Randomised controlled trial comparing European standard class 1 to class 2 compression stockings for ulcer recurrence and patient compliance

Compression for preventing recurrence of venous ulcers

BACKGROUND

Up to 1% of adults will have a leg ulcer at some time. Most leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or damaged valves. Venous ulcer prevention and treatment typically involves the application of compression bandages/stockings to improve venous return and thus reduce pressure in the legs. Other treatment options involve removing or repairing veins. Most venous ulcers heal with compression therapy, but ulcer recurrence is common. For this reason, clinical guidelines recommend that people continue with compression treatment after their ulcer has healed. This is an update of a Cochrane review first published in 2000 and last updated in 2014.

OBJECTIVES

To assess the effects of compression (socks, stockings, tights, bandages) for preventing recurrence of venous leg ulcers.

SEARCH METHODS

In August 2023, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, three other databases, and two ongoing trials registries. We also scanned the reference lists of included studies and relevant reviews and health technology reports. There were no restrictions on language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated compression bandages or hosiery for preventing the recurrence of venous ulcers.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias, and extracted data. Our primary outcome was reulceration (ulcer recurrence anywhere on the treated leg). Our secondary outcomes included duration of reulceration episodes, proportion of follow-up without ulcers, ulceration on the contralateral leg, noncompliance with compression therapy, comfort, and adverse effects. We assessed the certainty of evidence using GRADE methodology.

MAIN RESULTS

We included eight studies (1995 participants), which were published between 1995 and 2019. The median study sample size was 249 participants. The studies evaluated different classes of compression (UK class 2 or 3 and European (EU) class 1, 2, or 3). Duration of follow-up ranged from six months to 10 years. We downgraded the certainty of the evidence for risk of bias (lack of blinding), imprecision, and indirectness. EU class 3 compression stockings may reduce reulceration compared with no compression over six months (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.76; 1 study, 153 participants; low-certainty evidence). EU class 1 compression stockings compared with EU class 2 compression stockings may have little or no effect on reulceration over 12 months (RR 1.70, 95% CI 0.67 to 4.32; 1 study, 99 participants; low-certainty evidence). There may be little or no difference in rates of noncompliance over 12 months between people using EU class 1 stockings and people using EU class 2 stockings (RR 1.22, 95% CI 0.40 to 3.75; 1 study, 99 participants; low-certainty evidence). UK class 2 hosiery compared with UK class 3 hosiery may be associated with a higher risk of reulceration over 18 months to 10 years (RR 1.55, 95% CI 1.26 to 1.91; 5 studies, 1314 participants; low-certainty evidence). People who use UK class 2 hosiery may be more compliant with compression treatment than people who use UK class 3 hosiery over 18 months to 10 years (RR for noncompliance 0.69, 95% CI 0.49 to 0.99; 5 studies, 1372 participants; low-certainty evidence). There may be little or no difference between Scholl UK class 2 compression stockings and Medi UK class 2 compression stockings in terms of reulceration (RR 0.77, 95% CI 0.47 to 1.28; 1 study, 166 participants; low-certainty evidence) and noncompliance (RR 0.97, 95% CI 0.84.1 to 12; 1 study, 166 participants; low-certainty evidence) over 18 months. No studies compared different lengths of compression (e.g. below-knee versus above-knee), and no studies measured duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects.

AUTHORS' CONCLUSIONS

Compression with EU class 3 compression stockings may reduce reulceration compared with no compression over six months. Use of EU class 1 compression stockings compared with EU class 2 compression stockings may result in little or no difference in reulceration and noncompliance over 12 months. UK class 3 compression hosiery may reduce reulceration compared with UK class 2 compression hosiery; however, higher compression may lead to lower compliance. There may be little to no difference between Scholl and Medi UK class 2 compression stockings in terms of reulceration and noncompliance. There was no information on duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects. More research is needed to investigate acceptable modes of long-term compression therapy for people at risk of recurrent venous ulceration. Future trials should consider interventions to improve compliance with compression treatment, as higher compression may result in lower rates of reulceration.

Black holes in compression therapy: A quest for data

OBJECTIVE

Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included.

METHODS

The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included.

RESULTS

The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation.

CONCLUSIONS

We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data.

