Patients' perceptions of chronic leg ulcers

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Primary care disease management for venous leg ulceration—study protocol for the Ulcus Cruris Care [UCC] randomized controlled trial (DRKS00026126)

Background

Venous leg ulcers (VLU) have a prevalence of 1–2% in developed countries, and affected patients are severely and long-term impaired in daily activities, work, and social participation. Evidence-based outpatient treatment based on compression therapy is frequently not implemented. The “Ulcus Cruris Care” project was established to develop a disease management concept to improve outpatient treatment for patients with VLU in German primary care. For this purpose, a multifaceted intervention was conceived consisting of an online training for general practitioners and medical assistants, standardized treatment recommendations, e-learning and print-based information for patients, and a software support for case management. The main aims of the Ulcus Cruris Care intervention are to promote standardized treatment according to current scientific knowledge, to facilitate case management for VLU patients exerted by medical assistants, and to support patient education and participation in the treatment process. The UCC trial was designed to evaluate the effectiveness of the Ulcus Cruris Care intervention.

Methods

The UCC trial is a prospective cluster-randomized controlled multicenter trial. Fifty GP practices are intended to be recruited and randomized 1:1 to intervention or control arm. Patients with venous leg ulcers will be recruited by participating GP practices, to include a total of 63 patients in each arm. The primary outcome is time to ulcer healing. Secondary outcomes comprise number and sizes of ulcers, recurrence, pain intensity according to the visual analog scale, health-related quality of life according to EQ-5D-5L, depressiveness according to Patient Health Questionnaire (PHQ-9), patient satisfaction according to the Patient Assessment of Chronic Illness Care (PACIC-5A) query, and adherence to VLU treatment. The outcome analysis of the UCC trial is accompanied by a health economic analysis and a process evaluation.

Discussion

The UCC trial will evaluate whether the Ulcus Cruris Care intervention may lead to faster wound healing, higher health-related quality of life, and lower use of medical resources. If the intervention turns out to have a positive impact on assessed outcomes, comprehensive implementation in primary care may be considered.

Trial registration

The trial protocol (version 1 as of July 19, 2021) has been registered in the German Clinical Trials Register on August 30, 2021 (DRKS00026126).

Wound bed preparation: a case series using polyhexanide and betaine solution and gel-a UK perspective

OBJECTIVE

The burden of wound care within the NHS is estimated at a cost of £5.3 billion per year and is set to rise annually by 30%. This case series describes the results of using polyhexanide (PHMB) and betaine wound irrigation solution and gels (Prontosan, B.Braun Medical Ltd., UK) across the UK in hard-to-heal (also described as chronic) wounds up to 20 years' duration, with an observation period of greater than one month. Over half of the hard-to-heal wounds were healed and vast improvements to all other wounds were observed. Improvements to wound bed condition were reported as early as two days after commencing initial treatment, with decreases in malodour, exudate, slough and pain reported across the case series. In addition to wound bed improvements, a reduction in dressing change frequency of 55% was observed in hard-to-heal wounds under the new treatment regime.

The Impact of Stress on Pressure Ulcer Wound Healing Process and on the Psychophysiological Environment of the Individual Suffering from them

Introduction:

The occurrence of a pressure ulcer constitutes a major psychological and physiological burden and it has been linked with a reduced quality of life and increased stress of the individual.

Objective:

The main objective was to investigate the impact that stress has on pressure ulcer healing process and on the psychophysiological environment of the individual suffering from them.

Method:

The scientific literature was reviewed through Cinahl, Pub-med, EBSCO, Medline and Google scholar. The articles were chosen due to their direct correlation with the objective under study and their scientific relevance.

Results:

Increased stress has been demonstrated to increase the glucocorticoids levels affecting negatively the production of wound healing cytokines (IL1α, IL1β and TNFα). Matrix metalloproteases has been identified to be unregulated in occasions of increased stress in acute wounds. Stress has also been correlated with poor health behaviors that may not have a direct link on the wound healing process, although they can in part explain or enhance some of the effects of stress on wound healing.

Conclusion:

The correlation between stress and wound healing in acute wounds has been thoroughly investigated and its negative effects have been established. The presence of a pressure ulcer can have a detrimental impact on the stress level of an individual although further investigation is needed to establish the role of stress in chronic wounds such as pressure ulcers.

Understanding the Hawthorne effect in wound research-A scoping review

The Hawthorne Effect (HE) is considered a methodological artefact in research, although its definition and influence on research outcomes lack consensus. This review explored how this term has been mentioned and discussed in the area of wound research. A scoping review was conducted on ProQuest Central, Scopus, EbscoHost, and online databases of indexed wound journals using the methodological framework by Arksey and Malley. A review protocol was applied to detail key terms, truncation and Boolean operators, and inclusion and exclusion criteria. Search findings were reported using PRISMA guidelines. A total of 38 articles reporting primary evidence were identified. Three themes emerged from the review: wound researchers' awareness of HE, the acknowledgement of the existence or otherwise of HE, and the mentioning of HE in passing. These results reflect a lack of attention to and understanding and awareness of the HE in the area of wound research. It is suggested that the HE receives more attention as a methodological concern, and its potential influence is considered and mitigated when planning future studies. Recommendations are provided to minimise the impact of the HE on the rigour of the research and confidence afforded to research findings.

The psychosocial impact of leg ulcers in patients with sickle cell disease: I don't want them to know my little secret

BACKGROUND

Sickle cell disease (SCD) impacts millions of individuals worldwide and more than 100,000 people in the United States. Leg ulcers are the most common cutaneous manifestation of SCD. The health status of individuals living with chronic leg ulcers is not only influenced by clinical manifestations such as pain duration and intensity, but also by psychosocial factors. Garnering insights into the psychosocial impact can provide a more holistic view of their influence on quality of life.

