Exploring the Association between Hemochromatosis and Lower-Limb Venous Disease.

OBJECTIVE: Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. METHODS: Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. RESULTS: This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. CONCLUSIONS: This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

Clinical correlates of pain in adults with hard-to-heal leg ulcers: a cross-sectional study.

OBJECTIVE: Pain is a complex symptom associated with hard-to-heal (chronic) leg ulcers that is often poorly managed. The objective of this study was to gain greater understanding by investigating relationships between physical and psychosocial factors, and pain severity in adults with hard-to-heal leg ulcers. METHOD: A secondary analysis of data collected for a longitudinal, observational study of adults with hard-to-heal leg ulcers was undertaken. Data were collected over a 24-week period, including variables relating to sociodemographics, clinical variables, medical status, health, ulcer and vascular histories, and psychosocial measures. Multiple linear regression modelling was used to determine the independent influences of these variables on pain severity, as measured with a Numerical Rating Scale (NRS). RESULTS: Of 142 participants who were recruited, 109 met the inclusion criteria for this study, of whom: 43.1% had venous ulcers; 41.3% had mixed ulcers; 7.3% had arterial ulcers; and 8.3% had ulcers from some other cause. The final model explained 37% (adjusted r2=0.370) of the variation in the pain NRS scores. Controlling for analgesic use, salbutamol use (p=0.005), clinical signs of infection (p=0.027) and ulcer severity (p=0.001) were significantly associated with increased pain, while the presence of diabetes (p=0.007) was significantly associated with a decrease in pain. CONCLUSION: Pain is a highly complex and pervasive symptom associated with hard-to-heal leg ulcers. Novel variables were identified as being associated with pain in this population. The model also included wound type as a variable; however, despite being significantly correlated to pain at the bivariate level of analysis, in the final model, the variable did not reach significance. Of the variables included in the model, salbutamol use was the second most significant. This is a unique finding that, to the authors' knowledge, has not been previously reported or studied. Further research is required to better understand these findings and pain in general.

Promoting Person-Centered Care for Health Baccalaureate Students: Piloting an Interprofessional Education Approach to Wound Management.

OBJECTIVE: To describe and analyze the implementation of a wound management interprofessional education experience for nursing, podiatry, pharmacy, and exercise and nutrition science health baccalaureate students. The disciplines outside of nursing were invited to join the classes of a wound care elective unit in nursing. METHODS: This study included the development and implementation of a wound care program and observation of all students enrolled in the health disciplines where wound management education was relevant. RESULTS: Results indicated an increase in students' recognition of their roles and the roles of others within an interprofessional healthcare team. Facilitators reported that students learned to share information and work collaboratively to plan care for people with wounds. CONCLUSIONS: The outcomes confirm that the structured wound management program of interprofessional education within a Faculty of Health course promoted student recognition of wound management and the essential shared approach to person-centered care.

Exploring the prevalence and management of wounds for people with dementia in long-term care.

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Differences between national and international guidelines for the management of diabetic foot disease.

AIM: No studies have investigated if national guidelines to manage diabetic foot disease differ from international guidelines. This study aimed to compare guidelines of Western Pacific nations with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. METHODS: The 77 recommendations in five chapters of the 2015 IWGDF guidance documents were used as the international gold standard reference. The IWGDF national representative(s) from 12 Western Pacific nations were invited to submit their nation's diabetic foot guideline(s). Four investigators rated information in the national guidelines as "similar," "partially similar," "not similar," or "different" when compared with IWGDF recommendations. National representative(s) reviewed findings. Disagreements in ratings were discussed until consensus agreement achieved. RESULTS: Eight of 12 nations (67%) responded: Australia, China, New Zealand, Taiwan, and Thailand provided national guidelines; Singapore provided the Association of Southeast Asian Nations guidelines; and Hong Kong and the Philippines advised no formal national diabetic foot guidelines existed. The six national guidelines included were 39% similar/partially similar, 58% not similar, and 2% different compared with the IWGDF recommendations. Within individual IWGDF chapters, the six national guidelines were similar/partially similar with 53% of recommendations for the IWGDF prevention chapter, 42% for wound healing, 40% for infection, 40% for peripheral artery disease, and 20% for offloading. CONCLUSIONS: National diabetic foot disease guidelines from a large and diverse region of the world showed limited similarity to recommendations made by international guidelines. Differences between recommendations may contribute to differences in national diabetic foot disease outcomes and burdens.

Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool.

