Exploring the Association between Hemochromatosis and Lower-Limb Venous Disease.

OBJECTIVE: Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. METHODS: Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. RESULTS: This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. CONCLUSIONS: This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

Clinical correlates of pain in adults with hard-to-heal leg ulcers: a cross-sectional study.

OBJECTIVE: Pain is a complex symptom associated with hard-to-heal (chronic) leg ulcers that is often poorly managed. The objective of this study was to gain greater understanding by investigating relationships between physical and psychosocial factors, and pain severity in adults with hard-to-heal leg ulcers. METHOD: A secondary analysis of data collected for a longitudinal, observational study of adults with hard-to-heal leg ulcers was undertaken. Data were collected over a 24-week period, including variables relating to sociodemographics, clinical variables, medical status, health, ulcer and vascular histories, and psychosocial measures. Multiple linear regression modelling was used to determine the independent influences of these variables on pain severity, as measured with a Numerical Rating Scale (NRS). RESULTS: Of 142 participants who were recruited, 109 met the inclusion criteria for this study, of whom: 43.1% had venous ulcers; 41.3% had mixed ulcers; 7.3% had arterial ulcers; and 8.3% had ulcers from some other cause. The final model explained 37% (adjusted r2=0.370) of the variation in the pain NRS scores. Controlling for analgesic use, salbutamol use (p=0.005), clinical signs of infection (p=0.027) and ulcer severity (p=0.001) were significantly associated with increased pain, while the presence of diabetes (p=0.007) was significantly associated with a decrease in pain. CONCLUSION: Pain is a highly complex and pervasive symptom associated with hard-to-heal leg ulcers. Novel variables were identified as being associated with pain in this population. The model also included wound type as a variable; however, despite being significantly correlated to pain at the bivariate level of analysis, in the final model, the variable did not reach significance. Of the variables included in the model, salbutamol use was the second most significant. This is a unique finding that, to the authors' knowledge, has not been previously reported or studied. Further research is required to better understand these findings and pain in general.

Exploring the prevalence and management of wounds for people with dementia in long-term care.

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Implementation of the Champions for Skin Integrity model to improve leg and foot ulcer care in the primary healthcare setting.

AIMS: To facilitate evidence-based leg and foot ulcer management through implementation of the Champions for Skin Integrity model to education in primary health care in Australia. BACKGROUND: Leg and foot ulcers are frequently seen wounds in general practice and wound care the most frequently performed activity by practice nurses. The literature reports the lack of evidence-based leg and foot ulcer assessment, management and prevention strategies in this setting, and previous research in regard to confidence and knowledge has indicated that general practice health professionals have the greatest need for education in wound care. DESIGN: Pre-post, nonequivalent group research design. METHODS: The Champions for Skin Integrity model of evidence-based wound management utilised strategies including workshops, development of Champions and use of resources. Pre- and post-implementation health professional surveys and patient clinical audits were completed. Descriptive statistics were calculated for all variables. Paired t tests identified statistically significant differences between the pre/post staff survey data. STROBE guidelines for reporting were followed (See Appendix S1). RESULTS: One hundred nine general practice healthcare professional staff attended the workshops. Significant outcomes were noted in increased levels of confidence in ability to assess, manage and prevent all types of leg and foot ulcers, as well as to apply evidence-based practice and change management following workshops. Pre- and post-skin audits also indicated an increase in evidence-based practices. CONCLUSION: Implementation of Champions for Skin Integrity strategies in this sample of primary healthcare professionals in general practice fostered a positive change in evidence-based wound management, assessment and prevention. RELEVANCE TO CLINICAL PRACTICE: The Champions for Skin Integrity model has supported increases in evidence-based practices in treatment and management of wounds in primary healthcare professionals, similar to the positive outcomes gained in the aged care setting. This is likely to lead to positive outcomes for those with wounds in this setting.

The effectiveness of hyperbaric oxygen therapy for healing chronic venous leg ulcers: A randomized, double-blind, placebo-controlled trial.

