Leg Ulcer Patients Research Articles

E-survey on venous leg ulcer among Dutch dermatologists

SummaryAim: To get insight into the frequency of venous leg ulceration in the Dutch dermato-logic practice, and into how this profession treats this disease.Design:Material and Methods: An e-survey was conducted. To all Dutch dermatologists and residents dermatology an email was sent with an online link to a questionnaire on venous leg ulcers.Results: The overall response was 30 %. 83.5 % of the doctors usually treat their patients according to the guideline. The dermatologic practice consists on average of 73 patients (range 0-500; SD 93) with leg ulceration, and yearly 54 new leg ulcer patients (range 0-300; SD 50) are seen. 65 % of the patients are women, 80 % is more than 45 years of age and 55 % is older than 65. Of all ulcers, 77 % has a venous aetiology, of which 59 % has a primary cause. Mean time to heal is 74 days (range 4-200; SD 39). Per year, dermatologists admit on average 7 patients (range 0-50; SD 11) because of leg ulceration. Eventually, 47 % of the admitted patients are treated by skin transplantation.Conclusions: This questionnaire gives a good insight in the epidemiology, and the diagnostic and therapeutic regimen for patients with venous leg ulcers in Dutch dermatologic practice.

Investigation of the effect of deprivation on the burden and management of venous leg ulcers: a cohort study using the THIN database.

BackgroundThere has been limited examination of the contribution of socio-economic factors to the development of leg ulcers, despite the social patterning of many underlying risk factors. No previous studies were found that examined social patterns in the quality of treatment received by patients with leg ulcers.MethodsUsing The Health Improvement Network (THIN) database we identified a cohort of over 14000 patients with a diagnosis of venous leg ulceration, prospectively recorded between the years 2001 and 2006, with linked area-level socio-economic information (Townsend deprivation quintile). We assessed socio-economic differences in the incidence and prevalence of leg ulcers using negative binomial regression. Socio-economic differences in two key areas of guideline recommended leg ulcer management, arterial Doppler assessment and compression bandaging, were assessed using multilevel regression.ResultsThe risk of incident venous leg ulceration increased for patients living in areas of higher deprivation, even after adjustment for known risk factors age and gender. Overall reported rates of Doppler assessment and provision of compression therapy were low, with less than sixteen per cent of patients having a database record of receiving these recommended diagnostic and treatment options. Patients diagnosed with incident venous leg ulcers living in the most deprived areas were less likely to receive the recommended Doppler-aided assessment for peripheral vascular disease than patients living in the least deprived areas (odds ratio 0.43, 95% confidence interval 0.24–0.78). Documented provision of compression therapy did not vary with deprivation.ConclusionsA socio-economic gradient in venous leg ulcer disease was observed. The overall rates of people with venous leg ulcers who were documented as receiving guideline recommended care (2001–2006) were low. Reported use of Doppler ultrasound assessment was negatively associated with socio-economic status. These findings suggest that the inequalities experienced by leg ulcer patients may be exacerbated by reduced access to guideline-based management.

Low Circulating Protein C Levels Are Associated with Lower Leg Ulcers in Patients with Diabetes

Activated protein C (APC) promotes angiogenesis and reepithelialisation and accelerates healing of diabetic ulcers. The aim of this study was to determine the relationship between the incidence of lower leg ulcers and plasma levels of APC's precursor, protein C (PC), in diabetic patients. Patients with diabetes who had a lower leg ulcer(s) for >6 months (n = 36) were compared with age-, type of diabetes-, and sex-matched subjects with diabetes but without an ulcer (n = 36, controls). Total PC was assessed using a routine PC colorimetric assay. There was a significantly (P < 0.001) lower level of plasma PC in patients with ulcers (103.3 ± 22.7, mean ± SD) compared with control (127.1 ± 34.0) subjects, when corrected for age and matched for gender and type of diabetes. Ulcer type (neuropathic, ischaemic, or mixed) was not a significant covariate for plasma PC levels (P = 0.35). There was no correlation between PC levels and gender, type of diabetes, HbA1c, or C-reactive protein in either group. In summary, decreased circulating PC levels are associated with, and may predispose to, lower leg ulceration in patients with diabetes.

