Pain in persons with chronic venous leg ulcers: A systematic review and meta-analysis

Unveiling the hidden pain and daily struggles of individuals with a venous leg ulcer: a thematic analysis

AIM

This study aimed to explore the experiences of pain among individuals living with venous leg ulcers (VLUs), focusing on how pain was described, its impact on daily living, and the coping strategies employed by them.

MATERIALS AND METHODS

A secondary qualitative analysis was conducted using data from a previous study on VLU self-management following nurse-led patient education. The original study employed a constructivist grounded theory approach, while this secondary analysis utilized Braun and Clarke's thematic analysis methodology. Semi-structured interviews from 22 participants were analyzed to identify emergent themes related to pain. MAXQDA® software was used to ensure traceability of coding, and rigor was ensured through triangulation and reflexive memos.

RESULTS

Three themes emerged: (1) Description of Wound-Related Pain where participants described pain as persistent, multifaceted, and often excruciating, using terms such as "burning" and "stinging." Pain intensity varied across individuals, with some comparing it to childbirth. (2) Impact on Daily Living where pain considerably affected emotional well-being, mobility, social interactions, and sleep. Many participants experienced emotional exhaustion, frustration, and social isolation due to their condition. (3) Pain Management Strategies where participants used both pharmacological (e.g., paracetamol, tramadol) and non-pharmacological methods (e.g., leg elevation, self-hypnosis) for pain relief. The role of healthcare providers was essential, though some participants felt their pain was inadequately addressed.

CONCLUSION

VLU-associated pain is a prevalent and debilitating aspect of individuals' lives, impacting both physical and psychological health. Comprehensive pain management strategies that integrate both pharmacological and psychosocial approaches should be enhanced to improve patient outcomes.

Assessing the Safety, Tolerability and Efficacy of Cell-Free Amniotic Fluid in the Treatment of Non-Healing Venous Ulcers: Initial Experience From a Prospective, Multicenter, Phase II Study

Non-healing venous leg ulcers represent a significant healthcare problem that accounts for about $32 billion of spending in the US alone. Consequently, novel treatment strategies represent a major unmet need. The current study (part one of Phase II study [NCT04647240]) assesses the safety, tolerability and efficacy of the use of cell-free human amniotic fluid in treating venous leg ulcers that did not heal following the correction of venous reflux. Patients received cell-free amniotic fluid injections in and around the wound either weekly or biweekly over 12 weeks. Primary outcomes included safety, tolerability and efficacy assessed by complete wound closure, wound area reduction and pain reduction. Eleven patients met enrollment eligibility, and nine completed the study. Five patients achieved complete wound closure by week 12. The average percent reduction in wound area was 83.7%, and pain scores were significantly lower by the study endpoint. No difference was observed in wound healing rates between weekly or biweekly treatment, but bi-weekly treatment was associated with nominally faster recovery. Patients tolerated the treatment, and no side effects were reported. These results indicate that cell-free amniotic fluid injection is a feasible, safe and effective treatment for non-healing venous leg ulcers.

Updating Wound Care Algorithms: A Systematic, Focused Review

PURPOSE

The purpose of this project was to update the underlying evidence base for basic wound care in the Solutions Wound Care Algorithms and revise this resource as needed.

METHODS

The 14 major algorithm goals, guidelines, and outcomes of patient care and 34 detailed qualifying assessment and management statements/steps were reconstructed to encompass 21 qualifying statements/steps and aligned with their most recent (2013) levels of evidence. Next, a systematic, focused review of the literature was conducted to update the evidence levels using the Strength of Recommendation Taxonomy.

SEARCH STRATEGY

An English language search of CINAHL, Medline, Cochrane Library, and Joanna Briggs Institute (JBI) electronic databases was conducted for the years 2015-2023. For each wound type, the following search terms were used: meta-analysis, systematic review, randomized controlled trial, clinical practice guideline, clinical trial, and wound care/healing and dressings. Publications not focused on the patient population or qualifying statements were excluded.

FINDINGS

The search retrieved 59 elements that met the predetermined criteria for analysis and leveling. All qualifying statements and steps remain evidence-based. Higher quality evidence became available for nutritional status assessment, exercise to reduce risk factors for various types of lower extremity ulcers, using tap water to cleanse wounds; that delayed wound healing may be a sign of infection, and that silver-containing dressings are effective when used appropriately. No basic patient and wound care steps have the highest level of evidence (level 1) and strength of recommendation (A).

CONCLUSION

Compared to previous updates, we found fewer clinical trials indicating a need for research to improve evidence levels for various steps of basic wound assessment and care processes.

Polymer- and Lipid-Based Nanostructures Serving Wound Healing Applications: A Review

Management of hard-to-heal wounds often requires specialized care that surpasses the capabilities of conventional treatments. Even the most advanced commercial products lack the functionality to meet the needs of hard-to-heal wounds, especially those complicated by active infection, extreme bleeding, and chronic inflammation. The review explores how supramolecular nanovesicles and nanoparticles-such as dendrimers, micelles, polymersomes, and lipid-based nanocarriers-can be key to introducing advanced wound healing and monitoring properties to address the complex needs of hard-to-heal wounds. Their potential to enable advanced functions essential for next-generation wound healing products-such as hemostatic functions, transdermal penetration, macrophage polarization, targeted delivery, and controlled release of active pharmaceutical ingredients (antibiotics, gaseous products, anti-inflammatory drugs, growth factors)-is discussed via an extensive overview of the recent reports. These studies highlight that the integration of supramolecular systems in wound care is crucial for advancing toward a new generation of wound healing products and addressing significant gaps in current wound management practices. Current strategies and potential improvements regarding personalized therapies, transdermal delivery, and the promising critically evaluated but underexplored polymer-based nanovesicles, including polymersomes and proteinosomes, for wound healing.

Optimising outcomes with 'Wound Balance' and dressings containing superabsorbent polyacrylate polymers

The ever-increasing burden of hard-to-heal wounds requires emphasis placed on early intervention to help heal wounds and improve patient quality of life. A patient's healing potential can be optimised by applying the 'Wound Balance' holistic framework for wound assessment, care planning and quality of life considerations. This holistic management can be facilitated with appropriate dressings, such as dressings containing superabsorbent polyacrylate polymers (SAPs), including RespoSorb® Silicone Border (Hartmann). SAP-containing dressings can absorb exudate and bind and lock away wound inhibitors, such as proteases and micro-organisms, reversing the factors associated with hard-to-heal wounds to enable a healing environment similar to an acute wound. Three case studies demonstrate the positive benefits of using RespoSorb Silicone Border in clinical practice. The dressings proved easy to use and comfortable, with atraumatic changes and long wear times, providing a costeffective option for patients with both acute and hard-to-heal wounds.

Using patient-reported experiences to inform the use of foam dressings for hard-to-heal wounds: perspectives from a wound care expert panel

Caring for patients with hard-to-heal (chronic) wounds requires a multifaceted approach that addresses their diverse needs, which can contribute to the complexity of care. Wound care providers must have a comprehensive understanding of the patient's comorbid conditions and psychosocial issues to provide personalised and effective treatment. Key quality indicators for effective wound care involves not only selecting appropriate local wound care products, such as foam dressings, but also addressing individual patient experiences of wound-related pain, odour, itch, excessive wound drainage, and self-care needs. The purpose of this review is to inculcate the wound care practice community, research scientists and healthcare industry with a sense of accountability in order to work collaboratively in addressing these unmet care needs.

