Tratamientos utilizados en los pacientes hospitalizados por úlceras flebostáticas / Treatments Used in Patients Hospitalized for Phlebostatic Ulcers

Introducción: Las úlceras flebostáticas son de difícil curación, no existe un tratamiento único y efectivo, por lo que hay que combinarlos en un mismo paciente. Objetivo: Identificar los tratamientos utilizados en los pacientes ingresados por úlceras flebostáticas y la relación entre el tiempo de estadía hospitalaria, el tratamiento recibido y el estado de las úlceras al egreso hospitalario. Métodos: Estudio descriptivo ambispectivo en 121 ingresos hospitalario con el diagnóstico de úlceras flebostáticas. Las variables de estudio fueron: tratamientos recibidos, estado de la lesión al egreso y estadía hospitalaria. Se asociaron las variables entre sí utilizando la prueba Ji-cuadrada no paramétrica para variables independientes. Resultados: En los 121 ingresos se realizó tratamiento convencional, el 93,4 por ciento recibió antibióticos; el 60,3 po ciento tratamiento compresivo; y quirúrgico en el 56,2 por ciento, con predominio del injerto libre de piel en 72,1 por ciento de estos tratamientos quirúrgicos. El 42,2 por ciento egresó con la lesión curada (tratamiento quirúrgico). Se encontraron asociaciones directas entre el tratamiento quirúrgico con la estadía hospitalaria (( 2 = 31,22; p= 0,0001), con la cura de la lesión (( 2 = 19,92; p= 0,0100) y con su estado al alta hospitalaria (( 2 = 36,07; p= 0,0001). Conclusiones: El tratamiento más empleado es el quirúrgico y dentro de estos, el autoinjerto dermo-epidérmico es el más utilizado, puesto que presenta los mejores resultados en cuanto a la curación de la lesión pero mayor estadía hospitalaria en los pacientes(AU)

Introduction: Phlebostatic ulcers are difficult to heal; there is no single and effective treatment, so several treatments must be combined in the same patient. Objective: To identify the treatments used in patients admitted for phlebostatic ulcers and the relationship between hospital stay, treatment received, condition of the ulcers at hospital discharge. Methods: Ambispective descriptive study of 121 hospital admissions with the diagnosis of phlebostatic ulcers. The study variables were treatments received, status of the injury at discharge, and hospital stay. The variables were associated with each other, using the non-parametric Chi-square test for independent variables. Results: The 121 admissions received conventional treatment. 93.4 percent received antibiotics; 60.3 percent, compression treatment; and 56.2 percent, surgical treatment, with predominance of free skin grafting in 72.1 percent of these surgical treatments. 42.2 percent was discharged with the lesion healed (by surgical treatment). Direct associations were found between surgical treatment with hospital stay (( 2 = 31.22; p = 0.0001), with the cure of the lesion (( 2 = 19.92; p=0.0100), and with the ulcer state at hospital discharge (( 2 =36.07; p= 0.0001). Conclusions: The most used treatment is the surgical one, specifically the dermo-epidermal autograft, which presented the best outcome regarding the healing of the injury, but a longer hospital stay for the patients(AU)

Chronic venous ulcers: a review on treatment with fibrin sealant and prognostic advances using proteomic strategies

Venous ulcers are the main causes of chronic lower-limb ulcers. The healing difficulties encourage the research and development of new products in order to achieve better therapeutic results. Fibrin sealant is one of these alternatives. Besides being a validated scaffold and drug delivery system, it possesses excellent healing properties. This review covered the last 25 years of the literature and showed that the fibrin sealant is used in various clinical situations to promote the healing of different types of ulcers, especially chronic ones. These are mostly venous in origin and usually does not respond to conventional treatment. Commercially, only the homologous fibrin sealants obtained from human blood are available, which are highly efficient but very expensive. The heterologous fibrin sealant is a non-commercial experimental low-cost product and easily produced due to the abundance of raw material. The phase I/II clinical trial is already completed and showed that the product is safe and promisingly efficacious for the treatment of chronic venous ulcers. In addition, clinical proteomic strategies to assess disease prognosis have been increasingly used. By analyzing liquid samples from the wounds through proteomic strategies, it is possible to predict before treatment which ulcers will evolve favorably and which ones will be difficult to heal. This prognosis is only possible by evaluating the expression of isolated proteins in exudates and analysis using label-free strategies for shotgun. Multicentric clinical trials will be required to evaluate the efficacy of fibrin sealant to treat chronic ulcers, as well as to validate the proteomic strategies to assess prognosis.(AU)

Caracterización de los pacientes hospitalizados por úlceras flebostáticas / Characterization of the patients hospitalized due to phlebostatic ulcers

