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Venous Insufficiency Ulcers [keywords]
- Healing outcomes of MRSA-infected wounds with a protocol combining Oakin dressing with elements of the de-escalation theory. [Journal Article]
- J Wound Care 2014 Feb; 23(2):S4, S6-8, S10-1.
This paper presents a novel wound healing protocol for the treatment of MRSA-infected lower extremity wounds of various etiologies, and describes the healing rate at 30, 60 and 90 days.A total of 40 participants with singular wounds were enrolled and treated with a specially designed protocol, which involves elements of the de-escalation theory together with a wound dress containing Oakin, in a private practice setting or a wound care center. The primary endpoint was the number of participants who achieved wound closure at 90 days. Data analysed and collected included wound etiology, wound size, gender, healing time by setting, and days to heal overall. Due to the anticipated small cohort of wound types, several statistical calculations were considered, including one-way ANOVA, Pearson correlation, and Levene's test.All wounds were classified by etiology: 58% (n=23), diabetic neuropathic ulcers (DNU), 25% (n=10) venous insufficiency ulcers (VU), and 17% (n=7) pressure ulcers (PU). Overall, 35% (n=14) healed within 30 days (22.14 ± 4.47), 60% (n=24) healed in 60 days (31.76 ± 13.02), and 78% (n=31) healed in 90 days (40.81 ± 22.23). After 90 days, the remaining 23% (n=9) of participants were no longer followed.This clinical evaluation demonstrated the overall effectiveness of this treatment protocol by attaining nearly 80% wound closure within 90 days. This protocol is intended to provide a roadmap for clinicians to follow and adapt to their wound care practice should a high prevalence of MRSA-infected wounds be present.The author has disclosed that he has worked doing clinical case studies for Amerx Health Care Corp. and is on their speaker bureau. The author has also disclosed that he has no financial relationship or vested interest with Amerx Health Care Corp. No funding was provided by the NIH, Wellcome Trust, HHMI, or others.
- Overview of guidelines for the prevention and treatment of venous leg ulcers: a US perspective. [REVIEW]
- J Multidiscip Healthc 2014.:111-117.
Comprehensive care of chronic venous insufficiency and associated ulcers requires a multipronged and interprofessional approach to care. A comprehensive treatment approach includes exercise, nutritional assessment, compression therapy, vascular reconstruction, and advanced treatment modalities. National guidelines, meta-analyses, and original research studies provide evidence for the inclusion of these approaches in the patient plan of care. The purpose of this paper is to review present guidelines for prevention and treatment of venous leg ulcers as followed in the US. The paper further explores evidence-based yet pragmatic tools for the interprofessional team to use in the management of this complex disorder.
- The lived experiences of persons with chronic venous insufficiency and lower extremity ulcers. [Journal Article]
- J Wound Ostomy Continence Nurs 2014 Mar-Apr; 41(2):122-6.
The aim of this qualitative study was to describe the lived experience of chronic venous insufficiency (CVI) sufferers and to explore how this chronic disease affected their health-related quality of life.Participants included persons with a history of venous insufficiency and leg ulcers or active venous insufficiency patients. The research setting was a hospital-based outpatient wound care clinic in a small naval community approximately 1 hour from Seattle, Washington. A convenience sample of 10 patients participated in the study; 6 were women and their mean age was 66 years. Nine were white and 1 was African American, and all were currently retired, disabled, or unemployed.A 9-item interview guide was developed consisting of open-ended questions intended to elicit the lived experiences of persons with CVI.Respondents participated in 1 focus group or individual interviews. Interpretive phenomenological analysis was used to guide data collection and analysis. Three patients participated in individual interviews and 7 patients participated in a 1-hour focus group. Data obtained from personal interviews were handwritten and data from focus group were audio-recorded. Audio-recorded data from focus group participation were transcribed, analyzed, and compared with the handwritten interviews using interpretive phenomenological analysis.Four themes identifying the various emotional, physical, and social implications of living with CVI were identified. They were (1) knowledge deficit, (2) discomfort, (3) inconvenience, and (4) coping. Participants identified concerns with knowledge deficits surrounding CVI among nonwound specialized providers. Physical discomfort and issues around the inconvenience presented by the frequency of physician visits and the nature of the treatments for CVI were also noted as a great concern among all participants. Participants provided insight into the importance of a strong social network of friends and family as well as the importance of a good relationship with your medical providers to assist sufferers in coping with the disease process.Participants cited knowledge deficits regarding CVI among nonspecialized health care providers and the discomfort, pain, and inconvenience of suffering from CVI as contributors to poor health-related quality of life. Participants described family, friends, and caregiver relationships as being especially important in helping them cope with the disease process.
- Improving the management of varicose veins. [Journal Article]
- Practitioner 2013 Nov-Dec; 257(1766):21-4, 2-3.