The aim of this study was to validate a newly developed tool for predicting the risk of recurrence within 12 months of a venous leg ulcer healing. Performance of the tool to predict recurrence within a 12-month period was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Multi-site retrospective and prospective longitudinal studies were undertaken to validate a risk assessment tool for the recurrence of venous leg ulcers within 12 months. In the retrospective study (n = 250), 55% of venous leg ulcers recurred within 12 months, and the risk assessment total score had excellent discrimination and goodness of fit with an AUC of 0.83 (95% CI, 0.76-0.90, P < .001). The prospective study (n = 143) observed that 50.4% (n = 63) of venous leg ulcers recurred within 12 months of healing. Participants were classified using the risk assessment tool as being at low risk (28%), moderate risk (59%), and high risk (13%); the proportion of wounds recurring at 12 months was 15%, 61%, and 67% for each group, respectively. Validation results indicated good discrimination and goodness of fit, with an AUC of 0.73 (95% CI, 0.64-0.82, P < .001). Validation of this risk assessment tool for the recurrence of venous leg ulcers provides clinicians with a resource to identify high-risk patients and to guide decisions on adjunctive, tailored interventions to address the specific risk factors to decrease the risk of recurrence.

Predicting delayed healing: The diagnostic accuracy of a venous leg ulcer risk assessment tool.

The aim of this study was to validate a newly developed tool that can predict the risk of failure to heal of a venous leg ulcer in 24 weeks. The risk assessment tool was validated, and performance of the tool was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Retrospective and prospective validation was conducted through multi-site, longitudinal studies. In the retrospective study (n = 318), 30% of ulcers did not heal within 24 weeks, with the tool demonstrating an AUC of 0.80 (95% CI, 0.68-0.93, P < .001) for the total score. In the prospective study across 10 clinical sites (n = 225), 31% (n = 68) of ulcers did not heal within 24 weeks. Participants were classified with the RAT at enrolment as being at low risk (27%), moderate risk (53%) or high risk (20%) of delayed healing; the proportion of wounds unhealed at 24 weeks was 6%, 29% and 59%, respectively. Validation results of the total score indicated good discrimination and goodness of fit with an AUC of 0.78 (95% CI, 0.71-0.85, P < .001). Validation of this risk assessment tool offers assurance that realistic outcomes can be predicted for patients, and scores can guide early decisions on interventions to address specific risk factors for failing to heal, thus promoting timely healing.

Predicting the Likelihood of Delayed Venous Leg Ulcer Healing and Recurrence: Development and Reliability Testing of Risk Assessment Tools.

Venous leg ulcers are characterized by a long healing process and repeated cycles of ulceration. A secondary analysis of data from multisite longitudinal studies was conducted to identify risk factors for delayed healing and recurrence of venous leg ulcers for development of risk assessment tools, and a single-site prospective study was performed to as- sess the new tools' interrater reliability (IRR). The development of the risk assessment tools was based on results from previous multivariate analyses combined with further risk factors documented in the literature from systematic reviews, randomized controlled trials, and cohort studies with regard to delayed healing and recurrence. The delayed healing tool contained 10 items, including patient demographics, living status, use of high-compression therapy, ulcer area, wound bed tissue type, and percent reduction in ulcer area after 2 weeks. The recurrence tool included 8 items, including his- tory of deep vein thrombosis, duration of previous ulcer, history of previous ulcers, body mass index, living alone, leg elevation, walking, and compression. Using consensus procedures, content validity was established by an advisory group of 21 expert multidisciplinary clinicians and researchers. To determine intraclass correlation (ICC) and IRR, 3 rat- ers assessed 26 patients with an open ulcer and 22 with a healed ulcer. IRR analysis indicated statistically signi cant agreement for the delayed healing tool (ICC 0.84; 95% con dence interval [CI], 0.70-0.92; P <.001) and the recurrence tool (ICC 0.88; 95% CI, 0.75-0.94; P <.001). The development and reliability results of these risk assessment tools meet the recommendations for evidence-based, reliable tools and may bene t clinicians and patients in the management of venous leg ulcers. Studies to examine the items with low ICC scores and to determine the predictive validity of these tools are warranted.

Impact of audio-visual storytelling in simulation learning experiences of undergraduate nursing students.

BACKGROUND: Use of high fidelity simulation has become increasingly popular in nursing education to the extent that it is now an integral component of most nursing programs. Anecdotal evidence suggests that students have difficulty engaging with simulation manikins due to their unrealistic appearance. Introduction of the manikin as a 'real patient' with the use of an audio-visual narrative may engage students in the simulated learning experience and impact on their learning. A paucity of literature currently exists on the use of audio-visual narratives to enhance simulated learning experiences. OBJECTIVE: This study aimed to determine if viewing an audio-visual narrative during a simulation pre-brief altered undergraduate nursing student perceptions of the learning experience. DESIGN: A quasi-experimental post-test design was utilised. PARTICIPANTS: A convenience sample of final year baccalaureate nursing students at a large metropolitan university. METHODS: Participants completed a modified version of the Student Satisfaction with Simulation Experiences survey. This 12-item questionnaire contained questions relating to the ability to transfer skills learned in simulation to the real clinical world, the realism of the simulation and the overall value of the learning experience. Descriptive statistics were used to summarise demographic information. Two tailed, independent group t-tests were used to determine statistical differences within the categories. RESULTS: Findings indicated that students reported high levels of value, realism and transferability in relation to the viewing of an audio-visual narrative. Statistically significant results (t=2.38, p<0.02) were evident in the subscale of transferability of learning from simulation to clinical practice. The subgroups of age and gender although not significant indicated some interesting results. CONCLUSIONS: High satisfaction with simulation was indicated by all students in relation to value and realism. There was a significant finding in relation to transferability on knowledge and this is vital to quality educational outcomes.