METHODS

Semi-structured interviews were conducted with participants living with active SCD-associated leg ulcers or with a history of ulcers. Subjects were recruited from an ongoing study (INSIGHTS, Clin Trial.Gov NCT02156102) and consented to this qualitative phase of the study. Five areas were explored: leg ulcer pain, physical function, social-isolation, social relationships and religious support. Data was collected from 20 individuals during these interviews and a thematic analysis was performed and reported.

RESULTS

Twenty participants with a mean age of 42.4 (SD ± 11.1years) were included in the study. Major themes identified included:1) pain (acute and chronic); 2) compromised physical function as demonstrated by decreased ability to walk, run, and play sports; 3) social isolation from activities either by others or self-induced as a means of avoiding certain emotions, such as embarrassment; 4) social relationships (family support and social network); 5) support and comfort through their religion or spirituality.

CONCLUSIONS

SCD patients with leg ulcers expressed that they experience social isolation, intense and frequent ulcer pain, and difficulty in physical function. SCD-associated leg ulcers have been studied from a clinical approach, but the psychosocial factors investigated in this study informs how quality of life is impacted by the leg ulcers.

Health-Related Quality of Life in Patients with Venous Ulceration

Aim:

To review the role of Health Related Quality of Life (HRQL) assessments in the management of patients with venous ulceration.

Method:

A search of electronic databases and reference lists delivered numerous articles containing a variety of HRQL assessments for venous ulcer treatment.

Synthesis:

The salient points from the literature were collaborated in order to establish which outcome measures best reflect the quality of care delivered. The treatment of chronic venous leg ulceration is often prolonged and a permanent cure is frequently unattainable. An improvement in a patient's condition needs to be demonstrated in order to determine the benefit of a surgical treatment. The assessment of HRQL is increasingly recognised as a valuable surgical outcome measurement.

Conclusion:

The combination of ‘standard’ clinical outcome measures, the generic SF-36 and a specific ‘venous ulcer’ HRQL questionnaire can produce a more complete treatment outcome assessment in patients with venous ulceration.

Illness trajectories in patients suffering from leg ulcers: A qualitative study

The aim of this study was to identify illness trajectories in leg ulcers by analysing personal, social and relational dimensions related to leg ulcer onset and to the care process. Semi-structured interviews were conducted with 21 patients, one physician and four nurses. Patients’ medical records were also examined. Data were analysed using the grounded theory approach. Four illness trajectories were identified: possibility, denial, focus on illness and tragedy. The findings highlighted that leg ulcers can be experienced in different ways depending on the personal characteristics of the people suffering from them and the kind of relationship that exists between patients and healthcare professionals.

Validation of the Lymphoedema Quality-of-Life Questionnaire (LYMQOL) in Dutch Patients Diagnosed with Lymphoedema of the Lower Limbs

BACKGROUND

The Lymphoedema Quality-of-Life Questionnaire is a validated disease-specific instrument to measure the impact of lymphoedema on patients' lives. In this study, we tested its psychometric properties and validated the use of the questionnaire in its Dutch translation.

METHODS

We obtained the answers to a standardised questionnaire, including Lymphoedema Quality-of-Life Questionnaire and Short-Form (36) Health Survey, twice at an interval of 2 weeks in 60 patients with lower limb lymphoedema. Feasibility was tested on the basis of missing responses and response distribution. Structure was studied using factor analysis. The reliability of the Lymphoedema Quality-of-Life Questionnaire was assessed using Crohnbach's α and test-retest reliability. Construct validity was tested by correlating Lymphoedema Quality-of-Life Questionnaire scores with the Short-Form (36) Health Survey scores.

RESULTS

The response rate was 88.2%. One of the 22 items missed >10% of responses; another showed a borderline ceiling effect. Internal consistency was good and test-retest reliability was excellent. The Lymphoedema Quality-of-Life Questionnaire correlated well with the physical component of the Short-Form (36) Health Survey and moderately with the mental component, suggesting that its construct validity was good.

CONCLUSION

The Dutch Lymphoedema Quality-of-Life Questionnaire can be used for health-related quality-of-life research in lower limb lymphoedema patients.

Why don't patients adhere to compression therapy?

This article explores the psychological influences on patients and their choices over adopting (or not) the advice of health-care professionals (HCPs) with regard to their own health. The article will examine some key theories by reviewing studies as well as examining how the patient-HCP relationship has evolved over time to try and improve patient adherence. Although specifically focusing on the area of venous leg ulcers and compression therapy, the theories relate to many health conditions. Despite health advice and compression treatments being the cornerstone of ulcer prevention and recurrence when adhered to, patient adherence levels are often persistently poor, both anecdotally and via clinical study. This article attempts to explain what influences a patient's adherence.

The psychosocial impact of chronic wounds on patients with severe epidermolysis bullosa

OBJECTIVE

To explore the lived experience of individuals with chronic wounds associated with dystrophic and junctional epidermolysis bullosa (EB),to improve understanding and, therefore, enhance the care provided to this group of patients by acquiring in depth data on the psychosocial issues that affect them.

METHOD

A phenomenological study using interpretive phenomenological analysis was employed. A purposive sampling method was used with six individuals replying to postal invitation to participate.

RESULTS

Following one-to-one interviews, six superordinate themes were identified. These were: coping, pain, perceptions, emotional impact, social impact and support network, each with subordinate themes. All of the superordinate themes have been identified by previous research into chronic wounds, burns and disfiguring conditions; however, new subordinate themes arose.