A novel optimization approach for bio-design of therapeutic compression stockings with pressure fit

For physical-based compression therapeutic modalities, especially compression stockings (CSs), their pressure performances are necessarily evaluated by the standardized cylinder leg mannequins before biological applications. However, the insufficient pressure supply caused by morphological shape diversities between circular leg mannequins and irregular bio-bodies limits the clinical effectiveness and user compliance of CSs. Therefore, an operable and efficiency approach for optimization bio-design and digital development of CSs with enhanced compression performances needs to be proposed. The present study has adopted three-dimensional (3D) body scanning and reverse engineering technologies for lower limb cross-sectional geometric characterization and morphological classification. The irregularity of biological leg circumferential slices was determined and clustered as four levels relating to individual curvature variations. Sequentially, a new pressure prediction model was constructed through characterized geometric variations for bio-based bodies, then its acceptability was validated with good agreement by wearing trials (mean prediction accuracy was 2.53 ± 0.52 mmHg). Thus, the digital pressure reshaped development guidance was obtained based on the classified irregular levels and established pressure prediction models. Consequently, this study provides a novel reliable optimization bio-design solution for manufacturing of therapeutic compression textiles and facilitates the medical efficacy and precision of compression therapy in practical use.

No More Venous Ulcers-What More Can We Do?

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

Lower-Extremity Vascular Ulcers: Assessment and Approaches to Management

Healing of skin wounds of the lower extremities can be complicated by concomitant vascular disease. Dysfunction of the arterial, venous, and/or lymphatic systems can compromise the healing of skin ulcers of the legs, creating a burden for patients from painful, draining wounds and placing patients at risk for infection, amputation, and even death. Insights into vascular pathophysiology and an understanding of the processes of wound healing permit an evidence-based approach to patients with vascular leg ulcers. Clinical trials have demonstrated opportunities to improve the care of patients with vascular leg ulcers, thereby reducing morbidity and mortality and easing patients' burdens.

The influence of different sub-bandage pressure values in the prevention of recurrence of venous ulceration-A ten year follow-up

OBJECTIVE

The aim of this study was to establish the efficacy of three different strengths of compression systems in the prevention of venous leg ulcer (VLU) recurrences during a 10-year follow up period.

METHODS

An open, prospective, randomized, single-center study included 477 patients (240 men, 237 women; mean age 59 years). Patients were randomized into three groups: Group A) 149 patients (allocated to wear elastic stocking 18-25 mmHg). Group B) 167 patients (wearing compression device exerting 25-35 mmHg), and Group C) 161 patients (treated with multilayer compression system exerting 35-50 mmHg).

RESULTS

Overall, 65% (234/360) of patients had recurrent VLU within 10 years. Recurrence occurred in 120 (96%) of 125 in group A, in 89 (66.9%) of 133 patients in group B and in 25 (24.5%) of 102 patients in group C (p < 0.05).

CONCLUSION

Compression systems with the higher compression class provide lower recurrence rate.

To explore the factors that impact on patient concordance with venous leg ulcer management using compression therapy

It is understood that intervention for venous leg ulcer (VLU) management is more successful the sooner compression is applied, yet healing rates of VLUs are falling and recurrence rates increasing. This literature review seeks to explore the factors affecting patient concordance with compression therapy to manage VLU. Of the literature searched, 14 articles were identified and four themes of reasons for non-concordance emerged: education; pain/discomfort; physical limitations; and psychosocial issues. The reasons for non-concordance are vast and complex; district nurses must explore these reasons to help improve the alarming rates of non-concordance. A personalised approach is necessary to meet individual needs. High risks of ulcer recurrence are noted and a greater understanding of the chronic nature of ulceration should be conveyed. Follow-up care and building trust is linked with higher rates of concordance. Further research is needed within district nursing as the majority of venous ulceration is managed within the community.

Developing a Suite of Resources to Improve Patient Adherence to Compression Stockings: Application of Behavior Change Theory

PURPOSE

Poor patient adherence to compression stockings remains a difficult and pervasive problem for clinicians, with costly repercussions for patients and health-care systems. The purpose of this paper was to describe the application of behavior change theory to the systematic development of a suite of resources, aimed at improving patient adherence to wearing compression stockings.

METHODS

Employing a non-empirical approach, behavior-change theory was used to develop an innovative intervention as part of a multi-phase project. Target behaviors, barriers and potential enablers were identified in relation to stocking adherence. An impact-likelihood matrix for behavior prioritization was used to identify possible areas for intervention within occupational therapy outpatient clinics. Selection of suitable resources and their consequent development were based on a narrative and problem-solving process by a panel of clinical experts.

