Effects and associations of nutrition in patients with venous leg ulcers: A systematic review

The role of Bromelain and Liposomal Vitamin C in the treatment of chronic venous disease

Chronic venous disease (CVD) is a prevalent condition leading to significant morbidity and affecting quality of life. Among conservative treatment strategies, venoactive drugs are often recommended by major guidelines for the management of CVD. Bromelain and vitamin C are now emerging as promising options in the management of several chronic diseases owing to their anti-inflammatory, immunoregulatory, and antioxidant properties, though evidence remains scarce in this setting. This systematic review of the literature, endorsed by the Italian Society of Angiology and Vascular Medicine (Societa Italiana di Angiologia e Patologia Vascolare, SIAPAV), aims to evaluate the efficacy and safety of these compounds in the treatment of CVD. A comprehensive search yielded nine studies, two on bromelain and seven on vitamin C. No studies have evaluated the effects of bromelain and vitamin C alone or in combination, whereas both molecules were administered in combination with other nutritional supplements. Overall, CVD-related symptoms and edema seem to improve with dietary supplement containing these two compounds, with no major safety issues reported. Bromelain and vitamin C may thus represent attractive options in the management of patients with symptomatic CVD and/or presence of venous edema, provided optimal conservative treatment is in place. Dedicated clinical studies are needed to clarify the efficacy and safety of a combination of these molecules in CVD management.

Creation of a National Chronic Wound Registry-Challenges and Opportunities

Chronic wounds pose an increasing burden on the healthcare system and data on wound outcomes and are needed to evaluate and address disparities and reform healthcare policies. In Singapore, data on chronic wounds are fragmented and to address this, we established a Chronic Wounds Registry (CWR) to collect harmonised data on chronic wounds and their outcomes over 6 months. This is a multi-centre prospective cohort study from Nov 2019 to Nov 2021. Patients with chronic wounds were enrolled at multi-speciality acute care hospitals and data were prospectively collected on baseline characteristics, including subject demographics, clinical data, wound images, interventions/treatment, cost burden and patient reported health-related quality of life (HRQOL). Patients were followed up for 6 months and wound outcomes recorded at Month 1, Month 3 and Month 6 time points. Despite the onset of COVID pandemic, a total of 812 patients were recruited in our study. Mean age was 63.5 ± 11.6 years with 66% men and 59% of Chinese ethnicity. Twenty percent of all the wounds were recurrent and patients with venous leg ulcers (VLU) (32%) had the highest recurrence. At 6 months, 225 (46%) of the neuro-ischemic ulcers (NIU), 152 (60%) of the VLUs and 29 (46%) of the pressure injuries (PI) had healed. Major (5%) amputations were highest in patients with NIUs. All-cause mortality was highest (30%) and HRQOL was lowest for patients with PIs (-0.18). Development of a national wound registry is both feasible and essential to consolidate key data elements on chronic wounds. The CWR in its current state captured the local epidemiology, patient journey in acute care hospitals, which will benefit in healthcare policymaking and harmonise care across different levels of healthcare system. The next phase of the CWR aims to track patients in all settings and collect data on the entire patient journey following an episode of wounding.

The (dis)organization of leg ulcer care: A realist synthesis

BACKGROUND

Venous leg ulcers affect 1.5% of the UK adult population. Leg ulcers are painful, can be malodourous and are associated with poor quality of life. Leg ulcers are predominantly cared for by nurses in the community. Frequently, patients receive suboptimal treatment through unwanted variations in care and simple ulcers deteriorate to become hard-to-heal wounds. It is important to understand the current UK system of care and how nurses and patients navigate through it.

AIM

The aim of this paper was to understand how, when, for whom and in what context leg ulcers are cared for in the United Kingdom and specifically, the current system of care, the nurses' role and the patients' experience in this system of care.

DESIGN

A realist synthesis of the literature was undertaken, reported following the RAMESES publication standards: Realist syntheses.

DATA SOURCES

An iterative literature search was conducted across three recognized health collections from January 2010 to January 2022 that included descriptive studies as well as primary research.

RESULTS

73 papers were included.

