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Venous Insufficiency Ulcers [keywords]
- [Ankle brachial index measurement]. [English Abstract, Journal Article]
- Acta Med Croatica 2014 Oct.:123-6.
Ultrasound examinations are noninvasive diagnostic methods which, along with appropriate history and clinical examination, provide basic information on the etiology and spread of the disease, as well as on treatment options required in patients with chronic venous insufficiency and arterial flow impairment. Doppler flow meter offers useful data on venous blood return, primarily in great veins, while both deep and superficial veins as well as arteries can be visualized and data on venous and arterial hemodynamics obtained by duplex ultrasonography. In addition, Doppler flow meter provides data on the peripheral arterial system action through ankle brachial index measurement, which will guide the choice of compression therapy when deciding on the treatment of peripheral arterial disease and mixed arteriovenous leg ulcers. However, diagnosis of arterial insufficiency requires additional examinations.
- [Differential diagnosis and work up of chronic leg ulcers]. [English Abstract, Journal Article]
- Acta Med Croatica 2014 Oct.:25-30.
Many factors contribute to the pathogenesis of leg ulcers. The main causes are chronic venous insufficiency, peripheral arterial occlusive disease (PAOD) and diabetes. Some leg ulcers are caused by combinations of these well-known etiologic factors. The most common cause of PAOD is arteriosclerosis. In diabetic patients, distal symmetric neuropathy and peripheral vascular disease are probably the most important etiologic factors in the development of leg ulcers. Less frequent causes of chronic leg ulcers are hematologic diseases, autoimmune diseases, genetic defects, infections, primary skin disease, cutaneous malignant diseases, use of some medications and therapeutic procedures, and numerous exogenous factors. Diagnosis of leg ulcer is made upon medical history, clinical picture, palpation of arteries, functional testing and serologic testing. Device-based diagnostic testing should be performed for additional clarification. Also, lesion biopsy should be taken for histopathology, direct immunofluorescence, bacteriology and mycology. The knowledge of differential diagnosis is essential for ensuring treatment success in a patient with leg ulcer.
- [Chronic wounds as a public health problem]. [English Abstract, Journal Article]
- Acta Med Croatica 2014 Oct.:5-7.
Chronic wounds represent a significant burden to patients, health care professionals and the entire health care system. Regarding the healing process, wounds can be classified as acute or chronic wounds. A wound is considered chronic if healing does not occur within the expected period according to the wound etiology and localization. Chronic wounds can be classified as typical and atypical. The majority of wounds (95 percent) are typical ones, which include ischemic, neurotrophic and hypostatic ulcers and two separate entities: diabetic foot and decubital ulcers. Eighty 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 rest are mostly neuropathic ulcers. Chronic wounds significantly decrease the quality of life of patients by requiring continuous topical treatment, causing immobility and pain in a high percentage of patients. Chronic wounds affect elderly population. Chronic leg ulcers affect 0.6-3 percent of those aged over 60, increasing to over 5 percent of those aged over 80. Emergence of chronic wounds is a substantial socioeconomic problem as 1-2 percent of western population will suffer from it. This estimate is expected to rise due to the increasing proportion of elderly population along with the diabetic and obesity epidemic. It has been proved that chronic wounds account for the large proportion of costs in the health care system, even in rich societies. Socioeconomically, the management of chronic wounds reaches a total of 2-4 percent of the health budget in western countries. Treatment costs for some other diseases are not irrelevant, nor are the method and materials used for treating these wounds. Considering etiologic factors, a chronic wound demands a multidisciplinary approach with great efforts of health care professionals to treat it more efficiently, more simply and more painlessly for the patient, as well as more inexpensively for health care funds.
- Surgical Treatment of Large Vascular Leg Ulcers: A Retrospective Review Evaluating Risk Factors for Healing and Recurrence. [JOURNAL ARTICLE]
- Dermatol Surg 2014 Oct 10.