RESULTS

Of 14 potential domains embedded in the Theoretical Domains Framework, the key target behaviors and barriers were associated with eight domains. Michie's Behavior Change Wheel revealed recommendations in six subdivisions and of these, four intervention functions were selected by the panel, based on their potential impact and likelihood of adoption in clinical practice. Findings led to the development of a suite of resources comprising a new questionnaire, a clinical decision tree, augmented by clinical answer sheets corresponding to each of the barriers.

CONCLUSION

Application of behavior change theory informed the design of a behavior change intervention comprising an integrated suite of resources for novice and experienced clinicians.

PRACTICE IMPLICATIONS

These novel resources have potential to improve patient adherence to compression stockings and consequently generate health-care savings through reduced need for wound care products, and medical interventions with translation to other settings and conditions requiring compression stockings. Patient outcomes will likely be improved with reduced pain, improved quality of life and earlier resumption of usual occupations.

[Medical compression stockings for chronic venous diseases and lymphedema : Scientific evidence and results of a patient survey on quality of care]

Hintergrund und Ziele

Medizinische Kompressionsstrümpfe (MKS) sind bei chronischer venöser Insuffizienz (CVI) aller Stadien indiziert und beim Lymphödem eine unverzichtbare Therapiekomponente; 8 % der deutschen Bevölkerung tragen vom Arzt verordnete MKS, Frauen häufiger als Männer (12 % vs. 5 %) und insbesondere Personen ab 60 Jahren (17 %). Die Adhärenz der Patienten ist relevant für eine erfolgreiche Behandlung mit MKS. Untersucht wurde die Versorgung mit MKS aus Patientensicht.

Patienten und Methodik

Die vorliegende Studie untersuchte 2019 die Versorgungsqualität durch strukturierte Interviews mit 414 repräsentativ ausgewählten Nutzern. Die Erkenntnisse werden vor dem Hintergrund wissenschaftlicher Evidenz zur Wirkung der MKS diskutiert.

Ergebnisse

Venenprobleme sind der häufigste Verordnungsgrund (44 %), gefolgt von Lymphödemen (22 %) bzw. Mehrfachindikationen (27 %). Patienten tragen MKS zumeist täglich und durchschnittlich 11 h/Tag; 89 % der Patienten waren zufrieden bzw. sehr zufrieden mit den MKS und berichteten je nach Indikation ein differenziertes Wirkprofil. Dieses reflektiert die umfangreiche wissenschaftliche Evidenz zur klinischen Wirksamkeit der MKS. Ein wichtiger Faktor für die Patientenadhärenz ist die ärztliche Schulung und Aufklärung.

Schlussfolgerungen

MKS werden von Patienten sehr gut akzeptiert. Bei der Verordnung sollen praktischen Aspekte wie An- und Ausziehen, empfohlene Tragedauer und -häufigkeit sowie der Wirkmechanismus der MKS vermittelt werden.

Graphic abstract

Compression hosiery for venous disorders and oedema: a question of balance

Compression therapy for venous and lymphatic conditions may be delivered via a range of treatment modalities using many different technologies, depending on the patient's condition and needs. Clinical decision-making relies on accurate assessment of the patient, their presenting and underlying clinical condition, skill and training of the applier and the available resources. However, changes in the patient's condition or lifestyle may necessitate re-evaluation of the treatment pathway. Generally, compression bandages and Velcro wraps are used in the intensive acute phase of treatment, with self-management using compression hosiery or wraps being used for long-term maintenance to prevent recurrence. Although guidelines recommend the highest class of compression hosiery for maximum effectiveness, clinical evidence shows practical challenges associated with application and tolerance of higher pressures and stiffness. An audit of a new type of compression garment was conducted, and it showed that incorporating stiffness into circular knitted hosiery helped overcome some of these challenges with improvements in limb size, skin softening and wound size. Additionally, self-management was facilitated by the ease of donning and doffing.

DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers

BACKGROUND

Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy.

METHODS

This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates.

DISCUSSION

This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence.

ETHICAL COMMITTEE REFERENCE

C.A. 2111 Galway Clinical Research Ethics Committee REGISTRATION: Clinical Trials.gov registration NCT03640689 , Registered on 21 August 2018.

Improving Adherence to Wearing Compression Stockings for Chronic Venous Insufficiency and Venous Leg Ulcers: A Scoping Review

PURPOSE

Patient adherence to wearing compression stockings in the management of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is low. Poor adherence with compression stockings contributes to recurrence and impaired healing of VLUs. As such, the purpose of this review was to report on the scientific evidence related to adherence and explore modifiable factors which impact adherence with compression stockings.