CONCLUSION

In the absence of UK national guidance that recommends how leg ulcer care is organized and delivered, care is commissioned locally, with variable outcomes. Patients with venous leg ulcers would like to be looked after by knowledgeable, skilled and confident nurses, in well-equipped and staffed clinics; nurses who have the ability to make clinical judgements to alter their treatment when necessary and are empowered to refer to specialist centres when further support is required.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This synthesis offers guidance to commissioners and providers to change how leg ulcer care is organized.

PATIENT OR PUBLIC CONTRIBUTION

The views of a patient and public group was sought at each stage of the synthesis.

Patients with venous leg ulcers can be managed safely in the community ----results of an observational comparison study in Singapore

AIM

To examine the healing outcomes of patients with venous leg ulcers requiring compression bandaging in community care versus tertiary care.

METHOD

This was an analytical observational cohort study. Venous leg ulcer (VLU) patients who required compression bandaging were recruited from an outpatient vascular clinic between May 2021 and August 2022. Eligible patients received two-or four-layer compression bandaging and followed up with the community care or tertiary care centre nurses. The primary outcome was the difference in the total surface area of the VLU after 12 weeks, and the secondary outcome was the patient's quality of life, as measured by the Cardiff Wound Impact Schedule (CWIS).

RESULTS

Forty-seven VLU patients were recruited; 27 received compression bandaging in the community care and 20 by the tertiary care centre. Mean age 70 years old (SD 11.04). The two most prevalent comorbidities were hypertension (51.06 %) and diabetes mellitus (38.29 %). Among those who completed follow-up (12 weeks), the median difference of the total surface area of the VLU between community-based care (p = 0.02) versus tertiary-based care (0.003) was significant. However, there was no difference in the healing status between community and tertiary-based care (p = 0.68). There was no difference in the quality of life of patients between groups.

CONCLUSION

This first tropical study comparing VLU healing outcomes between community and tertiary care found no significant difference in healing with compression bandaging by nurses in either setting. However, the small sample size and high dropout rate limit the generalizability of the findings, necessitating a larger-scale study with longer follow-up. Despite these limitations, the study is a crucial step toward improving wound care services in Singapore, and highlights the need for further research to guide future community wound care implementation.

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.

The Impact of Nutritional Condition and Compression Treatment on Venous Ulcer Recovery: A Systematic Review

Venous ulcers are open wounds commonly associated with chronic venous insufficiency. Each patient's healing process is unique, and factors like nutrition and compression therapy can affect it. Compression therapy and optimal nutritional status can assist in improving venous blood circulation, decreasing swelling, and promoting wound healing. This in-depth review looks at all the recent research on how nutrition and compression therapy can help heal venous ulcers, aiming to develop evidence-based guidelines for improving treatment outcomes. The systematic review, registered in the International Prospective Register of Systematic Reviews (PROSPERO) and following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles, conducted an extensive electronic search in databases such as PubMed, MEDLINE, Cochrane, Web of Science, and Scopus. Using Medical Subject Headings (MeSH) terms and different types of studies, the search method focused on studies that directly looked at how nutrition and compression therapy affected the healing of venous ulcers. After deduplicating and screening publications, a collaborative full-text review was conducted to determine their inclusion. As a result, several research studies were chosen for the qualitative synthesis. The authors created a data extraction form to document important variables such as demographics, therapy specifics, and wound features. Several studies on patients with venous ulcers have shown that consuming basic nutrients can improve wound healing. Treatment results differed depending on the types of compression and pressure intensity. Although minimal data indicates the possible benefits of two-layer therapy, a definitive comparison is still uncertain. Further clinical studies are necessary to investigate a wider range of dietary factors and to evaluate different treatments in similar situations.

The effectiveness of nursing interventions in adherence to self-care for preventing venous ulcer recurrence: A systematic literature review

Venous ulcers affect up to 3% of the global population, with a high impact on economies and quality of life. This is exacerbated by its recurrence rates, which reach 70% at 12 months after healing. The perpetuation of these cycles of healing and recurrence is not interrupted or even attenuated by the self-care activities recommended and directed toward their prevention. In this context, we sought to identify the effectiveness of interventions that promote adherence to self-care to prevent venous ulcer recurrence. In August 2022, we conducted a literature search via EBSCO in the following databases: CINAHL Complete, MEDLINE Complete, Cochrane Database of Systematic Reviews, Scopus, and Web of Science. The inclusion criteria were researched in the form of randomised controlled trials or systematic literature reviews, and 99 studies were identified. During the different times of selection, four studies met the defined inclusion criteria and were included. As the main conclusions, the emphasis goes to the importance of the use of compression and the greater effectiveness of higher compression classes for the prevention of recurrence. Different educational methodologies seem to be important to increase knowledge about prevention, specifically regarding the aetiology of recurrence and the implementation of prevention measures.