Incidence and risk factors for developing infection in patients presenting with uninfected diabetic foot ulcers.

OBJECTIVE: There is a paucity of research on patients presenting with uninfected diabetic foot ulcers (DFU) that go on to develop infection. We aimed to investigate the incidence and risk factors for developing infection in a large regional cohort of patients presenting with uninfected DFUs. METHODS: We performed a secondary analysis of data collected from a validated prospective state-wide clinical diabetic foot database in Queensland (Australia). Patients presenting for their first visit with an uninfected DFU to a Diabetic Foot Service in one of thirteen Queensland regions between January 2012 and December 2013 were included. Socio-demographic, medical history, foot disease history, DFU characteristics and treatment variables were captured at the first visit. Patients were followed until their DFU healed, or if their DFU did not heal for 12-months, to determine if they developed a foot infection in that period. RESULTS: Overall, 853 patients were included; mean(standard deviation) age 62.9(12.8) years, 68.0% male, 90.9% type 2 diabetes, 13.6% indigenous Australians. Foot infection developed in 342 patients for an overall incidence of 40.1%; 32.4% incidence in DFUs healed <3 months, 55.9% in DFUs healed between 3-12 months (p<0.05). Independent risk factors (Odds Ratio (95% confidence interval)) for developing infection were: DFUs healed between 3-12 months (2.3 (1.6-3.3)), deep DFUs (2.2 (1.2-3.9)), peripheral neuropathy (1.8 (1.1-2.9)), previous DFU history (1.7 (1.2-2.4)), foot deformity (1.4 (1.0-2.0)), female gender (1.5 (1.1-2.1)) and years of age (0.98 (0.97-0.99)) (all p<0.05). CONCLUSIONS: A considerable proportion of patients presenting with an uninfected DFU will develop an infection prior to healing. To prevent infection clinicians treating patients with uninfected DFUs should be particularly vigilant with those presenting with deep DFUs, previous DFU history, peripheral neuropathy, foot deformity, younger age, female gender and DFUs that have not healed by 3 months after presentation.

Provisional Matrix Deposition in Hemostasis and Venous Insufficiency: Tissue Preconditioning for Nonhealing Venous Ulcers.

Significance: Chronic wounds represent a major burden on global healthcare systems and reduce the quality of life of those affected. Significant advances have been made in our understanding of the biochemistry of wound healing progression. However, knowledge regarding the specific molecular processes influencing chronic wound formation and persistence remains limited. Recent Advances: Generally, healing of acute wounds begins with hemostasis and the deposition of a plasma-derived provisional matrix into the wound. The deposition of plasma matrix proteins is known to occur around the microvasculature of the lower limb as a result of venous insufficiency. This appears to alter limb cutaneous tissue physiology and consequently drives the tissue into a 'preconditioned' state that negatively influences the response to wounding. Critical Issues: Processes, such as oxygen and nutrient suppression, edema, inflammatory cell trapping/extravasation, diffuse inflammation, and tissue necrosis are thought to contribute to the advent of a chronic wound. Healing of the wound then becomes difficult in the context of an internally injured limb. Thus, interventions and therapies for promoting healing of the limb is a growing area of interest. For venous ulcers, treatment using compression bandaging encourages venous return and improves healing processes within the limb, critically however, once treatment concludes ulcers often reoccur. Future Directions: Improved understanding of the composition and role of pericapillary matrix deposits in facilitating internal limb injury and subsequent development of chronic wounds will be critical for informing and enhancing current best practice therapies and preventative action in the wound care field.

The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial.

An increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems are available. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a four-layer compression bandage system and Class 3 compression hosiery on healing and quality of life (QL) in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and QL for 24 weeks. After 24 weeks, 86% of the four-layer bandage group and 77% of the hosiery group were healed (P = 0·24). Median time to healing for the bandage group was 10 weeks, in comparison with 14 weeks for the hosiery group (P = 0·018). The Cox proportional hazards regression found participants in the four-layer system were 2·1 times (95% CI 1·2-3·5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in QL or pain measures. Findings indicate that these systems were equally effective in healing patients by 24 weeks; however, a four-layer system may produce a more rapid response.