A new methodology for costing wound care

Increasing pressure on health care budgets highlights the need for clinicians to understand the true costs of wound care, in order to be able to defend services against indiscriminate cost cutting. Our aim was to develop and test a straightforward method of measuring treatment costs, which is feasible in routine practice. The method was tested in a prospective study of leg ulcer patients attending three specialist clinics in the UK. A set of ulcer-related health state descriptors were defined on the basis that they represented distinct and clinically relevant descriptions of wound condition ['healed', 'progressing'; 'static''deteriorating; 'severe' (ulcer with serious complications)]. A standardised data-collection instrument was used to record information for all patients attending the clinic during the study period regarding (i) the health state of the ulcer; (ii) treatment received during the clinic visit and (iii) treatment planned between clinic visits. Information on resource use was used to estimate weekly treatment costs by ulcer state. Information was collected at 827 independent weekly observations from the three study centres. Treatment costs increased markedly with ulcer severity: an ulcer which was 'deteriorating' or 'severe' cost between twice and six times as much per week as an ulcer which was progressing normally towards healing. Higher costs were driven primarily by more frequent clinic visits and by the costs of hospitalisation for ulcers with severe complications. This exercise has demonstrated that the proposed methodology is easy to apply, and produces information which is of value in monitoring healing and in potentially reducing treatment costs.

Chronic leg ulcers in adult patients with rheumatological diseases – a 7‐year retrospective review

Chronic leg ulcers in patients with rheumatological diseases can cause significant morbidity. We performed a retrospective case review to describe the epidemiology, clinical features and outcome of chronic leg ulcers in this group of patients. Twenty-nine patients with underlying rheumatological conditions, such as, rheumatoid arthritis (15 patients), systemic lupus erythematosus (8 patients), overlap syndromes (3 patients), systemic sclerosis (1 patient) and ankylosing spondylitis (1 patient) were included. The ulcers were mostly located around the ankle (55·2%) and calves (37·9%). The predominant aetiology of the ulcers, in decreasing order of frequency, was venous disease, multifactorial, vasculitis or vasculopathy, infective, pyoderma gangrenosum, ischaemic microangiopathy and iatrogenic. Treatment modalities included aggressive wound bed preparation, compression therapy (17 patients), changes in immunosuppressive therapy (15 patients), hyperbaric oxygen therapy (4 patients) and cellular skin grafting (2 patients). Management of chronic leg ulcers in rheumatological patients is challenging and the importance of careful clinicopathological correlation and treatment of the underlying cause cannot be overemphasised.

Changes in the Aetiological Spectrum of Leg Ulcers after a Broad-scale Intervention in a Defined Geographical Population in Sweden

Objective: The study aims to compare the spectrum of leg ulcer aetiology in Skaraborg County in 1988 and 2002, an evaluation of 14 years of targeted leg ulcer intervention. Design: Cross-sectional study within the professional health-care system in Skaraborg County. Materials: In 2002, 621 leg ulcer patients were identified through a cross-sectional population survey. Methods: Half of the registered patients were randomly selected and offered clinical examination. A total of 198 patients with 246 legs underwent examination and were categorised in detail according to aetiology. Data were compared with the initial study in 1988. Results: Venous incompetence was present in 140 (57%) legs and the dominating cause in 94 (38%) of the leg ulcers, 40 (16%) due to deep venous incompetence. Arterial insufficiency was identified in 90 (37%) legs and the dominating aetiological factor in 41 legs (17%), eight (3%) being critical ischaemic ulcers. The relative risk (RR) of developing a leg ulcer in 2002 vs. 1988 was 0.77. The RR of a venous ulcer was reduced by 46%, arterial by 28%, while there was an increase in diabetic ulcers by 29% and multifactorial by 42%. Conclusion: The aetiological spectrum of leg ulcers has changed, most likely due to a new management strategy in the care of leg ulcer patients.