Superficial reflux ablation and revascularization improve the long-term prognosis of venous and arterial leg ulcers but do not solve the problem of protracted healing of large chronic wounds. Skin grafting has been shown to successfully heal chronic leg ulcers.To identify risk factors for ulcer healing and recurrence after shave therapy and split-skin grafting in patients with large ulcers treated surgically for venous insufficiency.Single-center retrospective cohort study involving 72 chronic leg ulcers with a mean area of 77 ± 132 cm. Healing and recurrence rates were determined using life-table analysis. Clinical, demographic, and hemodynamic parameters were correlated with healing and recurrence using Cox regression analysis.Sixty ulcers (83%) healed after a mean of 1.9 months and 15 ulcers (25%) recurred after a mean of 12.7 months. Healing was positively associated with compression treatment (hazard ratio [HR]: 2.02, 95% confidence interval [CI]: 1.14-3.59) and negatively associated with ulcer duration (HR: 0.99, 95% CI: 0.98-1.0). Male sex, ulcer duration, and deep venous reflux were identified as significant risk factors for ulcer recurrence (HR: 0.14, 95% CI: 0.03-0.73; HR: 1.02, 95% CI: 1.0-1.04; and HR: 5.4, 95% CI: 1.30-22.31).Early surgical intervention improves healing and reduces the risk of ulcer recurrence.
- Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: a randomised controlled trial. [JOURNAL ARTICLE]
- Phlebology 2014 Oct 8.
Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on healing.All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices <0.85 or >1.25, no venous reflux on duplex and <20% of ulcer surface covered with slough. Participants were randomly allocated to either 4-layer compression bandaging alone or 4-layer compression bandaging + larvae. Surface areas of ulcer and slough were assessed on day 4; 4-layer compression bandaging was then continued and ulcer size was measured every 2 weeks for up to 12 weeks.A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3-21.3) cm(2) and 8.1 (4.3-13.5) cm(2) in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann-Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm(2) in the 4-layer compression bandaging group (P < 0.05) and 4.2 cm(2) (P < 0.001) in the 4-layer compression bandaging + larvae group. Median percentage area reduction of slough was 50% in the 4-layer compression bandaging group and 84% in the 4-layer compression bandaging + larvae group (Mann-Whitney U test, P < 0.05). The 12-week healing rate was 73% and 68% in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Kaplan-Meier analysis, P = 0.664).Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.
- The perspectives of adults with venous leg ulcers on exercise: an exploratory study. [Journal Article]
- J Wound Care 2014 Oct; 23(10):496-509.
Exercise has the potential to offer a range of health benefits in addition to improving healing outcomes for people with venous leg ulcers (VLUs). However, despite evidence-based recommendations, most of these individuals do not engage in regular exercise. The aim of this study was to gain an understanding of the perspectives of adults with VLUs, in relation to exercise.This was a qualitative design using semi-structured interviews and discussions. Ten participants with venous leg ulceration volunteered to participate. Recruitment was through a specialist wound clinic. Verbatim data were collected by an experienced moderator using a semi-structured guide. Data saturation was reached after three group discussions and two interviews. A random selection of transcripts was sent back to the participants for verification. Thematic content analysis was used to determine major themes and categories. Two transcripts were independently analysed, categories and themes independently developed, cross checked and found comparable. Remaining transcripts were analysed using the developed categories and codes.Regardless of their current exercise routine, participants reported exercising before venous leg ulceration and expressed an interest in either becoming active or maintaining an active lifestyle. Overall, four themes emerged from the findings: i) participant understanding of the relationship between chronic venous insufficiency and exercise patterns; ii) fear of harm impacts upon positive beliefs and attitudes to exercise; iii) perceived factors limit exercise; and iv) structured management facilitates exercise.The value of exercise in improving outcomes in VLUs lies in its capacity to promote venous return and reduce the risk of secondary conditions in this population. Despite motivation and interest in being exercise active, people with VLUs report many obstacles. Further exploration of mechanisms that assist this patient population and promote understanding about management of barriers, coupled with promotion of enabling factors, is vital for improving their exercise participation.The authors declare that they have no competing interests.
- [Role of enterosorbents in treatment of complicated varicose disease]. [English Abstract, Journal Article]
- Klin Khir 2014 Jun; (6):43-5.
Results of treatment of 43 patients, suffering varicose disease, complicated by trophic disorders, were analyzed. To the patients a complex was prescribed, including sorpents, angioprotectors, locally - ointments. There were operated 14 patients.
