Objective The importance of wound cytokine function in chronic venous leg ulcers remains poorly understood. This study evaluated the relationship between local and systemic concentrations of wound ...cytokines and wound healing in patients with chronic venous ulceration. Methods This prospective observational study was set in a community- and hospital-based leg ulcer clinic. Consecutive patients with chronic leg ulceration and ankle-brachial pressure index >0.85 were prospectively investigated. All patients were treated with multilayer compression bandaging. Wound fluid and venous blood samples were collected at recruitment and 5 weeks later. In the wound fluid and venous blood, cytokines and factors reflecting the processes of inflammation (interleukin 1β, tumor necrosis factor-α), proteolysis (matrix metalloproteinases-2 and -9), angiogenesis (basic fibroblast growth factor bFGF, vascular endothelial growth factor), and fibrosis (transforming growth factor-β1 TGFβ1 ) were measured. Ulcer healing was assessed using digital planimetry at both assessments. Results The study comprised 80 patients (43 men, 37 women). Median (range) ulcer size reduced from 4.4 (0.1-142.4) cm2 to 2.2 (0-135.5) cm2 after 5 weeks ( P < .001; Wilcoxon signed rank), although 17 of 80 ulcers increased in size. The volume of wound fluid collected strongly correlated with ulcer size (Spearman rank = 0.801, P < .01). Initial wound fluid concentrations of bFGF correlated with ulcer size (Pearson coefficient = 0.641, P < .01), and changes in wound fluid TGFβ1 concentrations inversely correlated with changes in ulcer size (Spearman rank = −0.645, P = .032). There were no significant correlations between changes in other factors and ulcer healing. Wound fluid and serum cytokine concentrations correlated poorly. Conclusion Wound fluid collection volume correlates with ulcer size. Ulcer healing correlated with increased concentrations of TGFβ1 , possibly reflecting increased fibrogenesis in the proliferating wound. Aside from this, there was a large variation in wound and serum cytokine levels that largely limits their usefulness as markers of healing.
Chronic venous leg ulceration can be managed by compression treatment, elevation of the leg, and exercise. The addition of ablative superficial venous surgery to this strategy has not been shown to ...affect ulcer healing, but does reduce ulcer recurrence. We aimed to assess healing and recurrence rates after treatment with compression with or without surgery in people with leg ulceration.
We did venous duplex imaging of ulcerated or recently healed legs in 500 consecutive patients from three centres. We randomly allocated those with isolated superficial venous reflux and mixed superficial and deep reflux either compression treatment alone or in combination with superficial venous surgery. Compression consisted of multilayer compression bandaging every week until healing then class 2 below-knee stockings. Primary endpoints were 24-week healing rates and 12-month recurrence rates. Analysis was by intention to treat.
40 patients were lost to follow-up and were censored. Overall 24-week healing rates were similar in the compression and surgery and compression alone groups (65%vs 65%, hazard 0·84 95% CI 0·77 to 1·24; p=0·85) but 12-month ulcer recurrence rates were significantly reduced in the compression and surgery group (12%vs 28%, hazard −2·76 95% CI −1·78 to −4·27; p<0·0001). Adverse events were minimal and about equal in each group.
Surgical correction of superficial venous reflux reduces 12-month ulcer recurrence. Most patients with chronic venous ulceration will benefit from the addition of simple venous surgery.
The aim of this pilot study was to assess the effect of pre-operative inspiratory muscle training (IMT) on respiratory variables in patients undergoing major abdominal surgery.
Respiratory muscle ...strength (maximum inspiratory MIP and expiratory MEP mouth pressure) and pulmonary functions were measured at least 2 weeks before surgery in 80 patients awaiting major abdominal surgery. Patients were then allocated randomly to one of four groups (Group A, control; Group B, deep breathing exercises; Group C, incentive spirometry; Group D, specific IMT). Patients in groups B, C and D were asked to train twice daily, each session lasting 15 min, for at least 2 weeks up to the day before surgery. Outcome measurements were made immediately pre-operatively and postoperatively.
In groups A, B and C, MIP did not increase from baseline to pre-operative assessments. In group D, MIP increased from 51.5 cmH(2)O (median) pre-training to 68.5 cmH(2)O (median) post-training pre-operatively (P < 0.01). Postoperatively, groups A, B and C showed a fall in MIP from baseline (P < 0.01, P < 0.01) and P = 0.06, respectively). No such significant reduction in postoperative MIP was seen in group D (P = 0.36).
