Cellulitis in chronic oedema of the lower leg: an international cross-sectional study.

BACKGROUND: Cellulitis and chronic oedema are common conditions with considerable morbidity. The number of studies designed to assess the epidemiology of cellulitis in chronic oedema is scarce. OBJECTIVES: To investigate the prevalence and risk factors of cellulitis in chronic leg oedema, including lymphoedema. METHODS: A cross-sectional study included 40 sites in nine countries during 2014-17. Adults with clinically proven unilateral or bilateral chronic oedema (oedema > 3 months) of the lower leg were included. The main outcome measures were frequency and risk factors for cellulitis within the last 12 months. RESULTS: Out of 7477 patients, 15·78% had cellulitis within the last 12 months, with a lifetime prevalence of 37·47%. The following risk factors for cellulitis were identified by multivariable analysis: wounds [odds ratio (OR) 2·37, 95% confidence interval (CI) 2·03-2·78], morbid obesity (OR 1·51, 95% CI 1·27-1·80), obesity (OR 1·21, 95% CI 1·03-1·41), midline swelling (OR 1·32, 95% CI 1·04-1·66), male sex (OR 1·32, 95% CI 1·15-1·52) and diabetes (OR 1·27, 95% CI 1·08-1·49). Controlled swelling was associated with a reduced risk (OR 0·59, 95% CI 0·51-0·67). In a subgroup analysis, the risk increased with the stage of oedema [International Society of Lymphology, stage II OR 2·04 (95% CI 1·23-3·38) and stage III OR 4·88 (95% CI 2·77-8·56)]. CONCLUSIONS: Cellulitis in chronic leg oedema is a global problem. Several risk factors for cellulitis were identified, of which some are potentially preventable. Our findings suggest that oedema control is one of these. We also identified that advanced stages of oedema, with hard/fibrotic tissue, might be an important clinical indicator to identify patients at particular risk.

A preliminary randomized controlled study to determine the application frequency of a new lymphoedema bandaging system.

BACKGROUND: Bandaging plays an important role in the treatment of lymphoedema. OBJECTIVE: To investigate efficacy and safety of the 3M™ Coban™ 2 compression system (Coban 2 system) with different application frequencies in comparison to short-stretch bandaging. METHODS: A multicentre, randomized, prospective study was performed with 82 patients suffering from arm or leg lymphoedema stage II or late stage II. Patients were allocated to traditional short-stretch bandaging five times per week or to the Coban 2 system applied two, three or five times per week for 19 days. Limb volume and adverse events were recorded at each study visit. The primary endpoint was percentage volume reduction. RESULTS: The highest lymphoedema volume reduction was achieved with the Coban 2 system applied two times per week. A mean reduction of 18·7% (SD 14·5) in legs and 10·5% (SD 8·3) in arms was achieved. More frequent bandage changes of three and five times per week did not demonstrate additional benefits. Short-stretch bandaging five times per week showed a mean volume reduction of 10·9% (SD 5·2) and 8·2% (SD 3·1) for legs and arms, respectively. Bandage slippage was low for all treatment groups. A relevant change in overall mobility was achieved during the use of the Coban 2 system. The adverse reactions were in agreement with already known side-effects and did not differ remarkably between the treatment groups. CONCLUSION: The 3M™ Coban™ 2 compression system applied twice weekly demonstrated a high rate of volume reduction and a good safety profile. Oedema reduction was still effective with 4 days between bandage change, which allows a constant therapeutic effect in routine practice. This should give the patient a high degree of independence and mobility.

The experience of patients with complex wounds and the use of NPWT in a home-care setting.

