10.19) respectively.

Conclusions:

PRP is safe, simple and effective procedure in treating chronic venous ulcers

Pycnogenol® in chronic venous insufficiency and related venous disorders

The present review provides an update of the biological profile of Pycnogenol in the light of its use in the treatment of chronic venous insufficiency (CVI) and related venous disorders such as deep vein thrombosis (DVT), post-thrombotic syndrome, long haul air-travel-related leg oedema, venous ulcers and acute haemorrhoids. Pycnogenol is a French maritime pine bark extract produced from the outer bark of Pinus pinaster Ait. subsp. atlantica. Its strong antioxidant, anti-inflammatory and vasodilator activities, antithrombotic effects and collagen stabilizing properties make it uniquely able to target the multi facet pathophysiology of CVI and related venous disorders. Clinical studies have shown that it can reduce oedema of the legs in CVI, reduce the incidence of deep venous thrombosis during long haul flights and enhance the healing of venous ulcers and haemorrhoidal episodes by topical application and/or oral administration. This review highlights clinical research findings on the safety, compliance and efficacy of Pycnogenol, including its use in combination products.

Sequelae of untreated venous insufficiency

Untreated venous insufficiency results not only in a gradual loss of cosmesis but also in variety of complications including persistent pain and discomfort, hemorrhage, superficial thrombophlebitis, and progressive skin changes that may ultimately lead to ulceration. In rare instances, chronic soft tissue changes may lead to stiffness of the ankle joint, fixed plantar flexion, and periostitis. This article reviews the variety of complications caused by venous insufficiency.

Is chronic venous ulcer curable? A sample survey of a plastic surgeon

INTRODUCTION

Venous ulcers of lower limbs are often chronic and non-healing, many a time neglected by patients and their treating physicians as these ulcers mostly do not lead to amputation as in gangrenous arterial ulcer and also cost much to complete the course of treatment and prevention of recurrence.

MATERIALS AND METHODS

One hundred and twenty two lower limb venous ulcers came up for treatment between May 2006 and April 2009. Only twenty nine cases completed the treatment. The main tool of investigation was the non invasive Duplex scan venography. Biopsy of the ulcer was done for staging the disease. Patients' choice of treatment was always conservative and as out-patient instead of hospitalisation and surgery, which required a lot of motivation by the treating unit.

RESULTS

Out of twenty nine cases, ten cases were treated conservatively and seven (24.13%) healed well. Remaining nineteen cases were given surgical modality in which fifteen cases (51.74%) were successful. Only seven cases (24.13%) failed to heal. Compression stockings were advised to control oedema, varices and pain. Foot care, regular exercises and follow-up were stressed effectively.

Two percent topical phenytoin sodium solution in treating pyoderma gangrenosum: a cohort study

Oral phenytoin is an extensively used medicine for the treatment of convulsive disorders. Topical phenytoin has also been used for various types of ulcers. To determine the effectiveness of 2% topical phenytoin sodium solution in treating recalcitrant pyoderma gangrenosum. Six patients with treatment-resistant pyoderma gangrenosum who attended to Dermatology Unit/Ward were taken to the study and applied topical 2% phenytoin sodium solution to the wounds alone with other systemic therapy. Response to the treatment was assessed weekly. Three patients had idiopathic PG and other three had secondary diseases. At the end of the 4th week four patients showed complete resolution of the ulcers whereas other two patients showed the partial resolution. No adverse effects were noted. Phenytoin sodium 2% solution is beneficial for pyoderma gangrenosum (PG) with various etiologies. It enhanced the healing of the ulcer especially when the patient has treatment resistant disease.

Advances in the management of leg ulcers--the potential role of growth factors

Venous ulcers are a major health problem because of the increased costs of the treatment and the refractory nature of the ulcers. The treatment cost is estimated to be around 1 billion dollars per year in the United States (US), and the average cost for one patient over a lifetime exceeds dollars 400,000. There has been an increasing trend in the use of growth factors in their management. Genetic engineering has revolutionised the research of wound healing, as the majority of recombinant growth factors are now available for in vitro and in vivo studies. Online searches of Medline, Pub Medical and Embase were carried out using the terms venous ulcers, leg ulcers, growth factors and growth hormone. The literature regarding the potential role of growth factors in the management of leg ulcers is reviewed. The important clinical studies are critically analysed with a view to appreciate the emerging therapies and the further research possibilities in the management of venous leg ulcers. Clinical results with the use of growth factors in non-healing wounds are encouraging. However, small sample sizes and inconsistent end points in different clinical studies have been the main hurdle in reaching a definite conclusion. Further research is needed to provide the definite evidence. Future developments may include different delivery methods for the growth factors, use of different combinations of growth factors administered simultaneously or, sequentially, bioengineered skin grafts and chemical induction of angiogenesis with the use of gene transfer techniques.

Shaping the trajectory of patients with venous ulceration in primary care

OBJECTIVE

To explore the patient's experience of venous ulceration and how it is shaped within primary care.

DESIGN

Qualitative grounded theory study.

PARTICIPANTS AND SETTING

Thirty-nine patients, 33 nurses and 14 general practitioners in a major health district in England.

RESULTS

The findings indicate that patients with the chronic condition of venous hypertension are handled in an anomalous way within primary care when they present with ulcers on their lower limbs. The trajectory projections for the patients are not developed from the usual basis of a medically defined condition-specific diagnosis but from a symptom-specific diagnosis. This leads to an unusual context of care where there is a serious but unrecognized conflict of focus between the nurses and their patients. The nurses in this study tended to set priorities related to the ulcer and to the underlying pathology, whereas the patients wanted help in pain management and in normalizing their lives. The patients eventually came to a position of 'guarded alliance'2 that in this study took one of three forms: adapting and enduring, emphasizing the positive, or negotiating for comfort.

CONCLUSION

The acute care approach applied to patients with this chronic condition led to a situation where the professionals usurped the self-care potential of the patients and navigated rather than piloted them through an acute phase of an underlying chronic illness. This in turn, led to poor quality of life for many of the patients and to frustration for the nurses who were failing to achieve the outcomes they desired. Both perspectives need to be encapsulated into the treatment approach for patients with this condition: healing the ulcer and normalizing the patients' lives can and should form the basis of care.