Can tissue dielectric constant measurement aid in differentiating lymphoedema from lipoedema in women with swollen legs?

BACKGROUND: Distinguishing lymphoedema from lipoedema in women with swollen legs can be difficult. Local tissue water content can be quantified using tissue dielectric constant (TDC) measurements. OBJECTIVES: To examine whether TDC measurements can differentiate untreated lower extremity lymphoedema from lipoedema, and to test interobserver agreement. METHODS: Thirty-nine women participated in the study; 10 patients with lipoedema (LipP), nine patients with untreated lymphoedema (U-LP), 10 patients with lymphoedema treated with compression bandaging for ≥ 4 weeks (T-LP) and 10 healthy controls. All subjects were measured at three predefined sites (foot, ankle and lower leg). All groups except U-LP were measured by three blinded investigators. Using a handheld device, a 300-MHz electromagnetic wave is transmitted into the skin via a 2.5-mm depth probe. TDC calculated from the reflected wave is directly proportional to tissue water content ranging from 1 (vacuum) to 78.5 (pure water). RESULTS: Mean ± SD TDC values for U-LP were 48.8 ± 5.2. TDC values of T-LP, LipP and controls were 34.0 ± 6.6, 29.5 ± 6.2 and 32.3 ± 5.7, respectively. U-LP had significantly higher TDC values in all measurement sites compared with all other groups (P < 0.001). A cut-off value of 40 for ankle and lower-leg measurements correctly differentiated all U-LP from LipP and controls. Intraclass correlation coefficients were 0.94 for the ankle and the lower leg and 0.63 for the foot. CONCLUSIONS: TDC values of U-LP were significantly higher than those of T-LP, LipP and controls and may aid in differentiating lymphoedema from lipoedema. Interobserver agreement was high in ankle and lower-leg measurements but low in foot measurements.

Do ready-made compression stockings fit the anatomy of the venous leg ulcer patient?

OBJECTIVE: How usable two standardised measuring methods are for the selection of three different brands of ready-made below-knee compression stockings. Furthermore, this study aims to determine how many of the included patients fit into a ready-made compression stocking in a limited selection of brands. METHOD: Consecutive patients suffering from venous insufficiency and treated at a specialised wound healing centre were included in this prospective comparative study. Two standardised measuring methods were used to evaluate the suitability of three different brands of ready-made below knee compression stockings. The circumference was measured at three points and seven points below the knee. The results of these measurements were compared to three selected brands of ready-made compression stockings. RESULTS: Together, 43 consecutive patients (25 men and 18 women) were included in the study. When the leg was measured at three points, 53.5%, 34.9% and 0% of the patients fitted into brand 1, brand 2 and brand 3 of the ready-made compression stockings, respectively. When measured at seven points, only 4.7% of the patients fitted into brand 1, 7% in brand 2 and 0% of the patients fitted into brand 3. CONCLUSION: These results demonstrate that there is a need to standardise measuring methods in the selection of ready-made below-knee compression stockings and a need for an evaluation of the present stocking sizes in relation to the anatomy of the venous leg ulcer patient. This study has shown that ready-made compression stockings presently prescribed will not properly fit the majority of patients to prevent oedema and ulcer recurrence. Further studies focused on the development of new sizes or changes in fitting recommendations may help solve these problems. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with regard to the manuscript or its content.

Point prevalence of wounds and cost impact in the acute and community setting in Denmark.