OBJECTIVE: To explore the experience of patients living with complex wounds and the impact of undergoing negative pressure wound therapy (NPWT) as part of their treatment. METHOD: Qualitative data were collected from eight patients, using semi-structured interviews. A purposive, stratified sampling approach was used to identify participants with a range of wound types, as well as age and gender. Participants were recruited from one primary care trust and were interviewed, following 10 days of treatment with NPWT. The matrix-based 'Framework' approach, from the National Centre for Social Research, was used to structure the analysis. RESULTS: Of the eight participants recruited, five were female and three male, with an age range of 46-77 years. Five overarching categories, with their constituent themes, were identified from the data. The first, developing a wound through crisis, has three themes: a failing body, missed diagnosis and failed professional intervention. The second category, decreased control, has four related themes: poor communication; failed wound healing; poor discharge planning and failure to recover. The third category, increased control, has four themes: understanding what is happening; symptom control; positive professional relationships and returning to health. The fourth category, using NPWT, has two themes: information and understanding of NPWT and expectations and experience of NPWT. The final category sets out participant recommendations about the device and has two themes: device issues and improving professional practice. CONCLUSION: This study investigated the experience of patients undergoing NPWT for complex wounds in the home setting and reveals a number of the psychosocial effects of using this therapy in this environment. Participants saw NPWT as an active intervention, associated with improved wound healing and symptom control. The participant experience described in this study, and the recommendations they make, provide a valuable resource to inform service improvement programmes and wound research. DECLARATION OF INTEREST: This study was supported by a research grant from Smith & Nephew Ltd.

Clinical predictors of leg ulcer healing.

Background Identification of factors associated with healing can help in understanding the causes of delayed healing in chronic leg ulceration, and can allow for programmes to be developed to modify these factors to improve patient outcomes. Objectives To determine factors associated with healing in patients with chronic leg ulceration of all types within a defined patient population. Methods The patients were identified within the combined acute/community leg ulcer service within Wandsworth Primary Care Trust. All identified patients agreed to be interviewed and those who were able underwent clinical and noninvasive testing to determine the cause of the ulceration. Follow ups were to a maximum of 48 weeks, with time to healing given as the principal outcome measure. Analysis was by the Cox proportional hazards model for both univariate and multivariate analysis. Results were expressed as hazard ratio with 95% confidence intervals derived from the models. Results In total, 113 patients took part in this study. Univariate analysis revealed statistically significant differences for delayed healing according to the ulcer duration (P = 0.002), complexity of the ulcer aetiology (P = 0.035), presence of lipodermatosclerosis (P = 0.02), history of deep vein thrombosis (DVT) (P = 0.03) and thrombophlebitis (P = 0.03). Multivariate analysis showed that ulcer duration (P = 0.014), DVT (P = 0.008) and a lack of Pseudomonas on wound swab (P = 0.005) were independently associated with delayed healing. Conclusions The results indicate the complexity of determining risk factors for poor healing in patients with chronic leg ulceration. There appears to be little scope for interventions to improve healing from the factors identified.

Psychological factors in leg ulceration: a case-control study.

BACKGROUND: There is increasing recognition of the role that psychological status plays in the development and outcomes of chronic disease, but little understanding of its importance in chronic leg ulceration. OBJECTIVES: To examine psychological health and perceived social support in patients with chronic leg ulceration. METHODS: Patients with leg ulceration within a defined population were matched for age and gender (1:1) with community controls in a matched case-control study. Analysis was by conditional logistic regression and matched t-test analysis. RESULTS: Ninety-five patients (60 women and 35 men; 59% aged over 75 years) were identified and matched to the same number of controls. Cases had significantly poorer health-related quality of life in all domains of the Nottingham Health Profile (all P < or = 0.001), compared with controls. Levels of depression (Hospital Anxiety and Depression Scale) were significantly greater in the patient group (mean 5.3 vs. 3.6, P < 0.001). Social support (Medical Outcomes Study Social Support Survey scale) showed significantly fewer social networks and less perceived social support in patients than controls (P = 0.008). Patients used significantly fewer coping strategies (COPE scale) than controls, particularly with regard to problem-focused coping strategies. CONCLUSIONS: Patients with leg ulceration experience poor psychological health with a greater risk of depression, less perceived social support and greater social isolation. Systems of care should offer an environment that reduces social isolation and increases support to this patient group.

Assessing community nurses' level of knowledge of lymphoedema.

