Risk factors for the recurrence of venous leg ulcers in adults: A systematic review protocol.

BACKGROUND: Venous leg ulcers are slow to heal, and recurrence is frequent. Living with venous leg ulcers can affect physical and psychological health, and result in financial burden for individuals. Physiological and psychosocial factors are associated with venous leg ulcer recurrence. As over 50% of venous leg ulcers will recur within 12 months of healing, a comprehensive knowledge of holistic risk factors associated with recurrence is required by health professionals involved in the care of the person with venous leg ulcers. AIM: To develop a systematic review protocol to determine the risk factors for recurrence of venous leg ulcers in adults. METHOD AND ANALYSIS: This protocol was developed according to the Preferred Reporting Items Form Systematic Review and Meta-Analysis Protocols (PRISMA-P). The inclusion criteria will be based on the PICOS mnemonic-adults with a history of venous leg ulcer/s (participants), risk factor/s under physiological (general/medical), clinical, demographics, psychosocial categories (I (intervention) or E (exposure), venous leg ulcer non-recurrence (comparison group), venous leg ulcer recurrence (outcomes to be measured) and will include study designs of original qualitative, quantitative and mixed method studies (study designs to be included). Methodological quality will be assessed using the Mixed Methods Appraisal Tool. This Systematic Review Protocol was registered in PROSPERO [CRD42021279792]. RESULTS: If meta-analysis is not possible, a narrative review of results will be presented. CONCLUSIONS: This systematic review on recurrence of venous leg ulcers can provide evidence-based information for preventive strategies for recurrence of a healed venous leg ulcer. The standardised approach outlined in this systematic review protocol offers a rigorous and transparent method to conduct the review.

Treatment of recalcitrant chronic leg ulcer in a known sickle cell anaemia patient using honey and fresh hbaa red cell concentrate in a Nigerian secondary healthcare facility.

Sickle hemoglobin (HbS) formed by the point mutation in the genetic code of beta-globin chain leading to valine substituting glutamic acid at position 6 of the beta-chain. The resultant sickle cell disease (SCD) characterized by occlusion of microvasculature by red blood cells is associated with multiple organ pathologies. One of such complications is chronic leg ulcers. We report a case of chronic leg ulcer, in a known sickle cell anemia patient, which did not respond to the wound dressing methods at the hospital's disposal. The ulcer was successfully treated using standard operative procedure (S.O.P) in wound care, applying local honey, and use of blood transfusion. EA was a 20-year-old university undergraduate who was admitted to April 2019 in Central Hospital Benin City with chronic leg ulcer of 1 year duration. She was also anemic with hemoglobin concentration of 3.0 g/dl (packed cell volume 15%). The wound was dressed with local honey, and anemia corrected with blood transfusion using concentrated red cells lacking the HbS trait. There was a progressive improvement in the healing of the ulcer with total closure after 4 months of treatment. Maintenance and follow-up measures were instituted to prevent reoccurrence. This report showed that honey has remarkable properties in promoting wound healing. Its usage in combination with transfusion of HbA red blood cells to manage chronic leg ulcers in SCD patients is advocated. However, this calls for further studies and research.

Résumé Sickle Hemoglobin (HbS) formé par la mutation ponctuelle dans le code génétique de la chaîne bêta-globine conduisant à la valine substituant l'acide glutamique à la position 6 de la bêta-chaîne. La drépanocytose résultante est caractérisée par l'occulusion de la microvasculature par les globules rouges malades avec les pathologies multiples associées d'organe. Une de ces complications est les ulcères chroniques de jambe. Nous rapportons un cas d'ulcère chronique de jambe dans un patient connu d'anémie de drépanocytose qui n'a pas répondu au pansement de blessure à la disposition d'hôpitaux. L'ulcère a été traité avec succès en utilisant la procédure d'opération standard dans les soins de blessure, en appliquant le miel local et l'utilisation de la transfusion sanguine. Patient était une étudiante de 20 ans qui a été admise à l'hôpital central de la ville du Bénin en avril 2009 avec des antécédents d'ulcère chronique de jambe d'une durée d'un an. Elle était également anémique avec la concentration d'hémoglobine de 3.0g/dl (Volume de cellules emballées 15%). La blessure était habillée avec du miel local et l'anémie a été corrigée avec la transfusion sanguine utilisant des globules rouges concentrés manquant du trait de HbS. Il y avait l'amélioration progressive dans la guérison de l'ulcère avec la fermeture totale après quatre mois de traitement. Des mesures d'entretien et de suivi ont été mises en place pour prévenir la récidive. Ce rapport a montré que le miel a des propriétés remarquables dans la promotion de la cicatrisation des plaies. Son utilisation en combinaison avec la transfusion de globules rouges HbA pour gérer les ulcères chroniques de jambe dans les patients de SCD est préconisée. Toutefois, cela exige d'autres études et recherches.

Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: An open label trial.

Non-Uremic Calciphylaxis (NUC) is a rare condition that often manifests as intractable and painful integumentary wounds, afflicting patients with a high burden of co-morbidity. The Endocannabinoid System (ECS) is a ubiquitous signalling system that is theorised to be dysregulated within wound beds and associated peri-wound tissues. Preclinical research has shown that the dominant chemical classes derived from the cannabis plant, cannabinoids, terpenes, and flavonoids, interact with the integumentary ECS to promote wound closure and analgesia. This is a prospective open label cohort study involving two elderly Caucasian females with recalcitrant NUC leg ulcers of greater than 6 months duration. Topical Cannabis-Based Medicines (TCBM) composed of cannabinoids, terpenes, and flavonoids were applied daily to both the wound bed and peri-wound tissues until complete wound closure was achieved. Wounds were photographed regularly, and the digital images were subjected to planimetric analysis to objectively quantify the degree of granulation and epithelization. Analgesic utilisation, as a surrogate/proxy for pain scores, was also tracked. The cohort had a mean M3 multimorbidity index score of 3.31. Complete wound closure was achieved in a mean of 76.3 days. Additionally, no analgesics were required after a mean of 63 days. The treatments were well tolerated with no adverse reactions. The positive results demonstrated in very challenging wounds such as NUC, among highly complex patients, suggest that TCBM may have an even broader role within integumentary and wound management. This treatment paradigm warrants being trialled in other wound types and classes, and ultimately should be subjected to randomised controlled trials.

Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone.

BACKGROUND AND OBJECTIVES: In patients with lymphedema, the disruption of the lymphatic network increases skin turgor and fibrosis of subcutaneous tissue, delays wound healing, causing recurrent ulcerations and infections. In these cases, management of ulcers can be challenging. METHODS: Between January 2016 and June 2018, patients presenting with lymphedema were enrolled at our Institution. We selected patients with severe lymphedema and ulcers of lower limbs and we performed a surgical approach, involving free gastroepiploic lymph nodes and omentum flap, harvested through laparoscopy. RESULTS: We enrolled 135 patients presenting for lymphedema. Among them, 10 eligible cases underwent excision of the ulcer and reconstruction with omentum flap. Mean age was 57.8 years and average follow-up 24.1 months. Circumferences and skin tonicity significantly decreased from the preoperative period. Lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network. No episodes of infection were recorded in the postoperative period. CONCLUSIONS: Our combined procedure merges free flap techniques and lymphedema surgery: omentum covers the defect while providing a new source of lymph nodes, improving the lymphatic networks of the affected limb. This technique can highly increase the quality of life of the patient in a single-stage operation with fast recovery and low donor site morbidity.

ß-Thalassemia intermedia: a comprehensive overview and novel approaches.

ß-Thalassemia intermedia is a clinical condition of intermediate gravity between ß-thalassemia minor, the asymptomatic carrier, and ß-thalassemia major, the transfusion-dependent severe anemia. It is characterized by a significant clinical polymorphism, which is attributable to its genetic heterogeneity. Ineffective erythropoiesis, chronic anemia, and iron overload contribute to the clinical complications of thalassemia intermedia through stepwise pathophysiological mechanisms. These complications, including splenomegaly, extramedullary erythropoiesis, iron accumulation, leg ulcers, thrombophilia, and bone abnormalities can be managed via fetal hemoglobin induction, occasional transfusions, chelation, and in some cases, stem cell transplantation. Given its clinical diversity, thalassemia intermedia patients require tailored approaches to therapy. Here we present an overview and novel approaches to the genetic basis, pathophysiological mechanisms, clinical complications, and optimal management of thalassemia intermedia.