CONCLUSION

This study highlighted the need for individuals with EB to have a multidisciplinary approach to their care with a particular need for pain management, psychological intervention and nursing support from those whom clients perceive as understanding the requirements of patients with EB. Further research into identity issues in individuals with EB is advocated.

DECLARATION OF INTEREST

There were no external sources of funding for this study.The authors have no conflicts of interest to declare.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1% of people at some time in their lives and are often painful. The main treatments are compression bandages and dressings. Topical treatments to reduce pain during and between dressing changes are sometimes used.

OBJECTIVES

To determine the effects of topical agents or dressings for pain in venous leg ulcers.

SEARCH METHODS

For this third update the following databases were searched: Cochrane Wounds Group Specialised Register (searched 9 May 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4); Ovid MEDLINE (2009 to April Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations May 08, 2012); Ovid EMBASE (2009 to 2012 Week 18); and EBSCO CINAHL (2009 to May 2 2012). No date or language restrictions were applied.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of topical agents or dressing for the treatment of pain in venous ulcers were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed trial selection, data extraction and risk of bias assessment.

MAIN RESULTS

Six trials (343 participants) evaluated Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream for the pain associated with ulcer debridement. The between-group difference in pain measured on a 100 mm scale was statistically significant in favour of EMLA (MD -20.65, 95% CI -12.19 to -29.11). No significant between-group differences in burning or itching were observed.Two trials (470 participants with venous leg ulcers) evaluated ibuprofen slow-release foam dressings for persistent venous leg ulcer pain. Compared with local best practice, significantly more participants in the ibuprofen dressing group achieved the outcome of >50% of the total maximum pain relief score between day 1 and day 5 than participants in the local best practice group (RR 1.63, 95% CI 1.24 to 2.15). The number needed to treat was 6 (95% CI 4 to 12). In the second trial, compared with an identical non-ibuprofen foam dressing, there was no statistically significant difference in the proportion of participants experiencing slight to complete pain relief on the first evening of treatment.Limited data were available to assess healing rates or adverse events.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that ibuprofen dressings may offer pain relief to people with painful venous leg ulcers. EMLA (5%) appears to provide effective pain relief during the debridement of venous leg ulcers. Further research should consider standardised pain assessment methods and assess both the effect on ulcer healing and the impact of long term use of these treatments.

Health-related quality of life and chronic venous leg ulceration: Part 2

Leg ulceration is a debilitating condition which compromises the quality of life of the sufferer, owing to factors such as pain, exudate, odour and social isolation. As nurses, much of the daily care provided for such patients focuses on the provision of wound care; often failing to fully address the wide ranging effects that the ulceration is having on the life of the sufferer. This article reviews the quantitative studies that have explored the health-related quality of life of patients with chronic venous leg ulceration and presents a synthesis of their findings.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1 per cent of people at some time in their lives. The main treatments are compression bandages and dressings. As these ulcers are often painful some clinicians choose particular dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes.

OBJECTIVES

To assess the effectiveness of dressings, local anaesthetics or topical analgesia for pain relief in venous leg ulceration.

SEARCH STRATEGY

For this update the search strings were revised and the following databases were searched: The Cochrane Wounds Group Specialised Register (Searched 16/12/09) The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 50; EBSCO CINAHL - 1982 to December 16 2009. No date or language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials which evaluated local interventions used to relieve venous leg ulcer pain were considered. Pain was defined as either persistent pain or pain at dressing changes or debridement. Ulcer healing and reported adverse events were also considered as further outcomes.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two review authors who independently assessed the potential trials.

MAIN RESULTS

Two trials evaluating interventions for persistent venous leg ulcer pain were identified for this review update. Both studies evaluated ibuprofen slow release foam dressings; one comparing it with local best practice and the other with an identical foam comparator. The primary end point for both studies was "pain relief achieved". When compared with a foam dressing alone, there was no evidence of a statistically significant effect of the ibuprofen foam dressing in terms of achieving some pain relief the first evening after treatment: 74% in the ibuprofen group (46/62) had pain relief compared with 58% (35/60) in the foam group (no significant difference: RR 1.27, 95%CI 0.98 to 1.65). In the second study 100% (32/32) of people with venous ulcers achieved some pain relief with the ibuprofen dressing on the first evening of treatment compared with 93% (26/28) in the local best practice group (no significant difference: RR 1.08, 95% CI 0.96 to 1.21). Pooling these studies in a meta-analysis (using a random effects model as significant heterogeneity present (p=0.1), I(2) = 64%) there is no evidence that ibuprofen dressings increase the pain relief experienced by the first evening of use (RR 1.15, 95% CI 0.91 to 1.44). We were not able to extract sufficient data to combine other pain outcomes from these trials. There was no difference in healing rates but slightly more adverse events with ibuprofen dressings than with a similar foam dressing without ibuprofen.Six trials evaluated interventions for the pain associated with debridement and were considered sufficiently similar to pool. There was a statistically significant reduction in debridement pain scores with 5% Eutectic Mixture of Local Anaesthetics (EMLA): lidocaine-prilocaine cream; the difference in means (measured on a 100 mm scale) was 20.6 mm (95% CI 12.19 to 29.11). Of these six trials, only one small trial measured healing as an outcome and found no difference in the numbers of ulcers healed at the end of the study.

AUTHORS' CONCLUSIONS

There is no evidence that ibuprofen dressings offer pain relief, as measured at the first evening of use, to people with painful venous leg ulcers compared with foam dressings or best practice.EMLA appears to provide effective pain relief for venous leg ulcer debridement but the effect (if any) of EMLA on ulcer healing remains unknown.

