Assessing quality of life in patients with hard-to-heal ulcers using the EQ-5D questionnaire.

OBJECTIVE: To assess health-related quality of life (HRQoL) in an unselected patient population with hard-to-heal ulcers from baseline through healing and at follow-up 6 months after healing. METHOD: Fifty patients were recruited and the sex and age of the patient and the ulcer aetiology, duration, and size were recorded. The generic instrument EQ-5D was used for two purposes. The first was to investigate the feasibility of this instrument for assessing HRQoL in this patient group. The second was to see if the EQ-5D results would add information to the Swedish Registry of Ulcer Treatment (RUT), a national quality registry which includes variables for pain, disturbed sleep, and mobility. RESULTS: We found a significant difference in HRQoL between patients with an open ulcer and those with a healed ulcer (p=0.02), but no significant difference between patients with a just-healed ulcer and patients at follow-up six months after ulcer healing (p=0.08). Sex, age, and length of ulcer duration at inclusion did not influence HRQoL (p=0.55, p=0.4, and p=0.9, respectively). Ulcer size seemed to influence HRQoL, though not significantly (p=0.07). CONCLUSION: This study confirms that HRQoL was improved after ulcer healing. Pain, as one of the five constructs measured by the EQ-5D, was significantly associated with open ulcers. The results from the EQ-5D questionnaire were hard to interpret in terms of capturing HRQoL in this unselected patient population. Despite some limitations, we consider that the simplicity of EQ-5D could make it feasible to use in the clinical setting. However, the results from EQ-5D did not add consistent information to RUT; therefore, this questionnaire will not be included in the registry.

Accurate diagnosis and effective treatment of leg ulcers reduce prevalence, care time and costs.

OBJECTIVE: This long-term follow-up recorded the prevalence, aetiology and treatment of hard-to-heal leg and foot ulcers, and an estimated nurses' time spent providing care, for the years 1994-2005. METHOD: A questionnaire was sent to all district and community nurses in the county of Blekinge, Sweden, during one week in 1994, 1998, 2004 and 2005. Calculating the costs of hard-to-heal leg and foot ulcer care was not a primary aim, but the reduction in prevalence and time spent on wound management suggested it was important to illustrate the economic consequences of these changes over time. RESULTS: Estimated prevalence of hard-to-heal leg and foot ulcers reduced from 0.22% in 1994 to 0.15% in 2005. Treatment time decreased from 1.7 hours per patient per week in 1994 to 1.3 hours in 2005. Annual costs of leg and foot ulcer care reduced by SEK 6.96 million in the study area from 1994 to 2005. CONCLUSION: Improved wound management was demonstrated; leg and foot ulcer prevalence and treatment time were reduced. The results could be attributed to an increased interest in leg and foot ulcer care among staff, which was maintained by repeated questionnaires, continuous education, establishment of a wound healing centre in primary care and wound management recommendations from a multidisciplinary group. The improved ulcer care reduced considerably the annual costs of wound management in the area.

Pinch graft skin transplantation for leg ulcers in primary care.

Pinch grafting offers an alternative approach to conventional management of chronic leg ulcers, and is particularly well suited for venous and diabetic ulcers. Relevant literature from 1872-1998 was reviewed. The method of pinch grafting is described here in detail, and is illustrated by two case reports. Since pinch grafting hastens the healing of granulating wounds, is easy to perform and does not require strict immobilisation, a revival of the method, with adaptation for primary care, should be encouraged.

Measuring the size of ulcers by planimetry: a useful method in the clinical setting.

OBJECTIVE: The aim of this study was to compare four measurement methods. Digital planimetry was compared with mechanical planimetry, placing the film over graph paper and counting the squares (grid tracing), and multiplying the two maximal perpendicular diameters of the ulcer (diameter product). METHOD: Twenty patients with 50 chronic leg ulcers of various aetiology and sizes (20 ulcers were < or = 3 cm2, 15 ulcers were > 3 cm2 and < or = 10 cm2, and 15 ulcers were > 10 cm2) were enrolled consecutively into this study. Ulcer area was calculated from film transparency tracings using a digital planimeter, a mechanical planimeter, grid tracing and diameter product. RESULTS: The mean difference of digital planimetry versus mechanical planimetry, grid tracing and diameter product was 0.51 cm2, 0.72 cm2 and -5.38 cm2, respectively. For all methods difference tended to increase with ulcer size. CONCLUSION: Digital and mechanical planimetry, together with grid tracing, appear to be appropriate means of obtaining accurate surface area measurements. Digital planimetry is a quick and practical method and could therefore be recommended in the clinical setting.

