Venous ulcers

“Hot Ulcer” of the Hand Caused by Retrograde Flow of Arterialized Blood from an Arteriovenous Fistula

Venous hypertension of the hand and forearm is a rare complication of upper extremity arteriovenous (AV) fistula operations for hemodialysis. In severe cases of hand venous hypertension, nonischemic skin ulceration may develop. Our observed case and systematic analysis of the literature show that these venous ulcers of the hand typically are associated with retrograde arterialization of distal fistula vein side branches. We suggest calling these hyperemic skin lesions “hot ulcers” in order to distinguish them from ischemic ulcers. In most instances, hot ulcers are curable by selective ligation of the venous tributaries. If proximal venous outflow is also obstructed, attempts of outflow reconstruction should be undertaken. If this is not feasible, the AV fistula needs to be completely reconstructed.

Topical dressings to manage pain in venous leg ulceration

The pain experienced by patients with venous leg ulceration can be severe, disabling and have an impact on their quality of life. Pain assessment should be an integral part of leg ulcer assessment, since unless pain is successfully managed, the patient may not be able to comply with compression bandaging or exercise and elevation, all of which are crucial components in the successful management of venous leg ulceration. Neuropathic pain can be difficult to identify for both patient and healthcare professional, if it is unrecognized and untreated the patient's ulceration may persist due to an inability to tolerate dressings or bandaging.

Evaluation of dermal pericapillary fibrin cuffs in venous ulceration using confocal microscopy

Dermal pericapillary fibrin is a hallmark of venous disease and is thought to play a pathogenic role in the development of ulceration. However, the actual spatial configuration of pericapillary fibrin is unknown, and it remains unclear whether it truly represents a barrier that can impair physiological exchanges between the blood and dermis. Using confocal microscopy on tissue specimens taken from the edges of venous ulcers in six patients, we report a detailed analysis of dermal pericapillary fibrin deposits. Sections were evaluated with an antibody to human fibrinogen/fibrin and viewed, vertically and horizontally, with confocal microscopy. The distribution of fibrin deposition was highly variable and patchy, with areas of great intensity next to others of marginal intensity. Vertical cut sections showed the highest concentration of fluorescent material next to the lumen of dermal capillaries. Horizontal sections showed that maximal fluorescence was distributed at random. Our findings indicate that fibrin deposits in venous ulcers are patchy and discontinuous around dermal vessels. As such, these deposits are unlikely to act as a true and stable anatomic barrier as originally proposed. However, pericapillary fibrin may still act as a physiological barrier under conditions of poor blood flow where even marginal or patchy fibrin deposition might have a greater effect on the exchange of oxygen and other nutrients between blood and dermis.

Survey of bacterial diversity in chronic wounds using pyrosequencing, DGGE, and full ribosome shotgun sequencing

BACKGROUND

Chronic wound pathogenic biofilms are host-pathogen environments that colonize and exist as a cohabitation of many bacterial species. These bacterial populations cooperate to promote their own survival and the chronic nature of the infection. Few studies have performed extensive surveys of the bacterial populations that occur within different types of chronic wound biofilms. The use of 3 separate16S-based molecular amplifications followed by pyrosequencing, shotgun Sanger sequencing, and denaturing gradient gel electrophoresis were utilized to survey the major populations of bacteria that occur in the pathogenic biofilms of three types of chronic wound types: diabetic foot ulcers (D), venous leg ulcers (V), and pressure ulcers (P).

RESULTS

There are specific major populations of bacteria that were evident in the biofilms of all chronic wound types, including Staphylococcus, Pseudomonas, Peptoniphilus, Enterobacter, Stenotrophomonas, Finegoldia, and Serratia spp. Each of the wound types reveals marked differences in bacterial populations, such as pressure ulcers in which 62% of the populations were identified as obligate anaerobes. There were also populations of bacteria that were identified but not recognized as wound pathogens, such as Abiotrophia para-adiacens and Rhodopseudomonas spp. Results of molecular analyses were also compared to those obtained using traditional culture-based diagnostics. Only in one wound type did culture methods correctly identify the primary bacterial population indicating the need for improved diagnostic methods.

CONCLUSION

If clinicians can gain a better understanding of the wound's microbiota, it will give them a greater understanding of the wound's ecology and will allow them to better manage healing of the wound improving the prognosis of patients. This research highlights the necessity to begin evaluating, studying, and treating chronic wound pathogenic biofilms as multi-species entities in order to improve the outcomes of patients. This survey will also foster the pioneering and development of new molecular diagnostic tools, which can be used to identify the community compositions of chronic wound pathogenic biofilms and other medical biofilm infections.

Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds

BACKGROUND

Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored.

OBJECTIVE

(1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine.

