Search

Objective: Wound management can be costly and challenging to the health services' scarce resources. Information regarding the number of wounds in a community care setting and their associated aetiology will provide nurses and nurse managers with an insight into the specific needs of these clients with wounds and highlight areas where care or services can be improved or further developed. This research aimed to establish the prevalence and aetiology of wounds, the current delivery of wound care, wound documentation and referral pathways in an Irish community care setting., Method: A retrospective chart review was carried out on all clients in the community care area who received wound care from the Public Health Nursing Service over a specified one-year period., Results: A total of 331 individuals were identified as having wounds, and nearly half presented with more than one wound, equating to 632 wounds in total (point prevalence (PP)=0.46%). A total of 56% (n=186; PP=0.14%) had leg ulcers (LUs), 18% (n=58; PP=0.04%) had pressure ulcers (PUs), 15% (n=49; PP=0.04%) had developed a diabetic foot ulcer (DFUs) and a further 11% (n=38; PP=0.03%) had wounds of other aetiologies. The mean duration of wounds was 11.37 months. Comorbidities were present in 99% (n=327) of clients with wounds, with cardiovascular disease observed in 87% (n=288) of clients and diabetes in 45% (n=148). Nursing wound-related concerns resulted in 52% (n=171) of clients receiving antibiotics, with 71% (n=121) being prescribed more than one dose. As many as 61% (n=104) of clients prescribed antibiotics did not have completed documentation to demonstrate a suspected wound infection. It was established that 16% of the Public Health Nursing Service's active caseload was made up of clients with wounds and the management of these wounds accounted for 65% of nursing time, equating to 28 full-time community nurses., Conclusion: This study has identified that people with chronic (hard-to-heal) wounds often present with more than one chronic disease, which may negatively influence the wound's healing trajectory, lengthening its duration. The criteria for onward referral for suspected wound infections have been examined and resulted in large numbers of poorly documented wound assessments, leading to a high reliance on the use of oral antibiotics as commonplace for the management of hard-to-heal wounds. Hard-to-heal wounds, such as lower LUs, PUs and DFUs, are either caused or significantly affected by the presence of underlying comorbidities. Therefore, aligning the prevention and management of these burdensome wounds with National Clinical Programmes will deliver efficient, cost-effective, holistic quality care to clients in Irish community healthcare settings.

The study aimed to investigate the prevalence and characteristics of pain in different ulcer types and to identify factors associated with pain experience in patients with lower-extremity ulcers. A cross-sectional single-centre study was performed, including 130 newly referred outpatients with lower-extremity ulcers. Pain intensity was measured with a visual analog scale (VAS) and pain characteristics with the short form mcgill pain questionnaire-2 (SF-MPQ-2). The mean pain intensity was 29.5 (SD 31.8) at rest and 35.5 (SD 34.1) during movement (0-100 VAS). 61.5% of the patients experienced pain (VAS > 0) at rest and 70.8% during movement. Moderate to severe pain at rest was seen in 39.2% and in 43.8% of patients during movement. The mean total score on SF-MPQ-2 (range 0-220) was 35.9 (SD 32.6). Most of the patients described pain as intermittent (mean 11.8 SD 13.9). Analgesics were prescribed for 78% of the patients. Ulcer type (i.e., arterial, immunological, pressure and venous) and age were associated with pain severity, and women had a significantly lower well-being score than men. Prevalence of pain in patients with lower-extremity ulcers was high across different ulcer aetiologies. Pain intensity and quality must be assessed to obtain adequate pain management., (© 2024 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.)

Objective: Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis., Methods: Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis., Results: This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers., Conclusions: This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To retrospectively evaluate the comorbidities, treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers (VLUs)., Method: Medicare Limited Data Standard Analytic Hospital Inpatient and Outpatient Department Files were used to follow patients who received medical care for a VLU between 1 October 2015 and 2 October 2019. Patients diagnosed with chronic venous insufficiency (CVI) and a VLU were propensity matched into four groups based on their treatment regimen. Episode claims were used to document demographics, comorbidities and treatments of Medicare enrolees who developed VLUs, as well as important outcomes, such as time to ulcer closure, rates of complications and hospital utilisation rates. Outcomes were compared across key propensity-matched groups., Results: In total, 42% of Medicare enrolees with CVI (n=1,225,278), developed at least one VLU during the study, and 79% had their episode claim completed within one year. However, 59% of patients developed another VLU during the study period. This analysis shows that only 38.4% of VLU episodes received documented VLU conservative care treatment. Propensity-matched episodes that received an advanced treatment or high-cost skin substitutes for a wound which had not progressed by 30 days demonstrated the best outcomes when their cellular, acellular, matrix-like product (CAMP) treatment was applied weekly or biweekly (following parameters for use). Complications such as rates of infection (33%) and emergency department visits (>50%) decreased among patients who received an advanced treatment (following parameters for use)., Conclusion: Medicare enrolees with CVI have diverse comorbidities and many do not receive sufficient management, which contributes to high rates of VLUs and subsequent complications. Medicare patients at risk of a VLU who receive early identification and advanced CAMP treatment demonstrated improved quality of life and significantly reduced healthcare resource utilisation., Competing Interests: Declaration of interest: This study was supported by MIMEDX Group Inc., US. JLD and RAF are employees of MIMEDX Group Inc. WHT and BH are consultants to MIMEDX Group Inc. VD, AO, MRK, JAN, NW and GM served on the Advisory Board of MIMEDX Group Inc.

Malignant skin tumors in the setting of chronic leg ulcers (CLUs) are often underdiagnosed which may contribute to treatment delay and poor outcomes. The aims of our study were to determine the incidence and clinical characteristics of skin cancers in leg ulcers in the Olmsted County population from 1995 to 2020. We used the Rochester Epidemiology Project (a collaboration between health care providers) infrastructure to describe this epidemiology, allowing "population-based" research. Electronic medical records of adult patients with International Classification of Diseases diagnosis codes for leg ulcers and skin cancers on the legs were queried. Thirty-seven individuals with skin cancers in nonhealing ulcers were identified. The cumulative incidence of skin cancer over the 25-year period was 37:7864 (0.47%). The overall incidence rate was 470 per 100,000 patients. Eleven (29.7%) men and 26 (70.3%) women were identified with mean age of 77 years. History of venous insufficiency was present in 30 (81.1%) patients and diabetes in 13 (35.1%) patients. Clinical characteristics of CLU with skin cancer included abnormal granulation tissue in 36 (94.7%) and irregular borders in 35 (94.6%) cases. Skin cancers among CLUs included 17 (41.5%) basal cell carcinomas, 17 (41.5%) squamous cell carcinomas, 2 (4.9%) melanomas, 2 (4.9%) porocarcinomas, 1 (2.4%) basosquamous cell carcinoma, and 1 (2.4%) eccrine adenocarcinoma. The apparent association between chronic wounds and subsequent biopsy-proven skin cancer of the same site was primarily observed in elderly patients; malignant transformation of wounds favored basal cell carcinoma and squamous cell carcinoma. This retrospective cohort study further characterizes the association between skin cancers and chronic leg wounds., (Copyright © 2023 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic affected the care of people with chronic leg ulcers (CLUs)., Aims: To understand how people with CLUs perceived illness, health care and the public health emergency during the second wave of the COVID-19 pandemic., Methods: Twenty people attending a wound care clinic in Northern Italy participated in semi-structured interviews and a thematic analysis was conducted using the software Atlas.ti 9., Findings: Results show that most of the participants evaluated their healthcare experience as positive but differed in their perceptions of the changes brought about by the pandemic according to their varied illness experiences and perceived social support. Participants were grouped in four trajectories that provided insight into the construction of personalised support strategies for people with CLUs., Conclusion: These results may help inform healthcare interventions and policies in the care of long-term conditions such as CLUs during a widespread emergency in future.