Four layer bandage compared with short stretch bandage for venous leg ulcers: systematic review and meta-analysis of randomised controlled trials with data from individual patients

OBJECTIVE

To compare the effectiveness of two types of compression treatment (four layer bandage and short stretch bandage) in people with venous leg ulceration.

DESIGN

Systematic review and meta-analysis of patient level data.

DATA SOURCES

Electronic databases (the Cochrane Central Register of Controlled Trials, the Cochrane Wounds Group Specialised Register, Medline, Embase, CINAHL, and National Research Register) and reference lists of retrieved articles searched to identify relevant trials and primary investigators. Primary investigators of eligible trials were invited to contribute raw data for re-analysis. Review methods Randomised controlled trials of four layer bandage compared with short stretch bandage in people with venous leg ulceration were eligible for inclusion. The primary outcome for the meta-analysis was time to healing. Cox proportional hazards models were run to compare the methods in terms of time to healing with adjustment for independent predictors of healing. Secondary outcomes included incidence and number of adverse events per patient.

RESULTS

Seven eligible trials were identified (887 patients), and patient level data were retrieved for five (797 patients, 90% of known randomised patients). The four layer bandage was associated with significantly shorter time to healing: hazard ratio (95% confidence interval) from multifactorial model based on five trials was 1.31 (1.09 to 1.58), P=0.005. Larger ulcer area at baseline, more chronic ulceration, and previous ulceration were all independent predictors of delayed healing. Data from two trials showed no evidence of a difference in adverse event profiles between the two bandage types.

CONCLUSIONS

Venous leg ulcers in patients treated with four layer bandages heal faster, on average, than those of people treated with the short stretch bandage. Benefits were consistent across patients with differing prognostic profiles.

Exploring patient perceptions of larval therapy as a potential treatment for venous leg ulceration

OBJECTIVES

To explore patient preferences and acceptability of two forms of larval therapy ('bagged' and 'loose').

BACKGROUND

Larval therapy is frequently used to treat patients with leg ulcers. However, patient preferences and acceptability of larval therapy when compared with other treatments is not established.

DESIGN

A survey of patient preferences between larvae and standard therapy (hydrogel) using randomized allocation of two questionnaires ('bagged' or 'loose' questionnaire). The questionnaire contained closed and open-response questions and was administered by a nurse researcher. Open responses enabled exploration of patients' preferences and the acceptability of larval therapy when compared with a standard treatment. Qualitative data were analysed for thematic content.

SETTING AND PARTICIPANTS

Thirty-five participants, aged 18 years and above, with at least one venous leg ulcer were recruited from a UK Hospital Vascular Outpatients Clinic.

FINDINGS

Majority of participants stated that they would consider larval therapy, irrespective of method of containment. Acceptance of therapy was influenced by length of time with (or recurrence of) ulceration, experiences of other treatments, social contact in hospitals and the experiences of others. Visual imagery was a key influence among participants who would refuse larval therapy. Refusal was mostly among older women (aged 70 years or above).

CONCLUSIONS

Eliciting patient preferences and increasing patient involvement in treatment decisions is an important part of quality improvement and improved health outcomes. These findings have relevance for practitioners offering larval therapy as a treatment option and for the feasibility of clinical trials.

The venous leg ulcer quality of life (VLU-QoL) questionnaire: development and psychometric validation

To develop and validate a disease-specific quality of life (QoL) measure, based on the conceptual model of the SKINDEX-29 for patients with a chronic venous leg ulcer (VLU), in-depth interviews, and focus groups of patients (n=36) with VLU were used to generate VLU-specific items. These items were added to selected SKINDEX-29 items that were adapted for use in VLU. Further samples of VLU patients were used for item reduction (n=124) and to assess the psychometric properties of the new tool (n=120). The final VLU-QoL contained 34 items: 17 items adapted from the SKINDEX-29 and 17 VLU-specific items. Factor analysis of the items confirmed the existence of three hypothesized domains: Activities (12 items), Psychological (12 items), and Symptom Distress (10 items). Reliability in terms of internal consistency and test-retest reliability was found to be good. The measure was also found to be valid and responsive to clinical change. The VLU-QoL has good psychometric properties. The instrument's sensitivity to differences in clinical outcome and responsiveness to change in clinical parameters makes it a useful tool to assess the outcomes of treatment from the patients' perspective.

Dressings for venous leg ulcers: systematic review and meta-analysis

OBJECTIVE

To review the evidence of effectiveness of dressings applied to venous leg ulcers.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Hand searches of journals and searches of electronic databases, conference proceedings, and bibliographies up to April 2006; contacts with dressing manufacturers for unpublished studies.

STUDIES REVIEWED

All randomised controlled trials that evaluated dressings applied to venous leg ulcers were eligible for inclusion. Data from eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Methodological quality was assessed independently by two reviewers.

RESULTS

The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials; relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings.

CONCLUSIONS

The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.

A systematic review on the impact of leg ulceration on patients' quality of life

BACKGROUND

A systematic review was conducted to analyse journal articles that describe or measure the impact of leg ulceration on patients' quality of life (QoL) in order to improve the content of an educational programme that aims to enhance self-care agency in leg ulcer patients.

METHOD

Original articles published in English and German between 1990 and 2006 were included if the findings were analysed at the level of patients. Articles were excluded if (1) they investigated the impact of specific treatments or settings on QoL or (2) focused mainly on arterial ulcers or diabetic foot ulcers.