METHODS

A systematic search was conducted from inception to 31 October 2019. Following the PRISMA-ScR Checklist, PubMed, Medline, CINAHL, Cochrane, Embase, OT Seeker and Web of Science were explored using search terms: compression/compression stocking/compression garment/compression sock/stockings/garments and adherence/compliance/concordance.

RESULTS

We identified 2613 papers of which 125 full text papers were assessed for eligibility and 69 met inclusion criteria. Papers were grouped and charted by concepts relevant to the research questions and narratively synthesized. Several dominant themes emerged, and a conceptual framework was developed incorporating modifiable variables, adherence itself, and outcomes related to adherence. Specifically considering interventions to improve adherence, only five of 14 randomized controlled trials were able to demonstrate improvements in adherence through unidimensional approaches. All nine of the case studies/series demonstrated a positive impact on adherence, eight of which described a personalized multidimensional approach. A lack of consensus around defining, measuring, and quantifying adherence with compression stockings was identified, resulting in wide variation in reported adherence rates.

CONCLUSION

Inconsistency in the definition and measurement of adherence limits meaningful interpretation of the literature. No individual intervention has consistently demonstrated improved adherence. Multidimensional interventions show promise but require further investigation with high-quality trials. Improving adherence appears to improve health outcomes in VLU /CVI populations but there is a lack of information directly linking improved adherence with cost outcomes.

TRIAL REGISTRATION

Open Science Framework: ACTRN12620000544976p.

Compression Stocking With 100% Donning and Doffing Success: An Open Label Randomised Controlled Trial

OBJECTIVE

The aim of this study was to test whether an investigational two layer stocking exerting 27-29 mmHg pressure at the medial supramalleolar level, but without compression in the foot and heel, is easier to put on and take off than a standard stocking of the same compression class (23-32 mmHg), and also to assess the prevention of diurnal oedema with both types of stocking.

METHODS

This was an open label randomised controlled trial, which included 47 patients. All participants were at least 65 years of age and suffered from chronic venous disease class C3 - C6 in one leg. The primary end point was donning success; secondary endpoints were doffing success, prevention of diurnal oedema over one day, and the comfort of wearing the stocking. Patients were randomly allocated to one of two groups. Both types of compression stocking were compared in each group for ease of donning and doffing in the manner of a crossover study. Subsequently, patients wore the stocking type assigned to their group for a whole day to evaluate comfort and the effect on diurnal leg volume.

RESULTS

All participants were able to don the investigational stocking unaided, compared with 75% for the standard stocking (p < .001). Unaided removal success was 100% with the investigational stocking vs. 66% for the standard stocking (p < .001). There was no significant difference in leg volume reduction between the study groups after a day of wear. The investigational stocking was also rated as being more comfortable than the standard stocking (p < .001).

CONCLUSION

The investigational stocking, which has no compression in the foot or heel area, is significantly easier to don and doff, with no inferiority in oedema prevention, compared with a standard stocking of the same compression class.

Reasons for patient non-compliance with compression stockings as a treatment for varicose veins in the lower limbs: A qualitative study

The study aims to explore the comprehensive reasons for patients’ non-compliance with graded elastic compression stockings (GECS) as the treatment for lower limb varicose veins. Phenomenological analysis was applied in this qualitative study. The patients diagnosed with lower limb varicose veins and undergoing elective surgery who showed non-compliance with GECS as the treatment were invited to have semi-structured, in-depth, face-to-face interviews. Colaizzi method was employed to analyze the data for emerging themes associated with the reasons for patients’ non-compliance. Four main themes and nine subthemes related to the reasons for non-compliance with GECS for lower limb varicose veins were summarized. The main themes that emerged were (1) gaps in the knowledge of GECS therapy as a treatment for lower limb varicose veins, (2) few recommendations from the doctors and nurses, (3) disadvantages of GECS, and (4) sociopsychological factors. These themes provide data for policy and planning to improve patients’ compliance with GECS in China. Patients, healthcare professionals, and policy makers should share the responsibility to improve patients’ compliance with GECS therapy.