Background: Chronic venous disorders are common, with varicose veins occurring in ∼40% of the population. Venous leg ulcers affect 1% to 2% of the population, with the prevalence increasing ≤4% for those aged >65 years. Both conditions are expensive and together are responsible for ≤2% of the annual healthcare budget expenditure of Western societies. The ESCHAR (effect of surgery and compression on healing and recurrence) and EVRA (early venous reflux ablation) trials demonstrated that surgical correction of superficial venous reflux reduced ulcer recurrence, resulted in faster healing times (EVRA), and was proved cost-effective. Largescale data regarding patients with chronic venous leg ulcers presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate the percentage of patients with leg ulcers presenting to dedicated vein centers who were found to have surgically correctable superficial venous insufficiency., Methods: The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry began collecting data in 2014 and is one of two national registries focused on chronic venous disorders. The database was queried first for the presence of an ulcer using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (C6 status). These de-identified data were further correlated by crossing the number of ulcers for the same limb using the revised venous clinical severity score (rVCSS). The demographics, index duplex ultrasound details, and rVCSS features for ulcer duration and compression use were analyzed. Once the presence of an ulcer had been validated by CEAP and rVCSS, the population was divided into groups according to the ultrasound-reported anatomic pathology (eg, normal, reflux, obstruction, reflux plus obstruction). The query was directed toward all patients seeking a venous evaluation at participating centers from January 2018 through January 2022., Results: More than 270,000 unique patient records were reviewed. Of the 270,000 records, 163,027 (60%) had had duplex ultrasound scans available, for 1794 unique patients (1879 limbs), representing 1.1% with a leg wound. Of these patients, 55.4% were men and 44.6% were women. Group S included patients with isolated superficial pathology (n = 1291; 68.7%). Group M included patients with mixed superficial and deep pathology (n = 238; 12.7%). Group D included patients with isolated deep vein pathology (n = 58; 3.1%). Finally, group N included patients with leg wounds but no venous pathology (n = 292; 15.5%). The rVCSSs for groups S and M were significantly higher than those for group N. In group S, the dominant patterns involved the great saphenous vein (GSV) above the knee (54.8%), the small saphenous vein (30.7%), and the anterior accessory GSV (14.4%). The frequency of single, double, and triple axial vein reflux identified 1.45 vessels eligible for ablation treatment per limb. In group M, the dominant patterns involved the GSV above the knee (61.7%), the small saphenous vein (26.2%), and the anterior accessory GSV (12.1%), for 1.52 axial segments per limb. Of the 84.4% of venous ulcer patients, duplex ultrasound analysis revealed that 97% of this large subset had had surgically correctable disease., Conclusions: The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry demonstrated that 85% of the leg wounds in the present study were venous in origin and 97% possessed surgically correctable disease. Our findings support early referral to dedicated vein centers with appropriate venous reflux management as a part of the multidisciplinary team caring for patients with venous leg ulcers., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Venous leg ulcers (VLUs) are the final stage of chronic venous insufficiency. This study aims to characterize the association between cardiovascular diseases and VLU., Methods: A multicentric case-control study analyzed 17,788 patients between 2015 and 2020. Cases were matched (1:2) by age and sex, and odds ratios (OR) were analyzed with conditional logistic regressions adjusted by risk factors., Results: The prevalence of VLU was 15.2%. 2390 cases were analyzed. Diseases found to be associated with VLU were atrial fibrillation (OR, 1.21; 95% CI: 1.03-1.42), pulmonary hypertension (OR, 1.45; 95% CI: 1.06-2.00), right heart failure (OR, 1.27; 95% CI: 1.13-1.43), peripheral artery disease (OR, 2.21; 95% CI: 1.90-2.56), and history of pulmonary embolism (OR, 1.45; 95% CI: 1.06-2.00)., Conclusions: Certain cardiovascular conditions showed an association with VLU. Further studies are warranted to evaluate the effect that treating concomitant cardiovascular diseases might exert on the natural history of venous leg ulcers.

Sickle cell disease is a common and highly morbid genetic condition that is characterized by multi-system involvement, including numerous cutaneous manifestations. Persistent and recurrent leg ulceration has long been considered the dermatological hallmark of those with sickle cell disease, but there have been recent descriptions of associated infection with rare pathogens and episodes of liverdoid vasculopathy. Growing considerations for this population in the literature include cutaneous reactions to common treatments such as hydroxyurea and clinical management of the intersection between sickle cell disease and conditions like plaque psoriasis. Recent studies have also demonstrated an increased resistance to skin carcinogenesis for those with sickle cell disease through unclear mechanisms. However, though the body of knowledge regarding cutaneous manifestations and considerations of sickle cell disease is slowly expanding, it does not match the considerable disease and symptom burden faced by these patients. More research is needed to better delineate our understanding of these cutaneous manifestations of sickle cell disease to improve outcomes and further management., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Although leg ulcers are a burdensome disease most common in those aged 65 years and older, frailty in this population has not yet been well established., Objectives: The aim of this study was to prospectively explore and compare the presence of frailty in elderly patients with chronic leg or foot ulcers by applying different validated frailty screening methods in three healthcare settings and to assess the feasibility of frailty screening., Methods: We compared frailty of leg ulcer patients referred to an academic hospital with a non-academic hospital, leg ulcer patients receiving (primary) homecare, and a dermato-oncology patient population (control group). Frailty and quality of life were assessed using four validated questionnaires: the Groninger Frailty Indicator, Geriatric-8, Mini-Cog and Wound Quality of Life. To analyse data multiple (non)-parametric tests were performed., Results: Fifty of 60 included leg ulcer patients (83%) scored "frail" on at least one frailty questionnaire (GFI, G8 or Mini-Cog). The number of patients scoring "frail" on two or three out of three applied frailty questionnaires were significantly higher in the academic and homecare ulcer population compared with the non-academic ulcer population and control group (p = 0.002). In the academic ulcer population mean Wound Quality of Life scores were 30.2 (SD 17.6), compared with 17.7 (SD 13.1) in the non-academic and 15.0 (SD 10.4) in the homecare ulcer population (p = 0.002)., Conclusion: The majority of patients suffering from leg ulcers in this study was frail. The highest frailty prevalence was observed in the academic and homecare ulcer populations. The largest impaired quality of life was reported in the academic ulcer population. In dermatology practice, implementing frailty screening and initiating appropriate (paramedical) supportive care should be considered to improve patient outcomes., (© 2022 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology.)

Objective: This audit was designed to identify the need of the population and the clinical activity associated with wounds and the management of lower limb swelling. The exploration focused on lower leg wound management, access to diagnostics and compression therapy across each audit site. The variation across the sites was explored to gather insight into the real-world barriers to providing evidence-based management for leg ulceration., Method: We undertook wound prevalence audits across six diverse community provider sites in England. The audit was undertaken by the local providers, with the inclusion of tissue viability and podiatry leads and key local stakeholders, often local quality leads, primary care leads and nursing directors. Each audit was undertaken with full engagement of local clinicians. Data were collected centrally, and each audit site received their own local analysis and report, with additional analytical support from the local tissue viability lead to ensure the feedback was contextualised for their stakeholders. Analysis was provided by Accelerate CIC Lymphoedema & Leg Ulcer Clinic., Results: A total of 2885 patients were reviewed via an online or a paper audit tool. In total, 2721 patients had one or more active wounds. However, 1350 patients had one or more lower leg wounds, with 164 patients being managed for lower limb swelling or prevention of leg ulceration; bilateral conditions ranged from 11-43% across audit sites. Of the six sites, two included both community and primary care providers, thus generating wound point prevalence data. The remaining four sites audited community nursing and podiatry services only, with two sites collecting data on lower limb wounds only rather than all wounds, generating point prevalence for their services only. Compression usage varied across care locations, with the greatest use being seen in community leg ulcer clinics, where it was >96% for 234 residents. Compression usage was lower in the home with a range of 14-62% among 692 residents. For 263 residents, where the cause of their lower leg wound was unknown, compression usage was very low at 12%. Compression usage decreased with age; for three audit sites this was noteworthy, with 65% of those aged >80 years not in receipt of compression. Compression usage had a direct impact on nursing activity; non-use of compression increased activity by 37%., Conclusion: Through the identification of wound location, this series of wound prevalence audits identified a greater number of patients with lower limb wounds than those recognised and classified as a leg ulcer. Substantial variation in access to diagnostics and compression therapy was observed between audit sites, and also between locations within their boroughs. The factors that reduced access to compression therapy included not classifying the lower leg wound as a leg ulcer, being cared for in the home and increasing age of the patient. Lack of compression usage increased nursing activity. Where there is lack of access to therapeutic intervention, the resultant patient harm is not systematically recognised or documented.