CONCLUSIONS

A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.

Update on tissue-engineered biological dressings

Tissue-engineered biological dressings offer promise in the treatment of burns, chronic ulcers, donor site and other surgical wounds, and a variety of blistering and desquamating dermatologic conditions. For example, the prevalence of diabetic foot ulcers ranges from 4.4% to 10.5% of diabetics, resulting in 82,000 lower extremity amputations annually; venous leg ulcers affect 0.18% to 1.35% of the population; and pressure ulcers are found in 5.0% to 8.8% of institutionalized patients and 14.8% of patients in acute care facilities. Despite the large number of potential beneficiaries, cellular tissue-engineered products have suffered setbacks in recent years and have garnered considerably lower market share than commercial promoters anticipated. The mechanism of action of these products is not universally agreed upon, but delivery of growth factors and extracellular matrix components to the wound is thought to be important; graft "take" is not usually considered to occur. These "engineered" products do not specifically match a treatment modality to an underlying pathology. Clinical effect is often modest, and sometimes not justi- fiable from a cost-benefit perspective. Nevertheless, clinical reports in the literature of uses of tissueengineered biological dressings continue to mount, indicating that these products are finding niche applications where clinical utility is high and the cost can be defended. Despite commercial setbacks, the first-approved products, Dermagraft, Apligraf, and Cultured Epidermal Autograft (Epicel) are still being marketed, and new ones, such as OrCel, continue to be developed. The major indications for these products are summarized and a brief review of the available clinical literature is offered.

Treatment of nonhealing ulcers with allografts

Chronic wounds often represent a significant medical and economic challenge. Clinicians seek novel therapies poised to foster production of granulation tissue and subsequent healing. Cadaveric allograft remains the mainstay in burn therapy. Research, however, shows that this treatment functions adjunctively in complex nonhealing wounds by manipulating the microenvironment, preventing desiccation of underlying bone and tendon, augmenting wound-bed preparation, and producing rapid closure. The following review presents the rationale for incorporating skin allografts into the wound healing algorithm, including chronic wound biochemistry, wound-bed preparation, current applications, combination therapies, cost considerations, and case studies. Diagnosis and treatment of underlying etiologies remains essential. A multidisciplinary approach using accepted treatment protocols helps reduce morbidity and expense associated with these lesions.

Orchestrating wound healing: assessing and preparing the wound bed

PURPOSE

To provide an overview of the steps needed to prepare the wound bed for healing.

TARGET AUDIENCE

This continuing-education activity is intended for physicians and nurses with an interest in learning about the process for preparing the wound bed for healing.

LEARNING OBJECTIVES

After reading the article and taking the test, the participant will be able to: 1. Describe the anatomy and physiology of the skin. 2. Describe the wound healing process, the local and systemic factors that may impair healing, and the parameters that assess the wound status. 3. Describe the steps in the process to prepare the wound bed for healing.

Development of a severity scale for evaluating the need for Graftskin in nonhealing venous ulcers

OBJECTIVE

To construct an easy-to-use severity scale based on data from a multicenter venous leg ulcer trial to predict which wounds will progress toward closure and which will remain unhealed.

DESIGN

Factors that have an impact on wound healing (eg, ulcer duration, depth, area, location, and fibrin) were identified in the literature. A severity scale was constructed based on these factors.

SETTING

Multicenter clinical trial.

PATIENTS

240 patients with venous leg ulcers of longer than 1 month's duration.

MAIN RESULTS

Wound duration and area were identified as having the greatest impact on ulcer healing. Using multivariate regression analyses, a wound score of 8 or less was considered mild to moderate. A severe wound, having a score of 9 or greater, was found to be unlikely to heal with compression therapy alone.

CONCLUSION

This severity scale can serve as an adjunctive tool in the prompt identification of ulcers with a poor healing prognosis and enable early intervention with alternate therapies. To optimize the severity scale, future trials should incorporate a method to review the interaction of known factors that impair wound healing.

Validation of venous leg ulcer guidelines in the United States and United Kingdom

BACKGROUND

Venous leg ulcers account for 85% of all lower-extremity ulcers, with treatment costs of 3 billion dollars and loss of 2 million workdays per year. The purpose of this study was to validate the clinical efficacy and cost effectiveness of multidisciplinary guidelines for the diagnosis and treatment of venous leg ulcers.

METHODS

Eighty (40 retrospective, 40 prospective) patients from the United States and United Kingdom were enrolled.

RESULTS

United States patients were 6.5 times and United Kingdom 2 times more likely to heal if a guideline was followed (P <0.001). A significant decrease was noted in healing time for both the United States and United Kingdom (P <0.01), and the median cost decreased significantly when the guideline was followed (P <0.01).