Pinch grafting in hospital and primary care: a cost analysis.

The cost of treating venous leg ulcers with pinch grafting was evaluated for 58 consecutive patients: 29 in hospital care and 29 in primary care. The mean age was 76.8 and 74.3 years and the mean ulcer size 15.1 and 13.5 cm2, respectively. The operation technique, pinch grafting, was the same for all patients but primary care patients were not immobilised postoperatively. Healing rate within 12 weeks was the same for patients in hospital care and primary care (31%). Treatment costs for one week pre-operatively and three weeks postoperatively amounted to 5109 Pounds per patient in hospital care and 870 Pounds per patient in primary care (p < 0.001), and the costs for one week pre-operatively and 12 weeks postoperatively were 6738 Pounds and 1806 Pounds, respectively (p < 0.001). Costs for patients whose ulcers healed within 12 weeks were 5552 Pounds for those receiving hospital care and 1676 Pounds for those receiving primary care (p < 0.001). Pinch grafting in primary care was shown to cost 3.3 to 5.9 times less, with the same healing outcome, than pinch grafting in hospital care.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]. / Varicer och venös insufficiens--behandlingsfilosofi inför 2000-talet.

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

Pinch grafting of leg ulcers in primary care.

Treatment of chronic leg ulcers consumes considerable primary care resources. For the patient, it often entails restrictions in everyday life. This study describes the results of 84 skin transplantations on 45 patients with 55 ulcerated limbs, using the pinch graft technique, performed in primary care from 1987-1993. The healing rate after 12 weeks for venous ulcers was 45%, and for neuropathic ulcers 44%. Venous ulcers represented 56% of all the ulcers, while 16% were neuropathic. One year postoperatively, 47% (19/40) of examined ulcers remained healed. The results from our study suggest that venous and neuropathic ulcers may be particularly well suited for skin transplantation, which can easily be performed in primary care.

Leg ulcers in patients with rheumatoid arthritis--a prospective study of aetiology, wound healing and pain reduction after pinch grafting.

OBJECTIVE: To study the aetiology of leg ulcers in patients with rheumatoid arthritis (RA) and to study healing and pain relief after pinch grafting. METHODS: Twenty patients with RA and leg ulcers were studied. Diagnosis of the ulcers was founded on the clinical picture and measurements of the ankle-brachial pressure index. To detect vasculitis, skin biopsies were taken for immunohistochemistry and histopathology. Pain severity was assessed pre- and post-operatively using a visual analogue scale. RESULTS: Ten of the 20 patients had ulcers with multifactorial aetiology. Fifteen had signs of venous insufficiency, 11 had histopathological evidence of vasculitis, four had reduced arterial circulation and two patients had diabetes. Healing after pinch grafting was found in eight patients, all of whom had an ulcer area less than 15 cm(2). Eleven out of 18 patients had pain reduction after pinch grafting. CONCLUSION: The causation of leg ulcers in patients with RA was found to be multifactorial, with vasculitis and venous insufficiency as the main determinants. Pinch grafting seems to be a good alternative to conservative treatment for minor leg ulcers for these patients, regarding both wound healing and pain relief.

Wound management for 287 patients with chronic leg ulcers demands 12 full-time nurses. Leg ulcer epidemiology and care in a well-defined population in southern Sweden.

OBJECTIVE: To study the prevalence, aetiology and treatment of chronic leg and foot ulcers, and to estimate the nurse's time in wound management. DESIGN: A structured questionnaire with 19 questions about chronic ulcers and wound management was sent to all district and community nurses in the county during 1 week in March 1998. A similar questionnaire has been administered regularly since 1986. SETTING: Primary and community care in the county of Blekinge, Sweden, with a population of 1,51,610. PATIENTS: 287 patients with chronic leg and foot ulcers were identified during the week studied. MAIN OUTCOME MEASURES: Prevalence of leg and foot ulcers, ulcer aetiology, treatment of ulcers and wound management time. RESULTS: The estimated prevalence of chronic leg and foot ulcers was 0.19%. Venous ulcers were the most common (38%), of which 87% were treated with some form of compression therapy. Seven percent of the nurse's workload was devoted to ulcer care. During the period 1986 to 1998, ulcers with missing or unknown aetiology decreased from 31% to 6% and ulcers with a duration of more than 2 years from 44% to 27%, while treatment time per ulcer decreased from 2.1 to 1.7 hours/week. CONCLUSION: Monitoring standards for ulcer aetiology through repeated questionnaires seems to ensure more accurate diagnoses. Thorough and detailed information about treatment time documents the workload for wound management.