Objective: To identify the prevalence of people with leg ulcers resulting from sickle cell disease, as well as to describe the clinical, social, economic, and demographic conditions of these people., Method: Descriptive study, carried out at the Minas Gerais Hematology and Hemotherapy Center Foundation. The study population consisted of individuals over the age of 18 with a diagnosis of sickle cell disease in the State of Minas Gerais, Brazil. Data collection was performed from August 2019 to April 2020 through interviews. For the prevalence calculation, a census was taken of 5,379 people over the age of 18 with sickle cell disease, 77 of whom had active leg ulcers. Descriptive data analysis was performed using SPSS software (version 20.0, Chicago, IL, USA)., Results: The prevalence of people with leg ulcers in Minas Gerais, Brazil was 1.4%. Of the 72 respondents, the average age was 39 years (range 18-64 years), 41.7% were single, 48.6% said they were black, 84.7% lived in their own house, 38.9% were retired, 61.1% had an income of one minimum wage. The median years of education was 10.5, 50% cited the church as a place for leisure activities, 79.2% denied smoking. Regarding pain, the median score was 3, the median baseline hemoglobin was 7.7 g/dL, and 91.7% had the HbSS genotype. The median age of the first ulcer was 18 years, 77.8% of active ulcers were recurrent, and 59.7% had only one active ulcer. The median time of existence of the ulcer was 3 years. The ulcer prevented 80.6% of people from doing some activity. Prejudice was experienced by 48.6% of the participants., Conclusion: The estimated prevalence of leg ulcers was lower than what it reported in the literature, however, the recurrence and the duration of ulcers were high. These findings bring reflection about the assistance to people with leg ulcer., Competing Interests: The authors have declared that no competing interests exist.

Objective: Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression in the community. However, little is known about the leg ulcer population and use of compression therapy in the hospital setting, where it is not often part of inpatient care. This study aimed to evaluate the proportion of inpatients with leg ulceration eligible for compression therapy., Method: A point prevalence audit was undertaken using three methods: patient electronic live report; a leg ulcer audit form; and an electronic record search. The following data were retrieved: patient age, sex, primary reason for admission, diabetes, mobility status, history of dementia, Clinical Frailty Scale score and presence of oedema. Ankle-brachial pressure index was measured to determine patients' eligibility for compression therapy., Results: The audit identified 80/931 (8.5%) inpatients as having confirmed, active leg ulceration. A total of 36/80 (45%) inpatients were assessed for eligibility for compression, of whom 25/36 (69.4%) were eligible for full compression, 2/36 (5.6%) reduced compression and 9/36 (25%) were not eligible for compression therapy., Conclusion: The audit demonstrated that a significant proportion of hospital inpatients with leg ulcers were eligible for compression therapy and that this patient population were heterogenous in terms of comorbidity profile, mobility, frailty and dementia, among other factors. Further research is required to explore the most feasible and effective compression options for inpatients with leg ulcers.

Background: Leg ulcers in adults are a major public health concern. Their incidence increases with age and many causes have been identified, predominantly associated with vascular diseases. Leg ulcers in children and teenagers are less frequent. The aim of our study was to identify the causes of leg ulcers in children and teenagers, and to evaluate their management., Methods: This retrospective multicenter study was conducted by members of the Angio-dermatology Group of the French Society of Dermatology and of the French Society of Pediatric Dermatology. Data from children and teenagers (< 18 years), seen between 2008 and 2020 in 12 French hospitals for chronic leg ulcer (disease course>4 weeks), were included., Results: We included 27 patients, aged from 2.3 to 17.0 years. The most frequent causes of leg ulcer were: general diseases (n=9: pyoderma gangrenosum, dermatomyositis, interferonopathy, sickle cell disease, prolidase deficiency, scleroderma, Ehlers-Danlos syndrome), vasculopathies (n=8: hemangioma, capillary malformation, arteriovenous malformation), trauma (n=4: bedsores, pressure ulcers under plaster cast), infectious diseases (n=4: pyoderma, tuberculosis, Buruli ulcer) and neuropathies (n=2). Comorbidities (59.3%) and chronic treatments (18.5%) identified as risk factors for delayed healing were frequent. The average time to healing was 9.1 months., Discussion: Leg ulcers are less frequent in children and teenagers than in adults and their causes differ from those in adults. Comorbidities associated with delayed healing must be identified and managed. Children and teenagers tend to heal faster than adults, but a multidisciplinary management approach is necessary., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Patients with chronic leg ulcer, pressure ulcer, or diabetic foot ulcer suffer from significant disease burden. With a view to improving healthcare provision sustainably, a predictive model of time to closure (time-to-event analysis) based on claims data was developed. To identify potential predictors of wound closure, clinical information absent from statutory health insurance (SHI) data was modelled. In patients with leg ulcers, age of the patient (hazard ratios [HR] 0.99), increasing number of comorbidities (HR 0.94), inpatient stays (HR 0.74), and treatment by a specialised wound care professional (HR 1.18) were significant predictors of time to closure (adjusted model). In almost all models, the number of inpatient stays and of comorbidities predicted a lower probability of healing. In addition, the age and the sex of the patient were found to be significant predictors in some models (leg ulcer: HR 0.99; pressure ulcer: HR 0.99). Increasing number of comorbidities and inpatient stays were predictors for closure time in all models. Since these predictors may give an indication of wound severity, further clinical information should be considered in future models, as also indicated by the moderate values of the c-statistics. This requires future data linkage between SHI and primary studies (eg, registers)., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Sickle leg ulcer (SLU) occurs as a result chronic occlusion of the vasculature with consequent necrosis of the skin and subcutaneous tissue usually in proximity of the malleoli. The description of clinical associations and the simultaneous occurrence of SLU and other complications of SCD compared to the non-SLU patients was the aim of this work. A total of 272 (60.8% males and 39.2% females) patients were captured during this time period out of which 68 (51 males and 17 females) had SLU out of whom 20 patients had bilateral leg ulcers. Prevalence of SLU was 25% and the median age of patients was 25 years, frequency of crisis 2 per annum and 44 (74.6%) had been transfused in the past. Median Hb of the group was 7.6 g/dl and 25% had values lower than 6.5. The occurrence of other complications in SLU patients was as follows; 10 had AVN, 9 priapism, 8 had osteomyelitis, 6 nephropathy, stroke 2, osteoarthritis 4 and cholelithiasis 4. There was a significant relationship between the occurrence of SLU and gender of the patient being more in 67males-Likelihood ratio 4.610 (p = 0.032) and the occurrence of pulmonary hypertension-Likelihood ratio 4.762 (p = 0.029). There was no significant association between the occurrence of SLU and other complications of SCD. Leg ulcer patients have a median age of 25 years with a prevalence of 25% but do not necessarily show other features of severe disease phenotypes. SLU patients were more likely to develop pulmonary hypertension. Further studies on impact of environmental factors on the occurrence of SLU are needed to further evaluate its aetiology., (© 2021 The Wound Healing Society.)