RESULTS

Twenty-four original research articles met the inclusion criteria; 11 studies used a quantitative, 11 studies a qualitative, and 2 used a mixed method approach. The findings were collapsed into 5 core domains. Quantitative studies commonly investigated the parameters of pain, sleep, social isolation, and physical mobility. Patients had significantly more pain, more restrictions regarding social functioning, less vitality, and limitations with respect to emotional roles compared to the respective controls. Other problem areas identified were restrictions in work capacity, recreation, social interaction, psychological well-being, as well as problems caused by treatment regimes. Inconclusive results were obtained regarding pain intensity, physical restrictions, and gender effects.

LIMITATIONS

Numerous original studies neither undertook a differentiation of participants by ulcer aetiology nor did they analyse the results according to gender differences.

CONCLUSION

As leg ulceration has an impact on QoL, national guidelines on the treatment of leg ulceration need to more specifically address these far-ranging effects identified in this review.

Living with venous leg ulceration: issues concerning adherence

Compression therapy is advocated for the treatment of chronic venous leg ulceration and the proportion of patients whose ulcers heal appears to be directly related to adherence (Moffatt, 2004). The aim of this study was to examine patients' understanding of adherence, in terms of their own experiences of compression bandage systems. Following full ethical approval, a purposeful sample of 6 participants was recruited to take part in a focus group. Free-flowing conversation was encouraged so that the participants could discuss issues that were important to them, although a series of prompts were available to stimulate the conversation when necessary. Four major themes were identified using a phenomenological approach: frustration with the healthcare system leading to a feeling of complacency with primary healthcare teams; functional limitations leading to adaptation of everyday life situations (e.g. bathing and coping with pain); emotional reactions affecting well-being and body image, and perception of others; and avoidance of transport, shopping and holidays.

Assessment of health-related quality of life in patients with lymphedema of the lower limb

The purpose of this study was to examine the use of a number of tools in the evaluation of health-related quality of life in patients with lower limb lymphedema, and to determine the consequences of cancer history and concurrent leg ulceration. Patients in one health trust having lower limb lymphedema were identified and interviewed at entry and after 24 weeks. The short form-36 (SF-36), modified Barthel scale, McGill short form pain questionnaire, and Euroqol were administered at both time points. Of the 164 (median age=76.9 years, 70.7% women) patients who comprised the study population, 15.2% had a history of cancer and 30.4% had coexisting current leg ulceration. Internal consistencies were high for all scales (Cronbach's alpha >0.80). There were high ceiling effects for a number of SF-36 scores, and high floor effects in these and the McGill short form pain questionnaire, scales. Despite these limitations, there was strong evidence that treatment led to significant improvements in six of eight scores of the SF-36, three of three scores of the McGill short form pain questionnaire and the modified Barthel scale (all p<0.05). The improvement in physical functioning was significantly greater for patients who entered the study with a leg ulcer (mean different=9.1, 95% confidence interval 2.1-16.1, p=0.011). Patients treated with compression bandaging had significantly greater improvements for physical functioning (10.2) than those treated with compression hosiery (-1.5) or no treatment (-2.0), p=0.001. Of the tools assessed, the SF-36, appears to be the most appropriate for use in this patient group.

Dressings for healing venous leg ulcers

BACKGROUND

Venous leg ulcers, sometimes called varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. Venous ulcers are characterised by a cyclical pattern of healing and recurrence. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound in order to achieve a 'moist wound environment'. There are a large number of dressing products and types available. It is unclear whether particular dressings aid healing of leg ulcers.

OBJECTIVES

To assess the effectiveness of wound dressings for the treatment of venous leg ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (April 2006) and CENTRAL (issue 1, 2006) and several other electronic databases (up to April 2005). Manufacturers of dressing products were contacted for unpublished studies.

SELECTION CRITERIA

Randomised controlled trials that evaluated dressings for the treatment of venous leg ulcers. There was no restriction in terms of source, date of publication or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Data from eligible studies were extracted and summarised using a data extraction sheet by two authors independently.

MAIN RESULTS

42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). In none of the comparisons was there evidence that any one dressing type was better than others in terms of number of ulcers healed. Current evidence does not suggest that hydrocolloids are more effective than simple low adherent dressings used beneath compression (9 trials; relative risk for healing with hydrocolloid 1.09 (95% CI 0.89 to 1.34)). For other comparisons there was insufficient evidence.

AUTHORS' CONCLUSIONS

The type of dressing applied beneath compression has not been shown to affect ulcer healing. For the majority of dressing types there was insufficient data to allow us to draw strong conclusions except for hydrocolloid compared with a low adherent dressing. The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression. Decisions regarding which dressing to apply should be based on local costs of dressings and practitioner or patient preferences.

Pain and quality of life for patients with venous leg ulcers: proof of concept of the efficacy of Biatain®-Ibu, a new pain reducing wound dressing

Wound pain is a serious problem for elderly patients suffering from chronic leg ulcers, and it may lead to reduced wound healing rates and reduced quality of life. Biatain-Ibu Non-adhesive (Coloplast A/S), a new pain-reducing moist wound healing dressing containing ibuprofen was tested for pain reduction, safety, and efficacy on 10+2 patients in a single-blinded crossover study against Biatain Non-adhesive (Coloplast A/S). Pain was measured with a Numeric Box Scale before, during, and after dressing change. Quality of life was measured using the World Health Organization-5 Well-Being Index. Dressing moist wound healing properties such as absorption capacity and leakage were tested together with assessment of wound exudate and blood plasma content of ibuprofen. Use of the Biatain-Ibu foam dressing correlated with a decrease in pain intensity scores from 7 in the run-in period to approximately 2.5 in the Biatain-Ibu treatment phase. Quality of life measures were improved which together with the reduced pain could contribute to faster wound healing. The moist wound healing properties of Biatain-Ibu were similar to that of the Biatain Non-adhesive and ulcer size was reduced by 24% during the treatment period. Neither side effects nor systemic plasma concentrations of ibuprofen were observed. These data indicate that Biatain-Ibu could reduce persistent and temporary wound pain, increase Quality of life, was found safe to use, and had excellent moist wound healing properties.