Prevention and Management of the Post-Thrombotic Syndrome

The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency secondary to prior deep vein thrombosis (DVT). It affects up to 50% of patients after proximal DVT. There is no effective treatment of established PTS and its management lies in its prevention after DVT. Optimal anticoagulation is key for PTS prevention. Among anticoagulants, low-molecular-weight heparins have anti-inflammatory properties, and have a particularly attractive profile. Elastic compression stockings (ECS) may be helpful for treating acute DVT symptoms but their benefits for PTS prevention are debated. Catheter-directed techniques reduce acute DVT symptoms and might reduce the risk of moderate-severe PTS in the long term in patients with ilio-femoral DVT at low risk of bleeding. Statins may decrease the risk of PTS, but current evidence is lacking. Treatment of PTS is based on the use of ECS and lifestyle measures such as leg elevation, weight loss and exercise. Venoactive medications may be helpful and research is ongoing. Interventional techniques to treat PTS should be reserved for highly selected patients with chronic iliac obstruction or greater saphenous vein reflux, but have not yet been assessed by robust clinical trials.

Patient-reported reasons for and predictors of noncompliance with compression stockings in a randomized trial of stockings to prevent postthrombotic syndrome

INTRODUCTION

Elastic compression stockings (ECSs) are used to treat symptoms of venous insufficiency. However, lack of patient compliance can limit their effectiveness. In a secondary analysis of the SOX Trial, a randomized trial of active vs. placebo ECSs worn for 2 years to prevent postthrombotic syndrome after deep vein thrombosis, we aimed to describe patient-reported reasons for nondaily use of ECS and to identify predictors of noncompliance during follow-up.

METHODS

At each follow-up visit of the SOX Trial, patients were asked how many days per week they wore study stockings, and if not worn daily, to specify the reason(s). Reasons for nondaily use of ECSs were tabulated. Multiple logistic regression modeling was used to identify predictors of stocking noncompliance during follow-up (defined as use <3 days per week).

RESULTS

Among the 776 patients who attended at least 1 follow-up visit, daily use of stockings at each visit was similar in the active and placebo ECS groups. Reasons for nondaily use of stockings was most frequently related to aversive aspects of stockings (~three-fourths of patients) and less often related to patient behaviors (~one-fourth of patients). In multivariate analyses, behavior-related and aversive aspect-related reasons for nondaily use of ECSs at the 1-month visit were significant predictors of noncompliance during follow-up (odds ratio [OR] = 4.41 [95% confidence interval, 2.12-9.17] and OR = 3.99 [2.62-6.08], respectively).

CONCLUSIONS

Aversive aspects of ECSs and patient behaviors are important reasons for noncompliance. Improving the appeal and tolerability of ECS and education directed at modifying patient behaviors may improve compliance.

Communication with patients using negative wound pressure therapy and their adherence to treatment

Objective:

The purpose of this study was to explore the challenges of communication between patients and health professionals, and patient adherence to treatment for hard-to-heal wounds when using negative wound pressure therapy (NPWT).

Methods:

Face-to-face, semi-structured interviews were conducted with patients undergoing NPWT. Specific features of the NPWT device were the priority for discussion although other factors central to communication and adherence were also explored.

Results:

A total of 24 patients took part in the study. Data saturation was achieved during the analysis. Patients required ongoing support to understand complex and often protracted treatment and this was particularly important when specialist technology was used. A distinction was highlighted between those who decided not to adhere with therapy and those who did so unintentionally. Participants faced difficulties in their communications with health professionals and in ensuring their needs were listened to and addressed.

Conclusion:

Further research is needed to achieve a better understanding of this distinction and to evaluate interventions which can sustain adherence behaviours. Further exploration of how to establish concordant patient/health professional communications is warranted.

Effects of preventive use of compression stockings for elderly with chronic venous insufficiency and swollen legs: a systematic review and meta-analysis

BACKGROUND

Many home-dwelling elderly use medical compression stockings to prevent venous insufficiency, deep venous thrombosis, painful legs and leg ulcers. Assisting users with applying and removing compression stockings demands resources from the home based health services, but the effects are uncertain. This systematic review aims to summarize the effects of preventive use of medical compression stockings for patients with chronic venous insufficiency and swollen legs.

METHODS

We conducted a search in six databases (Epistemonikos, Cochrane Database of Systematic Reviews, MEDLINE, Embase, CENTRAL and CINAHL) in March 2018. Randomized controlled trials evaluating the preventive effects of European standard compression stockings class 3 or 2 for elderly with chronic venous insufficiency and swollen legs were included. Primary outcomes were thrombosis, leg ulcers and mobility. Secondary outcomes were other health related outcomes, e.g. pain, compliance. We assessed risk of bias in the included studies and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool for evaluating the overall quality of evidence.