Changes in the Aetiological Spectrum of Leg Ulcers after a Broad-scale Intervention in a Defined Geographical Population in Sweden

ObjectiveThe study aims to compare the spectrum of leg ulcer aetiology in Skaraborg County in 1988 and 2002, an evaluation of 14 years of targeted leg ulcer intervention. DesignCross-sectional study within the professional health-care system in Skaraborg County. MaterialsIn 2002, 621 leg ulcer patients were identified through a cross-sectional population survey. MethodsHalf of the registered patients were randomly selected and offered clinical examination. A total of 198 patients with 246 legs underwent examination and were categorised in detail according to aetiology. Data were compared with the initial study in 1988. ResultsVenous incompetence was present in 140 (57%) legs and the dominating cause in 94 (38%) of the leg ulcers, 40 (16%) due to deep venous incompetence. Arterial insufficiency was identified in 90 (37%) legs and the dominating aetiological factor in 41 legs (17%), eight (3%) being critical ischaemic ulcers. The relative risk (RR) of developing a leg ulcer in 2002 vs. 1988 was 0.77. The RR of a venous ulcer was reduced by 46%, arterial by 28%, while there was an increase in diabetic ulcers by 29% and multifactorial by 42%. ConclusionThe aetiological spectrum of leg ulcers has changed, most likely due to a new management strategy in the care of leg ulcer patients.

Management of leg ulcers in patients with chronic venous insufficiency: the experience of a Dermatology Clinic in Bucharest, Romania

Venous ulcers are the most severe skin manifestation of chronic venous insufficiency. Treatment is complex and it is performed according to the stage of the disease. It includes changes of lifestyle, compressive therapy, phlebotropic medication, topical therapy of the ulcer, antibiotic therapy (topical and systemic), sclerotherapy, and surgical treatment. Patients with venous leg ulcers that attend the Second Dermatology Clinic of Colentina Clinical Hospital, are treated both as inpatients and as outpatients. They benefit from topical treatment and bandaging performed by specialized medical personnel in separate treatment room with strictly monitored conditions of asepsis and antisepsis. A follow-up study of these patients was made from January 1, 2009 to December 31, 2011. The average age of patients was 65.9 years (± 14.2), most of them being in the eight decade of life (31.9%). In almost half of the cases (44.2%), the patients spent more than 1 week in the hospital. Bacteriological investigations from the ulcers were performed in 55.1% of patients and the most frequent infectious agents were found to be Staphylococcus aureus (26.3%) and Enterobacter spp. (17.2%). Treatment of leg ulcer patients proves to be a long and complex one, a systematic and organized approach being needed in order to obtain healing of the wound.

Life-style advice and self-care strategies for venous leg ulcer patients: what is the evidence?

To ascertain the evidence for lifestyle changes and self-care activities encouraged by health professionals to prevent venous leg ulcer recurrence. A literature search was undertaken using online databases: Medline, CINAHL, Psychinfo and Cochrane for relevant literature between 1990 and 2012. A total of 16 papers were identified, with recurrent themes of physical activity, exercise, mobility and leg elevation emerging. The evidence for the efficacy of compression therapy in preventing recurrence is substantial and is not discussed here. There is some evidence that increasing physical activity, improving mobility and foot exercises may be beneficial in preventing ulcer recurrence. The evidence on the benefits of leg elevation on recurrence prevention is unclear and further research is needed.

Use of specialist knowledge and experience to manage patients with mixed aetiology leg ulcers

To discuss the role of the clinical nurse specialist in managing patients with ulceration caused by mixed venous arterial disease. A small scale retrospective audit study of eight mixed aetiology patients drawn from the caseload of leg ulcer patients within a specialist leg ulcer service in Ayrshire, Scotland was conducted by two specialist nurses with over 8 years' experience in specialist leg ulcer management. Patients were individually assessed using Doppler ultrasound and a rigorous set of validated risk factor criteria. Where Doppler ultrasound was considered to be unreliable, due to an inability to detect sounds, or where further diagnostic information was required in order to safely plan care, arterial duplex scanning was carried out by the cardiac department at Ayr Hospital. All patients were treated with a cohesive inelastic compression bandage system and closely observed by the specialist nurse. All eight patients with mixed aetiology leg ulcers were reported to experience complete ulcer healing within 6-30 weeks after first application of the inelastic bandage system. The regimen was well tolerated by all patients and no adverse events were recorded. With accurate assessment and treatment by a specialist team, patients with mixed venous arterial disease were safely and successfully managed where they may have remained unhealed. This was an independent retrospective audit study conducted by two clinical nurse specialists, with educational support by Activa Healthcare to assist in bringing it to print.

Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers

Compression therapy is not common for venous leg ulcer patients in Hong Kong. This randomized controlled trial compared the clinical effectiveness of compression bandaging using four-layer bandaging (4LB) or short-stretch bandaging (SSB) and usual care (moist wound healing dressing without compression). The 24-week study looked at venous leg ulcer patients aged >60 years in a community setting. The primary parameter was time to ulcer healing. Secondary parameters were ulcer area and pain reduction comparing week 0 (start) vs week 24 (end), measuring results per group and between groups. Intention-to-treat analysis involved descriptive statistics, survival analysis, and repeated measures analysis of variance. The log-rank test was used for univariable analysis. All withdrawn patients had a negative outcome score over the whole study duration. Of 321 patients who received randomized treatment, 45 (14%) did not complete the 24-week study period. At 24 weeks, Kaplan-Meier analysis on healing time was statistically significant (P < .001) in favor of the compression groups. The mean (SD) healing time in the SSB group (9.9 [0.77]) was shorter than that of the 4LB group (10.4 [0.80]) and the usual care group (18.3 [0.86]). Pain reduction was significant (P < .001) for the compression-treated groups only. Compression bandaging was more effective than usual care without compression. Both compression systems were safe and feasible for venous ulcer patients in a community setting in Hong Kong.

Split thickness skin grafts for the treatment of non-healing foot and leg ulcers in patients with diabetes: a retrospective review

We retrospectively reviewed 107 diabetic patients who received a split thickness skin graft (STSG) for treatment of a non-healing diabetic foot or leg ulcer to describe healing times based on patient characteristics, comorbidities or complications. The minimum follow-up was 6 months from the time of STSG application. The mean time to healing among all patients was 5.1 weeks (3 to 16 weeks). The mean healing time for patients with complications was 12.0 weeks (10 to 16 weeks) while the mean healing time for those without complications was 4.9 weeks (3 to 10 weeks). Overall complication rate was 2.8%. Patients with a STSG take of less than 95% had a mean healing time of 7.9 weeks compared to 4.8 weeks for those with a STSG take of 100% (p<0.001). The use of autologous STSG for treatment of non-healing diabetic foot and leg wounds is a viable method for soft tissue closure and may present a low complication rate and a satisfactory rate of healing.