OBJECTIVE: To estimate the wound-care related costs in two hospitals in Denmark. METHOD: A point-prevalence survey with a focus on resource consumption was carried out during a representative 1-week period in March 20 I 0, in two hospitals in Denmark: Regional Hospital Viborg, in the Viborg Municipality and Hillerod Hospital, in the Horsholm Municipality. Data were collected during a 2-day period for inpatients and outpatients in the hospitals and over a full week in the municipalities. The survey included information on the numbers, types and locations of the wounds, as well as resource consumption related to dressing changes. The estimation of costs was based on representative cost levels, including the salaries of health professionals or nurses and the cost of dressings and hospitalisation provided. RESULTS: In total, 33% (n=830) of inpatients had a wound. The majority of these were surgical/trauma wounds (25%), while pressure ulcers, leg ulcers and diabetic foot ulcers accounted for 3.3%, 1.7% and 1.6%, respectively. In the municipalities, there was a wound patient prevalence of 2.8 per I 000 population(I I I 000 acute wounds, 0.7/ I 000 pressure ulcers, 0.5/ I 000 leg ulcers and 0.3/ I 000 diabetic foot ulcers).The extrapolated figures for nurse time related to wound care per year was equivalent to I 0 full-time nurse positions in Hillerod Hospital, three in Viborg Hospital, 17 in Viborg Municipality and three in Horsholm Municipality. The total annual costs related to wound care was estimated as €3.6 million for Viborg Hospital, €4.1 million for Hillemd Hospital, € 1.2 million for Viborg Municipality and €232 548 for Horsholm Municipality, accounting for approximately 1.8% (Viborg), 1.6% (Hillerod), 2.4% (Viborg) and1.5% (Horsholm) of the total annual budgets. CONCLUSION: In the survey, 33% of the patients treated in the hospitals had a wound. Primary costs were defined as hospitalisation costs and nurse time related to dressing changes. Total annual costs of treatment, including hospitalisation, were estimated as approximately 1.6-1.8% for the hospitals and 1.5-2.4% for the municipalities. The level of costs support the relevance of increased efforts to secure better wound prevention and treatment to reduce the staff-time consumption and hospitalisation costs.

Antimicrobials and Non-healing Wounds Evidence, controversies and suggestions.

Non-healing wounds are a significant problem for health-care systems worldwide. In the industrialised world, almost 1-1.5% of the population will have a problem wound at any one time. Furthermore, wound management is expensive; in Europe, the average cost per episode is 6650 euros for leg ulcers and 10 000 euros for foot ulcers, and wound management accounts for 2-4% of health-care budgets. These figures are expected to rise along with an increased elderly and diabetic population.1-4.

A new concept of a multidisciplinary lymphoedema centre: established in connection to a department of dermatology and the Copenhagen Wound Healing Center.

BACKGROUND: Lymphoedema is increasingly recognized as a significant problem in healthcare. The number of patients is growing, posing a future challenge to healthcare systems and economics. Over the past decade, specialized lymphoedema management has been established around the world to accommodate the growing demands. However, information on organization, experiences and outcome are scarce. OBJECTIVES: To conduct a clinical perspective analysis describing the establishment, organization, function and results of a new, multidisciplinary lymphoedema centre functioning as a university hospital unit in connection to a department of dermatology and the Copenhagen Wound Healing Center and integrated as a national expert function in the public healthcare organization of Denmark. METHODS: Data were collected following the establishment of a lymphoedema centre based on the structured, multidisciplinary organization of lymphoedema management. RESULTS: During the first 4·5 years a total of 8058 patient consultations were performed. The mean duration of symptoms at the first visit was 19 years (range 1-67) and 31% of patients had never received any diagnosis or treatment prior to referral. Complications were found in 48% of referred patients. All patients received appropriate diagnostic investigations and treatment according to best practice. Multidisciplinary assessment involving four or more different healthcare professions was needed in 86% of cases. Research opportunities and expert education of staff were enhanced. CONCLUSIONS: A multidisciplinary lymphoedema centre improves management, knowledge and awareness of lymphoedema. This model, with minor adjustments, may be applicable for other regions and countries.

Cost of wound treatment to increase significantly in Denmark over the next decade.

