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.     

Trial of two bandaging systems for chronic venous leg ulcers

A four-layer bandaging system developed at Charing Cross Hospital has been found to be effective in healing chronic venous ulcers but is not available on the Drug Tariff. An alternative system was devised from bandages available on the Drug Tariff and a community-based randomised controlled trial was undertaken to compare the two systems. Twenty-nine patients with a total of 35 ulcerated legs were recruited. Equal numbers of ulcerated legs healed using the two compression systems. Nineteen ulcerated legs did not heal, of which six were withdrawn from the trial-two in the trial system and four in the Charing Cross system. Of the 13 remaining ulcerated legs, for which treatment was completed, the mean reduction in ulcer area was 34% with the trial system and 39% with the Charing Cross system. The change in ulcer area was not statistically significant. However, a much larger trial is required in order to demonstrate definitively that the two bandaging systems are equivalent.     

A systematic review of compression treatment for venous leg ulcers

OBJECTIVE: To estimate the clinical and cost effectiveness of compression systems for treating venous leg ulcers. METHODS: Systematic review of research. Search of 19 electronic databases including Medline, CINAHL, and Embase. Relevant journals and conference proceedings were hand searched and experts were consulted. MAIN OUTCOME MEASURES: Rate of healing and proportion of ulcers healed within a time period. STUDY SELECTION: Randomised controlled trials, published or unpublished, with no restriction on date or language, that evaluated compression as a treatment for venous leg ulcers. RESULTS: 24 randomised controlled trials were included in the review. The research evidence was quite weak: many trials had inadequate sample size and generally poor methodology. Compression seems to increase healing rates. Various high compression regimens are more effective than low compression. Few trials have compared the effectiveness of different high compression systems. CONCLUSIONS: Compression systems improve the healing of venous leg ulcers and should be used routinely in uncomplicated venous ulcers. Insufficient reliable evidence exists to indicate which system is the most effective. More good quality randomised controlled trials in association with economic evaluations are needed, to ascertain the most cost effective system for treating venous leg ulcers.     

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.     

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.     

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.     

Nutrition, tissue oxygenation, and healing of venous leg ulcers

Little research has examined the healing and pain associated with saphenous vein (SV) harvest incisions, and no literature has addressed the associated distress and cosmetic result. The purpose of this study was to determine whether dry sterile gauze dressings, transparent film dressings or no dressings were more effective in hospitalized patients undergoing coronary artery bypass graft (CABG), in terms of minimizing leg incisional pain, minimizing the distress of a leg scar and improving the cosmetic appearance of the leg incision scar. Patients were randomized to dressing type on postoperative day (POD) 1, completed a pain and distress visual analogue scale (VAS) on PODs 1, 3 and 5, and a cosmetic result VAS upon discharge. Overall, leg incisional pain decreased over time (p < 0.05). Females reported decreasing pain between PODs 1 and 3, while males reported increasing pain between PODs 1 and 3 (p < 0.05). The film-dressing group reported decreasing pain from PODs 1 to 3, while the no-dressing and gauze-dressing groups reported increasing pain from PODs 1 to 3 (p < 0.05). Pain on POD 5 was positively correlated with an unfavorable cosmetic result (r = 0.42, p < 0.05), and distress on POD 5 was positively correlated with an unfavorable cosmetic result (r = 0.44, p < 0.05). The results of this study are encouraging and support the continued testing of dressings to minimize pain and distress, as well as enhancing cosmetic result.     

Colour duplex ultrasonography in the rational management of chronic venous leg ulcers

Colour duplex ultrasonographic imaging has largely replaced venography in the assessment of lower-limb venous disorders. This is a study of the use of duplex in the management of patients with chronic venous ulceration in community ulcer clinics. Patients with chronic leg ulceration and an ankle: brachial pressure index of 0.85 or greater were studied. Assessment of venous competence in both the deep and superficial systems of the affected and unaffected legs was performed using colour venous duplex imaging. Reflux was defined as reverse flow for greater than 1 s after manual calf compression. One hundred consecutive patients were assessed over 15 months. Of 111 ulcerated legs, 96 had active ulceration, while 15 had been ulcerated within the previous 6 months. Fifty-seven (51 per cent) of the 111 ulcerated legs had superficial incompetence alone (88 per cent long saphenous system or its perforators, 12 per cent short saphenous system). Six legs (5 per cent) had isolated deep venous incompetence. Forty-two legs had mixed superficial and deep venous reflux; 22 of these had undergone previous venous surgery. Colour venous duplex assessment demonstrated superficial venous disease in approximately half of limbs with chronic leg ulceration. Venous dysfunction in these patients is potentially curable by surgery.     