Over 30% of venous leg ulcers do not heal despite evidence-based treatment. This study aimed to determine the effectiveness of Hyperbaric Oxygen Therapy (HBOT) as an adjunct treatment for nonhealing venous leg ulcers. A randomized, double-blind, parallel group, placebo-controlled trial was undertaken in three hyperbaric medicine units. Adults with a venous leg ulcer, Transcutaneous Oxygen Measurement indicative of a hypoxic wound responsive to oxygen challenge, and without contraindications for HBOT; were eligible. Of 84 eligible patients, 10 refused and 74 enrolled. 43 participants achieved over 50% ulcer Percent Area Reduction (PAR) after four weeks of evidence-based care and were thus excluded from the intervention phase. Thirty-one participants were randomized to either 30 HBOT treatments (100% oxygen at 2.4 atmospheres absolute (ATA) for 80 minutes), or 30 "placebo" treatments, receiving a validated "sham" air protocol, initially pressurized to 1.2ATA, then cycled between 1.05-1.2ATA for eight minutes before settling at 1.05ATA. The primary outcome was numbers in each group completely healed. Secondary outcomes were ulcer PAR, pain and quality of life, 12 weeks after commencing interventions. The participants' mean age was 70 years (standard deviation (SD) 12.9) and median ulcer duration at enrolment was 62 weeks (range 4-3120). At 12 weeks, there was no significant difference between groups in the numbers completely healed. The HBOT intervention group had a mean of 95 (SD 6.53) ulcer PAR, compared to 54 (SD 67.8) mean PAR for the placebo group (t = -2.24, p = 0.042, mean difference -40.8, SE 18.2) at 12 weeks. HBOT may improve refractory healing in venous leg ulcers, however patient selection is important. In this study, HBOT as an adjunct treatment for nonhealing patients returned indolent ulcers to a healing trajectory.

Predicting delayed healing: The diagnostic accuracy of a venous leg ulcer risk assessment tool.

The aim of this study was to validate a newly developed tool that can predict the risk of failure to heal of a venous leg ulcer in 24 weeks. The risk assessment tool was validated, and performance of the tool was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Retrospective and prospective validation was conducted through multi-site, longitudinal studies. In the retrospective study (n = 318), 30% of ulcers did not heal within 24 weeks, with the tool demonstrating an AUC of 0.80 (95% CI, 0.68-0.93, P < .001) for the total score. In the prospective study across 10 clinical sites (n = 225), 31% (n = 68) of ulcers did not heal within 24 weeks. Participants were classified with the RAT at enrolment as being at low risk (27%), moderate risk (53%) or high risk (20%) of delayed healing; the proportion of wounds unhealed at 24 weeks was 6%, 29% and 59%, respectively. Validation results of the total score indicated good discrimination and goodness of fit with an AUC of 0.78 (95% CI, 0.71-0.85, P < .001). Validation of this risk assessment tool offers assurance that realistic outcomes can be predicted for patients, and scores can guide early decisions on interventions to address specific risk factors for failing to heal, thus promoting timely healing.

Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool.

The aim of this study was to validate a newly developed tool for predicting the risk of recurrence within 12 months of a venous leg ulcer healing. Performance of the tool to predict recurrence within a 12-month period was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Multi-site retrospective and prospective longitudinal studies were undertaken to validate a risk assessment tool for the recurrence of venous leg ulcers within 12 months. In the retrospective study (n = 250), 55% of venous leg ulcers recurred within 12 months, and the risk assessment total score had excellent discrimination and goodness of fit with an AUC of 0.83 (95% CI, 0.76-0.90, P < .001). The prospective study (n = 143) observed that 50.4% (n = 63) of venous leg ulcers recurred within 12 months of healing. Participants were classified using the risk assessment tool as being at low risk (28%), moderate risk (59%), and high risk (13%); the proportion of wounds recurring at 12 months was 15%, 61%, and 67% for each group, respectively. Validation results indicated good discrimination and goodness of fit, with an AUC of 0.73 (95% CI, 0.64-0.82, P < .001). Validation of this risk assessment tool for the recurrence of venous leg ulcers provides clinicians with a resource to identify high-risk patients and to guide decisions on adjunctive, tailored interventions to address the specific risk factors to decrease the risk of recurrence.

Reduced prevalence and severity of wounds following implementation of the Champions for Skin Integrity model to facilitate uptake of evidence-based practice in aged care.

AIMS AND OBJECTIVES: To evaluate the implementation of the Champions for Skin Integrity model on facilitating uptake of evidence-based wound management and improving skin integrity in residents of aged care facilities. BACKGROUND: The incidence of skin tears, pressure injuries and leg ulcers increases with age, and such wounds can be a serious issue in aged care facilities. Older adults are not only at higher risk for wounds related to chronic disease but also injuries related to falls and manual handling requirements. DESIGN: A longitudinal, pre-post design. METHODS: The Champions for Skin Integrity model was developed using evidence-based strategies for transfer of evidence into practice. Data were collected before and six months after implementation of the model. Data on wound management and skin integrity were obtained from two random samples of residents (n = 200 pre; n = 201 post) from seven aged care facilities. A staff survey was also undertaken (n = 126 pre; n = 143 post) of experience, knowledge and evidence-based wound management. Descriptive statistics were calculated for all variables. Where relevant, chi-square for independence or t-tests were used to identify differences between the pre-/postdata. RESULTS: There was a significant decrease in the number of residents with a wound of any type (54% pre vs 43% post, χ2 4·2, p = 0·041), as well as a significant reduction in specific wound types, for example pressure injuries (24% pre vs 10% post, χ2 14·1, p < 0·001), following implementation of the model. An increase in implementation of evidence-based wound management and prevention strategies was observed in the postimplementation sample in comparison with the preimplementation sample. This included use of limb protectors and/or protective clothing 6% pre vs 20% post (χ2 17·0, p < 0·001) and use of an emollient or soap alternative for bathing residents (50% pre vs 74% post, χ2 13·9, p = 0·001). CONCLUSIONS: Implementation of the model in this sample fostered an increase in implementation of evidence-based wound management and prevention strategies, which was associated with a decrease in the prevalence and severity of wounds. RELEVANCE TO CLINICAL PRACTICE: This study suggests the Champions for Skin Integrity model has the potential to improve uptake of evidence-based wound management and improve skin integrity for older adults.