Making Conscientious Decisions: Engaging in Venous Leg Ulcer Self-Management Following Nurse-Led Patient Education

Venous leg ulcers (VLUs) provoke multiple symptoms and impact individuals and society as a whole. Their treatment and prevention strategies require individual's involvement in self-management strategies. Insufficient knowledge with regard to prevention, management, and treatment has been identified as a critical factor related to VLUs and their recurrence. Therapeutic patient education (TPE) proposed as part of a management strategy for this population provides unclear benefits regarding wounds healing or prevention of recurrence. The aim of the study was to develop a theory explaining how individuals with a VLU experience an individualized nurse-led TPE program regarding self-management strategies. The constructivist approach of Charmaz to the grounded theory method was used to develop the theory. A total of 26 individuals contributed to the co-construction of the theory through face-to-face or telephone semi-structured interviews. Data analysis and data collection occurs simultaneously with a comparative process to reveal the conceptual categories, apply theoretical sampling, and define theoretical saturation. The theory of "Conscientiously Engaging in Self-Management" was co-constructed with the participants encapsulating four categories: "Being influenced by my own story," "Being personally informed," "Making conscientious decisions to engage in self-adapted management strategies," and "Integrating a conscientious way of living." This theory highlights individuals' voices and stories toward their journey of VLU self-management taking contextual factors into consideration. This new theory offers new knowledge about implementation of self-management strategies for individuals living with a VLU and will inform clinical practice and contribute to the development of targeted interventions.

High Symptom Burden in Patients With Advanced Chronic or Prolonged Infectious Diseases: Not Only Pain

INTRODUCTION

The growing evidence of increased life expectancy in the future reveals the high relevance of frailty in patients with chronic-degenerative diseases; identification and management of symptoms may improve significantly their quality of life. The objective of our study was to assess the symptom burden in patients with advanced chronic or prolonged infectious diseases.

MATERIALS AND METHODS

A cross-sectional study was performed enrolling 88 patients, referred to palliative care consultation for chronic pain, and evaluated using the Edmonton Symptom Assessment System to define Total Symptom Distress Score (TSDS) and high symptom burden (HSB) when more than six symptoms along with Numerical Rating Scale ≥4 were present.

RESULTS

All participants reported moderate to severe pain; in addition, 86 (97.7%) experienced a lack of well-being, 81 (92%) tiredness, 67 (76.1%) lack of appetite, 66 (75%) drowsiness, 66 (75%) depression, 56 (63.6%) anxiety, 49 (55.6%) nausea, and 39 (44.3%) shortness of breath. Forty-four patients (50%) had high TSDS, greater than 40.5, and presented lower Karnofsky Performance Scale (KPS) (median 40 vs. 70, p=0.0005), higher comorbidities (median 7 vs. 4, p=0.00001), and higher drug burden (median 9 vs. 6, p=0.0003) than those with low TSDS. Furthermore, considering symptom intensity, 40 patients (45.4%) had HSB and presented lower KPS (median 50 vs. 70, p=0.0005), higher comorbidities (median 7 vs. 4, p=0.00001), and higher drug burden (mean 9 vs. 6, p=0.01) compared to patients without HSB.

CONCLUSION

Our population had an HSB, in addition to pain, revealing high frailty. A correct assessment of symptoms is, therefore, required to manage patients with chronic infectious diseases. In this setting, attention should be given to identifying patients at high risk of HSB through a correct diagnosis and effective management, which should be based on a multi-professional approach.

Sleep, Fatigue, and Inflammatory Biomarkers in Older Adults with Chronic Venous Leg Ulcers Receiving Intensive Outpatient Wound Care

Objective: Chronic venous ulcers are a relatively common and distressing condition that disproportionately affects older individuals. Along with multiple concomitant issues such as wound drainage, pain, and mobility impairments, individuals with chronic venous leg ulcers (CVLUs) commonly report sleep disturbances and fatigue; however, limited research has examined these symptoms in relation to inflammatory biomarkers in this population over the intensive wound care treatment trajectory. This study aimed at describing the symptoms of sleep and fatigue in older adults with CVLUs receiving intensive wound treatment with weekly debridement and exploring the relationships between these symptoms and tumor necrosis factor-alpha (TNF-α), c-reactive protein (CRP), and interleukin (IL)-6. Approach: Demographics, clinical characteristics, Pittsburgh Sleep Quality Index (PSQI) scores, Brief Fatigue Inventory (BFI), TNF-α, CRP, and IL-6 levels were collected from 84 older adults with CVLUs at three time points (baseline, week 4, and week 8). Data analysis included descriptive statistics and Bayesian estimation of associations. Results: Findings showed a consistent pattern of poor sleep quality and mild fatigue among these individuals. Lower IL-6 levels at week 4 and higher CRP levels at week 8 were linked to poor sleep quality. Higher CRP levels were linked to greater fatigue at baseline and week 8. Sleep and fatigue were correlated at all time points. Innovation and Conclusion: This study highlights the importance of clinicians evaluating sleep and fatigue in those with CVLUs. Further research is needed to validate circulating inflammatory biomarkers to enhance our understanding of sleep and fatigue's role in wound healing.

Sensitivity of the Wound Edge Gene Signature "WD14" in Responding to Clinical Change: A Longitudinal Cohort Study

Introduction: WounD14 (WD14) gene signature is a recently developed tool derived from genetic interrogation of wound edge biopsies of chronic venous leg ulcers to identify heard-to-heal wounds and enable clinicians to target aggressive therapies to promote wound healing. This study aimed to evaluate if changes in wound clinical healing status were detected by the WD14 gene signature over time as this is currently poorly understood. Material and methods: WD14 was developed through gene screening and subsequent validation in 3 patient cohorts involving 85 consecutive patients with chronic venous leg ulcers referred to a tertiary wound healing unit. Patients underwent a wound edge biopsy to interrogate for a "healing" or "non-healing" genotype. A smaller cohort (18%) underwent a second biopsy, which comprised this pilot cohort reported herein. Twelve weeks following biopsy, wounds were clinically assessed for healing status based on reduction in size and compared to WD14 genotype. Results: Sequential biopsies and WD14 scores were derived from 16 patients. WD14 signature predicted wound healing status among this cohort at either visit (32 wound edge biopsies) with a positive predictive value (PPV) of 85.2% (95% CI 74.1%-92.0%) and negative predictive value (NPV) of 80.0% (95% CI 34.2%-96.9%). A total of 6 wounds underwent altered clinical status between the 2 visits. In this cohort, WD14 has a PPV of 66.7% (95% CI 47.3%-81.7%) and NPV of 100%. Conclusion: Although the WD14 gene signature did change with wound healing status, larger studies are required to precisely clarify its role and ability to prognosticate wounds of differing clinical status over time.

The Chronic Wound-Related Pain Model: Holistic Assessment and Person-Centered Treatment

Chronic wound-related pain is a complex biopsychosocial experience that is experienced spontaneously at rest and exacerbated during activities. Tissue debridement, trauma at dressing change, increased bioburden or infection, exposure of periwound skin to moisture, and related treatment can modulate chronic wound-related pain. Clinicians should consider multimodal and multidisciplinary management approach that take into account the biology, emotions, cognitive thinking, social environment, and other personal determinants of pain. Unresolved pain can have a significant impact on wound healing, patients' adherence to treatment, and individual's quality of life.

Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing

AIMS AND OBJECTIVES

The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. The purpose of this study was to examine the biopsychosocial model of pain by assessing the relationships between pain, stress, inflammation and healing in people with chronic wounds.

DESIGN

This was a 4-week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds in a chronic care hospital in Canada.

METHODS

Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. Participants were evaluated for pain by responding to the Brief Pain Inventory-Short Form, the McGill Pain Questionnaire-Short Form and the Leeds Assessment of Neuropathic Symptoms and Signs scale. Stress was measured by the Perceived Stress Scale (PSS). All wounds were assessed with the Pressure Ulcer Scale for Healing tool. The levels of matrix metalloproteinases were analysis by obtaining wound fluid from all participants.

RESULTS

A total of 32 individuals with chronic wounds participated in the study. Correlation analysis indicated pain severity was positively and significantly related to pain interference, McGill Pain Questionnaire scores, neuropathic pain and matrix metalloproteinase levels. Logistic regression was used to determine the predictors for high or low perceived stress. The only significant variable that contributed to the stress levels was BPI-I. Results suggested that participants who experienced higher levels of pain interference also had an increased odds to report high level of stress by 1.6 times controlling for all other factor in the model.

CONCLUSION

Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing.

Use of person-centred music to manage wound dressing-related pain: a mixed method case study

OBJECTIVE

To determine whether person-centred music (PCMusic) contributes to reducing pain during painful leg ulcer dressing change procedures indicated by: decreased levels of indicators related to stress; decreased pain scores; and a more favourable treatment climate during the dressing change procedure.

METHOD

A case study of a 51-year-old female patient with chronic inherited disease weakening her connective tissues. Quantitative data entailed temporal measurements of stress indicators including: heart pulse rate; oxygen saturation (SpO2); saliva cortisol; and a visual analogue scale (VAS). Qualitative data comprised phenomenological treatment descriptions and patient/licensed practical nurse (LPN) questionnaires.

RESULTS

The patient's body temperature remained steady throughout all treatments. Blood pressure was excluded due to missing data. No significant pulse rate differences in relation to music/no music could be observed during treatment. Comparing PCMusic to the patient's own other music (POOM), the pulse rate was greater in both magnitude and variation when the patient listened to POOM. Oxygen saturation showed no significant difference between PCMusic and music/no music. No significant difference was observed pre-/post-debridement with music. Similarly, no significant difference was observed pre-/post-debridement with no music. Treatment with no music showed the highest VAS score; PCMusic treatments had the lowest scores. Qualitative data showed that both patient and LPNs found that PCMusic decreased pain during dressing change.

CONCLUSION

The results of this case study indicate that PCMusic is a suitable complementary treatment to decrease patient pain. Patients' general health status is important when using quantitative stress/pain marker measurements. For cohort selection in future studies, we suggest healthy patients undergoing slightly painful or unpleasant treatments, patients in postoperative care and obstetric care.

Assessment of Wound-Related Pain Experiences of Patients With Chronic Wounds: A Multicenter Cross-Sectional Study in Eastern China

PURPOSE

The primary aims of this study were to evaluate the prevalence of wound-related pain (WRP) in patients with chronic wounds and assess the use of pain relief measures.

DESIGN

A cross-sectional study.

SUBJECTS AND SETTING

A convenience sample of patients with chronic wounds was recruited from outpatient clinics of 12 hospitals covering 7 of 13 cities in the Jiangsu province located in eastern China from July 10 to August 25, 2020. The sample comprised 451 respondents, and their mean age was 54.85 (SD 19.16) years; 56.1% (253/451) patients were male.

METHODS

An investigator-designed questionnaire was used to collect pain-related information from patients. The questionnaire consisted of 4 parts: (1) basic demographic and clinical information (patient and wound characteristics); (2) wound baseline pain; (3) wound-related procedural pain and pain relief method; and (4) the effect of WRP on the patient. Pain was assessed using the Numerical Rating Scale (NRS) scored from 0 (no pain) to 10 (worst pain). Severity of pain was based on NRS scores' classification as mild (1-3), moderate (4-6), and severe (7-10). The survey was conducted from July 10 to August 25, 2020. Participants were instructed on use of the NRS and then completed the questionnaire following dressing change independently.

RESULTS

The 3 most common types of chronic wounds were traumatic ulcers, surgical wounds, and venous leg ulcers. The 3 most prevalent locations were lower limbs, feet, and thorax/abdomen. Of all patients, 62.5% (282/451) and 93.8% (423/451) patients experienced wound baseline pain and wound-related procedural pain, respectively. The mean score of wound baseline pain was 3.76 (SD 1.60) indicating moderate pain. During wound management, the highest pain score was 6.45 (SD 2.75) indicating severe pain; the most severe pain scores were associated with debridement. The use of drugs to relieve wound pain was low, while the use of nondrug-based analgesia was relatively high. Because of WRP, patients with chronic wounds feared dressing changes, hesitated to move, and showed a decline in sleep quality.

CONCLUSIONS

Wound baseline pain and wound-related procedural pain were very common in patients with chronic wounds. In the future, targeted intervention plans should be developed by combining drug-based and nondrug-based analgesia according to pain severity.

Chronic wound-related pain, wound healing and the therapeutic potential of cannabinoids and endocannabinoid system modulation

Chronic wounds represent a significant burden on the individual, and the healthcare system. Individuals with chronic wounds report pain to be the most challenging aspect of living with a chronic wound, with current therapeutic options deemed insufficient. The cutaneous endocannabinoid system is an important regulator of skin homeostasis, with evidence of system dysregulation in several cutaneous disorders. Herein, we describe the cutaneous endocannabinoid system, chronic wound-related pain, and comorbidities, and review preclinical and clinical evidence investigating endocannabinoid system modulation for wound-related pain and wound healing. Based on the current literature, there is some evidence to suggest efficacy of endocannabinoid system modulation for promotion of wound healing, attenuation of cutaneous disorder-related inflammation, and for the management of chronic wound-related pain. However, there is 1) a paucity of preclinical studies using validated models, specific for the study of chronic wound-related pain and 2) a lack of randomised control trials and strong clinical evidence relating to endocannabinoid system modulation for wound-related pain. In conclusion, while there is some limited evidence of benefit of endocannabinoid system modulation in wound healing and wound-related pain management, further research is required to better realise the potential of targeting the endocannabinoid system for these therapeutic applications.