Introducción: Las úlceras en los miembros inferiores se relacionan desde los tiempos antiguos con las venas varicosas; es aceptado que dichas úlceras son una enfermedad frecuente y un grave problema de salud pública en todo el mundo y que la gran mayoría es el resultado de una insuficiencia venosa crónica. Objetivo: Caracterizar a los a los pacientes hospitalizados por úlceras flebostáticas. Métodos: Se realizó un estudio ambispectivo en 81 pacientes ingresados con el diagnóstico de úlceras flebostáticas. Las variables de estudio fueron: edad, sexo, cantidad de ingresos y estadía hospitalaria. Resultados: Se encontró un predominio del sexo femenino y de los mayores de 60 años en los 121 ingresos realizados. El 72,8 por ciento ingresó una sola vez y el 18,2 por ciento en más de una ocasión. La estadía hospitalaria fue de más de 21 días en el 55,4 por ciento. Conclusiones: Los pacientes hospitalizados con úlceras flebostáticas son predominantemente adultos mayores del sexo femenino, presentan una baja frecuencia de reingresos y una estadía hospitalaria prolongada(AU)

Introduction: The ulcers in the lower limbs are related from the old times with the varicose veins; it is accepted that the same ones are a frequent illness and a serious problem of public health in the world, and the great majority is the result of chronic venous insufficiency. Objective: To characterize the patients hospitalized due to phlebostatic ulcers. Methods: It was carried out an ambispective study in 81 patients admitted with the diagnosis of phlebostatic ulcers. The study variables were: age, sex, quantity of hospital admissions and hospital stay. Results: It was predominant in the 121 of the hospital admission: the female sex and people older than 60 years. 72.8 percent of the patients were admitted one time and 18.2 percent in more than one occasion. The hospital demurrage was of more than 21 days in 55.4 percent of the cases. Conclusions: The patients hospitalized due to phlebostatic ulcers are predominantly female elder people. It was possible to characterize the patients hospitalized with a low frequency of hospital re-admission and hospital demurrage(AU)

Relapsed lymphoma mimicking venous ulcer: A case report

Lymphoma presenting with ulceration is not typical. Wereport a case of relapsed DLBCL in a 73-year-old manpresenting with a chronic non-healing leg ulcer. He hasunderlying varicose veins with recurrent venous ulcers. This patient was diagnosed to have DLBCL six years earlier when he presented with recurrent epistaxis originating from a left nasal cavity nodule. Complete resolution was achieved after eight cycles of R-CHOP and intrathecal methotrexate. For this current problem, this patient was treated with rituximab combined with chemotherapy which resulted in healing of the ulcer.

Úlceras flebostáticas / Phlebostatic ulcers

Las úlceras flebostáticas son las más frecuentes en los miembros inferiores y constituyen una de las complicaciones más graves de la insuficiencia venosa crónica. Se caracterizan por ser invalidantes y tener alta repercusión socioeconómica. El objetivo de este trabajo es revisar los aspectos más relevantes de la epidemiología, la clínica y del tratamiento de las úlceras flebostáticas. Para la exploración bibliográfica se realizaron búsquedas de artículos en las bases de datos informatizadas on-line Medline, Cochrane Library, artículos publicados en páginas web, revistas líderes en la publicación de estudios sobre úlceras flebostáticas, el Consenso Latinoamericano sobre Úlceras Venosas, las Guías Prácticas de la Sociedad de Cirugía Vascular y el Fórum Americano de Flebología. Las úlceras flebostáticas son las más frecuentes de los miembros inferiores, más comunes en el sexo femenino y en mayores de 60 años. Repercuten en la calidad de vida del paciente y los gastos sanitarios. No existe tratamiento único para ellas, por lo que en un paciente se usan varios tratamientos o su combinación. Las evidencias científicas apuntan hacia las terapias compresivas como de primera línea. A pesar de los avances tecnológicos realizados en el tratamiento de estas úlceras, así como la gran variedad de los mismos, donde se complementan los más modernos con los ya existentes, las úlceras flebostáticas son de difícil curación y de alta recurrencia(AU)

The phlebostatic ulcers are the most common in the lower limbs and represent the most serious complications of the chronic venous insufficiency. These ulcers are disabling and have a significant social and economic impact. The objective of this paper was to review the most outstanding aspects of the epidemiology, the clinical manifestations and the treatment of the phlebostatic ulcers. The literature search was made in Medline, Cochrane Library, articles published in different web pages, leading journals in the publication of studies about phlebostatic ulcers, Latin American Consensus on Venous Ulcers, Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. The phlebostatic ulcers are the most frequent in the lower limbs, mainly in females and in patients older than 60 years. They have an impact on the quality of life of patients and on health expenditures. There is not a unique treatment for this type of ulcers, so several therapies or a combination of them is used. The scientific evidences point to the compressive therapies as the first-line method. Despite the technological advances in the treatment of these ulcers, and their great variety, in which the already existing ones and the latest ones complement each other, these ulcers are difficult to be cured and highly recurrent(AU)