Objective . To identify the bacterial isolates and their antibiotics susceptibility pattern among patients with lower limb ulcers admitted at a tertiary hospital in northern Tanzania. Methodology. A cross-sectional study was conducted between April and July 2018 at the Kilimanjaro Christian Medical Centre. Questionnaire was used to obtain the demographics and clinical information of participants. Wound samples were collected and culture method used to identify the bacteria and their susceptibility patterns. Results. Out of 65 participants, 55 (84.6%) had positive aerobic bacterial growth. Twelve (18 %) participants had more than one bacterium. Fifty-nine (88.1%) were gram-negative bacteria. Proteus vulgaris (13, 19.9%), Pseudomonas spp (10, 14.8%), and Staphylococcus aureus (8, 11.7%) were the common isolates. Out of 59 gram-negative bacterial, 47 (78%) were sensitive to amikacin. Staph were sensitive to oxacillin (75%; n = 8) and vancomycin (50%; n = 8). Gram-negative were common isolates and were resistant to amoxicillin/clavulanic acid but sensitive to amikacin. Conclusion . The observed resistance to antibiotics calls for continuous monitoring of the resistance pattern to guide the empirical management of patients with leg ulcer.

Background: Sickle cell anaemia affects about 4 million people across the globe, making it an inherited disorder of public health importance. Red cell lysis consequent upon haemoglobin crystallization and repeated sickling leads to anaemia and a baseline strain on haemopoiesis. Vaso-occlusion and haemolysis underlies majority of the chronic complications of sickle cell. We evaluated the clinical and laboratory features observed across the various clinical phenotypes in adult sickle cell disease patients., Methods: Steady state data collected prospectively in a cohort of adult sickle cell disease patients as out-patients between July 2010 and July 2020. The information included epidemiological, clinical and laboratory data., Results: About 270 patients were captured in this study (165 males and 105 females). Their ages ranged from 16 to 55 years, with a median age of 25 years. Sixty-eight had leg ulcers, 43 of the males had priapism (erectile dysfunction in 8), 42 had AVN, 31 had nephropathy, 23 had osteomyelitis, 15 had osteoarthritis, 12 had cholelithiasis, 10 had stroke or other neurological impairment, 5 had pulmonary hypertension, while 23 had other complications. Frequency of crisis ranged from 0 to >10/year median of 2. Of the 219 recorded, 148 of the patients had been transfused in the past, while 71 had not., Conclusion: The prevalence of SLU, AVN, priapism, nephropathy and the other complications of SCD show some variations from other studies. This variation in the clinical parameters across different clinical phenotypes indicates an interplay between age, genetic and environmental factors.

Objective: To determine the prevalence of leg ulcers, and to describe the affected patients, wounds, and treatment., Method: Observational, cross-sectional prevalence study. An ad hoc online questionnaire was sent to all nurses attending Primary Care centres of the "Gerencia de Atención Integrada de Cuenca" (Integrated Care Management of Cuenca, Spain). Data regarding patient sociodemographic and clinical variables, lesion characteristics and the type of intervention (concerning prevention and treatment) were collected., Results: In total, 152 professionals (response rate = 98.1%) completed the questionnaire, collecting data from 131,190 inhabitants. A total of 63 patients (75.5 ± 12.6 years old) with 75 ulcers were identified, finding an overall prevalence of .480‰ (CI 95%: .375-.614), distributed as: venous ulcer .274‰ (n = 36), diabetic foot .145‰ (n = 19), and arterial ulcer .061‰ (n = 8). The prevalence was similar regarding gender (.535‰ vs .426‰, respectively, p = .365), but men exhibited more diabetic foot (.214‰ vs .076‰, p = .037). In all three types of lesions prevalence increased with age, reaching 1.743‰ in 64+ age group. The median of the leg ulcer duration and corrected area were 190.0 ± 340.0 days and 5.0 ± 13.7 cm 2 , respectively, with a recurrence rate of 74.7%., Conclusions: The prevalence of chronic leg ulcers was lower than that reported in other studies, although with high recurrence rates. Overall estimators from previous studies may have overestimated the prevalence, especially in regions with a high rural component., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Objective: To evaluate the presence of anemia in patients with chronic lower limb ulcers based on profile and hematometric indices., Method: This is a cross-sectional study carried out in a university hospital in Rio de Janeiro. The sample was composed of 64 participants with lower limb ulcers and evolution time greater than 12 weeks. Data was collected between May/2016 and December/2017 from hematological analyses, records from medical records, and wound assessment form., Results: 36 (56.2%) were male; 38 (59.4%) between 60 and 80 years old; 56 (87.5%) with chronic diseases and 52 (81.2%) with venous ulcers. 6 years mean of active ulceration. Anemia was detected in 36 (56.2%), 27 (75%) of which were normochromic and normocytic; 14 (38.8%) had deficiency anemia recorded in their medical chart., Conclusion: The low hemoglobin concentration is recurrent among the participants characterizing an anemia condition, whose profile reveals congruence to the anemia of chronic disease.

Aims and Objectives: The aims of this study were to explore the prevalence of background pain and identify demographic, clinical and psychosocial factors associated with moderate to severe background pain in persons with leg ulcers., Background: All chronic leg ulcers are potentially painful. Research indicates that 80% of persons with chronic leg ulcers experience wound-related background pain. However, studies on factors associated with pain have small samples and findings are inconclusive., Design: Exploratory cross-sectional study., Method: This quantitative study recruited persons with chronic leg ulcers (N = 252) from two wound care clinics using consecutive sampling method. Data were obtained through screening interview, clinical examination and questionnaires. Logistic regression with stepwise backwards elimination was used to identify factors associated with moderate to severe background pain. The STROBE checklist for cross-sectional studies was used for reporting this study., Results: Background pain was reported by 64% of the participants. Inferential statistical analyses suggest that between 58% and 69% of persons with chronic leg ulcers suffer from this type of pain. Factors associated with moderate to severe pain were older age, female gender, reduced sleep quality and diminished health status. In the final model, reduced sleep quality increased the likelihood of having moderate to severe pain in persons with good health status while not in persons with diminished health status., Conclusion: Ulcer-related background pain is common in persons with chronic leg ulcers. Older females reporting insomnia symptoms also had increased risk of moderate to severe ulcer-related background pain. These participants also perceived their health status to be better., Relevance to Clinical Practice: This study demonstrates that ulcer-related background pain and associated factors needs more attention in clinical practice. Furthermore, nurses and other healthcare professionals should integrate biopsychosocial strategies to assess and manage ulcer-related background pain., (© 2021 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Purpose: To evaluate the relationship between clinical severity and functionality, sleep quality, depression, and quality of life (QoL) in patients with CVI with or without leg ulcers., Methods: A total of sixty patients with CVI were enrolled in the study. The patients were C2-6 according to the CEAP classification. All the patients were assessed with Venous Clinical Severity Score (VCSS) for clinical severity, Visual Analog Scale (VAS) for pain, right and left lower limb (RLL and LLL) circumference measurements for edema, 6-min-walk test (6-MWT) for functional capacity, Lower Extremity Functional Scale (LEFS) for functionality, Pittsburg Sleep Quality Index (PSQI) for sleep quality, Beck Depression Inventory version I (BDI-I) for depression, and The Quality of Life Questionnaire for Chronic Venous Diseases-20 (CIVIQ-20) for QoL., Results: The mean age of the patients was 45.83 ± 13.25 years, and the mean duration of disease was 8.30 ± 7.42 years. There was a significant association between VCSS and VAS-rest/activity, edema-RLL/LLL, PSQI, BDI-I, LEFS, and CIVIQ-20 in patients without leg ulcers. In addition, a significant association was found between VCSS and VAS-rest/activity and CIVIQ-20 in patients with leg ulcers., Conclusion: The current study showed that an association has been found between clinical severity and pain at rest and during activity, edema, sleep quality, depression, lower extremity function, and QoL in patients without ulcers. However, clinical severity has been correlated with only pain at rest and during activity, and QoL in patients with leg ulcers., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Objectives: to analyze the microbiological profile of leg ulcers of patients treated at outpatient clinics and hospitals regarding the type of microorganism, microbiological selection of antibiotics, and techniques for the collection of culture material., Methods: literature review performed on LILACS, IBECS, MEDLINE, and CINAHL databases, resulting in a descriptive analysis of 27 studies., Results: 35.7% of the studies occurred in an outpatient care scenario; and 64.2% in hospitals. There was a predominance of swab (100%) in outpatient care and biopsy (55.5%) in the hospital. Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus were more common at both levels of assistance. Methicillin-resistant Staphylococcus aureus was isolated in both., Conclusions: the microbiological profile of infections was similar, with the presence of resistant bacteria in both environments. This fact causes concern and raises the need for research to elucidate it. The studies did not compare the effectiveness between biopsy and swab.