Systematic review of topical interventions for the management of pain in chronic wounds

Chronic wounds adversely affect quality of life. Pain is associated with chronic wounds, and its impact can vary according to wound aetiology, condition, and patient factors. This systematic review examined the effectiveness of topical interventions in the management chronic wound-related pain guided by PRISMA recommendations of randomised controlled trials (RCTs) where pain reduction is the primary outcome. Inclusion criteria were adults (older than 18 years) with chronic venous, arterial, diabetic, or pressure ulcers where pain has been managed through topical administration of pharmacological/nonpharmacological agents. Searches were conducted in Ovid Embase, Ovid MEDLINE, EBSCOhost, CINAHL, CENTRAL, PubMed, Web of Science, and Scopus. Studies were screened for eligibility; risk of bias and data were extracted by 2 independent assessors. Searches retrieved 10,327 titles and abstracts (7760 after deduplication). Nine full texts (1323 participants) examining ibuprofen (n = 4), morphine (n = 2), BWD + PHMB [polihexanide-containing biocellulose wound dressing] (n = 1), and EMLA (n = 2) were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Meta-analysis was not possible, but initial exploration suggests improved outcomes (reduced pain) for ibuprofen when compared with controls. Two studies involving morphine showed conflicting findings. Included studies often had small samples, and considering confounding factors (eg, comorbidities), the results should be interpreted with caution. Review of included studies suggests that topical interventions may provide pain relief in individuals with chronic wounds. Further adequately powered RCTs are recommended to assess the efficacy of topical interventions for the management of chronic wound-related pain.

Influence of pain on the quality of life in patients with venous ulcers: Cross-sectional association and correlation study in a brazilian primary health care lesions treatment center

We aimed to verify the association and correlation between pain and QoL in people with VU treated in a Brazilian Primary Health Care (PHC) lesions treatment center. This is an observational, cross-sectional study with a quantitative approach, carried out in a service specialized in the treatment of chronic injuries, linked to 29 PHC units. Sociodemographic and health characterization instruments were used. The Short Form Health Survey-36 (SF-36) and Visual Analogue Pain Scale (VAPS) also were used. The Kruskal-Wallis test verified the association between the scalar variables of QoL and pain intensity. With Spearman's correlation test, we verified the level of correlation between the scales applied. A total of 103 patients participated in the study. Higher QoL scores associated with moderate pain were found, especially in the Physical role functioning, Physical functioning, and Vitality domains. Correlation analysis showed its greatest (moderate) strength in the interaction between the highest scores in the Physical role functioning and Emotional role functioning domains with the lowest pain levels.

Clinical correlates of pain in adults with hard-to-heal leg ulcers: a cross-sectional study

OBJECTIVE

Pain is a complex symptom associated with hard-to-heal (chronic) leg ulcers that is often poorly managed. The objective of this study was to gain greater understanding by investigating relationships between physical and psychosocial factors, and pain severity in adults with hard-to-heal leg ulcers.

METHOD

A secondary analysis of data collected for a longitudinal, observational study of adults with hard-to-heal leg ulcers was undertaken. Data were collected over a 24-week period, including variables relating to sociodemographics, clinical variables, medical status, health, ulcer and vascular histories, and psychosocial measures. Multiple linear regression modelling was used to determine the independent influences of these variables on pain severity, as measured with a Numerical Rating Scale (NRS).

RESULTS

Of 142 participants who were recruited, 109 met the inclusion criteria for this study, of whom: 43.1% had venous ulcers; 41.3% had mixed ulcers; 7.3% had arterial ulcers; and 8.3% had ulcers from some other cause. The final model explained 37% (adjusted r²=0.370) of the variation in the pain NRS scores. Controlling for analgesic use, salbutamol use (p=0.005), clinical signs of infection (p=0.027) and ulcer severity (p=0.001) were significantly associated with increased pain, while the presence of diabetes (p=0.007) was significantly associated with a decrease in pain.

CONCLUSION

Pain is a highly complex and pervasive symptom associated with hard-to-heal leg ulcers. Novel variables were identified as being associated with pain in this population. The model also included wound type as a variable; however, despite being significantly correlated to pain at the bivariate level of analysis, in the final model, the variable did not reach significance. Of the variables included in the model, salbutamol use was the second most significant. This is a unique finding that, to the authors' knowledge, has not been previously reported or studied. Further research is required to better understand these findings and pain in general.

The association of wound factors and symptoms of fatigue and pain with wound healing in chronic venous leg ulcers

The purpose of this study was: (1) to characterise the association of wound area, wound exudate C-reactive protein (CRP), broad-spectrum matrix metalloprotease protein (MMPs), and symptoms of fatigue and pain in individuals with chronic venous leg ulcers (CVLUs) over time and (2) to identify factors associated with the wound healing trajectory in CVLUs. Seventy four participants with CVLU who received weekly sharp debridement were recruited from a wound care clinic during the 8-week study period. To examine associations among wound CRP, MMPs, pain, fatigue, and wound healing trajectory over time, we calculated Bayes factors (BF) based on a linear mixed model. The mean age of participants was 71.8 (SD = 9.8) and the mean wound area was 2278 mm² (SD = 7085 mm² ) at baseline. Higher fatigue was strongly associated with higher MMPs (BF = 9, 95% HDI: [-.05, .43]), lower CRP (BF = 11, 95% HDI: [-.02, .002]), and large areas of wound (BF = 20, 95% HDI: [-.001, .01]). Higher CRP and MMPs activity in wound exudate and higher fatigue were associated with a larger wound area. To facilitate wound healing, clinicians need to utilise the multifactorial approach, which includes wound treatment and management of symptoms such as pain and fatigue, because of the molecular and psycho-behavioural factors involved in wound healing.

[Treatment of chronic wounds]

The treatment of chronic wounds often poses a therapeutic challenge. Assessment of the pathogenesis of the wound, causative and symptomatic interventions are key. Concerning treatment-concepts the evaluation of comorbidities, pain management, the nutrition status of as well as the mobility of the patient are recommended.

A Highly Efficacious Electrical Biofilm Treatment System for Combating Chronic Wound Bacterial Infections

Biofilm infection has a high prevalence in chronic wounds and can delay wound healing. Current treatment using debridement and antibiotic administration imposes a significant burden on patients and healthcare systems. To address their limitations, a highly efficacious electrical antibiofilm treatment system is described in this paper. This system uses high-intensity current (75 mA cm-2 ) to completely debride biofilm above the wound surface and enhance antibiotic delivery into biofilm-infected wounds simultaneously. Combining these two effects, this system uses short treatments (≤2 h) to reduce bacterial count of methicillin-resistant S. aureus (MRSA) biofilm-infected ex vivo skin wounds from 1010 to 105.2 colony-forming units (CFU) g-1 . Taking advantage of the hydrogel ionic circuit design, this system enhances the in vivo safety of high-intensity current application compared to conventional devices. The in vivo antibiofilm efficacy of the system is tested using a diabetic mouse-based wound infection model. MRSA biofilm bacterial count decreases from 109.0 to 104.6 CFU g-1 at 1 day post-treatment and to 103.3 CFU g-1 at 7 days post-treatment, both of which are below the clinical threshold for infection. Overall, this novel technology provides a quick, safe, yet highly efficacious treatment to chronic wound biofilm infections.

Biofilms in Chronic Wound Infections: Innovative Antimicrobial Approaches Using the In Vitro Lubbock Chronic Wound Biofilm Model

Chronic wounds have harmful effects on both patients and healthcare systems. Wound chronicity is attributed to an impaired healing process due to several host and local factors that affect healing pathways. The resulting ulcers contain a wide variety of microorganisms that are mostly resistant to antimicrobials and possess the ability to form mono/poly-microbial biofilms. The search for new, effective and safe compounds to handle chronic wounds has come a long way throughout the history of medicine, which has included several studies and trials of conventional treatments. Treatments focus on fighting the microbial colonization that develops in the wound by multidrug resistant pathogens. The development of molecular medicine, especially in antibacterial agents, needs an in vitro model similar to the in vivo chronic wound environment to evaluate the efficacy of antimicrobial agents. The Lubbock chronic wound biofilm (LCWB) model is an in vitro model developed to mimic the pathogen colonization and the biofilm formation of a real chronic wound, and it is suitable to screen the antibacterial activity of innovative compounds. In this review, we focused on the characteristics of chronic wound biofilms and the contribution of the LCWB model both to the study of wound poly-microbial biofilms and as a model for novel treatment strategies.