Supporting adherence and healthy lifestyles in leg ulcer patients: systematic development of the Lively Legs program for dermatology outpatient clinics

OBJECTIVES

The objective of our project was to develop a lifestyle program for leg ulcer patients at outpatient clinics for dermatology.

METHODS

We used the intervention-mapping (IM) framework for systematically developing theory and evidence based health promotion programs. We started with a needs-assessment. A multidisciplinary project group of health care workers and patients was involved in all five IM steps; formulating proximal program objectives, selecting methods and strategies, producing program components, planning for adoption and implementation and planning for evaluation. Several systematic literature reviews and original studies were performed to support this process.

RESULTS

Social Cognitive Theory was selected as the main theory behind the program 'Lively Legs' and was combined with elements of Goal-Setting Theory, the precaution adoption model and motivational interviewing. The program is conducted through health counseling by dermatology nurses and was successfully pre-tested. Also, an implementation and evaluation plan were made.

CONCLUSION

Intervention mapping helped us to succeed in developing a lifestyle program with clear goals and methods, operational strategies and materials and clear procedures.

PRACTICE IMPLICATIONS

Coaching leg ulcer patients towards adherence with compression therapy and healthy lifestyles should be taken on without delay. Systematic development of lifestyle programs for other patient groups should be encouraged.

Chronic leg ulcers, part 2: Do they affect a patient's social life?

This article describes a qualitative study into how chronic venous leg ulceration impacts on the social dimension of a patient's life and is presented in two parts. Part one discussed the background to the study, gave an overview of the literature and described the methodology. This second part will discuss the findings in relation to the literature together with implications for practice.

Injection Drug Use and Wound Care

Persons who have injected drugs present challenges to providing wound care. They tend to have multiple physical and psychosocial problems and abuse many substances. They may mistrust health care providers because of past experiences and their perceived negative attitude toward providers. Because they often self-treat abscesses and wounds before seeking care, the infection or wound can be large. A complete history and physical examination should be obtained. All aspects of the person's background will have an impact on wound healing. Wounds need careful assessment and diagnosis. Correct diagnosis of the wound is critical for the proper treatment. Treatment decisions must also include pain control, financial concerns, living arrangements, insurance, and the person's ability to perform the care. Patient education is a critical link in enhancing positive wound healing outcomes.

Measuring the impact of venous leg ulcers on quality of life

OBJECTIVE

To identify health-related quality-of-life (HRQoL) issues in patients with venous leg ulcers, with the aim of generating items for a treatment outcome measure.

METHOD

Thirty-eight patients with venous leg ulcers were interviewed by a psychologist using a semi-structured guide; they also completed a HRQoL questionnaire (modified Skindex). Data from the questionnaire were examined to explore the impact of venous leg ulcers on patients' lives. Interview transcripts were analysed using qualitative methods to identify additional venous leg ulcer-specific HRQoL items.

RESULTS

Skindex scores indicated that older patients had worse HRQoL (p<0.05), as did those with pain and non-healing ulcers. Ulcer duration and size did not correlate with HRQoL. Interviews revealed the following effects of ulceration: pain (80.5%); itching (69.4%); altered appearance (66.7%); loss of sleep (66.6%); functional limitation (58.3%); and disappointment with treatment (50%). Based on the interview transcripts, items were generated and discussed with an expert panel, with a view to including them in a venous leg ulcer-specific HRQoL questionnaire.

CONCLUSION

Disease-specific HRQoL outcome measures should be considered when evaluating treatments for venous leg ulcers.

The use of qualitative research methodologies to explore leg ulceration

Qualitative research is used increasingly within tissue viability and this article specifically presents its use within the body of literature on leg ulceration. This article offers a discussion of the key features of qualitative methodology, such as subjectivity, bracketing, rigour and the analytic process. Furthermore it will be shown that understanding the underpinning philosophical approach is essential for clinicians undertaking qualitative research. The rich data obtained through this approach will be presented, revealing how a person living with leg ulceration can be heard.

Does leg ulcer treatment improve patients' quality of life?

OBJECTIVE

To investigate the impact of 'disease' and treatment on quality of life in patients with venous leg ulceration.

METHOD

Sixty-five patients with venous leg ulcers were recruited and treated. At study entry and exit or following complete wound closure, whichever occurred first, each patient was assessed using the SF-36 quality-of-life questionnaire. Data analysis included an investigation of the study population as whole, differences between patients whose ulcers did and did not heal and between gender and age. Health domain means for all patients were compared with age equivalent norms (AENs) at both entry and exit.

RESULTS

There was a significant improvement in the SF-36 domains of bodily pain, health transition, mental health and social functioning for all 65 patients. Patients whose ulcers healed also showed a statistically significant improvement in the vitality domain. Patients whose ulcers did not heal had statistically significant improved scores for bodily pain and health transition. At entry all SF-36 values, except for general health, were lower than the AENs. On exit, scores for bodily pain, general health and mental health were comparable with the AEN; values for the remaining five domains increased at exit.

CONCLUSION

The results highlight that good wound management and effective compression therapy can improve quality of life in patients with venous leg ulceration, whether or not the patient's leg ulcer healed following treatment.