A simple index to predict healing in venous leg ulcers: a secondary analysis from four randomised controlled trials

OBJECTIVE

To investigate whether the use of a simple baseline measurement predicts venous leg ulcer healing at 12 and 24 weeks.

METHOD

This was a secondary analysis of a cohort of four randomised controlled trials (RCTs) of treatments adjuvant to compression. Self-reported ulcer duration, and measured ulcer length and width, to calculate estimated ulcer area, were used to obtain a Margolis index score. The score created three prognostic strata for likelihood to heal within 24 weeks, and the number of participants healed and time-to-healing were compared.

RESULTS

There were a total of 802 participants across the four RCTs-408 (50.9%) in two 12-week trials and 394 (49.1%) in two 24-week trials. The mean age of participants was 63.7±17.6 years, and 372 were female (46.4%). The Margolis index score at baseline was 0 for 320 participants (predicted normal healing); 1 for 334 participants; and 2 for 148 participants (both 1 and 2 predicted slow-to-heal). Overall, 248 (77.5%) of those participants who scored 0 at baseline healed within 24 weeks, compared with 182 (54.5%) of participants who scored 1, and 30 (20.3%) participants who scored 2. The median time-to-healing was 40 (24-62) days, 57 (35-100) days and 86.5 (56-151) days, respectively. The area under the receiver operating characteristic curve was 0.69 and 0.77, respectively, for the 12 and 24 week trials.

CONCLUSION

A simple baseline index identifies participants with normal or slow-to-heal wounds and could be used to demonstrate prognostic balance between treatment groups in trials. This approach could also be used in clinical practice to assist with managing expectations and for early identification of patients who may best benefit from adjuvant treatments.

Blood Reflux-Induced Epigenetic Factors HDACs and DNMTs Are Associated with the Development of Human Chronic Venous Disease

Blood reflux and metabolic regulation play important roles in chronic venous disease (CVD) development. Histone deacetylases (HDACs) and DNA methyltransferases (DNMTs) serve as repressors that inhibit metabolic signaling, which is induced by proatherogenic flow to promote aortic endothelial cell (EC) dysfunction and atherosclerosis. The aim of this study was to elucidate the relationship between blood reflux and epigenetic factors HDACs and DNMTs in CVD. Human varicose veins with different levels of blood reflux versus normal veins with normal venous flow were examined. The results show that HDAC-1, -2, -3, -5, and -7 are overexpressed in the endothelium of varicose veins with blood reflux. Blood reflux-induced HDACs are enhanced in the varicose veins with a longer duration time of blood reflux. In contrast, these HDACs are rarely expressed in the endothelium of the normal vein with normal venous flow. Similar results are obtained for DNMT1 and DNMT3a. Our findings suggest that the epigenetic factors, HDACs and DNMTs, are induced in venous ECs in response to blood reflux but are inhibited in response to normal venous flow. Blood reflux-induced HDACs and DNMTs could inhibit metabolic regulation and promote venous EC dysfunction, which is highly correlated with CVD pathogenesis.

Factors associated with chronic venous disease: study in 1,136 patients treated for varicose veins of the lower limbs in a specialized clinic

Background

Varicose veins are a highly prevalent condition in the general population, generating variable reasons for consultation that can alter the patient's quality of life, with prevalence and associated factors that vary in different series.

Objectives

To describe the epidemiological profile of patients who consulted for varicose veins by evaluating main symptoms and associated variables.

Methods

Between 2019 and 2020, 1,136 patients attending vascular surgery consultation in a specialized outpatient center were evaluated. Demographic variables, presented symptoms, complications, and associated factors, such as body mass index, parity and family history, were recorded.

Results

A total of 1136 patients were evaluated (79.8% women and 20.2% men), with a mean age of 53.51 years. The presence of symptoms was similar in men and women; the most frequent complications were ulcer, varicorrhage, and superficial venous thrombosis. Most patients showed CEAP 1, 2 and 3 (n = 909) and more than half were overweight or obese (n = 679) with a predominance of those classified as C4. Sixty-nine per cent had a positive family history of varicose veins. There was no difference between severity of varicose veins and time working in the standing or sitting position, but there was a greater presence of C5 or C6 ulcer among patients standing for more than 4 hours.