Homocysteine and Inflammatory Cytokines in the Clinical Assessment of Infection in Venous Leg Ulcers

Inflammation and biofilm-associated infection are common in chronic venous leg ulcers (VU), causing deep pain and delayed healing. Albeit important, clinical markers and laboratory parameters for identifying and monitoring persistent VU infections are limited. This study analyzed 101 patients with infected (IVU) and noninfected VUs (NVU). Clinical data were collected in both groups. The serum homocysteine (Hcys) and inflammatory cytokines from the wound fluid were measured. In addition, microbial identification, antibiotic susceptibility, and biofilm production were examined. IVU were 56 (55.4%) while NVU were 45 (44.5%). IVUs showed a significant increase in the wound's size and depth compared to NVUs. In addition, significantly higher levels of interleukin (IL)-6, IL-10, IL17A, and tumor necrosis factor-alpha (TNF-α) were found in patients with IVUs compared to those with NVUs. Notably, hyperhomocysteinemia (HHcy) was significantly more common in patients with IVUs than NVUs. A total of 89 different pathogens were identified from 56 IVUs. Gram-negative bacteria were 51.7%, while the Gram-positives were 48.3%. At the species level, Staphylococcus aureus was the most common isolate (43.8%), followed by Pseudomonas aeruginosa (18.0%). Multidrug-resistant organisms (MDROs) accounted for 25.8% of the total isolates. Strong biofilm producers (SBPs) (70.8%) were significantly more abundant than weak biofilm producers (WBP) (29.2%) in IVUs. SBPs were present in 97.7% of the IVUs as single or multispecies infections. Specifically, SBPs were 94.9% for S. aureus, 87.5% for P. aeruginosa, and 28.6% for Escherichia coli. In IVU, the tissue microenvironment and biofilm production can support chronic microbial persistence and a most severe clinical outcome even in the presence of an intense immune response, as shown by the high levels of inflammatory molecules. The measurement of local cytokines in combination with systemic homocysteine may offer a novel set of biomarkers for the clinical assessment of IVUs caused by biofilm-producing bacteria.

Topical interventions for the management of pain in chronic wounds: A protocol for a systematic review

Background: Venous, arterial, diabetic and pressure ulcers, collectively known as chronic wounds, negatively impact individuals across psychological, social and financial domains. Chronic wounds can be painful and the nature, frequency and impact of pain can differ depending on wound aetiology, wound state and on numerous patient factors. While systemic pharmaceutical agents have some effect in managing pain, there is a need to examine topical agents applied to the wound bed for pain relief. The objective of this study is to examine and synthesise existing literature on the effectiveness of topical agents in managing pain in venous, diabetic, pressure, arterial and mixed venous/arterial ulcers. Methods: We will use Cochrane Systematic Review methodology to identify and synthesise eligible randomised controlled trials (RCTs) evaluating the effectiveness of topical agents in reducing pain in chronic wounds. Embase, Medline, PubMed, CENTRAL, CINAHL, Scopus and Web of Science will be searched from inception to end of June 2022 without language limits. We will independently extract data on the pharmaceutical agent, participant demographics, aetiology, condition of the wound, and type, nature and frequency of pain using a pre-designed data extraction form. Subgroup and sensitivity analysis will be performed to address heterogeneity across studies if appropriate. Further stratification and analyses will be based on included study variables and outcomes. Discussion: Wound pain is primarily managed via systemic pharmaceutical agents. However, patients express reluctance regarding systemic analgesic drugs, fearing addiction. Additionally, persons with chronic wounds have co-morbidities including hypertension, diabetes, or cardiovascular disease and are already taking multiple medications. Topical analgesia can potentially mitigate some of the perceived disadvantages of systemic agents but the available range of these agents and their effectiveness in managing pain in chronic wounds is not so well understood. This review will focus on such agents across a range of the most common chronic wounds.

The importance of periwound skin in wound healing: an overview of the evidence

DECLARATION OF INTEREST

The authors have no conflicts of interest.

Impairments in ankle range of motion, dorsi and plantar flexors muscle strength and gait speed in patients with chronic venous disorders: A systematic review and meta-analysis

Objective

To verify the differences in ankle range of motion (ROM), muscle strength of dorsi and plantar flexors, and gait speed among healthy subjects, and patients with chronic venous disorders (CVD) with and without venous leg ulcer.

Methods

A systematic review and meta-analysis ( http://osf.io/b7n3k ) were conducted following a search of MEDLINE, Web of Science, CINAHL, LILACS, Scopus, and EMBASE databases.

Results

Eight papers were included. The ankle ROM was significantly lower both in dorsiflexion and plantar flexion in patients with venous leg ulcer when compared to healthy individuals and CVD patients without venous leg ulcer. The muscle strength of the plantar flexors and gait speed were reduced in CVD patients when compared to healthy ones.

Conclusion

Impaired muscle strength and gait speed can be detected in CVD patients compared to healthy individuals, and ankle ROM tends to be reduced in CVD patients even in the absence of venous leg ulcers.

Dermatological Conditions Inducing Acute and Chronic Pain

Pain is a common condition in dermatology. The aim of this review is to analyse the characteristics of pain in dermatology. Some skin diseases are conventionally known to cause pain; e.g. ulcers, pyoderma gangrenosum and herpes zoster. Common dermatoses, such as psoriasis or atopic dermatitis, can also cause significant pain. Some conditions are characterized by neuropathic pain and/or pruritus, without visible primary lesions: e.g. the neurocutaneous diseases, including small fibre neuropathies. Patients often fear pain in skin surgery; however, surgical procedures are rather well tolerated and any pain is mainly due to administration of local anaesthetic. Some therapies may also be uncomfortable for the patient, such as photodynamic therapy or aesthetic procedures. Thus, pain in dermatology is common, and its aetiology and characteristics are very varied. Knowledge of the different situations that cause pain will enable dermatologists to propose suitable analgesic solutions.

Concurrent optical and magnetic stimulation therapy in patients with lower extremity hard-to-heal wounds

OBJECTIVE

The treatment of patients with hard-to-heal wounds represents a major multidisciplinary challenge. Therefore, the development and clinical validation of new technologies remains extremely important. The novel application of concurrent optical and magnetic stimulation (COMS) offers a promising noninvasive approach to support physiological wound healing processes, especially in hard-to-heal wounds.

METHOD

In a multicentre, prospective, comparative, clinical trial, patients with hard-to-heal wounds on lower extremities of different aetiologies were treated with COMS as an adjunct to standard of care (SOC). The primary endpoint was safety; secondary endpoints were wound healing, pain and wound-specific quality of life (Wound-QoL).