RESULTS

Five randomized controlled trials met the inclusion criteria. Comparing compression stockings class 2 to class 1, meta-analysis showed a reduction in leg ulcer recurrence at 12 months (RR 0.52; 95% CI 0.30 to 0.88). The quality of evidence was assessed as moderate by GRADE. One study (100 participants) did not detect a difference between compression stockings class 3 versus class 2 on ulcer recurrence after six months (RR 0.64; 95% CI 0.20 to 2.03). In another study, patients wearing class 3 compression stockings had lower recurrence risk compared with patients without stockings (RR 0.46; 95% CI 0.27 to 0.76) at six months and (RR 0.43; 95% CI 0.27 to 0.69) at 12 months. We found no difference between class 2 and class 1 stockings on subjective symptoms of chronic venous insufficiency or outcomes of vein thrombosis or mobility.

CONCLUSION

Compression stockings class 2 probably reduce the risk of leg ulcer recurrence compared to compression stockings class 1. It is uncertain whether the use of stockings with higher compression grades is associated with a further risk reduction. More randomized controlled trials on vein thrombosis and mobility are needed.

Clinical superiority of an innovative two-component compression system versus four-component compression system in treatment of active venous leg ulcers: A randomized trial

Objective

To evaluate the efficacy, safety and acceptability of an innovative two-component versus a well-established four-component compression systems in the management of venous leg ulcer.

Method

Multicentre randomized controlled trial in patients with active venous leg ulcer. Patients were followed-up monthly for a maximum of 16 weeks. The primary endpoint was the complete healing rate at 16 weeks.

Results

Ninety-two patients were randomized to either the two-component BIFLEX® Kit group ( n = 49) or the four-component PROFORE® group ( n = 43). In the full analysis set ( n = 88), a complete healing rate of 48.9% and 24.4% was reported in BIFLEX® Kit versus PROFORE® groups, respectively (i.e. a superiority of 24.5%, p = 0.02). Acceptability of BIFLEX® Kit was higher from both the patients’ and physicians’ perspectives.

Conclusion

The BIFLEX® Kit represents a valid alternative therapy in the management of venous leg ulcer according to its clinical efficacy, safety and acceptability with potential positive impacts on healthcare costs.

Compression Stockings for the Prevention of Venous Leg Ulcer Recurrence: A Health Technology Assessment

BACKGROUND

People with chronic venous insufficiency who develop leg ulcers face a difficult condition to treat. Venous leg ulcers may persist for long periods of time and have a negative impact on quality of life. Treatment requires frequent health care provider visits, creating a substantial burden across health care settings.The objective of this health technology assessment was to evaluate the effectiveness, safety, cost-effectiveness, budget impact, and patient experiences of compression stockings for prevention of venous leg ulcer recurrence.

METHODS

We conducted a systematic review of the literature to identify randomized trials and observational studies examining the effectiveness of compression stockings in reducing the risk of recurrence of venous leg ulcers after healing and/or reported on the quality of life for patients and any adverse events from the wearing of compression stockings. We performed a literature search to identify studies and evaluated the quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.We conducted a cost-utility analysis with a 5-year time horizon from the perspective of the Ontario Ministry of Health and Long-Term Care. We compared compression stockings to usual care (no compression stockings) and simulated a hypothetical cohort of 65-year-old patients with healed venous ulcers, using a Markov model. Model input parameters were obtained primarily from the published literature. In addition, we used Ontario costing sources and consultation with clinical experts. We estimated quality-adjusted life years gained and direct medical costs. We conducted sensitivity analyses and a budget impact analysis to estimate the additional costs required to publicly fund compression stockings in Ontario. All costs are presented in 2018 Canadian dollars.We spoke to people who recently began using compression stockings and those who have used them for many years to gain an understanding of their day-to-day experience with the management of chronic venous insufficiency and compression stockings.