OBJECTIVE: To demonstrate that changes in demography, life expectancy and incidence of background diseases (including type 2 diabetes mellitus) during the period 2009-2020 will significantly increase the costs of wound care in Denmark. METHOD: A simple activity-based equation, which was applied to Danish national statistics on medical conditions and key financial figures from previously published surveys. RESULTS: Currently, DKK 735m (99m Euro) is spent each year on municipal wound care. Denmark's population is 5.4 million and about 18,000 wounds can be expected annually in the municipal sector, requiring more than three million dressing changes. These figures are expected to rise significantly up until 2020. The percentage of senior citizens will rise by 22% during this time and the number of patients with type 2 diabetes mellitus will increase by 22-24,000 per year. Improved treatments and longer life expectancies will increase the elderly population by 40,000. These changes will cause a gradual rise in wound care costs of up to 30%, corresponding to DKK 224m (30m Euro) in 2020. However, by adopting a national strategy based on best practice guidelines, it may be possible to intercept this increase in costs. A national strategy in Denmark seems to have the potential to reduce costs by a matching 30%. If Denmark fails to adopt a national strategy, an accumulated loss of DKK 1.5 billion (206m Euro) can be expected over the next decade. CONCLUSION: Wound therapy will pose a major economic challenge to Denmark in future if no intervention is carried out. This study presents an empirical model calculating the economic consequences of future challenges such as demography, lifestyle and type 2 diabetes mellitus. It is suggested that a national strategy for wound therapy may convert a future deficit to zero-balance. Similar challenges are expected in other western European countries.

Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management.

While there is a consensus that clinical practice should be evidence based, this can be difficult to achieve due to confusion about the value of the various approaches to wound management. To address this, the European Wound Management Association (EWMA) set up a Patient Outcome Group whose remit was to produce recommendations on clinical data collection in wound care. This document, produced by the group and disseminated by JWC, identifies criteria for producing rigorous outcomes in both randomised controlled trials and clinical studies, and describes how to ensure studies are consistent and reproducible.

The EWMA Patient Outcome Group.

Across Europe, clinical experts in wound care and industry representatives have joined forces to propose recommendations for clinical data collection on chronic wound management. Here, the chair of the group, Finn Gottrup, outlines its main objectives.

The resource impact of wounds on health-care providers in Europe.

Most of the literature focuses on the resources required to manage particular wound types, rather than the cost of wounds to health-care organisations. Until this information is available, wound care is unlikely to be a management priority.

Current management of wound healing.

While the understanding of wound pathophysiology has progressed considerably over the past decades the improvements in clinical treatment has occurred to a minor degree. During the last years, however, new trends and initiatives have been launched, and we will continue to attain new information in the next decade. It is the hope that increasing parts of the new knowledge from basic wound healing research will be implemented in daily clinical practice. The development of new treatment products will also continue, and especially new technologies with combined types of dressing materials or dressing containing active substances will be accentuated. Further developments in the management structure and education will also continue and consensus of treatment guidelines, recommendations and organization models will hopefully be achieved.

Trends in surgical wound healing.

The understanding of acute and chronic wound pathophysiology has progressed considerably over the past decades. Unfortunately, improvement in clinical practice has not followed suit, although new trends and developments have improved the outcome of wound treatment in many ways. This review focuses on promising clinical development in major wound problems in general and on postoperative infections in particular.

Combined use of an ibuprofen-releasing foam dressing and silver dressing on infected leg ulcers.

OBJECTIVE: To investigate the effect and safety of an ibuprofen-releasing foam (Biatain-Ibu, Coloplast A/S) combined with an ionised silver-releasing wound contact layer (Physiotulle Ag, Coloplast A/S) on painful, infected venous leg ulcers. METHOD: This open non-comparative study involved 24 patients with painful, exuding, locally infected, and stalled venous leg ulcers. Persistent pain and pain at dressing change were monitored using a 11-point numerical box scale (NBS). The composition of the wound bed, the dressing combination's ability to absorb exudate and minimise leakage, ibuprofen content in the exudate, reduction in wound area and adverse effects were also recorded. RESULTS: Persistent wound pain decreased from a mean of 6.3 +/- 2.2 to 3.0 +/- 1.7 after 12 hours and remained low thereafter. Pain at dressing change also decreased and remained low. Forty-eight hours after the first dressing application, the mean concentration of ibuprofen in the wound exudate reached a constant level of 35 +/- 21 microg/ml. After 31 days, the relative wound area had reduced by 42%, with an associated decrease in fibrin and an increase in granulation tissue. The number of patients with wound malodour decreased from 37% to 4%. No serious adverse events were reported. CONCLUSION: The combined use of the ibuprofen-releasing foam dressing and silver-releasing contact layer reduced wound pain and promoted healing without compromising safety.