Cuidados de enfermagem aos clientes com úlceras venosas uma revisão integrativa da literatura / Cuidados de enfermería para clientes con úlceras venosas una revisión integral de la literatura / Nursing care to clients with venous ulcers an integrative review of the literature

Objective: To describe the nursing care recommended in the literature to customers with venous ulcers. Method: Integrative literature bases VHL, LILACS, MEDLINE and SciELO. There were selected 10 articles, based on the inclusion criteria. Results: The analysis of the items resulted in thematic categories: the importance of nurses in the assessment of the client with venous ulcers and strategies used in the care of clients with venous ulcers. The first deals with the actions of the nurse go beyond the execution of dressing, requiring the evaluation of the client in its entirety in the second treatment strategies. Conclusion: The analysis of the articles showed the concern regarding the evaluation of the client in its entirety. Despite the diversity of technologies presented in the literature, highlights the need to conduct research with significant levels of evidence in order to optimize healing time, relapse prevention, encouragement of self-care and comfort of the client.

Objetivo: Descrever os cuidados de enfermagem recomendados na literatura aos clientes com úlcera venosa. Método: Revisão integrativa da literatura nas bases BVS, LILACS, MEDLINE e SCIELO. Selecionados10 artigos, baseando-se nos critérios de inclusão. Resultados: A análise dos artigos resultou nas categorias temáticas: importância do enfermeiro na avaliação do cliente com úlcera venosa e estratégias utilizadas no cuidado de clientes com úlceras venosas. A primeira aborda que as ações do enfermeiro vão além da realização de curativos, exigindo a avaliação do cliente em sua integralidade; na segunda, as estratégias de tratamento. Conclusão: A análise dos artigos evidenciou a preocupação em relação à avaliação do cliente em sua integralidade. Apesar da diversidade de tecnologias apresentadas na literatura, evidencia se a necessidade realizar pesquisas com níveis de evidência significativos, visando a otimização do tempo de cicatrização, prevenção de recidivas, estímulo ao autocuidado e conforto do cliente.

Objetivo: Describir los cuidados de enfermería se recomienda en la literatura a los clientes con úlceras venosas. Método: Literatura Integrativa, bases BVS, LILACS, MEDLINE y SciELO. Seleccionado 10 artículos, sobre la base de los criterios de inclusión. Resultados: El análisis de los elementos resultó en categorías temáticas: la importancia de las enfermeras en la evaluación del cliente con úlceras venosas y estrategias utilizadas en la atención de clientes con úlceras venosas. La primera trata de la actuación de la enfermera van más allá de la ejecución de vestir, lo que requiere la evaluación del cliente en su totalidad en el segundo estrategias de tratamiento. Conclusión: El análisis de los artículos mostró la preocupación con respecto a la evaluación del cliente en su totalidad. A pesar de la diversidad de las tecnologías presentadas en la literatura, se destaca la necesidad de llevar a cabo la investigación con importantes niveles de pruebas con el fin de optimizar el tiempo de curación, prevención de recaídas, el fomento del autocuidado y la comodidad del cliente.

Análise do atendimento clínico de portadores de úlceras crônicas em membros inferiores / Analysis of the clinical care of patients with chronic ulcers of the lower limbs

Introdução: Úlceras crônicas em membros inferiores podem apresentar diferentes etiologias, sendo as mais frequentes: venosa, arterial, traumática, infecciosa e diabética. O tratamento dessas feridas é dinâmico e depende da evolução da reparação tecidual. Esse tratamento inclui métodos clínicos e cirúrgicos, sendo o curativo o método não cirúrgico mais frequentemente utilizado. Curativos podem ser desde de coberturas inertes até veículos para atuação de princípios ativos no leito da ferida. A principal indicação de ativos está relacionada a efeitos de desbridamento e controle da população bacteriana, possibilitando o preparo desses leitos para resolução cirúrgica ou espontânea. Método: Esse estudo é observacional, longitudinal, retrospectivo, de amostra randomizada no qual pretendemos analisar o atendimento prestado aos portadores de úlceras crônicas em membros inferiores no Ambulatório de Feridas Crônicas da Divisão de Cirurgia Plástica do HCFMUSP entre 2011 e 2013. Resultados: Foram analisados prontuários de indivíduos de ambos os gêneros, idade média 60 anos, portadores de úlceras crônicas em diferentes estágios evolutivos. Foram pesquisadas comorbidades, doença de base, tamanho da lesão, tratamentos utilizados e evolução das feridas. Notouse predomínio das causas vasculares (69,2%) como doenças de base. Todos os pacientes foram primeiramente tratados com curativos contendo princípios ativos, para preparo do leito das feridas. Desses, 84% foram encaminhados para resolução cirúrgica das feridas. Houve fechamento espontâneo em 1,5% dos casos. Os demais pacientes (14,5%) apresentaram piora das lesões com tratamento tópico, necessitando outras formas de preparo desse leito. Conclusão: Agentes tópicos podem ser uma forma ambulatorial/domiciliar efetiva de preparo do leito de úlceras crônicas para resolução cirúrgica.