RESULTS

One randomized controlled trial reported that the recurrence rate was significantly lower at 12 months in people who were assigned to the compression stocking group compared with people assigned to the control group (risk ratio 0.43, 95% CI, 0.27-0.69; P = .001) (GRADE: Moderate). Three randomized controlled trials reported no significant difference in recurrence rates between the levels of pressure. One randomized controlled trial also reported that the risk of recurrence was six times higher in those who did not adhere to compression stockings than in those who did adhere. One single-arm cohort study showed that the recurrence rate was considerably higher in people who did not adhere or had poor adherence (79%) compared with those who adhered to compression stockings (4%).Compared with usual care, compression stockings were associated with higher costs and with increased quality-adjusted life years. We estimated that, on average, the incremental cost-effectiveness ratio of compression stockings was $27,300 per quality-adjusted life year gained compared to no compression stockings. There was some uncertainty in our results, but most simulations (> 70%) showed that the incremental cost-effectiveness ratio remained below $50,000 per quality-adjusted life-year. We estimated that the annual budget impact of funding compression stockings would range between $0.95 million and $3.19 million per year over the next five years.People interviewed commonly reported that chronic venous insufficiency had a substantial impact on their day-to-day lives. There were social impacts from the difficulty or inability to walk and emotional impacts from the loss of independence and fear of ulcer recurrence. There were barriers to the wearing of compression stockings, including replacement cost and the difficulty of putting them on; however, most people interviewed reported that using compression stockings improved their condition and their quality of life.

CONCLUSIONS

The available evidence shows that, compared with usual care, compression stockings are effective in preventing venous leg ulcer recurrence and likely to be cost-effective. In people with a healed venous leg ulcer, wearing compression stockings helps to reduce the risk of recurrence by about half. Publicly funding compression stockings for people with venous leg ulcers would result in additional costs to the Ontario health care system over the next 5 years. Despite concerns about cost and the daily chore of wearing compression stockings, most people interviewed felt that compression stockings provided important benefits through reduction of swelling and prevention of recurrence.

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

Critical Evaluation of Delayed Healing of Venous Leg Ulcers: A Retrospective Analysis in Canadian Patients

BACKGROUND

Venous leg ulcers (VLUs) are common but challenging health problems. Better understanding of the risk factors involved in delayed healing of VLUs may therefore guide individualized treatment plans to improve patient outcomes.

OBJECTIVE

We sought to identify the risk factors associated with delayed healing of VLUs in patients seen at a tertiary academic wound care clinic.

METHODS

A retrospective analysis of 554 patients who presented to the Toronto Regional Wound Healing Clinic for VLUs in a 3-year period was performed. Patient and ulcer characteristics were recorded. Multivariate analyses were performed to compare patients with ulcer resolution and those whose ulcers did not resolve after 12-month follow-up.

RESULTS

The average age of the patients was 67.3 ± 0.7 years, with 56 % being female. The most common comorbidities were hypertension (54 %), dyslipidemia (33 %), a history of smoking (30 %), and diabetes (26 %). Ulcer resolution was associated with a smaller ulcer size (odds ratio [OR] 0.984 [95 % confidence interval (CI) 0.973, 0.996]), shorter ulcer duration (OR 0.704 [95 % CI 0.574, 0.865]), and dyslipidemia (OR 1.848 [95 % CI 1.052, 3.246]).

CONCLUSION

Pro-healing factors associated with VLUs were a smaller ulcer size and a shorter ulcer duration. Dyslipidemia was also associated with improved healing, potentially owing to the use of statins. Patients presenting with poorer-prognosis VLUs should receive more aggressive treatment with earlier referral to vascular surgery.

Prevenção de recidiva de úlcera varicosa: um estudo de coorte

Resumo Objetivo Determinar a taxa de recidiva de úlcera varicosa, e verificar a associação entre recidiva e medidas de prevenção adotadas. Métodos Estudo de coorte com 50 pacientes maiores de 18 anos com úlcera varicosa pós-cicatrização acompanhados durante 10 anos. A recidiva foi avaliada por meio de inspeção direta durante a avaliação clínica, e as medidas de prevenção usadas foram informadas pelo paciente. Utilizou-se o teste qui quadrado de Pearson, sendo significante p-value ≤0,05. Resultados A recidiva de úlcera varicosa foi de 62,2%, a maioria em mulheres, seguida por idosos, analfabetos e aposentados. Mostrou-se medida eficaz na prevenção de recidivas o seguinte conjunto: uso da meia de compressão, repouso e aplicar creme hidratante. Conclusão A taxa de recidiva de úlcera varicosa foi elevada e as principais medidas de prevenção aplicadas em conjunto foram usar meia de compressão, repousar e aplicar creme hidratante.

Debridement for venous leg ulcers

BACKGROUND

Venous ulcers (also known as varicose or venous stasis ulcers) are a chronic, recurring and debilitating condition that affects up to 1% of the population. Best practice documents and expert opinion suggests that the removal of devitalised tissue from venous ulcers (debridement) by any one of six methods helps to promote healing. However, to date there has been no review of the evidence from randomised controlled trials (RCTs) to support this.