Conclusions

Describing the characteristics of patients with varicose veins helps to understand the disease and to focus efforts towards those who are more susceptible. The results of this research are similar to those found in other populations.

Effects of Oral Nutritional Supplementation on Patients with Venous Ulcers: A Clinical Trial

Background: The dosage and safety of nutritional supplements for patients with venous ulcers are still not well established. Aim: To evaluate the effects of a high calorie, high protein, arginine-, zinc-, and vitamins A, C, and E-enriched nutritional supplement on the biochemical profile, dietary intake, anthropometry, muscle strength, and characteristics of lesions of patients with venous ulcers. Methods: A controlled before−after clinical trial with a four-week follow-up involved 27 patients with venous ulcers under outpatient treatment in Brazil. It was administered in two to three doses per day (200 mL each) of a high-calorie and high-protein supplement enriched with arginine, zinc, and vitamins A, C, and E. Patients were assessed for anthropometric parameters, dietary intake, biochemical tests, and healing conditions according to the Pressure Ulcer Scale for Healing (PUSH). Results: It was observed that an increase in energy and protein supply led to an adequate intake of immunonutrients (zinc and vitamins A, C, and E), increased body weight, increased body mass index, and stronger handgrip strength. The injury area and the score on the PUSH notably decreased after the intervention (p < 0.001). Conclusions: The administered supplement, at the tested dosage, improved the nutritional status and characteristics of lesions in patients with venous ulcers.

Was hat die Ernährung mit der Wundheilung zu tun?

Bei einer Störung im Ablauf der Wundheilung kann es zu einem verzögerten oder fehlenden Wundverschluss kommen. Als ein möglicher Störfaktor gilt die Ernährung. Man muss zwischen quantitativer und qualitativer Mangelernährung unterscheiden. Gerade übergewichtige Patienten leiden oft an einer qualitativen Mangelernährung und Sarkopenie.

Spezifische Erkrankungen machen eine entsprechende diätetische Nahrungsempfehlung notwendig. So findet man bei dialysepflichtigen Patienten, Dekubitus-Patienten und Ulcus cruris-Patienten oft einen Eiweißmangel. Auch niedrige Level an Vitamin C, Zink, Folsäure, Vitamin D oder Spurenelementen können die Wundheilung negativ beeinflussen.

Größere prospektive Studien sollten klären, ob eine Substitution dieser Mangelzustände den gewünschten positiven Effekt auf die Wundheilung hat. Es erscheint aber sinnvoll, eine ausgewogene Ernährung und an die individuellen Ernährungsgewohnheiten angepasste Verbesserung der Aufnahme von Vitaminen, Spurenelementen und Eiweißen anzustreben.

The Effect of an Educational Intervention on Self-Care in Patients with Venous Leg Ulcers-A Randomized Controlled Trial

Background: Although patients with venous leg ulcers are involved in ulcer management, little is known about why and how these patients self-treat their ulcers without direct supervision by health professionals. Yet patients’ knowledge of ulcer management can be important for achieving ulcer closure and/or preventing recurrence. This study thus investigates the effects of an educational intervention on knowledge of self-care among patients with venous leg ulcers, mainly on wound dressing practice, compression therapy, physical activity and nutrition. Methods and participants: This research was conducted in three outpatient hospitals in central Croatia. An educational brochure was made and distributed to patients; patients were surveyed about caring for venous leg ulcers before the brochure was distributed and after 3 months. Results: In total, 208 patients were involved in the study: 112 in the experimental group and 96 in the control group. The educational intervention increased awareness of compression therapy, knowledge of recurrence prevention, appropriate lifestyle habits, and warning signs related to venous leg ulcers. Conclusions: Patient education on illness and self-care is necessary to achieve positive effects in self-care knowledge. In this study, patients learned how to change dressings, learned how to improve their lifestyle, and were empowered to deal with their illness.

Construction and validation of educational technology for family members of people with venous ulcers

OBJECTIVE

To build and validate an educational technology in the form of a booklet, aimed at the family members of people with venous ulcers to assist them in their care.

