Arterial leg ulcers]

OBJECTIVE: To report three patients with persistent Müllerian duct syndrome (PMDS) associated with a unilateral testicular tumour. PATIENTS AND METHODS: Three adults with PMDS and an associated testicular malignancy were evaluated using physical examination, imaging, measurement of tumour markers, surgical exploration and chromosome analysis. RESULTS: The position of the uterus and fallopian tubes differed in all patients: one was in the scrotal sac, another in the abdomen and the third in the left inguinal canal. Two of the patients were cousins and their pedigree showed that they were probably in a sex-limited group. Both also had transverse testicular ectopia; fertility was documented in the younger patient. In all cases, the karyotype was proved to be 46, XY. CONCLUSION: We recommend that the diagnosis of PMDS is made radiologically and that the detection of Müllerian inhibiting factor is mandatory. As malignancy does not occur in the retained Müllerian ducts, hysterectomy should not be performed at abdominal exploration, although orchidectomy should be, because orchidopexy offers only limited protection against future malignancy if performed after 2 years of age. It is not necessary to perform testicular biopsy to detect tumour in the scrotal testis in this syndrome, because an impalpable tumour can be localized by ultrasonography.     

A new generation of dressings in the treatment of leg ulcers]

Current methods of topical treatment of leg ulcers are reviewed. Leg ulcers are chronic wounds in a trophically altered tissue that affects the healing capacity. Complete healing requires prolonged and rather expensive treatment and the patient is often disabled during this period. The conventional methods of treatment of leg ulcers, including various compresses, ointments, pastes and other topical drugs, that may possess a considerable sensitizing potential, are to an increasing extent replaced by updated therapy consisting in the use of a new generation of dressings. The latter include a number of materials that have been developed on the basis of recent knowledge of wound healing, such as hydrogels, hydrocolloids, xerogels, hydropolymer dressings, polyurethane foam sheets, alginate dressings, and non-adherent, non-woven cloth impregnated with silver and activated charcoal. The selection of the available materials must depend on the character and stage of the healing process. Each group of dressings exerts specific effects and none of them can recommended generally for the treatment of any types of ulceration. A brief survey of indications is given for each group to avoid their abuse.     

Pain in venous leg ulcers

A prospective study was conducted to assess the prevalence, severity and diagnostic utility of pain in patients with venous leg ulcers. A semi-structured questionnaire was completed by 140 consecutive patients in two specialist centres caring for patients with leg ulcers. A high proportion (64%) of the 94 patients with ulcers of purely venous aetiology reported severe pain; 50% of these patients were taking either mild analgesia or none at all. In 10 of 72 cases, leg elevation made the pain worse. Venous ulcers are painful. Pain in three distinct locations was reported by patients-within ulcers, around ulcers and elsewhere in the leg. The presence of severe pain does not necessarily indicate arterial disease or infection. Pain is, in general, inadequately controlled in these patients.     

Home care for venous leg ulcers

More than a quarter of the adult population in the United States is afflicted with lower extremity venous insufficiency, and 1 in 100 have had, or now have, stasis ulcers. Most of these patients will be treated on an outpatient basis, with many of them requiring home health care. The cost to treat venous ulcers alone has been estimated at $750 million to $1 billion a year. Understanding the pathogenesis and treatment of the problem is imperative as home health care nurses move into an era of cost containment and demographic shift toward an increasingly larger elderly population.     

Diagnosis and general treatment of leg ulcers

We report a case of occupational asthma and rhinitis caused by inhalation of 1,2-benzisothiazolin-3-one, an additive used as a microbicidal in detergent production, in a 26-year-old man employed in a chemical factory producing detergents. The subject's task consisted of pouring raw materials into the recipient of a machine which mixed the substances. Two months after the beginning of this job the patient complained of rhinitis and asthma at the workplace. The specific challenge test with 1,2-benzisothiazolin-3-one, one of the raw materials to which the subject was exposed, provoked an immediate prolonged asthmatic response and nasal symptoms, whereas exposure to other agents (e.g., alpha-amylase, alcalase or bezalkonium chloride) to which the patient was also exposed at work did not. To our knowledge this is the first case of occupational asthma and rhinitis caused by this compound.     

