Cohort study assessing the impact of COVID-19 on venous leg ulcer management and associated clinical outcomes in clinical practice in the UK

Decellularized dermis allograft for the treatment of venous leg ulceration: the DAVE RCT

BACKGROUND

Venous leg ulcers (VLUs) cause significant impairment to patients' quality of life (QoL) and up to 30% do not heal at 6 months. Decellularized dermis (DCD) allografts have been shown to be effective in improving healing rates of diabetic foot ulcers in RCTs. The DAVE RCT aimed to determine whether DCD is an effective, safe, and cost-effective treatment adjunct for VLUs.

METHODS

This was a multicentre RCT performed in the UK. Patients with lower limb ulcers ≥18 years with VLU, venous incompetence on duplex ultrasound, an ankle : brachial pressure index ≥ 0.8 and an index VLU present for at least 3 months and ≥2 cm2 in size were included. Patients were randomized to either the intervention (DCD graft and standard of care) or control arm (standard of care alone). The primary outcome was the proportion of patients with a healed index ulcer at 12 weeks.

RESULTS

From October 2019 to October 2022, 36 and 35 participants were randomized into the intervention and control arms respectively. Patient characteristics at baseline were similar between groups. Healing was recorded in 5.7% of the intervention group and 15.2% in the control group (OR 0.34, 95% c.i. 0.03 to 2.31). There were no significant differences in the secondary outcomes including the percentage change in ulcer area, time to healing, recurrence rates, and QoL. There were five serious adverse events attributed to DCD application. Early trial termination was advised after the interim data analysis due to a lower-than-expected primary outcome rate (11.3%).

CONCLUSIONS

Decellularized dermis grafts did not improve healing rates of venous leg ulcers, although the trial was terminated early due to poor healing rates in both the intervention and control arms. Important clinical benefits or harms of decellularized dermis grafts could not be excluded due to the small sample size.

TRIAL REGISTRATION

ISRCTN 21541209.

Improved Wound Healing by Direct Cold Atmospheric Plasma Once or Twice a Week: A Randomized Controlled Trial on Chronic Venous Leg Ulcers

Objective: This study compared the effect of two frequencies of direct cold atmospheric plasma (direct-CAP) treatment with standard of care (SOC) alone on healing of venous leg ulcers (VLUs). Approach: Open-label, randomized controlled trial (ClinicalTrials.gov NCT04922463) on chronic VLUs at two home care organizations in the Netherlands. All three groups received SOC for 12 weeks or until healing. In addition, treatment groups received direct-CAP once (1× direct-CAP) or twice (2× direct-CAP) a week, at specialized wound care facilities and the patients' residences. Primary outcome was percentage of wounds healed. Secondary outcomes included wound area reduction and adverse events. Results: In total, 46 patients were randomly allocated to receive SOC only (n = 15), SOC + direct-CAP once a week (n = 17), or SOC + direct-CAP twice a week (n = 14). A higher percentage of wounds healed within 12 weeks in the treatment groups 53.3% (1× direct-CAP, p = 0.16) and 61.5% (2× direct-CAP, p = 0.08) versus 25.0% (control). The largest wound area reduction was obtained with 2× direct-CAP (95.2%, p = 0.07), followed by 1× direct-CAP (63.9%, p = 0.58), versus control (52.8%). Absolute wound area reduced significantly compared with baseline in both treatment groups (p ≤ 0.001), not in control (p = 0.11). No device-related serious adverse events occurred. Innovation: Direct-CAP applied once or twice a week could substantially improve wound healing of VLUs in primary care. Conclusion: Together with other clinical safety and efficacy data, these results support the integration of direct-CAP as a valuable therapy for complex wounds.

A qualitative exploration of the barriers and facilitators to early lower limb assessment and onward referral for specialist treatment for patients with venous ulceration

Guidance for venous leg ulceration (VLU) recommends compression therapy and early referral for specialist vascular assessment within two weeks. Few patients receive timely assessment and referral. Reasons for this are unclear. The aim of this work was to explore nurses' perceptions of the barriers and facilitators to early assessment of VLU and referral for specialist treatment. One-to-one semi-structured interviews explored experiences caring for and referring patients with VLU to a vascular specialist. Maximum variation sampling and inductive thematic analysis were used. Eighteen nurses participated. Findings suggest junior nurses lack knowledge and confidence to care for VLU and often revert to a 'task-based' approach, exacerbated by staff shortages and limited training. Because VLU occurs in the context of competing conditions and pressures, comprehensive assessments are missed, and the need for referral is not established or prioritised. Supporting patients to self-manage is seen as a possible solution. Nurses reported disjointed pathways between primary and secondary care, compounded by poor MDT collaboration, ineffective communication systems and inadequate data sharing. Consequently, when the need for referral is established, communicating this between healthcare organisations is complex. Organisational and behavioural barriers impact nurses' ability to promote timely referral. Further exploration with patients and other healthcare professionals is needed.

[Effects of the COVID-19 pandemic on inpatient dermatosurgery in Germany : Retrospective evaluation of the surgical cases from nine dermatology clinics]

INTRODUCTION

Currently, only little data is available on the impact of the COVID-19 pandemic on inpatient dermatosurgical care in German dermatological clinics.