METHODS

A methodological study, which went through the stages of bibliographic survey and situational diagnosis for the construction of the booklet and validation of content, appearance, and adequacy with judges and the target audience. The Content Validity Index, the Suitability Assessment of Materials, and the Concordance Index were used.

RESULTS

In the validation with the content and appearance judges, the booklet showed an excellent overall Content Validity Index (tCVI=0.92). The technical judges evaluated the booklet as "superior" (average of 91%). The booklet underwent adjustments, and validation was performed with the target population, reaching an agreement rate higher than 75%.

CONCLUSION

The educational booklet developed was validated for content and appearance and considered suitable for use by family members of people with venous ulcers.

Malnutrition and its relation with diabetic foot ulcer severity and outcome: a review

BACKGROUND

Malnutrition has a detrimental effect on wound healing; hence, it might influence the outcome in people with a diabetic foot ulcer (DFU).The aim of this manuscript is to overview studies that describe the prevalence of malnutrition in DFU patients and assess the relation between malnutrition, DFU severity, and outcome.

METHODS

A literature review was performed. Malnutrition had to be defined by anthropometry and/or validated screening and assessment tools.

RESULTS

Five papers were included: one RCT, three prospective cohort studies and one retrospective observational study. A substantial number of patients were at risk for malnutrition (49%-70%) or were malnourished (15%-62%). In one study, nutritional status was related to DFU severity. Three authors demonstrated a negative influence of malnutrition on outcome. Two studies examined the prevalence of malnutrition after six months, but did not detect a decline in malnutrition rates.

CONCLUSIONS

Despite a large heterogeneity, all papers indicated that malnutrition is highly prevalent among DFU patients. Notwithstanding the lack of unequivocal evidence, malnutrition might have a negative influence on DFU outcome. Therefore, clinicians should pay attention to the nutritional status of people with a DFU.Abbreviations: BMI: Body Mass Index; DFU: Diabetic Foot Ulcer; DM: Diabetes Mellitus; GNRI: Geriatric Nutritional Risk Index; HbA1c: Glycated Hemoglobin; IWGDF: International Working Group on the Diabetic Foot; LEA: Lower Extremity Amputation; MNA: Mini Nutritional Assessment; MNA-SF: Mini Nutritional Assessment-Short Form; MUST: Malnutrition Universal Screening Tool; NRS-2002: Nutritional Risk Screening-2002; PAD: Peripheral Arterial Disease; RCT: randomized controlled trial; SGA: Subjective Global Assessment.

Factors associated with chronic venous disease: study in 1,136 patients treated for varicose veins of the lower limbs in a specialized clinic

Abstract Background Varicose veins are a highly prevalent condition in the general population, generating variable reasons for consultation that can alter the patient’s quality of life, with prevalence and associated factors that vary in different series. Objectives To describe the epidemiological profile of patients who consulted for varicose veins by evaluating main symptoms and associated variables. Methods Between 2019 and 2020, 1,136 patients attending vascular surgery consultation in a specialized outpatient center were evaluated. Demographic variables, presented symptoms, complications, and associated factors, such as body mass index, parity and family history, were recorded. Results A total of 1136 patients were evaluated (79.8% women and 20.2% men), with a mean age of 53.51 years. The presence of symptoms was similar in men and women; the most frequent complications were ulcer, varicorrhage, and superficial venous thrombosis. Most patients showed CEAP 1, 2 and 3 (n = 909) and more than half were overweight or obese (n = 679) with a predominance of those classified as C4. Sixty-nine per cent had a positive family history of varicose veins. There was no difference between severity of varicose veins and time working in the standing or sitting position, but there was a greater presence of C5 or C6 ulcer among patients standing for more than 4 hours. Conclusions Describing the characteristics of patients with varicose veins helps to understand the disease and to focus efforts towards those who are more susceptible. The results of this research are similar to those found in other populations.

