Real-life Data on Patient Characteristics, Cost and Effectiveness of Field-directed Treatment for Actinic Keratoses: An Observational Study.

Actinic keratoses (AK) occur frequently; however, real-life clinical data on personalized treatment choice and costs are scarce. This multicentre one-year observational study investigated patient-characteristics, cost and effectiveness of methylaminolaevulinate photodynamic therapy (MAL-PDT), imiquimod (IMI) and 5-fluorour-acil (5-FU) in patients with AKs on the face/scalp. A total of 104 patients preferred MAL-PDT, 106 preferred IMI and 110 preferred 5-FU. At baseline, significant differences between treatment groups were found; most patients were severely affected (mean 32.5 AK in PDT-group, 20.2 in IMI-group, 22.8 in 5-FU-group). A mean reduction in lesions of 81% after MAL-PDT, 82% after IMI and 88% after 5-FU was found after one year. Annual costs were €1,950 for MAL-PDT, €877 for IMI and €738 for 5-FU. These results show that, compared with clinical trials, in the real-life clinical setting AK patients are usually more severely affected and treatment costs are much higher. Furthermore, patient characteristics are important factors in treatment choice.

Dutch Venous Ulcer guideline update.

The revised guideline of 2013 is an update of the 2005 guideline "venous leg ulcer". In this special project four separate guidelines (venous leg ulcer, varicose veins, compression therapy and deep venous disorders) were revised and developed simultaneously. A meeting was held including representatives of any organisation involved in venous disease management including patient organizations and health insurance companies. Eighteen clinical questions where defined, and a new strategy was used to accelerate the process. This resulted in two new and two revised guidelines within one year. The guideline committee advises use of the C of the CEAP classification as well as the Venous Clinical Severity Score (VCSS) and a Quality of life (QoL) score in the assessment of clinical signs. These can provide insight into the burden of disease and the effects of treatment as experienced by the patient. A duplex ultrasound should be performed in every patient to establish the underlying aetiology and to evaluate the need for treatment (which is discussed in a separate guideline). The use of the TIME model for describing venous ulcers is recommended. There is no evidence for antiseptic or antibiotic wound care products except for a Cochrane review in which some evidence is presented for cadexomer iodine. Signs of infection are the main reason for the use of oral antibiotics. When the ulcer fails to heal the use of oral aspirin and pentoxifylline can be considered as an adjunct. For the individual patient, the following aspects should be considered: the appearance of the ulcer (amount of exudate) according to the TIME model, the influence of wound care products on moisturising the wound, frequency of changing compression bandages, pain and allergies. The cost of the dressings should also be considered. Education and training of patients t improves compliance with compression therapy but does not influence wound healing rates.

The effect of single phlebectomies of a large varicose tributary on great saphenous vein reflux.

OBJECTIVE: Phlebectomy of varicose tributaries is usually considered an additional treatment after or during saphenous ablation. As phlebectomies alone affect the hemodynamics of the venous system, this treatment can be effective as primary intervention in selected patients. The objective of this study was to analyze hemodynamic, clinical, and patient-reported outcomes after phlebectomies in a prospective multicenter study to determine predictors for treatment success, that is, restoration of great saphenous vein (GSV) competence. METHODS: Patients with symptomatic GSV and tributary incompetence (reflux > 0.5 second) at the level of the thigh were included. Duplex ultrasound (DUS) was used to assess GSV and tributary characteristics, and a reflux elimination test was performed. Three and 12 months after phlebectomy of the tributary, reflux and GSV diameter were evaluated with DUS. Clinical outcome measures were C class of the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification and Venous Clinical Severity Score; patients' reported outcome was determined by the Aberdeen Varicose Vein Questionnaire. To evaluate differences between the success and failure groups, baseline DUS characteristics, Venous Clinical Severity Score, CEAP class, and Aberdeen Varicose Vein Questionnaire score were compared. Multivariable logistic regression including all clinically relevant variables following a backward variable elimination process was used to determine predictors for success. The model was internally validated by 1000 bootstrap samples. RESULTS: The study included 94 patients (65 women, 29 men) with a mean age of 53 years. The majority had C2 or C3 disease. One year after treatment, GSV reflux had disappeared in 50% of patients (P < .01), and GSV diameter had decreased significantly (P < .01). Clinical outcome and Aberdeen Varicose Vein Questionnaire score improved significantly (P < .01) and symptoms had disappeared in 66%. Of 47 patients with persisting GSV incompetence, 15 did not receive additional treatment because they were asymptomatic. Independent predictors for success were low C class of the CEAP classification, low number of refluxing GSV segments, small diameter of the GSV above the tributary, and positive reflux elimination test result (P < .0001). The reflux elimination test appeared to be an important independent predictor, with >65% chance of success when the result was positive. CONCLUSIONS: At 1-year follow-up, treatment with single phlebectomies of a large tributary was effective to abolish GSV reflux in 50% of patients and to free 66% of patients from symptoms. Patients with limited disease progression and mild DUS alterations are most likely to benefit from this approach.