METHODS

A retrospective analysis of all dermatosurgical cases that were treated in inpatient setting in nine German dermatological clinics in four federal states in 2019, 2020 and 2021 was performed. The diagnoses were recorded using the ICD-10 codes. In addition, demographic data such as age, gender and the length of inpatient stay were analysed.

RESULTS

In 2019, 2020 and 2021, a total of 10,739, 9185 and 9828 dermatosurgical inpatients were treated respectively. Thus, the reduction of inpatient dermatosurgical cases was 14.5% in 2020 and 8.5% in 2021 compared to 2019. Inpatient surgical treatment of melanoma decreased by 10.1% of cases in 2020. This decrease was only 1.4% in 2021 compared to 2019. The number of inpatient surgeries performed for benign lesions such as melanocytic nevi or viral warts reduced sharply in both pandemic years.

CONCLUSION

Our data show for the first time how inpatient care for the entire spectrum of dermatosurgical diseases developed during the COVID-19 pandemic in Germany. After the initial marked decline in inpatient dermatosurgical cases in 2020, there was less difference in 2021 compared to 2019. This trend can be interpreted as an indication that there is still a strong need for inpatient dermatosurgical care that cannot yet be met on an outpatient basis.

Confronting a New Challenge in Plastic Surgery: MDR Infections in Patients with Chronic Wounds

BACKGROUND

The presence of a wound can be anywhere from non-problematic to life-threatening on a severity spectrum, with bacterial infection and resistance playing a major role in the development of chronicity, delaying wound healing. Wound colonization with multiple organisms and the limited number of effective antibiotics place a heavy burden on the healthcare system, with patients going through multiple surgeries during a prolonged hospitalization time. By analyzing the resistance patterns of pluri-bacterial populations and the approach used in managing complex cases, we aim to improve the protocols applied in caring for chronic wounds in our practice and share our experiences and observations.

METHODS

We designed a retrospective study on 212 diabetic and non-diabetic patients, aiming to evaluate the course of chronic wound treatment in our practice. We focused on the impact that MDR bacteria and diabetes have on surgical outcomes and their role in the healing process.

RESULTS

Patients who received empiric antibiotic therapy before being admitted eventually presented with multiple MDR bacteria compared to those who did not receive antibiotics (p = 0.014). The presence of at least one MDR bacteria in the wound bed was associated with ulcers reaching bone (p = 0.02) and was positively correlated with the number of surgeries performed (p < 0.001). Diabetes played a significant role in surgery-related complications (p = 0.02) and hospitalization time (p < 0.001).

CONCLUSIONS

Proper management of chronic wounds requires a comprehensive, multidisciplinary approach and a thorough understanding of antibiotic usage. To address this need, we have developed and implemented a chronic wound treatment protocol in our clinic, with the goal of discharging patients once their ulcers have been treated and closed. A key summary of the protocol presented is to reduce the incidence of MDR bacteria and improve the patient's quality of life.

Remote assessment and monitoring with advanced wound therapy to optimise clinical outcomes, access and resources

OBJECTIVE

Patients in rural communities may have limited access to wound care; however, this may be mitigated by using a shared care approach. This study assessed the impact of a remote assessment and monitoring tool in combination with adjunctive continuous topical oxygen therapy (cTOT) in patients with diabetes and hard-to-heal wounds.

METHOD

Patients with hard-to-heal wounds (defined as no visible improvement in the previous four weeks) were enrolled to this 12-week pilot study to validate a shared care approach using an Advanced Digital Wound Care Platform-telehealth (ADWCPt) system (eKare Inc., US) coupled with cTOT. Patient and wound assessments were reviewed by the clinician either remotely, via telehealth calls, or at the clinic, and the number of face-to-face clinic visits was recorded. Patient health status scores were captured before and after the study, along with feedback on usability of the remote platform and cTOT device.

RESULTS

The wounds in all eight patients studied reduced in size over 12 weeks (mean percentage area reduction 92.0%), and two wounds were completely re-epithelialised. Another wound almost healed (99.2% wound area reduction). Clinical interactions consisted of self-assessments (n=80, 50.0%), video assessments with the clinician (n=27, 16.9%), and face-to-face interactions in clinic (n=53, 33.1%). Operational efficiencies encompassed a 54.0% increase in the number of clinical interactions, whereas clinical time was reduced by 25.8%. Health status scores improved across all eight patients and feedback on the shared approach and cTOT device was favourable.

CONCLUSION

A shared care model with ADWCPt coupled with an innovative cTOT device saved time and resources, improving patient access and engagement, along with a marked improvement in the wound healing trajectory.

Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics

This article explores the impact of combining tissue viability and lymphoedema techniques on optimising time to healing.

AIM

To investigate the healing rates observed in patients who presented to wound and lymphoedema specialist clinics, located in the south eastern region of England, with venous/lymphovenous ulceration of the lower limb during the COVID-19 pandemic in 2020-2022 (30 months in all).

METHODOLOGY

A retrospective analysis of patient outcomes.

RESULTS

1041 patients were referred to the service, with a healing rate of 88.5% over 78 days.

DISCUSSION

When comparing 2013-2019 healing rates/time to healing vs 2020-2022 there was a decrease of 1.5% in the rate of healing and a mean reduction in time to healing of 40 days.

CONCLUSION

Despite the pandemic the service was able to maintain previous levels of outcomes and observed a decrease in the mean time to healing.