CONCLUSIONS

Implementation of a guideline for diagnosis and treatment of venous leg ulcers resulted in improvement in diagnosis, decrease in healing time, and an increase in healing rates resulting in lower costs.

Microcirculatory changes in travelers to a tropical country

BACKGROUND

Travelers to tropical areas seem to be affected by nonhealing leg ulcers more frequently. One of the factors that can affect wound healing in a negative manner is leg edema. This study was performed to determine whether there is increased leg edema in travelers to tropical areas.

METHOD

In this study, we measured the capillary filtration rate (CFR) of the lower leg by strain gauge plethysmography, as a measure of leg edema, on location in Surinam. Three groups were included: A, travelers in the first few weeks after arrival; B, travelers who had stayed in the tropics for a minimum of 2 months; C, native inhabitants.

RESULTS

The mean CFR (mL/100 mL tissue/min) was significantly higher in group A than in groups B and C; the difference between groups B and C was not significant (group A 0.05 mL/100 mL tissue/min (standard deviation (SD), 0.03) vs. group B 0.02 mL/100 mL tissue/min (SD, 0.02), P = 0.01, and vs. group C 0.02 mL/100 mL tissue/min (SD, 0.02), P = 0.01).

CONCLUSIONS

Travelers to tropical areas are affected by increased CFR in the first few weeks after arrival. A prolonged stay leads to the normalization of the CFR. Compression therapy is recommended for travelers to the tropics.

Chronic venous insufficiency in persons with a history of injection drug use

Persons with a history of injection drug use have many risk factors for the development of chronic venous insufficiency (CVI), yet this phenomenon has not been studied systematically in this population. Persons (N = 204) with a history of injection drug use who were in enrolled in a treatment center were examined for clinical manifestations of CVI. The CVI clinical classification was graded on a 7-point scale for each leg. Most participants (n = 179, 87.7%) exhibited clinical evidence of CVI. Significant predictors of CVI clinical manifestations were leg infections/cellulitis (rho =.53); years injection in the veins of the groin, legs, and feet (rho =.47); deep vein thrombosis (rho =.37); and total years injection heroin (rho =.27). There was a linear functional relationship between years of injection drug use and the CVI clinical classification, but only when the injections were in the veins of the groin, legs, or feet; otherwise, the specific mechanisms of this relationship were not evident. The findings indicate that CVI is a common occurrence in persons who have injected drugs.

Guidelines in practice: the effect on healing of venous ulcers

OBJECTIVE

To determine the effect of guidelines on vascular assessment, compression usage, dressing selection, and healing rates of patients with a venous ulcer.

DESIGN

Prospective descriptive intervention evaluation.

SETTING

Oxfordshire Community National Health Service (NHS) Trust, United Kingdom.

PATIENTS

40 consecutive prospective patients seen by Oxfordshire district nurses, either at home or at a wound clinic coordinated by district nurses located in a surgery office.

INTERVENTION

The Guideline for Diagnosis and Treatment of Venous Leg Ulcers (University of Pennsylvania) and the Oxfordshire Leg Ulcer Guideline.

MAIN OUTCOME MEASURES

Time to healing, compliance with vascular assessment, compression usage, and nursing costs.

MAIN RESULTS

91% of patients had a vascular assessment; all patients were treated with compression. Mean time to healing was 8 weeks and was not related to dressing selection or type of compression (short- versus long-stretch bandage). Nursing costs were slightly higher for wounds that healed after 12 weeks and were treated with a long-stretch bandage (Pound Sterling 170.00 [$250.00] vs Pound Sterling 272.00 [$395.00]).

CONCLUSION

Use of compression was influenced by guidelines that emphasize a vascular assessment. Choice of dressing or type of compression was not a significant factor in healing rates.

Compression wraps for venous ulcer healing: a review

Compression to the lower extremities is used to increase healing of venous stasis ulcers by improving the blood supply and reducing edema and distension. Compression wraps are available in elastic or non-elastic and in single to multilayer systems requiring varying types of application and exerting different levels of compression. Elimination of edema is so basic and important to venous ulcer healing that the most effective level of compression should be used. Controversy exists regarding the most effective sub-bandage pressure (ranging from 20 mm Hg to 45 mm Hg) for timely healing. Because of differences in compression wraps, selection of the most effective and efficient wrap can be difficult. The purpose of this integrated review was to determine healing rates of venous ulcers with various wraps. The studies reviewed provide reasonable evidence that venous ulcers can be healed with the use of compression wraps and that various wraps are effective when used with correct assessment, application, and fit by the caregiver, along with compliance and mobility of the patient.