RESULTS

A total of 40 patients were enrolled in this study (intention to treat population (ITTP), n=40). Of these patients, 37 were included in the analysis of the primary endpoint (primary endpoint population, (PEP), n=37). A further subgroup of 30 patients was included in the analysis of the secondary endpoint (secondary endpoint population (SEP), n=30). Finally, the SEP was stratified regarding patients' responsiveness to SOC in an SOC non-responder subgroup (NRSG), n=21, and in an SOC responder subgroup (RSG), n=9. A total of 102 adverse events (AEs) were recorded, of which 96% were 'mild' or 'moderate', and 91% were either a singular or transient event. Only 11 AEs were serious and associated with inpatient treatments unrelated to the studied intervention. In the NRSG, reductions in wound size were found to be statistically significant within the different study periods. Additionally, an acceleration of the healing rate was detected between the baseline and the first four weeks of COMS treatment (p=0.041). The rate of near-complete and complete wound closure in the SEP after 12 weeks were 60% and 43%, respectively. Pain reduction across the treatment group was statistically significant (p≤0.002 for both the SEP and NRSG). The Wound-QoL score improved by 24% during the study (p=0.001).

CONCLUSION

In this study, COMS treatment for patients with hard-to-heal wounds on lower extremities was a safe and effective novel treatment option, especially for patients who did not respond to SOC.

Healing of a chronic ulcer of the lower limb of venous origin with fresh human amniochorionic membrane allograft

In its fresh state, the amniochorionic membrane contains various multipotential cells, growth factors, and extracellular matrix proteins that contribute to the healing of chronic vascular ulcers. To demonstrate its effectiveness, a fresh human placental membrane allograft was applied to a chronic venous ulcer in the lower limb of an 89-year-old female patient with a 12 x 10 cm ulcerated lesion of 40 years of evolution in the malleolar area of her left lower limb. Sixty days after the graft, the ulcer was healed in 100% of its surface and a light pink scar on the edges indicated possible pigmentation. Fresh human amniochorionic membrane allograft is a therapeutic alternative for the healing of refractory chronic vascular ulcers of the lower extremities.

Chronic wounds: Treatment consensus

The Wound Healing Foundation (WHF) recognised a need for an unbiased consensus on the best treatment of chronic wounds. A panel of 13 experts were invited to a virtual meeting which took place on 27 March 2021. The proceedings were organised in the sub-sections diagnosis, debridement, infection control, dressings, grafting, pain management, oxygen treatment, outcomes and future needs. Eighty percent or better concurrence among the panellists was considered a consensus. A large number of critical questions were discussed and agreed upon. Important takeaways included that wound care needs to be simplified to a point that it can be delivered by the patient or the patient's family. Another one was that telemonitoring, which has proved very useful during the COVID-19 pandemic, can help reduce the frequency of interventions by a visiting nurse or a wound care center. Defining patient expectations is critical to designing a successful treatment. Patient outcomes might include wound specific outcomes such as time to heal, wound size reduction, as well as improvement in quality of life. For those patients with expectations of healing, an aggressive approach to achieve that goal is recommended. When healing is not an expectation, such as in patients receiving palliative wound care, outcomes might include pain reduction, exudate management, odour management and/or other quality of life benefits to wound care.

CONSTRUCT VALIDITY AND RELIABILITY OF THE LEG ULCER MEASUREMENT TOOL SCALE ADAPTED FOR BRAZIL

ABSTRACT Objective: to validate the Portuguese version of the Leg Ulcer Measurement Tool regarding construct and reliability. Method: this is a methodological research study. Data collection was conducted between January and July 2019. A total of 105 participants were included for construct validation and internal consistency and, of these, 50 were selected for intra-observer stability. For the analysis of construct validity, factor analysis was performed; for internal consistency, Cronbach's alpha coefficient was calculated, and for stability, the intraclass correlation coefficient. Results: A total of 12items were confirmed for the Brazilian reality, meeting all the theoretical requirements of the factor analysis model. As for the internal consistency (reliability) analysis, the Cronbach's alpha coefficient values (α=0.711) showed that the set of items that make up the scale measures the same characteristics and presents internal consistency. In the global stability analysis (ICC=0.823), the Leg Ulcer Measurement Tool test and retest scores presented good agreement, showing that the adapted scale is stable. Conclusion: the Leg Ulcer Measurement Tool scale adapted to the Portuguese language contains 12 items, with scores varying from 0 to 4 and, thus, produces a score from 0 to 48 points. It presents construct validity analyzed by means of factor analysis and reliability in terms of internal consistency and stability.

Background pain in persons with chronic leg ulcers: An exploratory study of symptom characteristics and management

This exploratory descriptive study aimed to describe characteristics and management of background pain related to chronic leg ulcers. A total of 121 participants were recruited from two wound care clinics using a consecutive sampling method. Data were obtained through screening interview, clinical examination, and questionnaires. The mean average background pain intensity was 4.5 (SD 2.56) (CI 95% 4.0-5.0). Pain interfered mostly with general activity (mean 4.3), sleep (mean 4.1), and walking ability (mean 4.0) (0-10 NRS). The most frequently reported descriptors of background pain were 'tender', 'stabbing', 'aching', and 'hot-burning'. Most of the participants stated that the pain was intermittent. Less than 60% had analgesics prescribed specifically for ulcer related pain, and the respondents reported that pain management provided a mean pain relief of 45.9% (SD 33.9, range 0-100). The findings indicate that ulcer related background pain is a significant problem that interferes with daily function, and that pain management in wound care is still inadequate.

Hydro-responsive wound dressings for treating hard-to-heal wounds: a narrative review of the clinical evidence

A break in skin integrity must be repaired as quickly as possible to avoid excess blood and fluid loss, and to minimise the onset of infection. Hard-to-heal wounds, in which the progression of the wound healing response is compromised, present several challenges to healing (for example, the presence of devitalised tissue acting as a physical barrier to healing and as a focus for bacterial contamination with the potential for subsequent infection). The objective of this article is to present, as a narrative review, the clinical evidence supporting the use of a unique hydro-responsive wound dressing (HydroClean, HRWD1, PAUL HARTMANN AG, Germany). The dressing provides a simple treatment option to address a number of clinical challenges clinicians must overcome in order to facilitate wound healing progression. These studies demonstrated that this product supported successful debridement/cleansing of a wide variety of wounds, including hard-to-heal wounds, enabled wound bed preparation, and lead to positive healing outcomes, including in wounds that previously had failed to heal. The simplicity of using HRWD1 as a single dressing can help clinicians overcome a variety of challenges when treating both acute and hard-to-heal wounds, which, with the benefit of proven patient outcomes, could make it an ideal choice for a first-line treatment.

Clinical evaluation of UrgoStart Plus dressings in real-life conditions: results of a prospective multicentre study on 961 patients

AIMS

This study aimed to evaluate the performances of lipid colloid technology with nano-oligosaccharide factor (TLC-NOSF) dressings with polyabsorbent fibres in an unselected population of patients under real-life conditions.

METHODS

A large, prospective, multicentre, observational study with three polyabsorbent TLC-NOSF dressings (UrgoStart Plus Pad, UrgoStart Plus and UrgoStart Plus Border, Laboratoires Urgo, France) was conducted in Germany between January 2019 and June 2020. Main outcomes included wound healing rate, clinical assessment of wound healing progression, local tolerance and acceptance of dressings, and changes in health-related quality of life (HRQoL) of the patients, assessed with the validated Wound-QoL questionnaire.