Background: Dermatitis of surrounding skin may complicate hard-to-heal leg ulcers, delaying wound healing. The coexistence of hard-to-heal leg ulcers and irritant or allergic contact dermatitis may create difficulties for both diagnostic and therapeutic management., Objective: The aim of our study was to evaluate the incidence of dermatitis occurring in the surrounding skin in a population affected by hard-to-heal leg ulcers during treatment, and to differentiate between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) with the use of a patch test. Furthermore, we investigated which medications were most probably related to these conditions., Method: We conducted an observational study from 21 February to 21 July 2017, enlisting all patients affected by hard-to-heal leg ulcers who attended the Wound Care Service of the Dermatologic Department of ASST, Spedali Civili, Brescia, Italy., Results: We enrolled 95 patients; 81 patients did not develop dermatitis, while 14 patients developed dermatitis of the surrounding skin. These patients underwent a patch test which gave a positive result in seven patients, permitting the diagnosis of ACD., Conclusion: Our study confirmed the incidence of dermatitis of the surrounding skin reported in the literature but reassessed the incidence of ACD as opposed to ICD.

Objective: The aim of the study was to analyze bacterial flora in venous leg ulcers, empiric and targeted antibiotic therapy, and factors influencing healing time., Materials and Methods: Data from 30 patients with venous leg ulcers were retrospectively analyzed. Collected data included: sociodemographic data, wounds information, number of comorbidities, results of the microbiological examination, and empiric and targeted antibiotic therapy. To compare the empiric and targeted treatment in terms of their compatibility, the group of patients was divided into the four subgroups: NEA (no empiric antibiotics), NA (no antibiotics), ETA+ (compatibility of empiric and targeted antibiotic), ETA- (no compatibility of empiric and targeted antibiotic)., Results: The average ulcer healing time was 163.4 ± 97.1 (range 51.0 to 426.0) days and increased by 28 days with each additional bacterial strain in the ulcer (p = 0.041). Healing time did not differ between the four groups. Staphylococcus aureus and Pseudomonas aeruginosa were the most frequent bacteria. Amoxicillinium/acidum clavulanicum was the most common empirical antibiotic and amoxicillinium/acidum clavulanicum, and levofloxacinum was the most common targeted antibiotic., Conclusions: Venous leg ulcer healing time was prolonged with each subsequent bacterial strain in the ulcer, and it was independent from systemic antibiotic therapy.

Purpose: The purpose of this study was to test our MUSTCOOL cooling patch intervention on the incidence of venous leg (VLU) and diabetic foot ulcer (DFU) recurrence over a previously healed wound., Design: A 6-month randomized controlled trial., Subjects and Setting: The target population was individuals with previously healed ulcers receiving care in outpatient wound centers in the Southeastern region of the United States. The sample comprised 140 individuals with recently healed ulcers; their average age was 62.4 years (SD = 12 years); 86 (61.4%) were male; and 47 (33.6%) were Black or African American., Methods: Participants were randomized to the MUSTCOOL or placebo patch. Both groups received instructions to apply the patch 3 times per week, and engage in standard of care including compression and leg elevation (VLU) or therapeutic footwear and hygiene (DFU). Demographic data were collected at baseline, and incidence measures taken at 1, 3, and 6 months. We also studied whether new ulcers developed on the adjacent leg or foot. Data were reported in frequencies/percentages., Results: One hundred seventeen participants (84%) were analyzed who completed 6 months of study participation. Thirteen percent (9/69) and 17% (12/69) developed a recurrent or new VLU, respectively; 29% (14/48) and 13% (6/48) developed a recurrent or new DFU, respectively. One person in the DFU group developed both a recurrent and new ulcer. For 9 recurrent VLUs, 6 (66.7%) recurred in the MUSTCOOL group and 3 (33.3%) receiving the placebo. Of the 15 recurrent DFUs (includes individual who developed both a recurrent and new ulcer), 10 (66.7%) recurred in the MUSTCOOL group and 5 (33.3%) receiving the placebo., Conclusions: While the incidence of ulcer recurrent was slightly higher in the MUSTCOOL group, this finding was not considered clinically relevant. Overall ulcer recurrence during the 6-month study period was lower than reports in the literature, the time frame in which recurrence rates are highest., Trial Registration: The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156)-https://clinicaltrials.gov/ct2/show/NCT02626156., Competing Interests: The authors have no conflicts of interest to report., (Copyright © 2021 by the Wound, Ostomy and Continence Nurses Society.)

Alpha thalassemia and beta-globin haplotype are considered classical genetic disease modifiers in sickle cell anemia (SCA) causing clinical heterogeneity. Nevertheless, their functional impact on SCA disease emergence and progression remains elusive. To better understand the role of alpha thalassemia and beta-globin haplotype in SCA, we performed a retrospective study evaluating the clinical manifestations of 614 patients. The univariate analysis showed that the presence of alpha-thalassemia -3.7-kb mutation (αα/-α and -α/-α) decreased the risk of stroke development (p = 0.046), priapism (p = 0.033), and cholelithiasis (p = 0.021). Furthermore, the cumulative incidence of stroke (p = 0.023) and cholelithiasis (p = 0.006) was also significantly lower for patients carrying the alpha thalassemia -3.7-kb mutation. No clinical effects were associated with the beta-globin haplotype analysis, which could be explained by the relatively homogeneous haplotype composition in our cohort. Our results reinforce that alpha thalassemia can provide protective functions against hemolysis-related symptoms in SCA. Although, several genetic modifiers can impact the inflammatory state of SCA patients, the alpha thalassemia mutation remains one of the most recurrent genetic aberration and should therefore always be considered first.

Background: A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes., Objectives: To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area., Methods: A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting., Results: twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm 2 ; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together., Conclusion: a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes., (Copyright © 2020 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Vasculopathy is a hallmark of sickle cell disease ultimately resulting in chronic end organ damage. Leg ulcer is one of its sequelae, occurring in ~ 5-10% of adult sickle cell patients. The majority of leg ulcer publications to date have emanated from single center cohort studies. As such, there are limited studies on the geographic distribution of leg ulcers and associated risk factors worldwide. The Consortium for the Advancement of Sickle Cell Research (CASiRe) was formed to improve the understanding of the different phenotypes of sickle cell disease patients living in different geographic locations around the world (USA, UK, Italy, Ghana). This cross-sectional cohort sub-study of 659 sickle cell patients aimed to determine the geographic distribution and risk factors associated with leg ulcers. The prevalence of leg ulcers was 10.3% and was associated with older age, SS genotype, male gender, and Ghanaian origin. In fact, the highest prevalence (18.6%) was observed in Ghana. Albuminuria, proteinuria, increased markers of hemolysis (lower hemoglobin, higher total bilirubin), lower oxygen saturation, and lower body mass index were also associated with leg ulceration. Overall, our study identified a predominance of leg ulcers within male hemoglobin SS patients living in sub-Saharan Africa with renal dysfunction and increased hemolysis.

This study estimates the prevalence and mortality of diseases of the deep veins of the legs such as deep vein thrombosis (DVT), postthrombotic syndrome (PTS), and venous leg ulceration (VLU). We used a random sample of 250 000 patients at age 50+ years of the register of the Allgemeine Ortskrankenkasse from 2004 to 2015. Selected manifestations of venous diseases assumed as risk factors for mortality were analyzed using Cox models while adjusting for various basic demographic and health characteristics. The prevalence in 2004 was 0.05% for DVT of the femoral veins, 0.50% for DVT of any deep veins, 0.86% for PTS, and 0.91% for VLU. The mortality rate in 2004 to 2015 was 20.40 deaths/100 person-years for DVT of the femoral veins, 10.69 for DVT of any deep veins, 4.34 for PTS, and 7.02 for VLU. The model revealed a 35% higher risk ( p < .001) in patients with any DVT, an 88% higher mortality ( p < .001) for femoral DVT, a 23% higher risk ( p < .001) for VLU, and no health disadvantage in persons with PTS. Our study revealed an increased mortality for patients with VLU and DVT. Even after adjustment for embolic events and infections of the venous ulcers mortality remained significantly higher.