Low-frequency ultrasound treatment of chronic venous leg ulcers in an outpatient therapy

An in vitro dye leakage study was performed to compare the sealing ability of glass ionomer, composite resin and glass ionomer/resin cement when used as restorative materials for G.V. Black class V cavities. In this research, standard Class V cavities were prepared in sound premolar teeth extracted for orthodontic reasons. The cavities were randomly divided into 3 groups. After filling the cavities with glass ionomer cement, composite resin and light curing glass ionomer/resin cement, the specimens were immersed in silver nitrate solution. Marginal microleakage at the interface between the cavity wall and restoration was evaluated. The results were analyzed by using Kruskal-Wallis and Mann Whitney U tests. Result of this in vitro study indicate that composite resin and glass ionomer/resin cement provide a better seal than glass ionomer cement.     

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.     

Wound fluid from venous leg ulcers degrades plasminogen and reduces plasmin generation by keratinocytes

Plasminogen, the pro-enzyme of plasmin, aids various processes essential for normal, acute wound healing, such as fibrinolysis and cell migration. We have investigated if plasminogen is available to perform these functions in chronic wounds such as venous leg ulcers. We report that plasminogen is degraded by fluid from venous leg ulcers to a number of fragments, including kringle domains 1-3, an angiostatin-related protein. The enzyme responsible was inhibited by the serine protease inhibitor phenyl-methylsulfonyl fluoride, but was not inhibited by alpha1-anti-trypsin, an inhibitor of neutrophil elastase, by alpha2-anti-plasmin, an inhibitor of plasmin, or by the matrix metalloprotease inhibitor 1,10 phenanthroline. Plasminogen degraded by wound fluid was a weaker substrate than intact plasminogen for plasmin generation by the keratinocyte cell line HaCaT. These results suggest that serine protease activity in leg ulcer fluid degrades plasminogen and support the hypothesis that keratinocyte migration may be impaired in leg ulcers because of a reduced availability of intact plasminogen for plasmin generation.     

Physiopathology of leg ulcers]

Polymicrobial endocarditis (PE) is uncommon, whether in series of cases of polymicrobial bacteriemia or of endocarditis. Among the 201 cases of infective endocarditis seen between 1986 and 1995 by an infectious diseases service, 12 patients had PE (6%). Nine were males, mean age was 28 years and ten were active intravenous drug users. All of them were HIV (+) and 50% had AIDS. Eleven subjects had infection of the tricuspid valve and 58% developed septic pulmonary emboli. The most common organism encountered was Staphylococcus aureus in 8 patients followed by Streptococcus viridans and S. pneumoniae in three. The most common combinations of organisms were S. aureus and S. pneumoniae in 3 cases and S. aureus and Pseudomonas aeruginosa in two. Two patients died, one with Xantomona maltophilia and another with Candida albicans. The symptoms of PE were usually indistinguishable from endocarditis caused by a single organism and the prognosis depended on the species rather than the number of organisms isolated.     

Planimetric rate of healing in venous ulcers of the leg treated with pressure bandage and hydrocolloid dressing

BACKGROUND: Venous leg ulcers are a common cause of morbidity, but few predictive parameters exist that can be used to follow their progress. OBJECTIVE: We investigated the use of healing rate as a useful parameter in the treatment of venous ulceration. METHODS: Twenty-seven venous ulcers being treated with a standard regimen were evaluated. We calculated the initial (4-week) and overall healing rates using the Gilman method (delta A/p). RESULTS: The average initial healing rate for all ulcers combined, the healed group, and the nonhealing group was 0.069, 0.087, and -0.005 cm/wk, respectively. Similarly, the average overall healing rate for all ulcers combined, the healed group, and the nonhealing group was 0.062, 0.089, and -0.043 cm/wk, respectively. CONCLUSION: The initial healing rate (delta A/p(0-4)) may be an appropriate end point for clinical investigations comparing therapies for the treatment of chronic venous leg ulcers.     

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.