The relationship between clinical severity and outcome measures in patients with chronic venous insufficiency with or without leg ulcer.

PURPOSE: To evaluate the relationship between clinical severity and functionality, sleep quality, depression, and quality of life (QoL) in patients with CVI with or without leg ulcers. METHODS: A total of sixty patients with CVI were enrolled in the study. The patients were C2-6 according to the CEAP classification. All the patients were assessed with Venous Clinical Severity Score (VCSS) for clinical severity, Visual Analog Scale (VAS) for pain, right and left lower limb (RLL and LLL) circumference measurements for edema, 6-min-walk test (6-MWT) for functional capacity, Lower Extremity Functional Scale (LEFS) for functionality, Pittsburg Sleep Quality Index (PSQI) for sleep quality, Beck Depression Inventory version I (BDI-I) for depression, and The Quality of Life Questionnaire for Chronic Venous Diseases-20 (CIVIQ-20) for QoL. RESULTS: The mean age of the patients was 45.83 ± 13.25 years, and the mean duration of disease was 8.30 ± 7.42 years. There was a significant association between VCSS and VAS-rest/activity, edema-RLL/LLL, PSQI, BDI-I, LEFS, and CIVIQ-20 in patients without leg ulcers. In addition, a significant association was found between VCSS and VAS-rest/activity and CIVIQ-20 in patients with leg ulcers. CONCLUSION: The current study showed that an association has been found between clinical severity and pain at rest and during activity, edema, sleep quality, depression, lower extremity function, and QoL in patients without ulcers. However, clinical severity has been correlated with only pain at rest and during activity, and QoL in patients with leg ulcers.

The profile of patients with venous leg ulcers: A systematic review and global perspective.

BACKGROUND: A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes. OBJECTIVES: To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area. METHODS: A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting. RESULTS: twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm2; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together. CONCLUSION: a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.

Ultrasound Devices to Treat Chronic Wounds: The Current Level of Evidence.

Chronic wounds cause considerable morbidity and utilize significant health care resources. In addition to addressing wound etiology and treating infection, regular debridement is a key component of wound care with a proven ability to accelerate healing. In this regard, a significant innovation in wound care has been the development of ultrasound debridement technology. The purpose of this review is to evaluate the current evidence behind the technology with an emphasis on noncontact low-frequency (NCLF) ultrasound. A number of studies, especially those evaluating NCLF technology, have demonstrated the potential of ultrasound debridement to effectively remove devitalized tissue, control bioburden, alleviate pain, and expedite healing. However, most of the studies are underpowered, involve heterogeneous ulcer types, and demonstrate significant methodological limitations making comparison between studies difficult; there is a paucity of data on cost-effectiveness. Future clinical trials on ultrasound debridement technology must address the design issues prevalent in current studies, and report on clinically relevant endpoints before adoption into best-practice algorithms can be recommended.

Cross-cultural adaptation of the Leg Ulcer Measurement Tool for Brazil: nursing methodology research.

OBJECTIVES: to translate and cross-culturally adapt the Leg Ulcer Measurement Tool to Brazilian Portuguese. METHODS: methodological study involving the steps of initial translation, synthesis of translations, back-translation, expert panel and pretest. For analysis by the expert committee, the content validity index was calculated and in the pretest for practicality, the agreement rate was calculated. Satisfactory agreement was considered when > 0.8 and 80%, respectively. RESULTS: the initial steps of translation were satisfactorily developed and there was little disagreement between the translators. In the expert panel, was obtained significant concordance of 0.97. The pretest was performed with ten nurses and 30 patients. The feasibility of the translated version was evaluated with 100% agreement. FINAL CONSIDERATIONS: the instrument presented a high level of concordance among the experts during all steps and showed content validity thereby making the adaptation appropriate for the Brazilian context.

[German national consensus on wound documentation of leg ulcer : Part 2: Routine care - classification of variable characteristics]. / Nationaler Konsensus zur Wunddokumentation beim Ulcus cruris : Teil 2: Routineversorgung ­ Klassifikation der Variablenausprägungen.