Sickle cell anemia (SCA) pathophysiology is characterized by the activation of sickle red blood cells, reticulocytes, leukocytes, platelets, and endothelial cells, and with the expression of several inflammatory molecules. Therefore, it is conceivable that variations in levels of proinflammatory cytokines may act as a signaling of differential clinical course in SCA. Here, we evaluated the clinical impact of proinflammatory cytokines interleukin 1-β (IL-1β), interleukin 6 (IL-6), and interleukin 8 (IL-8) in 79 patients with SCA, followed in a single reference center from northeastern Brazil. The main clinical/laboratory data were obtained from patient interview and medical records. The proinflammatory markers IL-1β, IL-6, and IL-8 were evaluated by using commercially available enzyme-linked immunosorbent assay kits. According to levels of the proinflammatory markers, we observed that patients who had a higher frequency of VOC per year (P = 0.0236), acute chest syndrome (P = 0.01), leg ulcers (P = 0.0001), osteonecrosis (P = 0.0006), stroke (P = 0.0486), and priapism (P = 0.0347) had higher IL-6 levels compared with patients without these clinical complications. Furthermore, increased levels of IL-8 were found in patients who presented leg ulcers (P = 0.0184). No significant difference was found for IL-1β levels (P > 0.05). In summary, the present study emphasizes the role of inflammation in SCA pathophysiology, reveals an association of IL-8 levels and leg ulcer occurrence, and indicates that IL-6 levels can be used as a useful predictor for poor outcomes in SCA.

Pain and discomfort are important symptoms in dermatology. The aim of this cross-sectional, multicentre study was to describe the prevalence of pain/discomfort and its associations in patients with several dermatological conditions across 13 European countries. The outcome was the prevalence of pain/discomfort according to a question of the EQ-5D questionnaire. Data collected from November 2011 to February 2013 were complete for 3,509 consecutive outpatients. Moderate or extreme pain/discomfort was reported by 55.5% of patients and 31.5% of controls with no skin conditions. The highest proportions were reported by patients with hidradenitis suppurativa (92.9%), leg ulcer (81.4%), prurigo (80%) and lichen planus (75.6%). Pain/discomfort was associated with older age, low educational level, clinical severity, flare on scalp or hands, itch, depression, anxiety, low quality of life, and thoughts of suicide. It is important to enquire specifically about pain/discomfort during clinical consultations and to address it when planning a patient's care.

Leg ulceration is a debilitating condition in which various factors play a role in determining patients' quality of life (QoL), and compression therapy has been shown to improve QoL. The 3M Coban 2 Lite Compression System provides reduced compression (25-30 mmHg) ideal for patients with painful venous leg ulcers (VLU) who are unable to tolerate high-strength compression or those with mixed-aetiology leg ulcers (MLU) who have an ankle-brachial pressure index (ABPI)≥0.5. This non-comparative evaluation aims to report the initial clinical experiences with 3M Coban 2 Lite and evaluate the performance of this two-layer reduced compression bandage system in treating chronic VLUs and MLUs. In total, 30 patients (12 men (40%); mean age=68.5 years) were enroled for evaluation. The duration of the chronic wounds was 28 months (range=1.5-144 months); 16 patients had VLUs, while 14 had MLUs. Complete healing was achieved in 6 (20%) patients, and an overall mean reduction in wound surface area (4.11 cm 2 ) was observed between the baseline and study endpoint (16 weeks). Thus, 3M Coban 2 Lite seems safe and effective for treating painful VLUs and MLUs in patients unable to tolerate high-strength compression.

Background: This trial addresses the global problem of chronic venous leg ulcers (CVLUs), wounds that cause significant infirmity for an estimated 9.7 million people annually, mainly older adults with comorbidities. Advanced therapies are needed because standard topical therapies are often ineffective or yield only short-term wound healing. Thus, we are testing a new oral therapy containing the bioactive elements of fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for targeting and reducing the high numbers of activated polymorphonuclear leukocytes (PMN) in wound microenvironments that keep CVLUs "trapped" in a chronic inflammatory state., Methods: This double-blind RCT will include 248 eligible adults ≥ 55 years of age with CVLUs receiving standard care at a large Midwest outpatient wound clinic. Participants are randomized to two groups: 12 weeks of daily oral therapy with EPA + DHA (1.87 g/day of EPA + 1.0 g/day of DHA) or daily oral therapy with placebo. At 0, 4, 8, and 12 weeks, across the two groups, we are pursuing three specific aims: Aim 1. Compare levels of EPA + DHA-derived lipid mediators, and inflammatory cytokines in blood and wound fluid; Subaim 1a. Compare inflammatory cytokine gene expression by PMNs in blood; Aim 2. Compare PMN activation in blood and wound fluid, and PMN-derived protease levels in wound fluid; Aim 3. Compare reduction in wound area, controlling for factors known to impact healing, and determine relationships with lipid mediators, cytokines, and PMN activation. Subaim 3a. Compare frequency of CVLU recurrence and levels of study variables in blood between the randomly assigned two subgroups (continuing EPA + DHA therapy versus placebo therapy beyond week 12) within the EPA + DHA group with healed CVLUs after 3 months of therapy. Subaim 3b. Compare symptoms of pain at all time points and quality of life at first and last time points across the two groups and two subgroups., Discussion: This trial will provide new evidence about the effectiveness of EPA + DHA oral therapy to target and reduce excessive PMN activation systemically and locally in patients with CVLUs. If effective, this therapy may facilitate healing and thus be a new adjunct treatment for CVLUs in the aging population., Trial Registration: ClinicalTrials.gov, NCT03576989; Registered on 13 June 2018.

Regardless of the amount of literature and evidence on leg ulcer management, there are still significant variations in treatment. Implementing a standardised leg ulcer pathway to ensure patients are appropriately and timely assessed could help reduce nursing time and overall costs, while improving healing outcomes and patients' quality of life. Such a pathway was introduced in Lincolnshire and Leicestershire, UK, to treat venous leg ulcers (VLUs). The results showed improved healing times, reduced costs and fewer nurse visits, among other findings.