- Acroangiodermatitis (Pseudo-Kaposi sarcoma). [Journal Article]
- Indian Dermatol Online J 2014 Jul; 5(3):323-5.
Acroangiodermatitis or Pseudo-Kaposi sarcoma is a rare angioproliferative entity, related to chronic venous insufficiency or certain other vascular anomalies. It is often associated with chronic venous insufficiency, arteriovenous malformation of the legs, chronic renal failure treated with dialysis, paralyzed legs and amputation stumps. We hereby describe a case of 45 year old female presenting with pitting pedal edema, multiple ulcers over bilateral lower limbs with irregular margins with erythema and hyperpigmentation of the surrounding skin. Color Doppler study of bilateral lower limbs was normal. Histopathological examination from one of the lesions showed hyperplastic epidermis, proliferation of capillaries in dermis, hemosiderin deposits and lymphocytic infiltrate. These features thus confirmed the diagnosis of Acroangiodermatitis.
- Behaviour of the plasma concentration of gelatinases and their tissue inhibitors in subjects with venous leg ulcers. [JOURNAL ARTICLE]
- Clin Hemorheol Microcirc 2014 Aug 26.
Venous leg ulcers are common in subjects with chronic venous insufficiency. The increased intraluminal pressure causes alteration of the skin microcirculation, leukocyte activation and release of proteolytic enzymes leading to ulceration. An impaired expression and activity of matrix metalloproteases (MMPs) and their tissue inhibitors (TIMPs) might influence extracellular matrix degradation and deposition in chronic venous ulcers with the failure of the healing process. Our aim was to evaluate plasma concentration of gelatinases (MMP-2 and MMP-9) and their inhibitors (TIMP-1 and TIMP-2) in subjects with venous leg ulcers before and after the compression therapy. We enrolled 36 subjects (12 men and 24 women, mean age 67.38 ± 12.7 yrs) with non-infected venous leg ulcers (CEAP C6), which underwent a color Duplex scan examination of the veins and arteries of the inferior limbs and were treated with a multi-layer bandaging system. The ulcer healing was obtained in 23 subjects only (9 men and 14 women). We evaluated, on fasting venous blood, the plasma levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 using ELISA kit, before and after the treatment. We observed a significant increase in plasma concentration of gelatinases and their inhibitors and in MMP-2/TIMP-2 ratio in subjects with leg ulcers in comparison with normal controls. In subjects with healed ulcers we found a decrease in MMP-9 and TIMP-1 levels and in MMP-2/TIMP-2 ratio compared to the baseline values, although higher levels of all the examined parameters in comparison with normal controls. In conclusion, plasma MMPs profile is impaired in subjects with venous leg ulcers and it improves after the healing, persisting anyway altered in respect to healthy controls.
- Validation of the disease-specific quality of life Wuerzburg Wound Score in patients with chronic leg ulcer. [Journal Article, Validation Studies]
- Vasa 2014 Sep; 43(5):372-9.
Aim of the study was to validate a newly developed disease-specific quality of life questionnaire (Wuerzburg Wound Score, WWS) in patients with chronic arterial or venous leg ulcers.In this prospective study 115 patients with vascular disease associated leg ulcer (54 arterial ulcer, 61 venous ulcer) were studied (mean age 66 ± 11 years, 51 % male). All patients completed the WWS at baseline, and after four and 12 weeks. To assess construct validity additionally all patients completed the generic QoL-questionnaires Short Form-36 (SF-36) and Nottingham Health Profile (NHP). Construct validity and responsiveness of the WWS were tested.WWS showed acceptable construct validity versus SF-36 (r = 0.5 - 0.78; P < 0.001) and NHP (r = 0.36 - 0.68; P < 0.001). Responsiveness of the WWS was superior to SF-36 (P < 0.05) and NHP (P = 0.01). Generic as well as disease-specific QoL were more impaired in patients with arterial ulcer.The WWS is a valid measure of disease-specific QoL in patients with leg ulcers and it is more sensitive than the generic instruments in detecting changes of wound healing over time. Further assessment of the psychometric properties of the WWS with larger patient samples is required before the test can be recommended for use in clinical practice.