BACKGROUND: Standards in the assessment and documentation of disease processes are the basis of guideline-based care. For the treatment of chronic wounds, especially leg ulcers, no approved parameters are available. OBJECTIVES: Against this background, our aim was to develop standards for the documentation of leg ulcer in routine care. This article presents the recommendations for the classification and characteristics of the variables. MATERIALS AND METHODS: The development of the documentation standard was based on a systematic literature research and was performed in a Delphi-based consensus process. The national consensus process included meetings as well as web-based questionnaires. The Consensus Group is coordinated by the German Center for Health Services Research in Dermatology (CVderm). RESULTS: The documentation standards and their variables for leg ulcer routine care were developed in seven meetings of the consensus group. The consensus group consists of 38 delegates of wound care societies, health insurances, wound networks and associations. DISCUSSION: For each variable, recommended in routine care, a distinct response scheme (defined set of variable characteristics) was defined. As a next step, a structured implementation process is required, which was part of the resolutions of the consensus group.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. / Standarddatensatz für die Evaluation bei Selektivverträgen bei Ulcus cruris : Nationaler Konsensus.

BACKGROUND: Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES: Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS: Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS: For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS: The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

Clinical Characteristics of Mixed Arteriovenous Leg Ulcers: A Descriptive Study.

PURPOSE: The purpose of this study was to identify the clinical characteristics of mixed arteriovenous leg ulcers (MLU) that differentiated them from venous leg ulcers (VLU). DESIGN: Secondary analysis of data from larger electronic database. SUBJECTS AND SETTING: The sample comprised 1007 persons with lower extremity ulcers. Two hundred sixty three individuals with MLU were compared to 744 individuals with VLU; their ankle brachial indices were 0.51-0.90 and 0.91-.30 respectively. Subjects were drawn from community care settings from across Canada. METHODS: Data concerning baseline demographic and pertinent clinical characteristics including ulcer history were collected using multiple validated instruments. The Leg Ulcer Assessment Tool was used to collect demographic and pertinent medical history, The Short Form Health Survey 12 and the Euro Wuol 5D (EQ-5D) were used to measure health related quality of life, the numeric pain scales was used to measure character and intensity of pain. Groups were compared using χ or Mann-Whitney U. RESULTS: Individuals with MLU were significantly older, has lower body mass index, a history of smoking, and more comorbid conditions than subjects with VLU. In many cases, clinical presentation was indicative of significant arterial insufficiency including cool extremities, shiny, cracked and inelastic skin, impaired capillary refill, and weak pedal pulses. Ulcer pain was highly prevalent, but overall pain rating was similar between groups. Mixed arteriovenous leg ulcers were associated with lower health related quality of life, greater mobility impairments, and more deficits in self-care and usual activities. CONCLUSION: Greater knowledge and understanding of the distinct characteristics of MLU is critical for appropriate screening, prevention, assessment and management of persons with this form of leg ulcer. Pain and health related quality of life factors are important considerations when evaluating and managing these patients.

The wound/burn guidelines - 5: Guidelines for the management of lower leg ulcers/varicose veins.

Varicose veins are treated at multiple clinical departments, but as patients often visit the dermatology clinic first due to leg ulcers, the present Guidelines for the Management of Lower Leg Ulcers/Varicose Veins were prepared in consideration of the importance of the dermatologist's role. Also, the disease concept of chronic venous insufficiency or chronic venous disorders and the CEAP classification of these disorders are presented. The objective of the present guidelines is to properly guide the diagnosis and treatment of lower leg ulcers/varicose veins by systematically presenting evidence-based recommendations that support clinical decisions.

Assessment, Definition, and Classification of Lower Limb Ulcers in Systemic Sclerosis: A Challenge for the Rheumatologist.