OBJECTIVES

To determine the effects of different debriding methods or debridement versus no debridement, on the rate of debridement and wound healing in venous leg ulcers.

SEARCH METHODS

In February 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting. In addition we handsearched conference proceedings, journals not cited in MEDLINE, and the bibliographies of all retrieved publications to identify potential studies. We made contact with the pharmaceutical industry to enquire about any completed studies.

SELECTION CRITERIA

We included RCTs, either published or unpublished, which compared two methods of debridement or compared debridement with no debridement. We presented study results in a narrative form, as meta-analysis was not possible.

DATA COLLECTION AND ANALYSIS

Independently, two review authors completed all study selection, data extraction and assessment of trial quality; resolution of disagreements was completed by a third review author.

MAIN RESULTS

We identified 10 RCTs involving 715 participants. Eight RCTs evaluated autolytic debridement and included the following agents or dressings: biocellulose wound dressing (BWD), non-adherent dressing, honey gel, hydrogel (gel formula), hydrofibre dressing, hydrocolloid dressings, dextranomer beads, Edinburgh University Solution of Lime (EUSOL) and paraffin gauze. Two RCTs evaluated enzymatic preparations and one evaluated biosurgical debridement. No RCTs evaluated surgical, sharp or mechanical methods of debridement, or debridement versus no debridement. Most trials were at a high risk of bias.Three RCTs assessed the number of wounds completely debrided. All three of these trials compared two different methods of autolytic debridement (234 participants), with two studies reporting statistically significant results: one study (100 participants) reported that 40/50 (80%) ulcers treated with dextranomer beads and 7/50 (14%) treated with EUSOL achieved complete debridement (RR 5.71, 95% CI 2.84 to 11.52); while the other trial (86 participants) reported the number of ulcers completely debrided as 31/46 (76%) for hydrogel versus 18/40 (45%) for paraffin gauze (RR 0.67, 95% CI 0.45 to 0.99). One study (48 participants) reported that by 12 weeks, 15/18 (84%) ulcers treated with BWD had achieved a 75% to 100% clean, granulating wound bed versus 4/15 (26%) treated with non-adherent petrolatum emulsion-impregnated gauze.Four trials assessed the mean time to achieve debridement: one (86 participants) compared two autolytic debridement methods, two compared autolytic methods with enzymatic debridement (71 participants), and the last (12 participants) compared autolytic with biosurgical debridement; none of the results achieved statistical significance.Two trials that assessed autolytic debridement methods reported the number of wounds healed at 12 weeks. One trial (108 participants) reported that 24/54 (44%) ulcers treated with honey healed versus 18/54 (33%) treated with hydrogel (RR (adjusted for baseline wound diameter) 1.38, 95% CI 1.02 to 1.88; P value 0.037). The second trial (48 participants) reported that 7/25 (28%) ulcers treated with BWD healed versus 7/23 (30%) treated with non-adherent dressing.Reduction in wound size was assessed in five trials (444 participants) in which two autolytic methods were compared. Results were statistically significant in one three-armed trial (153 participants) when cadexomer iodine was compared to paraffin gauze (mean difference 24.9 cm², 95% CI 7.27 to 42.53, P value 0.006) and hydrocolloid compared to paraffin gauze (mean difference 23.8 cm², 95% CI 5.48 to 42.12, P value 0.01). A second trial that assessed reduction in wound size based its results on median differences and, at four weeks, produced a statistically significantly result that favoured honey over hydrogel (P value < 0.001). The other three trials reported no statistically significant results for reduction in wound size, although one trial reported that the mean percentage reduction in wound area was greater at six and 12 weeks for BWD versus a non-adherent dressing (44% versus 24% week 6; 74% versus 54% week 12).Pain was assessed in six trials (544 participants) that compared two autolytic debridement methods, but the results were not statistically significant. No serious adverse events were reported in any trial.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that actively debriding a venous leg ulcer has a clinically significant impact on healing. The overall small number of participants, low number of studies and lack of meta-analysis in this review precludes any strong conclusions of benefit. Comparisons of different autolytic agents (hydrogel versus paraffin gauze; Dextranomer beads versus EUSOL and BWD versus non-adherent dressings) and Larvae versus hydrogel all showed statistically significant results for numbers of wounds debrided. Larger trials with follow up to healing are required.