Up to 30% of the UK population are affected by varicose veins. They are a manifestation of increased venous pressure in the lower limb caused by impaired venous return. Primary varicosities result from poor drainage from the superficial to the deep venous system. Secondary varicosities arise as a result of underlying pathology impeding venous drainage, such as deep venous thrombosis or increased intra-abdominal pressure caused by a mass, pregnancy or obesity. Patients with bleeding varicose veins should be referred to a vascular service immediately. Referral is also indicated in the following cases: symptomatic primary or recurrent varicose veins; lower limb skin changes thought to be caused by chronic venous insufficiency; superficial vein thrombosis and suspected venous incompetence; a venous leg ulcer or healed venous leg ulcer. Imaging is crucial in the assessment of the superficial and deep venous system to enable assessment of venous competence. The gold standard imaging technique is colour duplex ultrasonography. Duplex ultrasound should be used to confirm the diagnosis of varicose veins and the extent of truncal reflux, and to plan treatment for patients with suspected primary or recurrent varicose veins. Superficial vein ligation, phlebectomy and stripping have been the mainstay of treatment. In recent years, new techniques have been developed that are minimally invasive, enabling treatment of superficial venous incompetence with reduced morbidity. NICE recommends that endothermal ablation, in the form of radiofrequency or laser treatment, should be offered as treatment for patients with confirmed varicose veins and truncal reflux.
- Low-frequency Ultrasound for Patients With Lower Leg Ulcers Due to Chronic Venous Insufficiency: A Report of Two Cases. [Journal Article]
- Ostomy Wound Manage 2014 Feb; 60(2):52-61.
Low-frequency ultrasound may facilitate debridement and healing of chronic wounds, including lower leg wounds in patients with chronic venous insufficiency (CVI). To evaluate the use of a low-frequency ultrasound (LFU) device with a curette, two patients with CVI and chronic wounds were treated for a period of 2 to 3 weeks. A 63-year-old woman with rheumatoid arthritis and two wounds, one on the right lower leg (250 cm3) and one wound on the left medial leg (0.80 cm3), present for 12 months; and a 77-year-old man with cardiopulmonary issues with seven wounds, three on the left medial calf (1.2 cm3, 11.40 cm3, and 0.72 cm3), one on the left anterior calf (0.30 cm3), two on the right posterior calf (0.90 cm3, 0.30 cm3), and one on the right anterior calf (0.14 cm3), present for 3 months consented to participate in the study. Both patients received low-intensity (50-70 μm), low-frequency (35 kHz) ultrasound at an intensity of 50% through a saline mist in addition to antimicrobial dressing with silver, a multilayer compression bandage system applied at every visit, and pain medication as needed. Both patients received treatments every 1 to 3 weeks that were not timed. Treatment continued until no additional slough or other necrotic tissue could be removed from the wound bed; the female patient received two treatment sessions and the male received three. Average wound volume did not change significantly from the first to last treatment session (t(8) - 1.2, P = 0.26). Five wounds (56%) with initial measurements of 0.8 cm3, 0.72 cm3, 0.3 cm3, 0.3 cm3, and 0.14 cm3 reduced in volume by 100%. Mean wound characteristic scores changed significantly (P <0.05) for amount of fibrin, periwound skin, drainage amount, and color. In addition, the number of wounds filled with slough decreased from 89% at the first session to 22% at the final treatment session. The results of this study suggest LFU may have been beneficial for these patients with CVI. Additional studies using larger sample sizes are needed to evaluate the effect of this treatment on a variety of chronic wounds and to compare its effectiveness to other debridement methods.
- An integrated approach in the treatment of varicose ulcer. [Journal Article]
- Anc Sci Life 2013 Jan; 32(3):161-4.
Venous ulcers (stasis ulcers, varicose ulcers) are the wounds occurring due to inappropriate functioning of venous valves, usually of the legs. It is one of the most serious chronic venous insufficiency complications. The overall incidence rate is 0.76% in men and 1.42% in women. When a venous valve gets damaged, it prevents the backflow of blood, which causes pressure in the veins that leads to hypertension and, in turn, venous ulcers. These are mostly along the medial distal leg, which is often very painful, can bleed, and get infected. Treating varicose ulcers is a difficult task to the physician and a nightmare to the suffering patients, though a good number of the treatment principles are mentioned and practiced in allied sciences. In Ayurveda, this condition is considered as duṣṭa vraṇa. It can be managed with the specific s'odhana therapy. So, the same treatment protocol was used to treat the case discussed here, i.e. with Nitya virecana and by Basti karma. The wound was successfully treated and, therefore, is discussed in detail.
- The foot venous system: anatomy, physiology and relevance to clinical practice. [Journal Article]
- Dermatol Surg 2014 Mar; 40(3):225-33.