OBJECTIVE: To evaluate pathogenesis and clinical features of lower limb ulcers in systemic sclerosis (SSc) and to propose a classification that could be used in clinical practice. METHODS: Charts of 60 patients with SSc who had lower limb cutaneous lesions were reviewed. All patients had videocapillaroscopy and arterial and venous lower limb color Doppler ultrasonography (US). Arteriography was performed if occlusive peripheral arterial disease was suspected. RESULTS: The 554 lesions were classified as hyperkeratosis, ulcers, and gangrenes. There were 341 (61.6%) hyperkeratoses, 208 (37.5%) ulcers, and 5 (0.9%) gangrenes. Ulcers were divided into pure ulcers, ulcers associated with hyperkeratosis, and ulcers secondary to calcinosis. Involvement of arterial and venous macrocirculation as determined by color Doppler US was observed in 17 (18.3%) and 18 (30%) patients, respectively. Seventeen out of 37 patients with pure ulcers (45.9%) presented neither venous insufficiency nor hemodynamically significant macrovascular arterial disease. In these patients, pure ulcers were most likely caused by isolated SSc-related microvascular involvement (pure microvascular ulcers). The only significant risk factor for development of pure microvascular ulcers in the multivariate analysis was the history of lower limb ulcers (OR 26.67, 95% CI 2.75-259.28; p < 0.001). CONCLUSION: Results of our study indicate that lower limb ulcers in SSc often have a multifactorial pathogenesis that may be difficult to manage. Further studies are needed to validate the proposed classification and to assess the most appropriate management of lower limb ulcers in SSc.

The Wound Trend Scale: A Retrospective Review of Utility and Predictive Value in the Assessment and Documentation of Lower Leg Ulcers.

Wound assessment is essential to manage wound care. The Wound Trend Scale (WTS) is a paper-and-pen instrument comprised of 14 parameters designed to guide assessment of findings relevant to lower leg ulcer management and includes an infection screen and cues for physician consultation. To determine its clinical utility, predictive value, and reliability, data were retrospectively analyzed from a random sampling of medical records of patients seen at a Foot and Leg Clinic between January 1, 2007 and December 31, 2008. Patients had 1 leg or foot ulcer, 3 consecutive assessments scheduled according to wound status (twice weekly if at high risk for nonhealing or amputation, weekly for moderate risk, or 1 to 2 months if stable), known outcomes, and a maximum treatment period of 3 months. Patient demographics included ulcer etiology, comorbid conditions (diabetes, neuropathy, peripheral arterial disease), and wound outcomes (closed, infection, amputation and surgery). Predictive values, inter- and intrarater reliability (assessed among the authors and 5 additional nurses with expertise using the study instrument), and the impact of WTS education on the wound assessment process were determined using 5 representative cases. Parameters were compared using the t-test. Seventy (70) patient records were examined and subdivided by ulcer site: foot (below ankle, 37) and leg (ankle and above, 33). Of the 13 etiologies, the foot group had 4 and the leg group 10; the foot group had more diabetes (92%), neuropathy (76%), and peripheral arterial disease (95%) than the leg group (52%, 5%, and 70%, respectively). Ulcer duration before referral averaged 16.42 (range 4-144) months. Wound outcomes included closed (57), infection (21), amputation (13), and surgery (3). Healing predictive values were sensitivity (99%), specificity (87%), and positive and negative predictive values and test efficiency (all 96%). Inter- and intrarater reliability were .85 (range .16-.96) and .86 (range .50-1.00), respectively. On admission, leg ulcers had larger surface area (P <0.05), more edema (P <0.01), more granulation (P <0.05), and higher total WTS scores (P <0.05) than foot ulcers, which had more infections (P <0.05). Foot ulcers at the third assessment had decreased tissue depth (P <0.05), increased epithelial tissue (P <0.01), and lower total WTS score (P <0.05). Significant third assessment parameters for leg ulcers were reduced depth (P <0.001), less necrotic tissue (P <0.001), less exudate (P <0.01), improved periwound condition (P <0.05), reduced edema (P <0.001), and increased epithelialization (P <0.01). After exposure to the WTS experience, the number of parameters assessed increased from 2.6 (registered nurses) and 1.5 (student nurses) to both using 15 (P <0.001). Nurses complied 100% with physician consultation for cued risks. Patient outcomes were 81% closure, and 70% had physician consultation for the risks identified. WTS predictive performance was excellent and improved nursing assessment practices. Future research to identify parameter criteria validity is warranted.

[Diagnosing venous and venous/arterial ulcers]. / Le diagnostic de l'ulcère de jambe d'origine veineuse et mixte.