The importance of Mediterranean diet and hydration habitus in patients with lower limb ulcers: A pilot study

Chronic leg ulcers are a common condition among adults, causing pain and social distress. Population aging has contributed to the amplification of the disease with increased cardiovascular diseases such as myocardial infarction, stroke, limb ischemia, cancers, chronic respiratory diseases, and diabetes. The aim of this study was to evaluate the influence of the Mediterranean Diet (MD) and hydration on the healing rate of the ulcers. A group of 35 patients (M/F 16/19, mean age 78 ± 10 years) with venous, arterial, or mixed ulcers was subjected to a Food Frequency Questionnaire (FFQ) and a Hydration Habits Questionnaire (HHQ). Clinical and anthropometric data were collected. A one-year follow-up was conducted. Complete ulcer healing was observed in 26% of the patients, of whom 67% had a habit of high hydration (more than 1 liter /day), regardless of adherence to the MD. In our study population, about half showed a low adherence to the MD. A moderate-high adherence to the MD showed an increase of arterial ulcer healing compared to subjects with a low adherence to the MD, however, only when associated to a consumption of more than 1 liter of water daily. In conclusion, dietary assessments could help identify patients who are likely to benefit from nutritional interventions for improving overall health and wound healing. The habit of high hydration, namely more than 1 liter daily, can influence the wound healing rate.

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.

Experiences of Venous Leg Ulcer persons following an individualised nurse-led education: protocol for a qualitative study using a constructivist grounded theory approach

INTRODUCTION

Venous leg ulcers are slow-healing wounds with a high risk of recurrences. To prevent recurrences and promote healing, different nurse-led educational interventions have been developed. The impact of these interventions on self-management is ambiguous. Also, how persons with a venous leg ulcer experiences these educational sessions are poorly described.

AIM

This study protocol presents the methodology to provide a comprehensive explanation of participants' journeys-of how they experience their individualised education sessions concerning self-management.

METHODS AND ANALYSIS

A constructivist grounded theory approach according to Charmaz involving 30 participants will be used. Data will be collected through semistructured face-to-face interviews. Interviews will be transcribed verbatim and analysed with initial and focus coding using MAXQDA. Data collection and data analysis will occur iteratively, focusing on constant comparison to obtain well-developed categories. Categories will be reinforced using existent literature.

ETHICS AND DISSEMINATION

This pre-results study is embedded in a clinical trial (NCT04019340) and approved by ethical committee of the canton of Geneva (CCER: 2019-01964). A theory will emerge from participants' journeys informing future education sessions for patients with venous leg ulcers. The findings will be disseminated through peer-reviewed publications and communications.

Nurse-led patient education for persons suffering from a venous leg ulcer in outpatient's clinics and homecare settings: A scoping review

AIM OF THIS STUDY

To provide an overview of the available nurse-led individualized educational interventions, for persons with Venous Leg Ulcer (VLUs) in an outpatient or homecare settings.

MATERIALS AND METHODS

For this scoping review, a search was performed between December 2019 and January 2020. To identify sources of evidence a systematic search was conducted in PubMed, CINAHL, Embase, PsychINFO, Web of Science and LiSSa as well as in clinical trial registers to identify sources of evidence. All types of evidence associated with a nurse led-intervention were included.

RESULTS

Fifteen sources of evidence met the inclusion criteria. Educational sessions varied in modality, content and duration. Education sessions were face to face and supported by written materiel. The content focused on compression therapy and exercises. The duration and numbers of sessions varied. The most reported health related outcomes was wound healing.

CONCLUSION

This scoping review provides a broad overview of the available evidence and ongoing research for individualized nurse-led education persons with VLUs. Variability in the literature was found, which suggests that more intervention studies are needed to test and evaluate efficacy of nurse-led patient education.

Leg Ulcers in Sickle-Cell Disease: Treatment Update

Significance: Sickle-cell leg ulcers (SCLUs) are a severe, chronic, and recurrent complication of sickle-cell disease (SCD). There are no official recommendations for treatment. Recent Advances: Only a few studies with a high level of evidence have been conducted to evaluate treatment of SCLUs. However, several studies have been conducted with a high level of evidence to evaluate the efficacy of treatments in venous leg ulcers, and SCLUs could benefit from these treatments, especially when a venous incompetence or an edema is associated. Pathophysiology of SCLUs includes a vasculopathy related to chronic hemolysis and an endothelial dysfunction, which could be therapeutic approaches to SCLU treatment. Critical Issues: Therapeutic approaches to SCLUs can target SCD on the one hand and skin healing and associated aggravating factors on the other. A review of the literature found only case series and six randomized controlled trials; some offered encouraging results, but most had serious biases. Clinical trials specifically targeting SCLUs are difficult to realize because of the small number of affected patients, in comparison with patients with leg ulcers from other causes. Future Direction: Treating SCLUs remains a challenge. Data in the literature are currently insufficient to offer clear treatment guidelines because of several biases in controlled studies. New studies are under way to assess the efficacy of topical treatments and describe the microbiome of SCLUs. Prevention of SCLU recurrence should be assessed in future clinical trials because the high risk of recurrence is an unsolved critical issue.