Osteonecrosis and Leg Ulceration in Indian Sickle Cell Patients

Sir, Avascular necrosis of bone and cutaneous leg ulcers are the most common manifestation of patients with sickle cell disease (SCD) [1, 2]. The bone areas most frequently affected are cortical bone of the acetabulum, head of the femur, and head of the humerus. Osteonecrosis of the femoral head is common in patients with sickle cell disease. The hip and shoulder abnormalities are also seen in patients. Multifocal osteonecrosis is defined as disease of 3 or more anatomic sites. Patients diagnosed with osteonecrosis of the knee, shoulder and ankle should be evaluated for other joints for osteonecrosis. In patients with sickle cell disease, clinical complications including osteonecrosis can vary in frequency and severity, presumably due to the effects of genes that modify the pathophysiology initiated by the sickle mutation [3]. Baldwin et al. suggested genetic influence of BMP6 and ANXA2 SNPs with osteonecrosis in SCD [3]. The incidence of leg ulcers in patients with SCD ranges from 25.7% to 75% [4, 5]. Leg ulcers are a common sub-phenotype of sickle cell disease. Their cause is unknown, their prevention is impractical and their management, once present, is often difficult. Leg ulceration and avascular necrosis (AVN) in SCD has become serious problem in a few decades in India, however the incidence of leg ulcer and AVN in sickle cell patients has not been studied extensively in India till date. We had 150 sickle cell patients (60 sickle cell anemia, 75 sickle β-thalassemia and 15 sickle hemoglobin D) recruited from out patient department hematology AIIMS, New Delhi, India. Study period was 3 y. Signed consent form taken from all the patient and study was approved by institutional ethical committee. Diagnosis of patients was done by high performance liquid chromatography (Bio-Rad-VariantTMBio Rad, CA, USA). Complete blood count and red cell indices were measured by automated cell analyzer (SYSMEXK-4500, Kobe Japan). Osteonecrosis screening was done by X-ray and confirmation was done by magnetic resonance imaging (MRI) while leg ulceration was reported on physical examination. MRI is the most sensitive means of diagnosing AVN. MRI facilitates better response to treatment because with the use of MRI, avascular necrosis is diagnosed at an earlier stage and therapeutic measures are more successful the earlier they are begun. Out of 150 cases 14 (8 boys and 6 girls with mean age; 11.5±3.4 y) presented with osteonecrosis where seven were from HbSS, 6 from sickle beta thalassemia and one fromHbSD patients. Nine patients presented with femoral head ( 5 HbSS and 4 HbSβ-thal) while 3 hip (2 HbSS and 1HbSD) and 2 (HbSβ-thal)with shoulder osteonecrosis. Seven patients (4 boys and 3 girls with mean age; 12.3±2.6 y) presented with leg ulceration out of 150 SCD patients (5HbSS and 2 HbSβ-thal). None of the patients presented both complications i.e., leg ulceration and AVN together. Observation of the study concludes the increased risk of AVN (9.34%) and leg ulceration (4.67%) in Indian sickle cell patients where alpha thalassemia and high HbF is prevalent in patients.

Interleukin 8 Level, Reticulocyte Counting and aPTT Ratio in Brazilian Sickle Cell Anemia Patients with Leg Ulcers

Abstract 4835 Background:Sickle cell anemia (SCA) is characterized by a chronic inflammatory state in which oxidative stress, particularly in the endothelium, exerts a strong influence on the pathogenesis of vaso-occlusion and may be implicated in patients' clinical heterogeneity and survival. It has been suggested that the cytokine production profile of cells involved in the immune response may vary among patients with SCA. Leg ulcers (LU) represent a severe complication in these patients, and this condition has been associated with specific end-organ damage and an increase in morbidity and mortality. Recent studies have shown that venous obstruction, endothelial dysfunction, coagulopathy and infections are implicated in the complex pathogenesis of LU. Aims:To determine IL-1β, IL-6 and IL-8 plasma levels and gene expression rates as well as hematological and coagulation parameters and correlate these with the history of LU in adult SCA patients followed up at HEMOPE, in the state of Pernambuco, northeastern Brazil. Methods:Peripheral blood samples from 92 patients (median age 27 years; 42 female; 52 male; all Afro-descendants) in the steady state who had been diagnosed with SCA (HbSS), had not received a transfusion and were not using hydroxyurea were analyzed. Plasma levels of cytokines were determined by ELISA, and the gene expression rates by qRT-PCR. The patients' clinical and laboratorial characteristics were obtained from their medical charts. Statistical analysis was performed using the SAS System for Windows version 9.2. Results:Median age was higher in patients with a history of LU than in those without a history (33.1 vs. 28.4; p = 0.04). Although no statistically significant (p = 0.5) differences in IL-8 gene expression rates were observed, IL-8 plasma levels were significantly higher in patients with a history of LU than in patients without a history (23.8 vs. 7.7; p = 0.01) (Figure 1). Thus, patients with high levels of IL-8 had an increased risk for the occurrence of leg ulcers (OR = 1.01; 95% CI = 1.00–1.02). The ROC curve showed that IL-8 levels higher than 8.55 pg/mL could indicate the presence of LU (accuracy = 71.6%; sensitivity = 73.7%; specificity = 68.5%). The laboratory tests revealed reticulocyte counts and activated partial thromboplastin time (aPTT) ratios (R) that were significantly higher in patients with a history of LU than in those without a history (11.8 vs. 8.4, p = 0.01; 1.1 vs. 0.9, p = 0.04, respectively). Both the higher reticulocyte counts and R values were associated with increased risk for the occurrence of leg ulcers in these patients (OR = 1.12, 95% CI = 1.02 – 1.20; OR = 24.28, 95% CI = 1.20 – 486.09, respectively). Conclusion:In this study, patients who had had LU at some time in their lives showed significantly higher IL-8 levels, reticulocyte counts and R values than patients who had never had LU. Our results therefore suggest a relationship between the parameters described above and LU in patients with SCA. These parameters could perhaps be used, in association with different genetic modulators that may contribute to different clinical phenotypes observed in this disease, as markers of this clinical manifestation of SCA or of a propensity to develop it. [Display omitted] Financial Support: CAPES (Brazil)/FAPESP/CNPq/INCTS Disclosures:No relevant conflicts of interest to declare.

Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers

In Hong Kong, at the time of the study, compression treatment was not considered usual care for venous leg ulcer patients. This randomized controlled trial compared quality of life (QOL) aspects in venous leg ulcer patients of over 55-years of age, of short-stretch compression (SSB), four-layer compression bandaging (4LB) and usual care (UC) (moist wound healing dressing, no compression). Study period was 24-weeks, the primary outcome was the patient functional status, disease-specific and generic health-related QOL measures and ulcer healing rates, comparing week 1 vs. week 24 (end) results. Assessments included photogrammetry, Brief Pain Inventory, SF-12 Health Survey, Charing Cross Venous Ulcer Questionnaire and Frenchay Activity Index. Data analysis was performed using, where appropriate; Kaplan Meier and log rank chi-square and the repeated measures analysis of variance test. A total of 321 patients participated in the study, 45 (14%) withdrew for various reasons. Compression bandaging in both groups significantly reduced pain (P < 0.0001) and improved functional status and QOL. Healing rate at 24 weeks for both compression groups was significant (P < 0.001); for SSB this was 72.0% (77/107) vs. 67.3% in the 4LB group (72/107) and 29.0% (31/107) with usual care. The reduction in ulcer area from weeks 12 to 24 was significant only for SSB (P < 0.047). Compression was shown to be feasible for elderly community care patients in Hong Kong and is currently implemented as part of standard venous leg ulcer treatment.

The Lively Legs self-management programme increased physical activity and reduced wound days in leg ulcer patients: Results from a randomized controlled trial

ObjectiveInvestigating the effectiveness of the Lively Legs program for promoting adherence with ambulant compression therapy and physical exercise as well as effects on leg ulcer recurrence. DesignA randomized controlled trial. SettingEleven outpatient clinics for dermatology in the Netherlands participated in the study. Patients184 patients attending the outpatient clinic with leg ulcers based dominantly on a venous aetiology. Randomization was stratified by centre, age, sex and aetiology (purely venous or mixed). InterventionThe intervention group received additionally to usual care, lifestyle counselling according to the Lively Legs program, the control group received care as usual. Patient behaviour on physical activity (IPAQ), adherence to compression therapy and wound status were assessed every 6 months during a follow-up period of 18 months. Data analysis was based on the intention to treat principle, using a generalized linear model with additive link function and Bernouilli distributions. Effects on recurrence were analyzed after the first ulcer had healed using proportional hazard regression. ResultsThe results showed an increase in adherence with compression therapy in both groups, with no significant difference between the groups. The intervention group performed significantly better on conducting leg exercises (p<0.01) and 10min walks at five days a week (p<0.01). There was no difference on reaching 30min of walking on 5 days a week. The intervention group had less wound days (p<0.01), time till recurrence did not differ significantly (p=0.07). ConclusionThe Lively Legs program effectively increased the use of leg exercises and walking behaviour, and decreased wound time, however it did not significantly enhance use of compression stockings. Non significant effects regarding secondary outcomes may relate to the frailty of the sample.

Non-healing leg ulcers in a patient with dystrophic calcification and crest syndrome: a challenging clinical case

The management of non-healing leg ulcers in patients with CREST syndrome and subdermal calcification is rarely reported in medical literature. Only one similar case was found in the literature (1). Dealing with such patients can be a challenge for wound specialists. In this article, we discuss the clinical progress of an interesting case of extensive non-healing leg ulcers in a CREST patient with dystrophic calcification. The combination of systemic physiological deficits and immune compromise, along with the local physical abnormalities associated with the wound pose a complex multifactorial aetiological mix. There is no conclusive data on the optimal management of these wounds in CREST patients. It seems that ablation of the calcific deposits may offer some hope.