As part of a major project to develop a primary care trust-based framework of lymphoedema management, the educational needs of community nurses regarding the care of patients with lymphoedema were assessed using focus groups and questionnaires. Community nurses assessed their current knowledge and skill in the care and management of patients with lymphoedema as adequate or poor. They were concerned about their lack of knowledge and skill and were uncertain regarding their role relative to other professions involved in the care of this patient group. At the same time they understood the importance of their role in providing ongoing care, recognizing problems, offering sound advice and referring on to a specialist practitioner when necessary. Any education provision that prepares community nurses for their role within a framework of lymphoedema management should emphasize the important place they occupy in providing long-term care for this patient group.

Prevalence of leg ulceration in a London population.

BACKGROUND: Current prevalence estimates of chronic leg ulceration are frequently based on studies from the 1980s. During the last decade, major changes have occurred in the application of evidence-based practice to this condition. AIM: To determine the prevalence and cause of leg ulceration in a defined geographical population after 8 years of providing standardized evidence based protocols of care. DESIGN: Prospective survey. METHODS: Patients with leg ulceration of >4 weeks duration) within an integrated acute and community leg ulcer service were ascertained, interviewed and clinically assessed, using a standardized questionnaire on medical history, ulcer details and non-invasive vascular investigation to describe causes. Ulcers were classified by aetiology. RESULTS: We identified 113 patients in a population of 252 000, giving a crude prevalence of 0.45/1000 (95%CI 0.37-0.54/1000): 0.34/1000 in men, 0.54/1000 in women. Rates were highly dependent on age, increasing to 8.29 (men) and 8.06/1000 (women) in those aged >85 years. Of the responders, 62/113 (55%) had their ulcer for >1 year. Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs; a further 21 had ulceration primarily due to arterial disease. Complex causes were present in 48 (35%) limbs, mostly venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%). DISCUSSION: Our prevalence of chronic leg ulceration is approximately one-third of that predicted by previous studies using similar methodologies in the 1980s. Patients with ulceration have more complex aetiologies than previously recognized, which may be a consequence of both increasing ulcer chronicity and age.

Lymphoedema: an underestimated health problem.

BACKGROUND: Lymphoedema/chronic oedema is an important cause of morbidity in the population, but little is known of its epidemiology and impact on patients or health services. AIM: To determine the magnitude of the problem of chronic oedema in the community, and the likely impact of oedema on use of health resources, employment and patient's quality of life. DESIGN: Questionnaire-based survey. METHODS: Health professionals from dedicated lymphoedema services, specific out-patient clinics, hospital wards and community services (GP clinics and district nurses) were contacted to provide information on patients from within South West London Community Trust. A subset of the identified patients was interviewed. RESULTS: Within the catchment area, 823 patients had chronic oedema (crude prevalence 1.33/1000). Prevalence increased with age (5.4/1000 in those aged > 65 years), and was higher in women (2.15 vs. 0.47/1000). Only 529 (64%) were receiving treatment, despite two specialist lymphoedema clinics within the catchment area. Of 228 patients interviewed, 78% had oedema lasting > 1 year. Over the previous year, 64/218 (29%) had had an acute infection in the affected area, 17/64 (27%) being admitted for intravenous antibiotics. Mean length of stay for this condition was 12 days, estimated mean cost pound 2300. Oedema caused time off work in > 80%, and affected employment status in 9%. Quality of life was below normal, with 50% experiencing pain or discomfort from their oedema. DISCUSSION: Chronic oedema is a common problem in the community with at least 100 000 patients suffering in the UK alone, a problem poorly recognized by health professionals. Lymphoedema arising for reasons other than cancer treatment is much more prevalent than generally perceived, yet resources for treatment are mainly cancer-based, leading to inequalities of care.

Venous ulcer healing: effect of socioeconomic factors in London.