Background: Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction, or a combination of these with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It can result in a large financial burden on health systems. There is a wide variety of treatment options or therapies for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) is a relatively cheap option and potentially efficient way to deliver physical therapy for people with CVI., Objectives: To assess the efficacy and safety of balneotherapy for the treatment of people with chronic venous insufficiency (CVI)., Search Methods: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and the Clinical Trials.gov trials register to August 2018. We searched the LILACS and IBECS databases. We also checked references, searched citations and contacted study authors to identify additional studies., Selection Criteria: We included randomised and quasi-randomised controlled trials comparing balneotherapy with no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments., Data Collection and Analysis: Two review authors independently reviewed studies retrieved by the search strategies. Both review authors independently assessed selected studies for complete analysis. We resolved conflicts through discussion. We attempted to contact trial authors for missing data, obtaining additional information. For binary outcomes (leg ulcer incidence and adverse events), we presented the results using odds ratio (OR) with 95% confidence intervals (CI). For continuous outcomes (disease severity, health-related quality of life (HRQoL), pain, oedema, skin pigmentation), we presented the results as a mean difference (MD) with 95% CI., Main Results: We included seven randomised controlled trials with 891 participants (outpatients in secondary care). We found no quasi-randomised controlled trials. Six studies (836 participants) evaluated balneotherapy versus no treatment. One study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis) (55 participants). There was a lack of blinding of participants and investigators, imprecision and inconsistency, which downgraded the certainty of the evidence.For the balneotherapy versus no treatment comparison, there probably was no improvement in favour of balneotherapy in disease severity signs and symptom score as assessed using the Venous Clinical Severity Score (VCSS) (MD -1.66, 95% CI -4.14 to 0.83; 2 studies, 484 participants; moderate-certainty evidence). Balneotherapy probably resulted in a moderate improvement in HRQoL as assessed by the Chronic Venous Insufficiency Questionnaire 2 (CVIQ2) at three months (MD -9.38, 95% CI -18.18 to -0.57; 2 studies, 149 participants; moderate-certainty evidence), nine months (MD -10.46, 95% CI -11.81 to -9.11; 1 study; 55 participants; moderate-certainty evidence), and 12 months (MD -4.99, 95% CI -9.19 to -0.78; 2 studies, 455 participants; moderate-certainty evidence). There was no clear difference in HRQoL between balneotherapy and no treatment at six months (MD -1.64, 95% CI -9.18 to 5.89; 2 studies, 445 participants; moderate-certainty evidence). Balneotherapy probably slightly improved pain compared with no treatment (MD -1.23, 95% CI -1.33 to -1.13; 1 study; 390 participants; moderate-certainty evidence). There was no clear effect related to oedema between the two groups at 24 days (MD 43.28 mL, 95% CI -102.74 to 189.30; 2 studies, 153 participants; very-low certainty evidence). There probably was no improvement in favour of balneotherapy in the incidence of leg ulcers (OR 1.69, 95% CI 0.82 to 3.48; 2 studies, 449 participants; moderate-certainty evidence). There was probably a reduction in incidence of skin pigmentation changes in favour of balneotherapy at 12 months (pigmentation index: MD -3.59, 95% CI -4.02 to -3.16; 1 study; 59 participants; low-certainty evidence). The main complications reported included erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; moderate-certainty evidence), thromboembolic events (OR 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; moderate-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study; 59 participants; low-certainty evidence), with no clear evidence of an increase in reported adverse effects with balneotherapy. There were no serious adverse events reported in any of the studies.For the balneotherapy versus a phlebotonic drug (melilotus officinalis) comparison, we observed no clear difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study; 35 participants; very low-certainty evidence) and oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study; 35 participants; very low-certainty evidence). This single study did not report on the other outcomes of interest., Authors' Conclusions: We identified moderate- to low-certainty evidence that suggests that balneotherapy may result in a moderate improvement in pain, quality of life and skin pigmentation changes and has no clear effect on disease severity signs and symptoms score, adverse effects, leg ulcers and oedema when compared with no treatment. For future studies, measurements of outcomes such as disease severity sign and symptom score, quality of life, pain and oedema and choice of time points during follow-up must be standardised for adequate comparison between trials.

Introduction: Patients with leg ulcers often have severe edema of the lower extremities, which should be treated as part of a successful wound treatment. Today in Germany the necessary compression therapies are often performed with very error-prone and time-consuming short-stretch bandages only. Multicomponent systems, adaptive compression bandages and leg ulcer stocking systems are newer, much less error-prone treatment options. In addition to the often lacking knowledge, the fears of high costs are also mentioned as reasons for the lack of prescription of these systems. It was therefore our aim to investigate the costs of different treatment options, differentiated in the outpatient and inpatient sector., Methods: For the economic calculations, both material and personnel costs were taken into account for different scenarios., Results: Both material and personnel costs were included in the calculation. We were able to demonstrate that the cost for a continuous compression therapy for inpatients accrues between 5.29 Euros to 18.50 Euros per day. For the outpatient setting costs of 2.29 Euros to 34.29 Euros per day were calculated. The different constellations of compression therapy can make sense thus not only for medically but also for economically aspects., Conclusion: As a consequence of this data, both the different systems and the economic factors of compression therapy in patients with leg ulcers should be known to the therapists. These treatment options should then be prescribed and performed according to individual factors, taking into account the needs and abilities of the patients., Competing Interests: Joachim Dissemond hat Honorare für Vorträge, Beratungen oder Unterstützung für Forschung von folgenden Firmen, die Materialien für Kompressionstherapie herstellen erhalten: BSN medical, Paul Hartmann AG, medi, Juzo, Lohmann&Rauscher, medi, Smith&Nephew, Urgo.Kerstin Protz hat Honorare für Beratungen und/oder Vorträge von folgenden Firmen, die Materialien für Kompressionstherapie herstellen, erhalten: 3 M Medica, BSN medical, Paul Hartmann AG, Lohmann&Rauscher, URGO, Smith&Nephew, medi, Bauerfeind, Bösl Medizintechnik.Maurice Moelleken: keine.Knut Kröger hat Honorare für Vorträge, Beratungen oder Unterstützung für Forschung von folgenden Firmen, die Materialien für Kompressionstherapie herstellen, erhalten: Sanofi, UCB, Bayer, Pfizer, daiichi sankyo, medi, Hartmann, Lohmann&Rauscher, Urgo., (© Georg Thieme Verlag KG Stuttgart · New York.)

Chronic ulcers of the lower extremities are one of the most common medical problems encountered in western societies. The prevalence of leg ulcers is estimated to be 0.5-1.0% of the German population and is clearly associated with age. Therefore, in an aging society chronic leg ulcers are an important health issue with respect to increased morbidity and healthcare costs. The most frequent causes of leg ulcers are chronic venous insufficiency, peripheral arterial occlusive disease and diabetes mellitus. Efficient treatment necessitates an exact diagnosis and a close interdisciplinary collaboration. Affected patients often require instructions regarding self-help and support for competent nursing and prophylaxis. Therapeutic strategies, especially in the geriatric setting, aim to maintain the quality of life through preservation of patient mobility and autonomy.

Venous Leg Ulcers (VLU) occur in about 1% of the Western population. A VLU takes 3-12 months to heal, it recurs often, and it has a negative impact on the quality of life. The risk factors for the development of a first VLU are not well-understood and prevention of a first VLU therefore remains underappreciated. The aim of this study was to identify risk factors for developing a first VLU in adults (aged > 18 years) by searching the literature. We searched the Cochrane Library, Pubmed, Cinalh and Narcisto identify studies that investigated risk factors in developing a VLU. The last search was performed in January 2018. Two reviewers independently reviewed the abstracts and full-text articles, and assessed the methodological quality of the included studies. Results of studies using duplex scanning, and comparing participants with and without VLUs were included in the qualitative analysis. Where possible a quantitative meta-analysis was conducted. We found five studies that investigated the relation of several risk factors with VLU development. The methodological differences of the studies made it impossible to perform a quantitative analysis. The risk factors higher age (four studies), higher body mass index (four studies), low physical activity (four studies), arterial hypertension (four studies), deep vein reflux (three studies), deep venous thrombosis (three studies) and family history of VLU (three studies) were significantly associated with a VLU in the majority of the studies. To what extent they influence the development of a VLU remains unclear because of the limited number of studies that investigated the association of these risk factors with VLU development, and the heterogeneity of these studies. Further studies are needed to confirm the association of these risk factors with the development of a VLU and to explore overweight and low physical activity in more detail., (© 2018 European Academy of Dermatology and Venereology.)

We describe the first Italian case of Shewanella algae septicemia in an immunocompetent patient with chronic leg ulcers. The patient had been exposed to seawater before the onset of symptoms. Despite the absence of severe underlying diseases, the primary soft tissue infection of the leg was complicated by hematogenous dissemination.

Introduction: Peripheral arterial disease has an important impact on morbidity/mortality. The objective of this study was to quantify the impact of this disease in Portugal during the last eight years, expressed by the volume of admissions, treatment strategies and associated morbidity and mortality., Material and Methods: We collected data from the Diagnosis Related Group national database on primary diagnosis, procedures codes, demographic variables, a number of risk factors, and mortality of all cases admitted from 2009 to 2016 with a primary diagnosis of peripheral arterial disease coded according to the 9th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-9)., Results: In this study, peripheral arterial disease led to 27 684 hospitalisations, which corresponded to 26.7% of all admissions for vascular disease in this period. Approximately 49.9% of patients were admitted to the emergency department. The volume of procedures in patients with claudication decreased over the eight years, unlike patients with critical ischaemia, in which the number of procedures increased., Discussion: Age and the presence of cardiovascular risk factors have been associated with the severity of disease, as observed in our series. Overall hospital mortality varied, being significantly higher in patients with more advanced severity of the disease., Conclusion: Peripheral arterial disease represents an important burden in the overall volume of admissions in Portuguese public hospitals. A large number of patients was admitted in the context of emergency.