Testing the effectiveness of a self-efficacy based exercise intervention for adults with venous leg ulcers: protocol of a randomised controlled trial.

BACKGROUND: Exercise and adequate self-management capacity may be important strategies in the management of venous leg ulcers. However, it remains unclear if exercise improves the healing rates of venous leg ulcers and if a self-management exercise program based on self-efficacy theory is well adhered to. METHOD/DESIGN: This is a randomised controlled in adults with venous leg ulcers to determine the effectiveness of a self-efficacy based exercise intervention. Participants with venous leg ulcers are recruited from 3 clinical sites in Australia. After collection of baseline data, participants are randomised to either an intervention group or control group. The control group receive usual care, as recommended by evidence based guidelines. The intervention group receive an individualised program of calf muscle exercises and walking. The twelve week exercise program integrates multiple elements, including up to six telephone delivered behavioural coaching and goal setting sessions, supported by written materials, a pedometer and two follow-up booster calls if required. Participants are encouraged to seek social support among their friends, self-monitor their weekly steps and lower limb exercises. The control group are supported by a generic information sheet that the intervention group also receive encouraging lower limb exercises, a pedometer for self-management and phone calls at the same time points as the intervention group. The primary outcome is the healing rates of venous leg ulcers which are assessed at fortnightly clinic appointments. Secondary outcomes, assessed at baseline and 12 weeks: functional ability (range of ankle motion and Tinetti gait and balance score), quality of life and self-management scores. DISCUSSION: This study seeks to address a significant gap in current wound management practice by providing evidence for the effectiveness of a home-based exercise program for adults with venous leg ulcers. Theory-driven, evidence-based strategies that can improve an individual's exercise self-efficacy and self-management capacity could have a significant impact in improving the management of people with venous leg ulcers. Information gained from this study will provide much needed information on management of this chronic disease to promote health and independence in this population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000475842.

The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial.

An increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems are available. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a four-layer compression bandage system and Class 3 compression hosiery on healing and quality of life (QL) in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and QL for 24 weeks. After 24 weeks, 86% of the four-layer bandage group and 77% of the hosiery group were healed (P = 0·24). Median time to healing for the bandage group was 10 weeks, in comparison with 14 weeks for the hosiery group (P = 0·018). The Cox proportional hazards regression found participants in the four-layer system were 2·1 times (95% CI 1·2-3·5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in QL or pain measures. Findings indicate that these systems were equally effective in healing patients by 24 weeks; however, a four-layer system may produce a more rapid response.

Predicting the Likelihood of Delayed Venous Leg Ulcer Healing and Recurrence: Development and Reliability Testing of Risk Assessment Tools.

Venous leg ulcers are characterized by a long healing process and repeated cycles of ulceration. A secondary analysis of data from multisite longitudinal studies was conducted to identify risk factors for delayed healing and recurrence of venous leg ulcers for development of risk assessment tools, and a single-site prospective study was performed to as- sess the new tools' interrater reliability (IRR). The development of the risk assessment tools was based on results from previous multivariate analyses combined with further risk factors documented in the literature from systematic reviews, randomized controlled trials, and cohort studies with regard to delayed healing and recurrence. The delayed healing tool contained 10 items, including patient demographics, living status, use of high-compression therapy, ulcer area, wound bed tissue type, and percent reduction in ulcer area after 2 weeks. The recurrence tool included 8 items, including his- tory of deep vein thrombosis, duration of previous ulcer, history of previous ulcers, body mass index, living alone, leg elevation, walking, and compression. Using consensus procedures, content validity was established by an advisory group of 21 expert multidisciplinary clinicians and researchers. To determine intraclass correlation (ICC) and IRR, 3 rat- ers assessed 26 patients with an open ulcer and 22 with a healed ulcer. IRR analysis indicated statistically signi cant agreement for the delayed healing tool (ICC 0.84; 95% con dence interval [CI], 0.70-0.92; P <.001) and the recurrence tool (ICC 0.88; 95% CI, 0.75-0.94; P <.001). The development and reliability results of these risk assessment tools meet the recommendations for evidence-based, reliable tools and may bene t clinicians and patients in the management of venous leg ulcers. Studies to examine the items with low ICC scores and to determine the predictive validity of these tools are warranted.