Pre-operative specific IMT improves MIP pre-operatively and preserves it postoperatively. Further studies are required to establish if this is associated with reduced pulmonary complications.
Despite similar disease patterns and treatment, there is great variation in clinical outcome between venous ulcer patients. The aim of this study was to identify independent risk factors for venous ...ulcer healing and recurrence.
Consecutive patients assessed by a specialist nurse-led leg ulcer service between January 1998 and July 2003 with an ABPI>0.85 were included in this study. Independent risk factors for healing and recurrence were identified from routinely assessed variables using a Cox regression proportional hazards model.
A total of 1324 legs in 1186 patients were studied. The 24-week healing rate was 76% and 1 year recurrence rate was 17% (Kaplan–Meier life table analysis). Patient age (
p<0.001, HR per year 0.989, 95% CI 0.984–0.995) and ulcer chronicity (
p=0.019, HR per month 0.996, 95% CI 0.993–0.999) were independent risk factors for delayed ulcer healing. Ulcer healing time (
p<0.001, HR per week 1.016, 95% CI 1.007–1.026) and superficial venous reflux not treated with surgery (
p=0.015, HR 2.218, 95% CI 1.166–4.218) were independent risk factors for ulcer recurrence.
Elderly patients with longstanding ulcers should be targeted for further research and may benefit from adjunctive treatments to improve clinical outcomes. Patients not treated with superficial venous surgery were at increased risk of leg ulcer recurrence.
Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on ...healing.
All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices <0.85 or >1.25, no venous reflux on duplex and <20% of ulcer surface covered with slough. Participants were randomly allocated to either 4-layer compression bandaging alone or 4-layer compression bandaging + larvae. Surface areas of ulcer and slough were assessed on day 4; 4-layer compression bandaging was then continued and ulcer size was measured every 2 weeks for up to 12 weeks.
A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3-21.3) cm(2) and 8.1 (4.3-13.5) cm(2) in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann-Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm(2) in the 4-layer compression bandaging group (P < 0.05) and 4.2 cm(2) (P < 0.001) in the 4-layer compression bandaging + larvae group. Median percentage area reduction of slough was 50% in the 4-layer compression bandaging group and 84% in the 4-layer compression bandaging + larvae group (Mann-Whitney U test, P < 0.05). The 12-week healing rate was 73% and 68% in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Kaplan-Meier analysis, P = 0.664).
Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.
Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are ...decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable. Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients. This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.
Objective To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression. Design Randomised controlled trial.Setting ...Specialist nurse led leg ulcer clinics in three UK vascular centres.Participants 500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux.Interventions Compression alone or compression plus saphenous surgery. Main outcome measures Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time.Results Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test).Conclusion Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time. Trial registration Current Controlled Trials ISRCTN07549334.
New Zealanders are one of the healthiest populations in the world, but significant inequalities in health and oral health remain. New Zealand suffers a possible shortage of medical and dental ...practitioners and an agreed mal-distribution of both. This study examines the distribution of dental and medical practices in New Zealand's largest city Auckland, using modem Geographic Information System tools. The aim of the study is to determine if medical and dental practices are similarly distributed across the city.
The address for each dental and medical practice in Auckland was obtained and mapped over the census population data. A total of 442 medical and 256 dental practices were geo-coded in the study area. These practices overlaid the Auckland region, with a total population of 0.8 million, and an adult population (>9 years old) of 0.69 million. Auckland city was deemed, for this study, to be a region included in a 15km radius circle from a central reference point that was the General Post Office (GPO).
The medical practice to total population ratio ranged from 1:1,500 for people 121/2-15km from the GPO, to 1:1,200 for those within 21/2km. Dental practice to population ratio ranged from 1:2,700 for people living 121/2-15km from the GPO to 1:1,300 for those within 21/2km. Medical practices were relatively evenly distributed, regardless of distance from the GPO, but the fairly dense distribution of dental practices in the city's inner 21/2km circle rapidly decreased in density as distance from the GPO increased.
These results refute the hypothesis of this study in that there is a similar distribution of primary health practices (medical and dental) across the Auckland region.
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