Successful outpatient management of lymphoedema and lymphorrhoea with wrap around compression: a case study.

Referral to specialist centres for treatment of lymphoedema can often have long waiting times. Management of a patient with massive lymphoedema and lymphorrhoea was provided in a vascular outpatient setting. A new form of compression using a wraparound system was used for the management (Juxta-Fit, Medi UK). Despite having previously been non-concordant with treatment options, the patient was independent with product use. Lymphorrhoea ceased and there was a marked decrease in girth size. The patient's quality of life improved and maintenance treatment was provided. The use of this compression system could be a valuable treatment alternative to compression bandaging for a select patient group for the treatment of lymphoedema.

Managing chronic oedema in a patient with arterial disease and leg ulceration.

Treating lymphoedema in patients with critical arterial disease can be contraindicated. This case study describes current methods of managing lymphoedema in a patient with arterial disease and leg ulcers. The patient, a 65-year-old male, had paraplegia and lower-limb lymphoedema with leg ulceration for 18 years, as well as arterial disease. The patient was referred to the lymphoedema/vascular service in 2013. Duplex ultrasound indicated superficial femoral occlusion. The arterial disease was treated with an angiogram and angioplasty, and when the blood supply was improved, the lymphoedema was treated. Emphasis was placed on self-care and reducing the need for community nurse involvement. Selfcare included compression bandaging, use of FarrowWrap, low-level light therapy, and ulcer dressings. Outcomes were measured using a telemedicine software programme. The patient's lymphoedema was reduced, leg ulcers healed, and quality of life transformed.

The analgesic effect of electrostimulation (WoundEL®) in the treatment of leg ulcers.

This study aims to demonstrate the analgesic efficacy of electrostimulation (ES), a recognised treatment for leg ulcers. Patients treated by ES for leg ulcers between 2011 and 2013 were included in the study. The pain score obtained with the numerical rating scale (NRS) was reported before the start of the ES (D0), after 3 days (D3) and 1 week following treatment initialisation. The analgesic treatments (AT) were reported at each assessment. Seventy-three patients were included (mean age 75·19 years): 31 venous leg ulcers, 21 mixed venous leg ulcers, 2 arterial ulcers, 17 hypertensive ischaemic ulcers, 1 Hydrea(®)-induced ulcer and an amputation stump ulcer. The NRS at D0 was on average 5·3 (median = 6) while it was 2·2 at D7 (median = 2), that is P < 0·001. The results were also significant between D0 and D3 (P < 0·001). A decrease in the number of AT used was observed between D0 (2·0 AT per patient on average) and D7 (1·7 AT on average) (P < 0·001). We also observed a decrease in the consumption of grade 3 analgesics on D0 and D7 (P = 0·03). This study demonstrates the rapid analgesic efficacy of ES in leg ulcers, with a clear impact on the NRS score and especially on the decrease in analgesic consumption.

A VLU complicated by severe group a streptococcal infection resulting in necrotising fasciitis and septic shock: a case report.

This case study outlines the management of a patient with a venous leg ulcer whose swabs cultured Staphylococcus aureus and beta-haemolytic streptococcus group A while in hospital with cellulitis, which was treated with antibiotics as per sensitivities. However, the patient presented at the emergency department five weeks later with a diagnosis of invasive group A streptococcal disease resulting in necrotising fasciitis and streptococcal toxic shock syndrome. This paper describes the holistic care and wound management that the patient received.

Effectiveness of the frequency rhythmic electrical modulation system for the treatment of chronic and painful venous leg ulcers in older adults.