Introduction: Chronic leg ulcers are known as a major and snowballing threat to public health and the global economy. In Africa, there is controversy on the dearth of studies reporting the epidemiology of chronic leg ulcers. The present systematic review and meta-analysis aim at synthesising the prevalence, incidence and aetiologies of this ailment in this continent from contemporary data., Methods and Design: We will include cohort studies, case-control, cross-sectional studies and case series with more than 30 participants. Electronical databases including African Journals Online, MEDLINE, Excerpta Medica Database and Web of knowledge, and grey literature will be searched for relevant abstracts of studies published and unpublished between 1 January, 2000, and 28 February, 2019, without language restriction. The review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Each study included in this review will be assessed for methodological quality. Clinically homogenous studies will be pooled using random-effects meta-analysis. Visual inspection of funnel-plots and the Egger's test will be used to investigate publication bias. Meta-regression and subgroup analyses will be performed to investigate the possible sources of heterogeneity., Ethics and Dissemination: The present study will be based on published data; therefore, ethical approval is not required. Result of the review will be presented at conferences, to relevant health authorities and will be published in a biomedical peer-reviewed journal., Protocol Registration Number: CRD42018108250., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The prevalence of chronic wounds in the Helsinki metropolitan area in 2008 was investigated. Thereafter, a specialised wound care team was founded as part of the City of Helsinki Health Services, aiming for early diagnoses of chronic wounds. In the current study, we have repeated the prevalence study to analyse the changes in the prevalence of chronic wounds. A questionnaire on wound patients was sent to all units of social and health care in the Helsinki metropolitan area. We asked about the number of patients with wounds treated during a 24-hour period, as well the aetiology and location of the wounds. A total of 911 patients had, altogether, 1021 wounds. Thus, prevalence was 0.08%. Pressure and multifactorial ulcers were the most common aetiological groups, whereas wound without defined aetiology had diminished greatly (61%) The prevalence of chronic wound decreased when compared with 2008 (0.08% vs 0.1%). The number of elderly people aged over 65 years had increased 35%, and the age-adjusted prevalence had decreased. Wounds are treated mostly in primary care units and as outpatients. Therefore, the following conclusion may be reached: diagnostic process and implementation of treatment paths are strengthened within primary care units, yet prevalence of wounds has decreased., (© 2019 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The aims of the study were to describe and analyse the temporal trend of the prevalence and incidence of venous leg ulcers (VLU) over the years 2010 to 2014, to determine healing times and temporal trends in the study period, and to evaluate related aspects such as the use of the Ankle-Brachial Pressure Index (ABPI) in a primary care health centre. This was a retrospective study based on a time series (years 2010-2014) of the prevalence and incidence of VLUs in people aged over 40 years in a primary care centre in Barcelona City. We reviewed 3920 electronic health records selecting patients, per year (2010-2014), with VLUs based on the ICD-10 diagnoses. For prevalence, we took into account any patient with an active VLU in the year of study. For incidence, we took into account patients with a new VLU in the year of study. A descriptive analysis was carried out based on each of the collected variables. The variables were examined according to the years of study (time series) by one-factor analysis of variance (anova) or Kruskal-Wallis non-parametric test, as appropriate. A survival analysis by Kaplan-Meier curves and log-rank test was also performed. A total of 139 patients met the VLU criteria. Among them, only 79.2% were classified as having a VLU and had a correct ICD diagnosis. The prevalence and incidence increased over the years, doubling in patients aged over 65 years. Incidence increased from 0.5 new cases per 1000 people/year in 2010 to 1 new case for every 1000 people/year in 2014. Moreover, the prevalence ranged between 0.8 and 2.2 patients with VLU for every 1000 people/year. During the study period, a total of 84.2% of the VLUs healed (117/139 VLU). Regarding average annual time to healing, the trend indicates that lesions took less time to heal (Kruskal-Wallis test, P = 0.004), ranging between 453,9 weeks in 2005 to 19 weeks in 2014. The use of ABPI also evolved and was found to be increasingly performed prior to the appearance of the lesion. The epidemiological profile of people affected by VLUs continues to be, mainly, that of women of an advanced age, over 70 years. The frequency of VLU occurrence rose continually over the years, but healing took less time, and use of ABPI improved. Assigning a reference nurse in the wounds unit and the organisational structure around this problem may have an influence on improving care and the approach to these types of lesions., (© 2018 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Aim: This study aimed to validate the relationships between possible predictive factors and clinically diagnosed infection in adult patients with chronic leg ulcers., Methods: This study used a sample of 636 adult participants whose ulcers were diagnosed as either venous, arterial or mixed aetiology leg ulcers and had no clinical signs of infection at recruitment. Data were extracted from recruitment to 12 weeks from six longitudinal prospective studies from 2004 to 2015. Survival analysis was used to investigate mean time-to-infection, including the Kaplan-Meier method and the Cox proportional-hazards regression model., Results: The sample included 74.7% venous, 19.6% mixed and 5.7% arterial leg ulcers. There were 101 (15.9%) participants diagnosed with infection at least once within 12 weeks of follow-up. Mean time-to-infection was 10.89 weeks (95% CI = 10.66-11.12). After adjustment for potential confounders, a Cox proportional hazards regression model found that depression, using walking aids, calf ankle ratio <1.3, wound area ≥10 cm 2 and ulcers with slough tissue at recruitment were significant risk factors for wound infection., Conclusion: This study has validated the predictive ability of factors which have been found in a cross-sectional study to be significantly associated with infection in patients with leg ulcers, including venous leg ulcers, arterial leg ulcers and mixed aetiology leg ulcers. Results showed that patients with chronic leg ulcers, who either presented with depression, used walking aids, had a calf ankle ratio <1.3, a wound area ≥10 cm 2 or an ulcer with slough tissue, had greater likelihood of developing infection compared to those without these factors., (© 2018 John Wiley & Sons Ltd.)

Background: Nitric oxide (NO) plays a fundamental role in maintaining normal vasomotor tone. Recent clinical and experimental data suggest that NO may play a role in the pathogenesis and therapy of sickle cell disease (SCD). The aim of this study was to determine NO metabolites (NOx) in SCD patients at steady state and in vaso-occlusive crisis (VOC), as well as those with hemolytic clinical sub-phenotype that includes leg ulcers and priapism., Methodology: This was a case-control cross-sectional study conducted on a total of 694 subjects including 148 comparison group HbAA, 208 HbSS SCD patients in steady state, 82 HbSC SCD patients in steady state, 156 HbSS SCD patients in VOC, 34 HbSC SCD patients in VOC, 34 HbSS SCD patients in post VOC, 21 HbSS SCD patients with leg ulcer and 11 HbSS SCD patients with priapism, with age ranging from 15 to 65 years. Laboratory diagnosis of SCD was done at the Sickle Cell Clinic of the Korle-Bu Teaching Hospital. Plasma nitric oxide metabolites were measured using Griess reagent system by ELISA method., Results: Mean NOx of 59.66±0.75 µMol/L in the comparison group was significantly different from those in steady state ( P =0.02). During VOC, there was a significant reduction in mean NOx levels to 6.08±0.81 µMol/L ( P <0.001). Mean NOx levels were however, significantly higher (50.97±1.68 µMol/L) ( P <0.001) in the immediate postcrisis period. The mean NOx levels in the leg ulcer (21.70±1.18 µMol/L) ( P <0.001) and priapism (28.97±1.27 µMol/L) ( P <0.001) patients were significantly low as compared to the SCD patients in the steady state and comparison group., Conclusion: This study presents the first report on plasma NOx levels in SCD complication in Ghanaian SCD patients and confirms reduced plasma NOx levels in SCD patients in general., Competing Interests: Disclosure The authors report no conflicts of interest in this work.