Nutritional status and quality of nutrition in chronic wound patients

Malnutrition is a negative confounding factor influencing wound healing. The prevalence of malnutrition increases with age, as do chronic wounds. The aim of this prospective study was to analyse the nutritional status of patients with chronic wounds. Data collection of sociodemographic and nutritional parameters was based on an inter‐professionally developed questionnaire as well as the Mini Nutritional Assessment (MNA). A total of 90 patients with chronic wounds of different aetiologies were included. Pain and dental health were found to be significant factors: Patients with malnutrition or the risk of malnutrition had significantly lower tooth and oral health scores (rs = −0.218, P = .039), and higher pain levels at rest (rs = 0.339, P < .001), while dressing (rs = 0.268, P = .014), and upon exercising (rs = 0.303, P = .005). Our data address the impact of nutrition on chronic wounds and confirm the relationship between pain, dental health, and nutritional status. Clinicians should be aware of adequate pain management and dental health care in chronic wound patients. Further studies, particularly on characterisation of preventive and therapeutic measures in the nutrition of chronic wound patients, are of great importance.

The Most Severe Stage of Chronic Venous Disease: An Update on the Management of Patients with Venous Leg Ulcers

Venous leg ulcers (VLUs) are the most severe manifestation of chronic venous disease (CVD). Due to their chronic nature, high recurrence rate and slow healing time, VLUs account for 80% of all leg ulcers seen in patients with CVD. VLUs impose a heavy burden on patients that reduces their quality of life; VLUs also represent a major socioeconomic impact due to the cost and duration of care. The primary medical approach to treating VLUs is local compression therapy in combination with venoactive drug (VAD) pharmacotherapy to promote the reduction of the inflammatory reaction initiated by venous hypertension. Micronized purified flavonoid fraction (MPFF; Daflon^®) is the most widely prescribed VAD. MPFF counteracts the pathophysiologic mechanisms of CVD and ulceration and has proven to be an effective adjunct to compression therapy in patients with large and chronic VLUs. Two other non-VAD drugs, pentoxifylline and sulodexide, have also been shown to improve VLU healing and are also recommended in addition to compression therapy. However, MPFF is the only VAD with the highest strength of recommendations in the 2018 guidelines for the healing of VLUs.

Internal consistency and reliability of the Swiss-French translation of the venous leg ulcer self efficacy tool (VeLUSET)

OBJECTIVE

This study was conducted to assess the psychometric properties of the translated and adapted Venous Leg Ulcer Self Efficacy Tool (VeLUSET) in the new cultural context.

DESIGN

Validation study SETTING: Three outpatient clinics in Western Switzerland.

PARTICIPANTS

32 consecutive persons with venous leg ulcers (VLU).

MAIN OUTCOME MEASURES

To determine the internal consistency and reliability of the VeLUSET for use in a Swiss-French speaking venous leg ulcer population.

RESULTS

Overall, the Cronbach alpha for the VeLUSET-FR was 0.96 (95% CI 0.93 to 0.98) on test and retest. Lin's concordance correlation coefficient of test and retest scores was 0.93 (95% CI 0.86 to 0.96).

CONCLUSION

The results indicate that the VeLUSET-FR is a valid and reliable instrument for measuring self-efficacy among Swiss-French persons affected by a venous leg ulcer. Our findings show that the psychometric properties are similar to those of the original tool. Therefore, we suggest that the VeLUSET-FR can be effectively used for measuring self-efficacy in Swiss-French persons with VLU.

Use of the Nursing Outcomes Classification - NOC to assess the knowledge of patients with venous ulcer

OBJECTIVE

To evaluate the knowledge of patients with venous ulcers (VU) on their chronic disease, treatment, and prevention of complications, according to the Nursing Outcomes Classification-NOC.

METHODS

This is a cross-sectional study conducted between 2017 and 2018 in a Brazilian hospital. The sample consisted of 38 patients with VU attended in outpatient nursing consultations. The study analyzed sociodemographic, clinical and nine indexes from the Knowledge: Chronic Disease Management (1847) of the NOC, assessed using a five-point Likert scale, analyzed using descriptive statistics.