This review aims to summarize present knowledge of foot venous return, with a special interest in clinical and research implications.It is based on the latest available publications on foot anatomy and hemodynamics.Five systems are described: the superficial veins of the sole, the deep veins of the sole (with particular attention to the lateral plantar vein), the superficial dorsal plexus, the marginal veins and the dorsal arch and the perforating system. The Foot Pump: The physiology of venous return is briefly described, with an emphasis on the differences between standing and walking and the interplay of the foot and calf venous systems.The hypothesis that the foot and calf venous systems may be in conflict in several clinical conditions (localization of leg ulcers, corona phlebectatica, foot vein dilatation, arteriovenous fistulas of the foot, foot-free bandaging) is presented, briefly discussed, and mechanistically interpreted.Foot venous return could be more important than is commonly thought. Certain clinical conditions could be explained by a conflict between the mechanisms of the foot pump and the leg pumps most proximal to the foot, rather than by generic pump insufficiency, with possible effects on treatment and compression strategies.
- [Effect of compression therapy in the management of venous ulcer - practical experience]. [English Abstract, Journal Article]
- Acta Med Croatica 2013 Oct.:111-3.
Venous insufficiency is one of the most common causes of chronic wounds. Venous ulcers account for about 75% of all leg ulcers, and 50% of venous leg ulcers require long-term treatment lasting for more than 1 year. The most common location of venous ulcers is the lower third of the leg, as it is the site of strongest venous pressure; less often there are multiple venous ulcers that tend to be localized on both lower legs. In addition to the negative impact on the quality of life, such as immobility, pain and social isolation, which significantly affect the course and length of treatment, we cannot ignore the high costs of long-term and often uncertain treatment, which poses a major health, social and economic problem in the world and in our country.
- [List of diagnostic tests and procedures in leg ulcer]. [English Abstract, Journal Article]
- Acta Med Croatica 2013 Oct.:21-8.
Many factors contribute to the pathogenesis of leg ulcer. Most patients have venous leg ulcer due to chronic venous insufficiency. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. Leg ulcer may be of a mixed arteriovenous origin. In diabetic patients, distal symmetric neuropathy and peripheral vascular disease are probably the most important etiologic factors in the development of diabetic leg ulcer. Other causes of chronic leg ulcers are hematologic diseases, autoimmune diseases, genetic defects, infectious diseases, primary skin diseases, cutaneous malignant diseases, use of some medications and therapeutic procedures, and numerous exogenous factors. Diagnosis of leg ulcer is based on medical history, inspection, palpation of skin temperature, palpation of arteries, fascia holes, presence and degree of edema, firm painful cords, and functional testing to assess peripheral occlusive arterial disease or identify superficial and deep venous reflux of the legs. Knowledge of differential diagnosis is essential for ensuring treatment success in patients with leg ulcer. There are many possible etiologic factors of leg ulcers and sometimes, clinical findings are similar. Additional testing should be performed, e.g., serologic testing such as blood count, C-reactive protein, HBA1c, erythrocyte sedimentation rate, differential blood count, total proteins, electrolytes, coagulation parameters, circulating immune complex, cryoglobulins, homocysteins, AT, PAI-1, APC resistance, proteins C and S, paraproteins, ANA, ENA, ANCA, dsDNA, antiphospholipid antibodies, urea, creatinine, blood lipids, vitamins and trace elements. Also, biopsy of the lesion for histopathology, direct immunofluorescence, bacteriology and mycology should be included. Other tests are Raynaud (cold stimulation) test and pathergy test. Device-based diagnostic testing should be performed for future clarification. Ankle brachial pressure index, color duplex sonography, plethysmography, MSCT and MR angiography, digital subtraction angiography, phlebography, angiography, x-ray, and capillaroscopy in lupus erythematosus are indicated. Except for bacteriologic analyses of wound biopsies, there is no test to provide specific information on the wound condition.
- [Chronic wounds: differential diagnosis]. [English Abstract, Journal Article]
- Acta Med Croatica 2013 Oct.:11-20.
Wound is a disruption of anatomic and physiologic continuity of the skin. According to the healing process, wounds are classified as acute and chronic wounds. A wound is considered chronic if standard medical procedures do not lead to the expected healing, or if the wound does not heal within six weeks. Chronic wounds are classified as typical and atypical. Typical wounds include ischemic, neurotrophic and hypostatic wounds. Diabetic foot and decubitus ulcers stand out as a specific entity among typical wounds. About 80 percent of chronic wounds localized on lower leg are the result of chronic venous insufficiency, in 5-10 percent the cause is of arterial etiology, whereas the remainder are mostly neuropathic ulcers. About 95 percent of chronic wounds manifest as one of the above-mentioned entities. Other forms of chronic wounds are atypical chronic wounds, which can be caused by autoimmune disorders, infectious diseases, vascular diseases and vasculopathies, metabolic and genetic diseases, neoplasm, external factors, psychiatric disorders, drug related reactions, etc. Numerous systemic diseases can present with atypical wounds. The primary cause of the wound can be either systemic disease itself (Crohn's disease) or aberrant immune response due to systemic disease (pyoderma gangrenosum, paraneoplastic syndrome). Although atypical wounds are a rare cause of chronic wounds, it should always be taken in consideration during diagnostic procedure.