Disrupted lives: investigating coping strategies for non-healing leg ulcers

The aim of this study was to explore the lived experience of people who have non-healing venous ulcers using hermeneutic phenomenology. Unstructured interviews were carried out with five people who also completed a diary. Interpretative phenomenological analysis was utilized to identify themes and patterns. The core themes identified through analysis were biographical disruption, ways of coping, social implications and therapeutic relationships. The emergent themes reveal the impact of chronicity in participants' experience of chronic leg ulcers, their various emotional and problem-focused coping strategies and the positive role the district nurse plays in their lives. This study places leg ulceration within the body of literature on chronicity, linking nursing theory with the insights offered from health psychology.

Quality of life and leg ulceration from the patient's perspective

Chronic leg ulceration can have a profound impact on a patient's quality of life. Studies have shown that pain, and general interference with normal activities of living, are the major themes emerging which are often not dealt with in a consistent manner by healthcare professionals. A literature review of this subject shows that although a number of studies have been carried out on quality of life related to chronic leg ulceration, there is little evidence that these findings are being addressed in daily management of these often complex leg ulcer patients. The aim of this article is to examine the research relating to quality of life and leg ulceration, and to attempt to determine what the most important issues are from the patient's perspective, in an effort to improve the way nurses manage their care.

Leg ulcers: a review of their impact on daily life

BACKGROUND

Current nursing care for leg ulcer patients often focuses on wound care and providing compression therapy. Nurses perceive leg ulcer patients as 'under-served' with regard to problems patients experience in daily life. An overview of patient problems is a first and essential step in the development of comprehensive nursing care.

AIMS AND OBJECTIVES

To gather information about the impact of leg ulcers on patient's daily life as described in quantitative and qualitative studies.

DESIGN

Systematic literature review.

METHODS

Medline and Cinahl databases were searched for venous leg ulcer studies, up to 2002; this was followed by the 'snowball method'. Studies were selected in accordance with preset criteria.

RESULTS

A total of 37 studies was included. All studies report that leg ulcers pose a threat to physical functioning. Furthermore, a negative impact on psychological functioning is reported and, to a lesser degree, on social functioning. Major limitations are pain and immobility, followed by sleep disturbance, lack of energy, limitations in work and leisure activities, worries and frustrations and a lack of self-esteem. Patients have a significantly poorer quality of life compared with healthy people. Finally, patients report problems with regard to follow-up treatment.

CONCLUSIONS

Having a leg ulcer has a major impact on a patient's life. There are indications of under-treatment of pain.

RELEVANCE TO CLINICAL PRACTICE

Keeping in mind that leg ulceration is notorious for its chronic character, the negative impact on patient's life implies that many patients suffer over longer periods of time. This emphasizes the need to focus on quality of life aspects in patient care. There is much to gain, especially concerning pain and mobility. The development of comprehensive care programmes is essential.

Patients' perceptions and experiences of larval therapy

OBJECTIVE

To gain an insight into patients' perceptions and experiences of larval therapy.

METHOD

A phenomenological approach was adopted in which six patients who recently had had larval therapy were interviewed using an open, unstructured approach in two hospital settings. Data analysis was loosely based on Colaizzi's structured analysis technique.

RESULTS

Five themes emerged: past experiences of wounds leads to expectations of recurrence and a reduced quality of life; living with a chronic wound led to feelings of hopelessness; the skills and expertise of the nurse made patients feel hopeful; being informed helped patients to choose whether or not to have the therapy; the experience of larval therapy was not as scary as imagined.

CONCLUSION

The findings suggest that, although initially repellent, larval therapy is acceptable once treatment starts. The nurse-patient relationship was a significant factor in acceptance, along with autonomy and informed choice.

Direct Health Care Costs of 4 Common Skin Ulcers in New Mexico Medicaid Fee-for-Service Patients

OBJECTIVE

To determine health care costs associated with pressure ulcers, ulcers of the lower limbs, other chronic ulcers, and venous leg ulcers from the New Mexico Medicaid fee-for-service program perspective.

DESIGN

Retrospective analysis of claims database

MAIN OUTCOME MEASURES

Physician visit, hospital, and prescription costs were determined for New Mexico Medicaid patients with a primary and/or secondary diagnosis of 1 of 4 identified categories of skin ulcers from January 1, 1994, through December 31, 1998. Costs were determined in terms of mean and median annual cost per patient and total costs per year. Zero dollar claims were included within the cost calculations. All costs are expressed in 2000-dollar values.

MAIN RESULTS

Mean annual physician visit costs per patient ranged from $71 (standard deviation [SD] = $60) for venous leg ulcers in 1998 to $520 (SD = $1228) for pressure ulcers in 1996. Mean annual hospital costs per patient ranged from $266 (SD = $348) for other chronic ulcers in 1998 to $15,760 (SD = $30,706) for pressure ulcers in 1998. Mean annual prescription costs per patient ranged from $145 (SD = $282) for other chronic ulcers in 1998 to $654 (SD = $1488) for pressure ulcers in 1994.

CONCLUSION

The New Mexico Medicaid fee-for-service system incurred a total cost of approximately $11.6 million (in 2000 dollars) from 1994 through 1998 for the treatment of the 4 categories of skin ulcers studied. The data showed that the majority of wounds were coded as pressure ulcers, which had the highest associated costs.

Errors and discrepancies: a patient perspective on leg ulcer treatment at home

OBJECTIVE

This Norwegian study explored the treatment experiences of nine patients with a leg ulcer who lived at home.