Biophysical effects of repetitive removal of adhesive dressings on peri-ulcer skin.

OBJECTIVE: To study the effect of repeated removal of four different adhesive dressings on peri-ulcer skin using quantitative non-invasive techniques. METHOD: Forty-five patients with open (n = 29) or healed (n = 16) venous leg ulcers were included. Peri-ulcer skin was treated for 14 days with patches of two different hydrocolloid-based adhesive dressings, one polyurethane adhesive and one soft silicone adhesive dressing. Normal skin of the patients' ventral forearm was also treated identically. Adhesive patches of the dressings were replaced every second day. The skin barrier function was assessed by measuring transepidermal water loss and stratum corneum hydration by measuring electrical conductance. RESULTS: Thirty-nine patients completed the study. The hydrocolloid adhesives increased transepidermal water loss and conductance while the polyurethane and soft silicone adhesives did not influence these parameters significantly compared with adjacent non-treated peri-ulcer skin. For normal forearm skin, similar relative effects among the four adhesives were found. CONCLUSION: Repetitive treatment with hydrocolloid-based adhesive dressings induced major functional alterations of the stratum corneum. In contrast, a polyurethane adhesive and a soft silicone adhesive dressing did not alter transepidermal water loss or conductance of peri-ulcer skin.

Effect of a new silver dressing on chronic venous leg ulcers with signs of critical colonisation.

OBJECTIVE: To investigate the clinical performance and safety of a new silver-containing wound-contact layer, Physiotulle -Ag (Coloplast), in the treatment of chronic venous leg ulcers with delayed healing and signs of critical colonisation. METHOD: This was an open prospective non-comparative multicentre clinical study. Patients were treated for four weeks with Physiotulle -Ag, which was covered by Alione Hydrocapillary Dressing (Coloplast). RESULTS: Thirty patients were recruited into the study. One ulcer healed after three weeks of treatment. The mean relative ulcer area reduced by 55% after four weeks. Over the study period the mean amount of healthy granulation tissue increased from 26% to 62%, and the mean amount of fibrin decreased from 63% to 32%. The ratio of malodorous wounds was 50% at inclusion, 20% after one week and 3% after four weeks. The dressing was considered easy or very easy to apply in 100% and easy to remove in 89% of dressing evaluations. The dressing combination showed good exudate-management properties. Incidence and severity of maceration, erythema and eczema decreased during the study and no device-related adverse events were recorded. CONCLUSION: Physiotulle -Ag is safe and easy to use in chronic venous leg ulcers in which healing is delayed and with signs of critical colonisation.

Evaluation of the quality of venous leg ulcer care given in a multidisciplinary specialist centre.

OBJECTIVE: To determine the quality of venous leg ulcer care given in a multidisciplinary, specialist wound-healing centre and to identify problem areas that might affect it. METHOD: The case records of 90 consecutive patients with venous leg ulcers, diagnosed and treated at the Copenhagen Wound Healing Centre, Denmark, were retrospectively audited by a Scandinavian cross-sectional and multidisciplinary expert panel. Quality of care was audited in each case using implicit criteria. The experts then formulated key recommendations for good clinical practice for patients with venous leg ulcers. RESULTS: Quality of care was satisfactory in 74 patients (82%). The one-year healing rate was 77% (69/90), with a three-month recurrence rate of 12% (11/90). Identified problem areas included the lack of systematic assessment of patients' suitability for surgery; lack of systematic, duplex-verified diagnoses of venous aetiology; and the lack of systematic examination of distal arterial pressure. The recommendations include the need for venous diagnosis, differential diagnosis, compression therapy, surgery, systemic treatment, access to venous leg ulcer care and better communication. CONCLUSION: The quality of venous leg ulcer care given in this multidisciplinary centre was satisfactory.