Pinch grafting of leg ulcers in primary care

Treatment of chronic leg ulcers consumes considerable primary care resources. For the patient, it often entails restrictions in everyday life. This study describes the results of 84 skin transplantations on 45 patients with 55 ulcerated limbs, using the pinch graft technique, performed in primary care from 1987-1993. The healing rate after 12 weeks for venous ulcers was 45%, and for neuropathic ulcers 44%. Venous ulcers represented 56% of all the ulcers, while 16% were neuropathic. One year postoperatively, 47% (19/40) of examined ulcers remained healed. The results from our study suggest that venous and neuropathic ulcers may be particularly well suited for skin transplantation, which can easily be performed in primary care.     

Venous leg ulcers. Part 1: Aetiology

Cardiogenic pulmonary edema is a frequent cause of reparatory failure. We investigated the effects of nasal continuous positive airway pressure (CPAP) in patients with severe pulmonary edema associated with acute myocardial infarction. Twenty-nine consecutive patients were divided into 3 groups: firstly, 7 intubated patients who received mechanical ventilation at study entry comprised the intubation group. The rest of the patients were randomly assigned to either of the following 2 groups: 11 patients who received oxygen plus CPAP delivered by a nasal mask (CPAP group), and 11 patients who received oxygen only via face mask (oxygen group). All patients in the intubation group had cardiogenic shock. Two patients (18%) in the CPAP group and 8 patients (73%) in the oxygen group required mechanical ventilation with endotracheal intubation (p=0.03). The hospital mortality rate in the CPAP group (9%) was significantly lower than the oxygen group (64%, p=0.02). The pulmonary artery wedge pressure and heart rate were significantly lower in the CPAP group than in the oxygen group 24 h after study entry (p<0.05 and p<0.01). The mean pulmonary artery pressure 48 h after study entry was 18+/-5 mmHg in the CPAP group and 25+/-8 mmHg in the oxygen group (p<0.05). The PaO2/FiO2 ratio increased in the intubation group (168+/-69 to 240+/-57, p<0.05) and the CPAP group (137+/-17 to 253+/-67, p<0.01) 24 h after study entry. Arterial plasma endothelin-1 concentrations decreased significantly earlier in the CPAP group than in the oxygen group (p<0.05). In patients without cardiogenic shock, nasal CPAP lead to an early improvement in oxygenation and hemodynamics, and decreased the mortality rate. Early and active respiratory management is recommended in patients with pulmonary edema associated with acute myocardial infarction.     

Venous leg ulcers. Part 2: Assessment

The assessment of a patient with a leg ulcer is a complex process. As well as the ability to perform such tasks as Doppler ultrasound and ABPI measurements, nurses must be aware of factors that will delay healing or increase the likelihood of ulcer recurrence.     

Venous leg ulcers: short-stretch bandage compression therapy

Graduated compression therapy is rapidly becoming the treatment of choice for venous leg ulcers; it is cost-effective and offers faster healing rates than without compression. Holistic assessment of the patient along with education of the practitioner leads to the safe application of compression bandages. This article looks at the assessment of venous ulcers and how application of short-stretch bandages can achieve graduated compression, leading to rapid healing. As with any new skill, compression bandaging requires the practitioner to have received research-based education and practice and to have a clear understanding of how the technique achieves the objective.     

Four-layer bandaging and healing rates of venous leg ulcers

This paper reports the healing rates of venous leg ulcers in a community setting (Exeter and District Community Health Services NHS Trust) using the Charing Cross four-layer compression system. We report on 514 venous leg ulcers and show healing rates of 40% at 12 weeks, 50% at 17 weeks, 57% at 24 weeks and 80% predicted at 2 years. Patients were treated in one of 16 community leg ulcer clinics or in their homes. Nurses were allowed to use this system only after full training by the leg ulcer management service. Nurses had to prove their competence in leg ulcer assessment, Doppler measurement and the technique of four-layer compression. Even in patients whose leg ulcers did not heal, it was felt that the four-layer compression system was comfortable, convenient and cost effective with only weekly changes of bandages being necessary.     

New approaches to the treatment of venous leg ulcers

Increased understanding of the pathology of leg ulcers has made the differences in the pathologies of leg ulcers between patients more apparent. This article examines some areas of research that are advancing our understanding of the pathology of venous leg ulcers. The impact that this information is having on the development of new therapies and the implications for nursing practice are discussed.