METHOD

The study was descriptive and exploratory, with open-ended interviews. Five women and four men aged 60-96 years who had a leg ulcer for more than six weeks participated. Most had a venous/arterial leg ulcer, lasting from between four months to 'my whole adult life'.

RESULTS

Treatment was not always carried out in a correct and caring manner. The patients experienced trial and error in their treatment, delays in the arrival of the helpers, unhygienic methods and lack of information about the cause and treatment of their ulcer. Despite these problems, they had confidence in the treatment they received.

CONCLUSION

The treatment, hygiene and organisation of the care of patients with leg ulcers living at home needs improving.

The hidden side of nursing: why caring for patients with malignant malodorous wounds is so difficult

OBJECTIVE

This cross-sectional qualitative study used semi-structured telephone interviews with palliative care nurses working in urban and rural settings in Australia to explore their experiences of dealing with patients with malignant, often malodorous, wounds.

METHOD

This paper was the second phase of a research project examining the care of patients with malignant wounds. Of 71 palliative care nurses in New South Wales invited to participate, 26 took part, 17 of them working in community positions. The data from the telephone interviews were transcribed and analysed, using content analysis, and coded for themes relating to the nurses' experiences of caring for this patient group.

RESULTS

Nurses working in this setting strove to do the best for patients and their families under circumstances that are emotionally and physically difficult. Some of them suffered personal distress as a consequence. Patient isolation and altered body image are significant challenges for these nurses.

CONCLUSION

The nature of the work these nurses do, in particular the fact that they are dealing with cancers, tends to push them into literal and practical silence. But the researchers question whether this is always the best option. They ask if hiding feelings could be bad for nurses and patients alike. In qualitative research it is not appropriate to generalize the results, although lessons can be learnt from the experience of this group.

How living with a leg ulcer affects people's daily life: a nurse-led study

OBJECTIVE

This descriptive phenomenological study explored patients' experiences of living with a leg ulcer.

METHOD

Eight participants (five female and three male) were recruited from a secondary care leg ulcer clinic in a large UK teaching hospital. All had current venous leg ulceration, lasting between five months and 34 years. Data collection was via in-depth semi-structured interviews. Data categories were: symptoms; treatment; perceptions, emotions and coping strategies; and restrictions.

RESULTS

Leg ulcers have a significant impact on individuals' lives. The degree to which this occurs varies between each person.

CONCLUSION

Patients need consistent treatment that incorporates benchmarking. A support network to address the needs of those living with a leg ulcer should be considered. This study's findings should be promoted to raise awareness among health-care professionals, enabling them to provide more responsive care.

The use of polarised polychromatic non-coherent light alone as a therapy for venous leg ulceration

OBJECTIVE

This study assessed the effectiveness of polarised, polychromatic, non-coherent light therapy in the treatment of venous leg ulcers. Investigators in previous studies have advocated the use of light as an adjunct to other proven therapies or on its own.

METHOD

This was a pilot prospective case-series study. We enrolled 25 patients with venous leg ulcers. All were treated with light only. Phototherapy (light therapy) treatments were given once a day over four weeks.

RESULTS

All ulcers except one (99%) had a positive value for the change in healing area at the end of the four weeks. The total number of 73 leg ulcers recorded at the beginning of the study was reduced to 51 at the end of the four weeks (p < 0.01). The decrease in wound surface area following the treatment was statistically significant (mean: 57.15%; SD: 31.87%; p < 0.01).

CONCLUSION

Polarised, polychromatic light therapy applied as a monotherapy was associated with positive healing rates in patients with venous leg ulcers. It is a simple and non-invasive treatment. However, a well-designed randomised controlled study is needed to confirm the efficacy of this form of phototherapy and to objectively evaluate recommendations for its routine use in clinical practice.

Topical agents or dressings for pain in venous leg ulcers

BACKGROUND

Venous leg ulcers affect up to 1 per cent of people at some time in their life. These ulcers are often painful and some clinicians choose dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes.

OBJECTIVES

To assess the effectiveness of dressings, local anaesthetics or topical analgesia for pain relief in venous leg ulceration.

SEARCH STRATEGY

Cochrane Wounds Group Register and the Cochrane Collaboration Field in Complementary Medicine were searched in June 2002. Cochrane Pain Palliative and Supportive Care Group and Cochrane Wounds Group strategy were combined and used.

SELECTION CRITERIA

All randomised controlled trials which evaluated local interventions used to relieve venous leg ulcer pain were considered. Pain was defined as either persistent pain or pain at dressing changes or debridement.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two reviewers who independently assessed the potential trials. Details of eligible studies were summarised using a data extraction sheet which was checked by the second reviewer.

MAIN RESULTS

No trials evaluating interventions for persistent pain were identified for the initial review in 1999 nor the update in 2002. Three trials were included in the 1999 review comparing a eutectic mixture of local anaesthetic (EMLA) versus placebo for pain at debridement. In 2002 a further 3 trials were available (6 trials in total with 317 patients). The studies were considered sufficiently similar to pool and meta analysis found a statistically significant reduction in debridement pain scores with EMLA 5% cream. EMLA was associated with a reduction in pain scores (measured on a 100 mm scale) of 20.6 mm (95% Confidence Interval 29.11-12.19). One small trial measured healing as an outcome and found no difference in numbers of ulcers healed at the end of the study.

REVIEWER'S CONCLUSIONS

EMLA provides effective pain relief for venous leg ulcer debridement however, the effect of the product on ulcer healing is unknown. Research is required to determine the impact of debridement and of EMLA on ulcer healing. There were no trials addressing the treatment of persistent pain (between and at dressing changes) and further research is warranted.