Frequency rhythmic electrical modulation system (FREMS) is an innovative type of transcutaneous electrotherapy used in a rehabilitation setting for the treatment of pain, especially in diabetic patients. In a randomized clinical trial, we tested the hypothesis that FREMS is effective in the treatment of chronic and painful venous leg ulcers in 20 older patients. Group A (10 patients) received FREMS and topical treatment, whereas group B (10 patients) received topical treatment alone. Over a period of 3 consecutive weeks, 15 treatment sessions were done for each group. Wound healing and tissue repair were evaluated with the Visitrack digital planimetry system and photos. Pain was evaluated using the Visual Analogic Scale (VAS). The measurements were done at baseline and after 5, 10, and 15 days of treatment, with follow-up measurements after 15 and 30 days from the last treatment session. Group A showed a statistically significant decrease in ulcer area during the treatment and follow-up. The VAS score showed a statistically significant decrease after 5 and 10 days of treatment. Group B showed a statistically decrease in ulcer area after 5, 10, and 15 days of treatment with a reduction of VAS score only at 15 days of follow-up. At the end of the treatment, the comparison of the change in ulcer area and the change in VAS score of each group showed a statistically significant difference between groups, suggesting the therapeutic and analgesic efficacy of FREMS in reducing pain and area of chronic venous leg ulcers in older adults. Further investigation is needed to determine its reproducibility in larger case series or randomized clinical trials with longer follow-up periods.

Complementary and alternative medicine for older adults with venous leg ulcer pain.

Chronic pain management is an important, and often under-addressed, component in the care of older adults with venous leg ulcers (VLUs). Clinicians caring for older adults with VLUs must consider and address both the physiological and psychosocial aspects of chronic pain. Traditional pharmacological approaches to pain management are only part of the solution. One strategy is to adopt a more holistic approach to chronic pain management that includes complementary and alternative medicine (CAM) therapies. Unfortunately, there is a paucity of CAM research that focuses on the pain management of older adults with VLUs. Despite these limitations, pain management that includes discussion of relevant CAM modalities must be a priority for clinicians caring for older adults living with VLUs.

A case of refractory vasculitic ulcers in a systemic lupus erythematosus patient responding to rituximab and hyperbaric oxygen therapy.

Large refractory vasculitic ulcers are not commonly seen in systemic lupus erythematosus (SLE) patients. We report a case of refractory vasculitic ulcers responding to rituximab, a monoclonal antibody directed against CD20 cells leading to prolonged B cell depletion. This treatment was initiated after treatment with high-dose steroids and other immunosuppressants were ineffective/associated with significant side-effects. Following treatment with rituximab, there was sustained clinical improvement and subsequent reduction of prednisolone dose. Rituximab was well-tolerated. Concomitant methotrexate therapy and hyperbaric oxygen therapy (HBOT) may have aided the recovery of the patient's vasculitic ulcers. This case and anecdotal reports have illustrated the efficacy and safety of rituximab in the treatment of refractory SLE-related vasculitic ulcers. Further studies to determine the long-term efficacy and side-effects would be useful.

Factors influencing the outcome of lower-extremity diabetic ulcers treated with hyperbaric oxygen therapy.

The objectives of this study were to report outcomes of a large number of patients receiving hyperbaric oxygen therapy (HBO(2)T) for diabetic lower-extremity ulcers, and to identify likely outcome predictors. Five hyperbaric facilities supplied data on 1,006 patients. A sixth clinic served as a validation sample for the regression-based prediction model, and later additional data from Memorial Hermann Hospital were added. The severity of lower-extremity lesions was assessed upon initiation of HBO(2)T using the Modified Wagner scale, and the outcome described as healed, partially healed, not improved, amputated, or died. Overall, 73.8% of patients improved (granulated or healed). Factors significantly related to outcome included renal failure, pack-year smoking history, transcutaneous oximetry, number of HBO(2)T treatments, and interruption of treatment regimen. Number of treatments per week and treatment pressure (2.0 vs. 2.4 atmospheres absolute) were not significant factors in outcome. Concomitant administration of autologous growth factor gel did not improve outcome. A multiple regression model was fitted to the data that can be used to predict the outcome of diabetic patients undergoing HBO(2)T. Given the high cost of amputation and rehabilitation, these data suggest that hyperbaric oxygen treatment should be an important adjunctive therapy to heal lower-extremity lesions, especially those with a Wagner grade of 3 or higher.