Use of a hydrocapillary dressing in the management of highly exuding ulcers: a comparative study.

OBJECTIVE: To evaluate the safety and performance of Alione Hydrocapillary dressing (Coloplast A/S) in the management of highly exuding chronic venous leg ulcers and compare it with two hydropolymer dressings,Tielle and Tielle Plus (Johnson & Johnson). METHOD: A comparative clinical trial was conducted on 97 patients with an ankle brachial pressure index > or = 0.8 and a highly exuding leg ulcer. Ulcer duration was at least four weeks. Treatment continued until healing or for a maximum of 12 months. RESULTS: There was no statistically significant difference in healing time or wound area reduction between the two treatment protocols. The test dressing (Alione Hydrocapillary) had better absorption capacity and was more comfortable for the patients than the comparator dressings (Tielle/Tielle Plus) and adhered less to the wound bed.Also, more patients preferred the test dressing to their previous treatment. Although severe leakage and maceration were observed more frequently in the comparator group compared with the test group, this was not statistically significant. CONCLUSION: Both treatment protocols were safe and effective in treating highly exuding chronic venous leg ulcers. The test dressing performed as well as or better than the comparator dressings for all study parameters and more patients preferred the test dressing to their previous dressing compared with the comparator dressings.

Sustained silver-releasing dressing in the treatment of diabetic foot ulcers.

This study investigated the clinical performance and safety of a sustained silver-releasing foam dressing, Contreet Foam, in the treatment of diabetic foot ulcers. Twenty-seven patients with diabetic foot ulcers of grade I or II (Wagner's classification) were followed for six weeks: one week run-in using Biatain dressings, four weeks' treatment with Contreet dressings. Four ulcers healed during the four-week treatment with Contreet 56% in average. Contreet Foam showed good exudate management properties and was considered easy to use. Only two infections occurred showed that all six of the non-study ulcers developed an infection during the study. All ulcers (study ulcers as well as non-study ulcers) were treated according to good practice of diabetic wound care. There were no directions for the treatment of secondary wounds. No device-related adverse events were observed. This study demonstrated that Contreet Foam is safe and easy to use and effectively supports healing and good wound progress of diabetic foot ulcers.

Immunohistochemical characterization of the cutaneous cellular infiltrate in different areas of chronic leg ulcers.

Current understanding of the immunological mechanisms involved in the pathogenesis of venous leg ulcers is insufficient. In this study the cellular composition of skin biopsies taken from the center, the edge, and 2 cm distant from the edge of venous leg ulcers was characterized quantitatively by immunohistochemical staining. In the epidermis the mean numbers of Langerhans cells (CD1a+) were four times lower at the edge of the ulcer compared to clinically intact epidermis 2 cm distant from the edge. In the dermis a statistically significant increase in the mean numbers of macrophages (CD68+) and neutrophils (NP57+) from the distant area towards the center of the ulcer was observed. No significant differences were observed in the distribution of T cells nor in the ratio of CD4+/CD8+ T-cell subsets between the different regions of the ulcer. About 30% of T lymphocytes were CD8+ in all microenvironments. The center and the edge of the ulcer were dominated by macrophages comprising 63% and 53% of the cells respectively, while T lymphocytes dominated the distant area. The area 2 cm distant from the edge was also heavily infiltrated by macrophages and neutrophils. B cells (CD22+) and NK cells (CD56+) were relatively rare in all areas, comprising less than 3% of the dermal infiltrate. In conclusion, local microenvironments each with a different cellular composition can be defined within venous leg ulcers.