A bilayered living skin construct (APLIGRAF) accelerates complete closure of hard-to-heal venous ulcers

The efficacy of a bilayered, living skin construct (APLIGRAF(R) [Graftskin]) was evaluated in patients (n = 120) with hard- to-heal venous leg ulcers of greater than 1 year's duration. The study was prospective, randomized, and controlled. Patients received Graftskin plus compression therapy, or standard compression therapy (active control). Patients were evaluated for frequency and time to complete (100%) wound closure. Treatment with Graftskin was significantly more effective than active control in the percentage of patients healed by 6 months (47% vs. 19%; p < 0.005) and the median time to complete wound closure (p < 0.005). Analysis with multivariate regression methods, adjusting for factors generally thought to influence wound healing (duration, baseline area, depth, location, fibrinous wound bed, and infection), showed that patients treated with Graftskin were twice as likely to achieve complete wound closure by 6 months (p < 0.005), and over 60% more effective in achieving wound closure than active control (p < 0.01). These data indicate that Graftskin is an effective treatment for venous ulcers of greater than 1 year's duration.

Medical costs of treating venous stasis ulcers: evidence from a retrospective cohort study

Venous stasis ulcers (VSU) account for approximately 80-90% of lower extremity ulcerations. Given their prevalence and chronic nature, VSU are thought to impose a significant economic burden on Medicare (the USA's largest health insurance program) and other third party payers. However, comprehensive studies on the costs of VSU treatment are lacking. The objective of this study therefore was to examine comprehensively the direct medical costs of treating patients with a VSU in routine clinical practice. A cohort of 78 patients who presented with a VSU to the Cleveland Clinic Foundation (CCF), a large primary and tertiary referral center, was studied retrospectively. All inpatient and outpatient costs related to VSU treatment that were incurred during the year following VSU presentation or until the ulcer healed, whichever occurred first, were quantified. A total of 71 (91%) patients healed during the study. The average duration of follow-up was 119 days (median: 84 days). The average number of visits per patient was seven (range: 2 to 57). A total of 14 (18%) patients underwent 18 hospitalizations for VSU care. The average total medical cost per patient was $9685 (median: $3036). Home health care, hospitalizations and home dressing changes accounted for 48%, 25% and 21% of total costs, respectively. Total costs were related to duration of active therapy, ulcer size and the presence of at least one comorbidity (p<0.05). VSU are costly to manage, especially when time to healing is prolonged. The present findings reflect an underestimate of VSU costs since indirect costs were not examined. Time absent from work, forced early retirement, loss of functional independence and unquantifiable suffering may be additional factors that contribute to the overall burden of VSU.

Venous ulcers: etiology and care of patients treated with human skin equivalent grafts

Care for a patient with a venous ulcer is complex, necessitating collaboration of a multidisciplinary team to achieve the goal of providing comprehensive wound care and optimally managing complications, current conditions, and healing time. Patients often have venous ulcers for a long time, and they frequently have multiple diagnoses. Chronic ulcers that do not heal necessitate closure with a graft. Apligraf, (Novartis Pharmaceutical Corp, East Hanover, NJ), a human skin equivalent, is often used in nonhealing or difficult-to-heal ulcers. Knowledge of how to care for the grafted wound and protection of the grafted site is essential.

Clinical benchmark for healing of chronic venous ulcers. Venous Ulcer Study Collaborators

BACKGROUND

To determine the results of standardized ulcer treatment regimes and effects of the oral thromboxane A2 antagonist Ifetroban (250 mg daily) on healing of chronic lower-extremity venous stasis ulcers.

METHODS

In a prospective, randomized, double blind, placebo-controlled multicenter study, 165 patients were randomized to Ifetroban (n = 83) versus placebo (n = 82) for a period of 12 weeks. Both groups were treated with sustained graduated compression and hydrocolloid. Ulcer size was measured weekly by tracings and computerized planimetry. A total of 150 patients completed the study.

RESULTS

Complete ulcer healing was achieved after 12 weeks in 55% of patients receiving Ifetroban and in 54% of those taking a placebo with no significant differences; 84% of ulcers in both groups achieved greater than 50% area reduction in size.

CONCLUSIONS

These results are likely to be useful as a benchmark for comparison with other treatment protocols concerning the care of chronic lower-extremity stasis ulcers.

Treatment of venous leg ulcers: 1

The management of venous leg ulcers is an important issue for many health-care professionals. If treatment is to be successful, it is vital that clinicians understand the physiology and disease processes of the venous system in general, and of venous ulceration in particular. Part one of this two-part article presents an outline of the normal physiology of the venous system in the lower limb followed by a brief history of venous leg ulcers and an in-depth analysis of the way in which venous disease can lead to ulceration. The analysis compares traditional theories of leg ulcer development with current hypotheses. Part two will look at the treatment of venous ulcers and associated nursing implications.