RESULTS

A total of 961 patients with wounds of various aetiologies (leg ulcers (LU), diabetic foot ulcers (DFU), pressure ulcers (PU) and other types of wounds) were treated with the evaluated dressings in 105 centres for a mean duration of 62 days (standard deviation 37 days). By the last visit, a wound closure or an improvement in wound healing was reported in 92.0% of the treated wounds. The highest wound closure rates were achieved when the dressings were used as first-line treatment: 71.3% in DFUs, 52.9% in LUs, 53.6% in PUs and 61.8% in the other wounds. Improvement of the wound healing process was also associated with an 87.5% relative reduction of sloughy tissue, a decrease of the level of exudate in 68.9% of the wounds, and an improvement in the periwound skin condition in 66.4% of the patients at the final visit. The dressings were 'very well' or 'well' tolerated and 'very well' or 'well' accepted by the large majority of patients. The HRQoL questionnaires were completed both at initial and final visits by 337 patients, representative of the total cohort. Despite the relatively short duration of the wounds, the HRQoL of the patients was already impaired at baseline, with 81.6% of the patients being severely affected in at least one aspect of their HRQoL. By the final visit, significant improvements in each dimension of the patients' HRQoL were reported (p<0.001), along with a reduction of the proportion of patients in need of intervention and in the number of actions needed per patient in relation to their HRQoL.

CONCLUSIONS

These results are consistent with previous clinical evidence on TLC-NOSF dressings. They confirm the good healing properties and safety profile of these dressings, and that a significant improvement in patient HRQoL is achieved in non-selected patients treated in real-life practice. These data support the use of such dressings as a first-line intervention and until wound healing in the management of chronic wounds, in association with appropriate standard of care.

Potential predictors of quality of life in patients with venous leg ulcers: A cross-sectional study in Taiwan

Internationally, the impact of venous leg ulcers (VLUs) on the quality of life is well recognised; however, in Taiwan, the focus is only on chronic wound management. This cross‐sectional correlational study conducted at the cardiovascular and plastic surgery clinics of a regional teaching hospital between August 2019 and June 2020 investigates venous clinical severity, pain, fatigue, depression, sleep quality, quality of life, and related factors among 167 patients with VLUs. The potential predictors of the quality of life in terms of activities were venous clinical severity (P < 0.001), pain (P = 0.004), and fatigue (P < 0.001) after adjusting for covariates. The potential predictors of the quality of life in terms of the psychological domain were marital status (single/divorced) (P = 0.016), marital status (widowed) (P = 0.027), venous clinical severity (P < 0.001), pain (P = 0.001), and fatigue (P = 0.002). The potential predictors of the quality of life with regard to symptoms were venous clinical severity (P < 0.001), pain (P < 0.001), fatigue (P = 0.001), and depression (P = 0.038). These potential predictors can serve as the basis of interventions for patients with VLUs, such as those related to nutrition or training in wound dressing.

Multidimensional Pain Characteristics in Older Adults with Chronic Venous Leg Ulcers

Objective: Pain affects wound healing, treatment, and quality of life because it has significant impacts on physical, psychological, and social well-being. Despite the fact that more than half of chronic venous leg ulcer (CVLU) patients experience mild-to-moderate pain, the multidimensional characteristics of CVLU pain are not well documented. The objective of this study was to describe the multidimensional pain characteristics, including the sensory, affective, cognitive, and behavioral dimensions, of CVLU before debridement. Approach: Participants (N = 40) were recruited from a wound clinic. We conducted a descriptive analysis of clinical data, including pain, wound, and demographic characteristics, collected at the first visit. Results: The mean age of participants was 70.8 ± 9.1 years, 22 (55%) participants were female, and 35 (87.5%) were white. Participants reported mean current pain intensity (2.9 ± 2.7), least (1.2 ± 2.2) and worst (4.8 ± 3.4) pain intensity in 24 h, and tolerable pain level (4.9 ± 2.64) on a 0-10 scale. They described pain as periodic (66.7%, n = 26) with multiple pain quality descriptors (5.4 ± 2.9). Their past pain treatments provided some pain relief (65%, n = 25). For 68% (n = 27), their pain was the same as they expected. Nearly all had a tendency not to tell others about their pain (95%, n = 38). Innovation: This study is the first to describe the multidimensional pain characteristics of patients with CVLU as measured with PAINReportIt. Conclusion: Patients with CVLU reported willingness to tolerate a relatively high level of pain and experience the level of pain they anticipate. Multidimensional pain assessment will assist clinicians to select individualized therapies to manage pain and improve quality of life for these patients.

[Modern management of chronic wounds]

The treatment of patients with chronic wounds is a multiprofessional challenge. Based on a comprehensive diagnosis and integrated into a causal treatment concept, patients should always be treated with a modern wound therapy. This wound therapy should try to take into account many different factors such as the wound healing phases, infection status, exudate levels, but also individual patient wishes. Especially in the case of chronic wounds of the lower extremities and edema, compression therapy is also very important for therapy and recurrence prophylaxis. In addition, the pain, which is usually very distressing, should be recorded and adequately treated or avoided. Modern moist wound therapy can then support the healing of patients with chronic wounds, reduce complications and thus improve their quality of life.

Venous ulcer healing treated with conventional therapy and adjuvant laser: is there a difference?

OBJECTIVES

to evaluate the effects of venous ulcer healing in patients after six months of conventional treatment and adjuvant low-power laser therapy.

METHODS

prospective cohort study nested in a randomized clinical trial with 38 patients, allocated into an intervention group (conventional treatment and adjuvant laser therapy) and a control group (conventional treatment). Patients were followed up as outpatients, sociodemographic and clinical variables were collected, and indicators of the outcomes Wound healing: secondary intention (1103) and Tissue integrity: skin and mucous membranes(1101) of the Nursing Outcomes Classification. Generalized estimating equations, Kaplan-Meier tests, and robust Poisson regression were used in the analysis.

RESULTS

the clinical indicators Decreased wound size and Scar formation showed a statistically significant difference in the intervention group, higher number of healed wounds, lower rate, longer time to relapse.

CONCLUSIONS

laser therapy adjuvant to conventional treatment returned better results in healing and lower recurrence rates after six months of intervention.

The clinical impact of hydroresponsive dressings in dynamic wound healing: Part I

OBJECTIVE

Management of any wound, either acute or hard-to-heal, might involve the use of multiple and different wound dressings in its treatment. This approach is necessary to overcome the myriad of clinical challenges the wound presents, as well as any underlying comorbidities that might affect the clinical outcomes. This article describes the clinical effectiveness of a coordinated wound dressing treatment regimen.

METHOD

This was an open-labelled non-comparative study involving patients with a variety of hard-to-heal and acute wounds of differing levels of severity, but all of which required removal of devitalised tissue to enable wound healing to progress. The first phase used the hydroresponsive wound dressing HydroClean (PAUL HARTMANN AG, Germany). The PUSH score was used as the primary measurement parameter.