OBJECTIVE: To determine which social and clinical factors are associated with healing in patients with venous ulceration. DESIGN: Patients were questioned about social factors at their first visit to a community ulcer clinic. They were treated by high compression bandage system and were interviewed again after 12 weeks. SETTING: Community leg ulcer clinics held in health centres throughout Riverside Health Authority in London. PATIENTS: All patients referred to five community leg ulcer clinics with venous ulceration over a six month period. MAIN OUTCOME MEASURES: These were factors significantly associated with healing within 12 weeks of beginning treatment, measured by odds ratio (OR) given by logistic regression analysis. MAIN RESULTS: Of 168 patients with venous ulceration, 87 (52%) healed after 12 weeks of treatment. Univariate analysis showed that low social class (OR = 3.44, 95% CI 1.17, 10.14), lack of central heating (OR = 2.22, 95% CI 1.18, 4.18), and being single (OR = 2.77, 95% CI 1.15, 6.69) were all significantly associated with delayed healing. After adjustment for the known risk factors of ulcer size, ulcer duration, and general mobility only lack of central heating was still significant (OR = 2.27, 95% CI 1.11, 4.55). The remaining factors failing to achieve statistical significance because of their inter-relationship with the known risk factors. CONCLUSIONS: Clinical features of the ulcer seem to determine the progress of healing in patients with leg ulceration. Although there were associations between socio-economic factors and poor healing, adjustment for clinical risk factors generally led to lower non-significant associations. Only lack of central heating retained its association and may play a part in prolonging healing of venous ulceration.

Compression bandaging - the state of the art.

A review of the role of compression bandaging and the current techniques and materials employed. Recent developments are explained and the need for future research is discussed.

Perspectives on concordance in leg ulcer management.

Non-concordance is all too often blamed on the patient. In reality it is more likely to reflect the relationship between the patient and practitioner. The second article in this series on leg ulceration explores issues surrounding concordance.

The Charing Cross high compression four-layer bandage system.

A guide to the uses and contraindications of compression bandaging and an explanation of the Charing Cross System.

Reviews.

THE NURSING MANAGEMENT OF LEG ULCERS IN THE COMMUNITY WOUND BALLISTICS AND THE SCIENTIFIC BACKGROUND.

Who suffers most from leg ulceration?

This study examines health-related quality of life (HRQoL) in patients with leg ulceration and determines which patient groups are affected most by this condition. A cross-sectional study using the Nottingham Health Profile (NHP) and age/sex-matched normal scores in patients entering six clinical audit cycles was carried out. The 758 patients included in the study (mean age 74.6 years, 64% women) had been affected by leg ulceration for a median of 10.5 months (range 0.5 to 708). Patients produced significantly higher scores than age/sex-matched normal values for all domains of the NHP, indicating poorer HRQoL (all p < 0.001). Increasing age led to greater deficits in energy (p < 0.001) and mobility (p < 0.001) with greater social isolation (p = 0.044). Women experienced poorer energy, sleep patterns, mobility and emotional reactions (all p < 0.001), and increased physical pain and social isolation (p < 0.05) compared to men. However, higher scores may be expected for older women based on age/sex-matched normal values. After adjustment for age/sex-matched normal values, it was the younger patients who experienced a greater deficit in HRQoL over all domains of the NHP, with men scoring higher than women in the domains of bodily pain, sleep and social isolation (p < 0.001) and energy (p = 0.015). Leg ulceration has a major impact on patients' HRQoL as detected by the NHP. The excess in scores compared with age/sex-matched normal values indicate that it is younger male patients in whom ulceration makes a greater impact on HRQoL.

Letters.

THE IMPORTANCE OF NUTRITION COMPARATIVE STUDIES USING THE PEGASUS AIRWAVE SYSTEM COMPRESSION BANDAGING CORRECTIONS.

Assessing a calcium alginate dressing for venous ulcers of the leg.

A small study of Tegagel calcium alginate dressings is described, with a discussion of the methodology employed.

An exploration of patients' understanding of leg ulceration.

OBJECTIVE: This study aimed to identify patients' understanding of leg ulceration by examining their knowledge of the disease process and their expectations of their treatment outcomes. It also aimed to identify their attitudes to any patient information provided to them. METHOD: A total of 101 patients (median age: 75 years, range: 23-91; 54% female) with current leg ulceration of 16 months' median duration (range: 1-480) were asked about their understanding of their condition and treatment and their expectations of patient information provided by health-care professionals. RESULTS: The majority of patients believed they knew the cause of their ulceration (66%), most frequently attributing it to trauma (28%). The most important part of the treatment was felt to be bandaging (27%) and visiting the clinic (12%). Thirty-nine percent did not know what the term 'venous' meant. 'Trauma' was frequently described as a psychological problem, with only 7% associating the word with a knock or wound. Over half of the patients (64%) expressed an interest in acquiring further information, particularly on how they could assist ulcer healing (51%). CONCLUSION: For patient education to be effective, it must be tailored to the patients' vocabulary using simple concepts and straightforward, unambiguous messages.

