Standards of care for venous leg ulcers: compression therapy and moist wound healing

Using a modified Delphi methodology to gain consensus on the use of dressings in chronic wounds management

OBJECTIVE

Managing chronic wounds is associated with a burden to patients, caregivers, health services and society and there is a lack of clarity regarding the role of dressings in improving outcomes. This study aimed to provide understanding on a range of topics, including: the definition of chronicity in wounds, the burden of illness, clinical outcomes of reducing healing time and the impact of early interventions on clinical and economic outcomes and the role of matrix metalloproteinases (MMPs) in wound healing.

METHOD

A systematic review of the literature was carried out on the role of dressings in diabetic foot ulcer (DFU), and venous leg ulcer (VLU) management strategies, their effectiveness, associated resource use/cost, and quality of life (QoL) impact on patients. From this evidence-base statements were written regarding chronicity in wounds, burden of illness, healing time, and the role of MMPs, early interventions and dressings. A modified Delphi methodology involving two iterations of email questionnaires followed by a face-to-face meeting was used to validate the statements, in order to arrive at a consensus for each. Clinical experts were selected, representing nurses, surgeons, podiatrists, academics, and policy experts.

RESULTS

In the first round, 38/47 statements reached or exceeded the consensus threshold of 80% and none were rejected. According to the protocol, any statement not confirmed or rejected had to be modified using the comments from participants and resubmitted. In the second round, 5/9 remaining statements were confirmed and none rejected, leaving 4 to discuss at the meeting. All final statements were confirmed with at least 80% consensus.

CONCLUSION

This modified Delphi panel sought to gain clarity from clinical experts surrounding the use of dressings in the management of chronic wounds. A full consensus statement was developed to help clinicians and policy makers improve the management of patients with these conditions.

The Effects of Wearing Undersized Lower-Body Compression Garments on Endurance Running Performance

Purpose:

To examine whether wearing various size lower-body compression garments improves physiological and performance parameters related to endurance running in well-trained athletes.

Methods:

Eleven well-trained middle-distance runners and triathletes (age: 28.4 ± 10.0 y; height: 177.3 ± 4.7 cm; body mass: 72.6 ± 8.0 kg; VO2max: 59.0 ± 6.7 mL·kg–1·min–1) completed repeat progressive maximal tests (PMT) and time-to-exhaustion (TTE) tests at 90% VO2max wearing either manufacturer-recommended LBCG (rLBCG), undersized LBCG (uLBCG), or loose running shorts (CONT). During all exercise testing, several systemic and peripheral physiological measures were taken.

Results:

The results indicated similar effects of wearing rLBCG and uLBCG compared with the control. Across the PMT, wearing either LBCG resulted in significantly (P < .05) increased oxygen consumption, O2 pulse, and deoxyhemoglobin (HHb) and decreased running economy, oxyhemoglobin, and tissue oxygenation index (TOI) at low-intensity speeds (8–10 km·h–1). At higher speeds (12–18 km·h-1), wearing LBCG increased regional blood fow (nTHI) and HHb values, but significantly lowered heart rate and TOI. During the TTE, wearing either LBCG significantly (P < .05) increased HHb concentration, whereas wearing uLBCG also significantly (P < .05) increased nTHI. No improvement in endurance running performance was observed in either compression condition.

Conclusion:

The results suggest that wearing LBCG facilitated a small number of cardiorespiratory and peripheral physiological benefits that appeared mostly related to improvements in venous flow. However, these improvements appear trivial to athletes, as they did not correspond to any improvement in endurance running performance.

Efficacy and tolerance of a hydrocolloid dressing containing hyaluronic acid for the treatment of leg ulcers of venous or mixed origin

OBJECTIVE

This study was aimed at comparing efficacy and tolerance of a new hydrocolloid dressing containing hyaluronic acid (HC + HA) to a reference hydrocolloid not containing hyaluronic acid (HC) in the treatment of leg ulcers of venous or mixed origin.

RESEARCH DESIGN AND METHODS

This was an open, prospective study, randomized in parallel groups, in which 125 patients were enrolled and treated for up to 42 days. The primary efficacy criterion was the reduction of the wound area; other efficacy criteria were the condition of the wound bed, and of the surrounding skin, and presence and severity of symptoms such as pain and itching.