RESULTS

A total of 86 patients (38 male/48 female), with a mean age of 67.7±21.7 years, took part in the study. The results showed that the hydroresponsive dressing was effective in managing wound exudate production and promoting wound cleansing and debridement, supporting good wound bed preparation. Wound closure was observed in 16/86 (18.6%) wounds at the end of the study (20 weeks). This enabled clinicians to switch to alternative wound dressings to promote subsequent clinical healing outcomes.

CONCLUSION

In this study, the hydroresponsive wound dressing was highly effective in preparing a clean wound bed such that the next stage of wound healing could be supported.

Patient Explanation of Adherence and Non-Adherence to Venous Leg Ulcer Treatment: A Qualitative Study

The aim of this study was to understand which factors influence patients’ adherence to venous leg ulcer treatment recommendations in primary care. We adopted a qualitative study design, conducting phone interviews with 31 people with venous leg ulcers in Melbourne, Australia. We conducted 31 semi-structured phone interviews between October and December 2019 with patients with clinically diagnosed venous leg ulcers. Participants recruited to the Aspirin in Venous Leg Ulcer Randomized Control Trial and Cohort study were invited to participate in a qualitative study, which was nested under this trial. We applied the Theoretical Domains Framework to guide the data analysis. The following factors influenced patients’ adherence to venous leg ulcer treatment: understanding the management plan and rationale behind treatment (Knowledge Domain); compression-related body image issues (Social Influences); understanding consequences of not wearing compression (Beliefs about Consequences); feeling overwhelmed because it’s not getting better (Emotions); hot weather and discomfort when wearing compression (Environmental Context and Resources); cost of compression (Environmental Context and Resources); ability to wear compression (Beliefs about Capabilities); patience and persistence (Behavioral Regulation); and remembering self-care instructions (Memory, Attention and Decision Making). The Theoretical Domains Framework was useful for identifying factors that influence patients’ adherence to treatment recommendations for venous leg ulcers management. These factors may inform development of novel interventions to optimize shared decision making and self-care to improve healing outcomes. The findings from this article will be relevant to clinicians involved in management of patients with venous leg ulcers, as their support is crucial to patients’ treatment adherence. Consultation with patients about VLU treatment adherence is an opportunity for clinical practice to be targeted and collaborative. This process may inform guideline development.

Prevalence and factors associated with ulcer-related pain in persons with chronic leg ulcers-an explorative study

AIMS AND OBJECTIVES

The aims of this study were to explore the prevalence of background pain and identify demographic, clinical and psychosocial factors associated with moderate to severe background pain in persons with leg ulcers.

BACKGROUND

All chronic leg ulcers are potentially painful. Research indicates that 80% of persons with chronic leg ulcers experience wound-related background pain. However, studies on factors associated with pain have small samples and findings are inconclusive.

DESIGN

Exploratory cross-sectional study.

METHOD

This quantitative study recruited persons with chronic leg ulcers (N = 252) from two wound care clinics using consecutive sampling method. Data were obtained through screening interview, clinical examination and questionnaires. Logistic regression with stepwise backwards elimination was used to identify factors associated with moderate to severe background pain. The STROBE checklist for cross-sectional studies was used for reporting this study.

RESULTS

Background pain was reported by 64% of the participants. Inferential statistical analyses suggest that between 58% and 69% of persons with chronic leg ulcers suffer from this type of pain. Factors associated with moderate to severe pain were older age, female gender, reduced sleep quality and diminished health status. In the final model, reduced sleep quality increased the likelihood of having moderate to severe pain in persons with good health status while not in persons with diminished health status.

CONCLUSION

Ulcer-related background pain is common in persons with chronic leg ulcers. Older females reporting insomnia symptoms also had increased risk of moderate to severe ulcer-related background pain. These participants also perceived their health status to be better.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates that ulcer-related background pain and associated factors needs more attention in clinical practice. Furthermore, nurses and other healthcare professionals should integrate biopsychosocial strategies to assess and manage ulcer-related background pain.

Venous leg ulcer management in Australian primary care: Patient and clinician perspectives

BACKGROUND

Venous leg ulcers are the most common chronic wound seen in Australian primary care. Healing outcomes are protracted due to suboptimal use of clinical practice guideline recommendations. A better understanding of the differences between patients and clinicians may optimise management in primary care and improve healing and health outcomes for patients and healthcare spend in society.

OBJECTIVE

We explored venous leg ulcer management from patients' and primary care clinicians' perspective, including assessment, diagnosis, treatment, referral, and health education as outlined in the clinical practice guidelines.

DESIGN

We conducted a qualitative secondary analysis of data obtained from the qualitative face-to-face and telephone interviews with the primary care clinicians and telephone interviews with patients with venous leg ulcers.

SETTING

Clinicians were recruited from urban and rural primary health practices across Victoria, Australia. Patients were recruited from two specialist care wound clinics in Victoria.

PARTICIPANTS

We analysed data from interviews with 66 participants, including 31 patients with venous leg ulcers, 15 general practitioners and 20 practice nurses.

METHODS

Secondary analysis of qualitative data was carried out using thematic analysis. Interview transcripts were coded and analysed for common themes.

RESULTS

We found patients and clinicians reported differing perspectives related to venous leg ulcer management. Patients reported the need for earlier referral to specialist wound care clinics from primary care, emphasizing the need for vascular assessment and compression therapy. Clinicians discussed clinical judgements about when to refer rather than follow guideline recommendations. Clinicians frequently discussed managing venous leg ulcers using only topical dressing treatments, without compression therapy. Patients reported inadequate pain management for wound pain. Meanwhile, clinicians reported that they generally did not discuss wound pain management as part of overall venous leg ulcer management. Clinicians reported patients lacked an understanding about the role of compression in management of and subsequent healing outcomes. Patients stated they wanted more information about how to care for venous leg ulcers and how best to prevent recurrence, and needed more information than was already provided by clinicians. Conversely, clinicians reported less information is given to ensure patients were not overwhelmed with health information.

CONCLUSION

There are discrepancies between what patients want and what clinicians do. These data suggest that patients' preferences are aligned with venous leg ulcer clinical practice guideline recommendations. Greater awareness of the guidelines by health professional may not only reduce discrepancies they may improve health and healing outcomes. Tweetable abstract: Patients and primary care clinicians have different perspectives about venous leg ulcer management.

Pain in persons with chronic venous leg ulcers: A systematic review and meta-analysis

Pain is a serious problem for patients with leg ulcers. Research mainly focuses on dressing‐related pain; however, chronic background pain may be just as devastating. Our main objective was to describe the prevalence and characteristics of wound‐related background pain in persons with chronic venous leg ulcers. We performed a systematic review to synthesise data from quantitative studies. Studies were eligible if they reported original baseline‐ or cross‐sectional data on background pain in chronic venous leg ulcers. The initial search identified 2454 publications. We included 36 descriptive and effect studies. The pooled prevalence of wound‐related background pain (from 10 studies) was 80% (95% CI 65‐92%). The mean pain intensity score (from 27 studies) was 4 (0‐10 numeric rating scale) (95% CI 3.4‐4.5). Other pain characteristics could not be synthesised. We identified few sufficiently high‐quality studies on prevalence and intensity of wound‐related background pain in patients with chronic venous leg ulcers. Four of five persons experience mild to moderate pain. Because of poor quality of pain assessment and report, we believe that the available research does not provide a sufficiently nuanced understanding of background pain in this patient group.