Clinical audit and effective change in leg ulcer services.

An audit of clinical leg ulcer services was undertaken in South Bedfordshire and was followed by a process of implementation using research-based methods; a re-audit was conducted 18 months later. Using an adaptation of the Riverside model, patients were referred to community leg ulcer clinics. They were assessed using Doppler ultrasound; those with ABPI > 0.8 were treated using a high-compression four-layer bandage system. Those with ABPI 0.6-0.8 were treated using reduced compression, and those with ABPI < 0.6 were sent to their GP for referral for specialist opinion. In October 1993, the average cost of consumables for each patient was 8.53 pounds, and this rose to 10.14 pounds in May 1995. However, patients treated in community clinics had a reduced cost of consumables of 7.91 pounds compared with 10.78 pounds for patients treated at home. There was also a corresponding reduction in weekly treatments and an overall reduction in nursing time to treat patients. In 111 patients (134 limbs) treated by high compression in the community clinics, cumulative percentage healing was 54% after 12 weeks and 68% after 24 weeks. Although these results were lower than those achieved in the Riverside project, much of the difference can be explained by the different patient populations and ulcer duration. The results support a system of care which offers rationalisation of service, staff training and research-based effective assessment and treatment.

Nutritional intake in community patients with pressure ulcers.

Nutritional status has been associated with the development and healing of pressure ulcers. This study aimed to examine the dietary intake of adults who had pressure ulcers (n = 75) and a control group with no pressure ulcers (n = 100), randomly selected from those receiving treatment from community nurses. All participants were considered to be at risk of developing pressure damage. Dietary intake was assessed using a 24-hour recall method (completed by 84 participants) and a nutritional questionnaire (completed by all 175 participants). The mean age of participants was 79 +/- 6 years and 70% were women. Patients who had pressure ulcers had a lower energy intake (mean difference -185 kcal, 95% confidence interval -413 to 43) and intake of protein (mean difference -6.73 g/day, 95% CI -16.20 to 2.74) but neither factor achieved a standard level of statistical significance. However, when protein was categorised into quartiles, a significantly higher proportion of participants with low intake had pressure ulcers on chi-squared analysis (p = 0.043). More participants who had pressure ulcers required assistance with eating (odds ratio 4.55, 95% CI 1.53 to 13.54) and more had experienced recent taste changes (odds ratio 3.28, 95% CI 1.19 to 9.10). While these differences were significant, there were few major differences between those who had pressure ulcers and the control group. A number of participants in both groups had poor nutritional intake and other risk factors for malnutrition were also found. Poor nutrition is a problem for all patients receiving community nursing care, not just those with pressure ulceration. Due to acknowledged difficulties in recording nutritional intake in elderly patients, further assessment of dietary intake in those receiving community nursing services should be undertaken to support these results.

Venous leg ulceration: treatment by high compression bandaging.

Venous leg ulceration is a major tissue viability problem that is becoming better recognized as clinical wound care practice changes from being anecdotal-based to research-based. The current prevalence of leg ulceration in the UK, Sweden and Australia is approximately 1 percent of the adult population, and approximately half a million in the United States. Between 70 and 90 percent of leg ulcers in the UK are venous in origin. Research has shown that graduated compression bandaging is an appropriate method of managing venous leg ulceration for many patients. Since Stemmer's work showing the usefulness of higher levels of external pressure (40 mmHg), the reliability and predictability of the four layer high compression bandaging system has been demonstrated. The purpose of this article is to introduce the extent of the venous leg ulceration problem, discuss risk factors and other aspects of venous leg ulceration, support the use of graduated compression, and describe the four layer high compression bandage system. The success of the four layer system is linked to the wider issues of using a research-based approach to the assessment and management of venous leg ulcers, and such an approach is integral to cost-effective, high quality patient care.