RESULTS

The mean of the result Knowledge: Chronic Disease Management (1847) was 3.56±1.42. The clinical index Procedures involved in treatment regimen had the highest mean 4.18±0.21, followed by Pain management strategies with 3.92±0.27. In the association between knowledge and healing, the best scores were in patients with at least one healed VU.

CONCLUSION

The knowledge of the patients was moderate and it was necessary to promote educational actions according to individual demands.

Adjuvant therapies in venous leg ulcer management: A scoping review

Compression therapy is the current evidence-based approach to manage venous leg ulcers (VLU); however, adherence is a major barrier to successful treatment. Combination approaches may relieve the burden of treatment by shortening the time to ulcer healing. This scoping review conducted by Australian researchers aimed to establish the evidence of effectiveness of various adjuvant methods on wound healing and recurrence. Randomized Controlled Trials (RCTs), and Systematic Reviews (SR) and Meta-Analyses (MA) on VLU management approaches published from January 2015 to December 2018 were included in this review. The articles included in the scoping review were grouped according to the management approaches, including (1) pharmaceutical interventions, (2) surgical interventions, (3) topical agents, (4) the use of devices, and (5) other, such as physiotherapy and psychological interventions. Results of this scoping review indicate that there is a limited high-quality evidence of effectiveness in most adjuvant therapies on wound healing and recurrence. Given the low-quality evidence observed in this scoping review for adjuvant treatments, the implication for practice is that current management guidelines be followed. Further rigorous studies have the potential to produce better quality evidence. Quality of evidence can be improved by ensuring large sample sizes of a single etiology wounds, standardizing reporting outcomes, and maintaining detailed and evidence-based protocols in physiological or psychological interventions.

Systemic therapies for leg ulcers

Successful management of patients with leg ulcers requires identification of the underlying etiology, with subsequent initiation of causal treatment, if feasible. Supplementary measures of first choice include stage-adjusted wound treatment, usually combined with compression therapy. The significance of systemic drugs has been the subject of controversial debate, depending on the underlying cause of the condition. The present review article is therefore meant to highlight current aspects of systemic drug therapies for the treatment of leg ulcers associated with chronic venous insufficiency, peripheral arterial disease, livedoid vasculopathy, vasculitis, necrobiosis lipoidica, calciphylaxis and pyoderma gangrenosum. In summary, the majority of therapeutic options presented herein are used off-label. While systemic drugs are promising options for the more common types of wounds such as venous, mixed or arterial leg ulcers, they do not represent the current standard of treatment. By contrast, systemic agents play a key role in the management of many of the other disorders presented herein. These agents primarily include immunomodulatory and rheological drugs used to expedite wound healing.

Prevalence of Chronic Illness and Risk Factors for Chronic Illness Among Patients With Venous Leg Ulceration: A Cross-Sectional Study

Introduction. Chronic illness and risk factors for chronic illness are rising public health concerns for individuals and health care systems. Individuals with venous leg ulceration (VLU) have at least one chronic illness. As there is a projected increase in VLU prevalence there is a need to determine concurrent prevalence of risk factors for chronic illness among this population. Methods. A cross-sectional design conducted in 8 community, nurse-led, leg ulcer clinics. Results. Fifty patients (58%, n = 29 females) were enrolled. Seventy percent were >65 years old; 90% had at least one chronic illness; 60% had hypertension; 30% had atrial fibrillation; 18% had diabetes; 18% heart failure; and 28.6% musculoskeletal conditions. All had at least one risk factors for chronic illness (mean = 2.26), the most frequent being overweight (30%), obesity (30%), high cholesterol (22.2%), and restricted physical activity (22%). Participants took a mean 5.2 medications daily and 26% were on current oral antibiotics. Conclusions. Comprehensive, holistic assessment and regular reassessment with a preventative focus needs to consider chronic illness and risk factors for chronic illness. Patients with VLU are in frequent contact with their multidisciplinary team. This is an opportunity to improve care and make every encounter count.

Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures

BACKGROUND

Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors.

METHODS

Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures.

RESULTS

Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively.

CONCLUSIONS

Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.

LEVEL OF EVIDENCE

Level II, prognostic, prospective cohort study.