A venous ulcer can be diagnosed on the basis of elements arising from the questioning and the clinical examination of the patient. A venous Doppler ultrasound can specify the type of reverse flow (superficial and/or deep). Measuring the ankle brachial pressure index helps to eliminate or confirm any arterial involvement. Depending on the systolic pressure index, the ulcer will be considered as purely venous, mixed (arterial-venous) or predominantly arterial.

Improving wound score classification with limited remission spectra.

The classification of wounds into healing states depending on their absorption spectrum of visible and near infrared light remains an important task in dermatology. Moreover, a reduction of the spectrum that is used in the classification task to fewer but important wavelengths is desirable, as each measured wavelength increases the examination costs without necessarily providing further information to the classification of wound healing states. This paper addresses two aspects: First the improvement of the classification of wounds into healing states and second, a cost reduction by choosing only important wavelengths. Standard Data Mining methods are evaluated for their classification accuracy (CA) and compared to their performance when applying feature selection techniques that are used to reduce the amount of necessary wavelengths. The results indicate that the 1-nearest-neighbor approach (IB1 algorithm) comes up with the best CA, while only relying on a fraction (4%) of the standard wavelength spectrum.

[Diagnostic and treatment of leg ulcers]. / Aspectos diagnósticos y terapéuticos de las úlceras de las piernas.

Ulcers are a frequent cause of dermatologic consultation, and most correspond to leg ulcers. Major advances in the treatment of ulcers have occurred in recent years as a result of research that has led to new concepts such as the consideration of the chronic ulcer as an inflammatory process involving proinflammatory cytokines and deficits of growth factors. Furthermore, studies into the use of the wet dressing have led to the appearance of a wide variety of new dressings. The aim of this review is to update the reader's knowledge of the treatment of ulcers in general and of leg ulcers in particular, with a detailed description of the new dressings available and of the new therapies for use in refractory cases.

Leg ulcers in sickle cell disease.

Sickle cell disease is a single amino acid molecular disorder of hemoglobin leading to its pathological polymerization, red cell rigidity that causes poor microvascular blood flow, with consequent tissue ischemia and infarction. The manifestations of this disease are protean.Among them, leg ulcers represent a particularly disabling and chronic complication, often associated with a more severe clinical course.Despite the fact that this complication has been recognized since the early times of SCD, there has been little improvement in the efficacy of its management and clinical outcome over the past 100 years. Recently, vasculopathic abnormalities involving abnormal vascular tone and activated, adhesive endothelium have been recognized as another pathway to end organ damage in sickle cell disease. Vasculopathy of sickle cell disease has been implicated in the development of pulmonary hypertension, stroke, leg ulceration and priapism, particularly associated with hemolytic severity, and reported in other severe hemolytic disorders. The authors present the proceedings from the Educational Session on Chronic leg ulcers in Sickle cell disease, held during the 4th Annual Sickle Cell Disease Research and Educational Symposium, on February 17, 2010 in Fort Lauderdale, Fla.

The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study.

BACKGROUND: We used a model of lower-extremity ulceration to determine the impact of a podiatric lead limb preservation team on identified relationships among risk factors, predictors of ulceration, amputation, and clinical outcomes of lower-extremity disease in patients with diabetes mellitus. METHODS: A total of 485 patients with diabetes mellitus were randomly selected from the diabetic population and included in this retrospective cohort study. Patients were then stratified into two groups: those who received specialty podiatric medical care and those who did not. Data covering a 5-year period were collected using electronic medical records and chart abstraction to capture detailed treatment characteristics, ulcer status, and surgical outcomes. RESULTS: Overall, the frequencies of inpatient and outpatient encounters and the durations of hospital stays were significantly greater with increasing wound depth and in the presence of infection. In addition, the overall ulcer incidence was greater in patients with callus (34.3% versus 10.3%, P < .0001) with and without neuropathy (20.4% and 4.1%, P < .0001). Among patients treated in a specialty multidiscipline podiatric medical setting, the proportion of all amputations that were "minor" was significantly increased (33.7% versus 67.3%, P = .0006), and survival was significantly improved (19.5% versus 7.7%, P < .0001). CONCLUSIONS: Early identification of individuals at increased risk for lower-extremity ulceration and subsequent referral for advanced multidiscipline podiatric medical specialty care may decrease rates of ulceration and proximal amputation and improve survival in patients with diabetes mellitus who are at high risk for ulceration and limb loss.