RESULTS

After 42 days of treatment the median reduction of ulcer area was -42.6% (95% confidence interval [CI]: -66.6; -5.7) and -31.0% (95% CI: -51.6; -8.8) in the HC + HA group and in the reference HC group, respectively. The difference between treatments was not statistically significant. A reduction > or = 90% of the initial ulcer area was seen in 15 patients in the HC + HA dressing group and in only seven patients in the HC dressing group. Changes in wound bed condition in the two groups were not significantly different, except for a more marked reduction of fibrinous tissue in the HC + HA dressing group (p = 0.04), at Day 28. Both treatments were well tolerated.

CONCLUSIONS

The HC + HA dressing was equally well tolerated and with a trend to be more effective than the reference HC dressing in the treatment of leg ulcers of venous or mixed origin. Further research is needed to confirm these findings.

Paciente con úlceras vasculares y factores de riesgo cardiovascular

We present the case of a patient with severe obesity, type 2 diabetes mellitus, hypertension, and chronic venous insufficiency, as well as several vascular ulcers in the right extremity with complex clinical course. The importance of the treatment and follow-up of these vascular ulcers in primary care is essential to achieve healing or improvement. Because primary care centers can provide easy access and daily evaluation -if required-, the clinical course of vascular ulcers can be more favorable in this setting than in the hospital setting, where appointments are less frequent. In our case, the patient required several changes of treatment; at all times, the importance of controlling all the cardiovascular risk factors was explained to the patient. The involvement of the patient and his family in the disease, as well as follow-up in the primary care center, were essential to obtaining improvement.

Compression and peri-ulcer skin in outpatients' venous leg ulcers: results of a French survey

OBJECTIVE

To evaluate concordance with compression therapy in ambulatory patients with venous leg ulcers.

METHOD

This was a prospective observational survey conducted in general practice. Consecutive patients with venous leg ulcers about to receive a non-adherent primary dressing and with no contraindication to compression bandaging were selected. At the inclusion visit, size, local aspect of the ulcer and the peri-ulcer skin were scored. Patients were asked about concordance with compression and were given a questionnaire to be completed at home. If patients were seen at a three-week follow-up visit, ulcer and peri-ulcer characteristics and concordance were reassessed.

RESULTS

A total of 2842 patients were included, of whom 2532 were re-evaluated at three weeks and 1397 (49%) returned their questionnaire. A compression bandage was already available for 62.9% of these patients, and 62.7% said they used it on a daily basis, 23.3% wore it one or two days per week and 13.7% wore it irregularly or never. There was a statistically significant correlation between concordance with compression and ulcer and peri-ulcer skin severity scores (p < 0.001 and p = 0.042 respectively). At the follow-up visit, concordance with compression therapy improved (80.1% were wearing it regularly). Ulcer, peri-ulcer skin severity scores and ulcer size were significantly lower (p < 0.001) when concordance with compression therapy was good. However, 65.6% of patients considered applying compression very difficult; 45% considered it very unaesthetic and 23% judge wearing it to be very painful, while 9% thought it may worsen their ulcer.

CONCLUSION

On a short-term basis, concordance with compression can be substantially improved by simple measures with a clear favourable consequence on both ulcer status and peri-ulcer skin aspect when a non-adherent primary dressing is used. However, the acceptability of compression to patients is poor, and continuous effort is required to convince them of its importance.

Lower Extremity Arterial and Venous Ulcers

The prevalence of peripheral arterial disease in the general population is high, but the awareness of primary care providers of the disease process is low. The disease is not recognized by primary care providers. Early recognition and treatment of venous diseases that progress to postphlebotic syndrome, such as after a deep vein thrombosis, will prevent venous ulcers that add considerable expense to the health care system. Vascular assessment, including routine ABI measurement of patients who are in risk categories for vascular disease will identify those patients so that prevention programs can be put into place early. Major contributions to the understanding and management of leg ulcers and wound healing have been made in the last decade. However, there is still confusion as to the exact mechanism behind ulcer development and the best method to manage, cure,and prevent these ulcers has yet to be found.