Duration of wound fluid secretion from chronic venous leg ulcers is critical for interleukin-1α, interleukin-1β, interleukin-8 levels and fibroblast activation

Wound fluid collected from chronic wounds may be used as a simple gauge of the processes taking place in the tissue. There is lack of information on the optimal conditions for wound fluid procurement. We have studied possible diurnal variations and duration of wound fluid accumulation using retentive hydrophobic foam on the levels of prototypic cytokines [interleukin (IL)-1α, IL-1β], a chemokine (IL-8) and proteinases [matrix metalloproteinase (MMP)-9] in 23 chronic venous leg ulcer patients. Bioactivity of 1 and 24h wound fluids, and serum was also compared. There were no significant temporal changes in the levels of the above-mentioned four proteins, when comparing three consecutive 8-h intervals starting from 0800 that in turn did not differ significantly with the 24-h collection levels. IL-1α, IL-1β and IL-8 levels were higher (p<0.05) in 24h compared with 1h wound fluids, whereas MMP-9 levels were insensitive to the length of collection. The 24h wound fluids did not elicit DNA synthesis in adult human dermal fibroblasts in contrast to the 1h wound fluids (p=0.046) and serum (p=0.036). The polyurethane foam alone had no significant effects on the concentration of the examined analytes. The length of collection is critical when monitoring cytokine/chemokine and bioactivity levels of chronic wound fluid. The removal of accumulating unfavorable factors in chronic wound fluid may be important in wound management.

Quality of Care in Chronic Leg Ulcer in the Community: Introduction of Quality Indicators and a Scoring System

Background: Treatment of chronic wounds is complex, particularly as a standard for the assessment and evaluation of quality of care is missing. Objectives: To develop indicators for quality of care in chronic wounds in general, and to evaluate the quality of care in leg ulcers in Hamburg, Germany, in particular. Methods: Twenty indicators were derived from a national Delphi expert consensus to compute a single index of quality of care. This index was applied in a cross-sectional study involving a large spectrum of care providers and leg ulcer patients in the community. Trained wound experts interviewed and examined the patients, who had to complete standardized questionnaires. Results: On average, 64% of the quality criteria were met in the consecutive sample of 502 patients with chronic leg ulcers of any origin; 75% of the patients were satisfied with their wound care. Predictors of quality of care are presented. Conclusions: This instrument is feasible, valid and ready for comparisons of patient groups, regions and care systems, and for optimization processes in wound care.

Hyperhomocystéinémie et ulcères de jambes : étude prospective de 68 observations

Homocysteine is a sulphur-containing amino acid derived from methionine. Hyperhomocysteinaemia is now recognised as an independent risk factor for occlusive arterial disease and thrombotic venous disease. The aim of this study was to determine the prevalence of hyperhomocysteinemia in patients with leg ulcers. We prospectively investigated hospitalised patients for vascular leg ulcers between March 2008 and June 2009 at two dermatology centres. We collected details of cardiovascular disease and determined nutritional status by means of the MNA score. Fasting blood samples were taken and analyzed for homocysteine, albumin, prealbumin, folic acid, vitamin B12, creatinine and a complete blood count. Sixty-eight patients were enrolled in the study: 48 women and 20 men. Fifty-three percent of patients had venous leg ulcers, 18% had arterial leg ulcers and 20% had leg ulcers of mixed origin. The prevalence of hyperhomocysteinemia was 56%, with no differences according to ulcer type or gender. While the prevalence of hyperhomocysteinemia in our population of leg ulcer patients was high, this descriptive study does not allow us to establish any causal link between hyperhomocysteinemia and leg ulcers. Moreover, since the literature indicates that homocysteine-lowering therapy does not reduce cardiovascular and thromboembolic risk, there appears to be little call for further trials on hyperhomocysteinaemia and leg ulcers.