[Indications and methods of LAF therapy]. / Indikation und Methode der LAF-Therapie.

A variety of techniques for leg ulcer surgery have been developed in the last 20 years. In literature these techniques are always presented as competitive surgical methods for treating different forms of leg ulcers and are compared regarding their success. From our point of view, this approach seems inappropriate. Essentially there are 3 different techniques available: shave therapy, LAF therapy (removal of liposclerosis and fasciotomy) and fasciectomy. The choice of methods must be based on a classification of the ulcers, as each procedure is not suitable for ever type of ulcer. First we have to differentiate between venous ulcers and mixed leg ulcers. The venous ulcers should then be subdivided in ulcers developed in liposclerotic skin and ulcers which developed in atrophie blanche lesions. Finally the liposclerotic ulcers are classified according to Hach's classification system into 4 stages. In case of mixed leg ulcers with relevant occlusive arterial disease, attention should first be directed to improving the arterial blood supply; further approaches depend on how successful this is.

Pé diabético: o papel do enfermeiro nocontexto das inovações terapêuticas / Diabetic foot: the nurse role in the new therapeutics context / Pie diabético: el papel del enfermero en el contexto de lasinnovaciones terapéuticas

O propósito deste trabalho foi realizar uma revisão da literatura sobre as opções terapêuticas para o tratamentodo pé diabético e o papel do enfermeiro diante desta complicação crônica. Foi realizada uma pesquisa bibliográfica sobre o assunto em publicações científicas como periódicos e livros. Entre as modalidades terapêuticas utilizadas para o tratamento do pé diabético identificou-se o desbridamento e a revascularização daslesões, o uso dos fatores de crescimento e da oxigenoterapia; porém a amputação do pé/perna tem se caracterizado como o tratamento mais freqüente, em decorrência do estágio avançado da doença, na maioriados casos. A partir da indicação do tratamento mais adequado, tendo em vista o atendimento integral dasnecessidades do diabético, o enfermeiro tem papel fundamental na realização de curativos diários nas lesõesdos pés, na avaliação clínica da cicatrização, na assistência durante o período perioperatório, em casos de amputações, como também na assistência emocional aos pacientes e familiares.

The purpose of this work was to perform a literature review on the therapeutics options for the diabetic foot andthe nurse’s role in the treatment of this chronic problem. A bibliographical review on scientific papers and bookson the subject was performed. Among the therapeutic modalities used for the treatment of diabetic foot are thedebridement and revascularization of ulcers, the use of growth factors and the oxygen therapy. However, thefoot/leg amputation has been most frequent treatment due to the advanced stage of the disease in the majority ofthe patients. Deciding on the most appropriated treatment in order to fulfill all needs of the diabetic individuals, thenurse has played an important role by applying daily bandages on feet lesions, clinically evaluating cicatrisation,and assisting the patient during pre-surgical period when amputation is needed, as well as, providing emotionalsupport to patients and their families.

El propósito de este estudio fue realizar una revisión de la literatura sobre las opciones de la terapéutica, para eltratamiento del pie diabético y la función del enfermero delante de esta complicación crónica. Fue realizada unainvestigación bibliográfica sobre el asunto en publicaciones científicas, como periódicos y libros. Entre las modalidades terapéuticas utilizadas para el tratamiento del pie diabético se identificó el desbridamiento y larevascularización, el uso de los factores del crecimiento y de la oxigenoterapia, pero la amputación del pie/piernase ha caracterizado como el tratamiento más frecuente, en decurso de la etapa avanzada de la enfermedad, enla mayoría de los casos. A partir de la indicación del tratamiento más adecuado, teniendo en vista el atendimientointegral de las necesidades del diabético. El enfermero presentó tiene el papel fundamental en la realización decurativos diarios en las lesiones de los pies, en la evaluación clínica de la cicatrización, en la asistencia duranteel período perioperatorio, en casos de amputación, como también en la asistencia emocional a los pacientes yfamiliares.