Bacterial resistance to silver in wound care and medical devices.

This review discusses the molecular and genetic evidence for silver resistance in bacteria isolated from skin wounds and medical devices with reference to a case study of resistant Enterobacter cloacae from the leg ulcers of an elderly woman.

Contact sensitization in patients with chronic venous leg ulcers in Singapore.

Contact sensitization rates are high in patients with chronic venous leg ulcers. Allergic contact dermatitis poses a significant hindrance to the healing of the wounds. There are no published studies examining the rate of contact sensitization in Asian patients. Our objective was to determine the rate of contact sensitization in patients with chronic venous leg ulcer in Singapore and the variation in the common allergens based on local practices in comparison with Western countries. 44 patients were patch tested to the National Skin Centre standard series, steroid series, medicaments, topical Chinese medicaments, and to modern wound dressings used. The overall rate of contact sensitization was 61.4%. The common allergen groups were topical antibiotics (18.2%) and topical traditional Chinese medicaments (TTCM) (15.9%). Individually, colophony (11.3%), Saw Hong Choon skin ointment (Kam Bo Med, Hong Kong, Hong Kong) (11.3%), Balsam of Peru (9.1%), and povidone iodine (9.1%) were among the most frequent allergens. The sensitization rate among users of TTCM was notably high (41%). A high rate of contact sensitization was found in our study, similar to previous reports from the West. TTCM play a major role as possible allergens in our patients. In Asian patients, a history of its usage should be elicited, and patch testing should include the commonly used TTCM where possible.

Infección cutánea por fusarium en paciente inmunocompetente / Skin infection with fusarium in an immunocompetent patient

Fusarium spp. son hongos distribuidos por todo el mundo que pueden producir una gran variedad de infecciones cutáneas, principalmente en individuos inmunodeprimidos. Se presenta un caso de infección cutánea por Fusarium sp. que se manifestó como úlceras superficiales dolorosas en las piernas de una paciente inmunocompetente que se había aplicado «barros medicinales» como remedio «natural» para el dolor de piernas. Se obtuvo la curación con itraconazol oral y curas locales

Fusarium spp. are fungi found throughout the world and can cause a great variety of skin infections, mainly in immunodepressed individuals. We present a case of skin infection with Fusarium sp. which manifested as painful superficial ulcers on the legs of an immunocompetent female patient, who had applied «medicinal mud» as a «natural remedy» for leg pain. The condition was cured with oral itraconazole and local treatments

A pilot study to determine whether a static magnetic device can promote chronic leg ulcer healing.

OBJECTIVE: To determine if UlcerCare, a specialised self-securing static magnetic device, can promote the healing of chronic leg ulcers. METHOD: This double-blind placebo-controlled pilot study involved 26 patients with chronic leg ulcers, receiving care consistent with RCN guidelines, who were randomly allocated to receive either UlcerCare leg wrap (treatment) or an identical sham non-magnetic device (control). Wounds were assessed for 12 weeks at four weekly intervals using digital photography, Verge Videometer analysis and patient questionnaires to determine changes in ulcer size, level of pain and function. RESULTS: Statistically significant reductions in ulcer measurement were noted in the treatment group when compared with the placebo group. CONCLUSION: The results demonstrate a significant healing effect in the treatment group. A larger randomised controlled study is recommended to investigate the effects on ulcer-associated pain and quality of life.

The relationship between pain and leg ulcers: a critical review.

Leg ulceration may have a profound impact on the individual: in some cases activities of living become subservient to the degree of pain experienced. Pain control, which is viewed as a key function in health care, appears marginalized in leg ulcer management. Pain can be intense, bringing psychological implications for the patient. Knowledge deficiency in practitioners' management of venous and arterial leg ulcers was identified in the literature. This may lead to unnecessary pain caused by inappropriate dressings, misdiagnosis, or poor technique in the use of compression therapy. A holistic approach to the patient using evidence-based standardized practice may improve the patient's experience.