Introduction: Chronic ulcers of the lower limbs may have different etiologies, with the most frequent being venous, arterial, traumatic, infectious, and diabetic. The treatment of these wounds is dynamic and depends on the evolution of tissue repair. This treatment includes clinical and surgical methods, and dressings are the most frequently used. Dressings can range from inert covers to vehicles for actuation of active substances in the wound bed. The main indication for these substances is related to the effects of debridement and control of the bacterial population, enabling the preparation of wound beds for surgical or spontaneous resolution. Method: This study is an observational, cross-sectional, retrospective study, with random sampling, aimed at assessing the care provided to patients with chronic ulcers of the lower limbs in the Outpatient Clinic for chronic wounds of the Plastic Surgery Division, HCFMUSP, between 2011 and 2013. Results: The clinical charts of 481 patients of both sexes, with a mean age 60 years, were analyzed; all had chronic ulcers in different stages of evolution. Comorbidities, underlying disease, size of the lesion, treatments, and evolution of wounds were evaluated. A predominance of vascular disease (69.2%) was the underlying cause. All patients were initially treated with dressings containing active agents, for preparation of the wound bed. Of these, 84% were referred for surgical management of wounds. There was no spontaneous closure in 1.5% of cases. The remaining patients (14.5%) showed worsening of lesions with topical treatment, and required other forms of preparation of the wound bed. Conclusion: Topical agents may be an effective outpatient/home method to prepare the wound bed of chronic ulcers for surgical management.

Percepção dos idosos sobre o viver com úlcera venosa / Percepción de ancianos sobre el vivir con úlcera venosa / Perception of eldery about living with venous ulcer

Este trabalho teve como objetivo geral analisar a percepção de idosos sobre o viver com úlcera venosa e como objetivos específicos apreender a percepção do idoso sobre o viver com úlcera venosa e caracterizar o idoso que vive com úlcera venosa, através de um estudo exploratório, descritivo, com abordagem qualitativa, realizado na cidade de Jequié-BA, em uma Clínica Escola de Fisioterapia, com oito idosos, de ambos os sexos, acometidos por úlceras venosas. A coleta de informações aconteceu através de um roteiro de entrevista semiestruturado contendo uma parte com dados sócios demográficos para a caracterização dos sujeitos e uma específica relativa ao tema, que foram apreciados através da Análise de Conteúdo Temática proposto por Bardin. Os resultados mostraram que houve predominância de idosas, com idade entre 64 e 80 anos, brancas, casadas, católicas, com até o 5º ano de escolaridade e residentes na zona urbana de Jequié-Bahia. Das entrevistas emergiram três categorias: 1ª) Viver com a úlcera venosa é um sofrimento, apoiada em três subcategorias: A úlcera venosa provoca dor, A úlcera venosa provoca recidiva e A úlcera venosa provoca limitações; 2ª) Viver com a úlcera venosa é conviver com o estigma, sustentada por duas subcategorias: Enfrentar os preconceitos e Vivenciar constrangimentos e, por fim, a terceira categoria: 3ª) Viver com a úlcera venosa demanda fé/resignação/ aceitação, ancorada em três subcategorias: A fé no enfrentamento das adversidades provocadas pela úlcera venosa; A insatisfação com os serviços de saúde, e por fim, Aceitar e resignar-se. O estudo mostrou que os idosos com úlcera venosa a percebem como sofrimento marcado pela dor, pela recidiva da ferida e pelas limitações impostas por ela. Vivenciam o estigma causado pelo preconceito e constrangimento por terem no corpo uma marca que os excluem socialmente. Para enfrentarem o sofrimento, e o estigma apegam-se à fé e à religiosidade acreditando que os serviços de saúde possam melhorar o atendimento às pessoas acometidas por essa enfermidade, que resignados com sua vida procuram sobreviver da melhor forma possível. (AU)

Treatment of venous ulcers with fibrin sealant derived from snake venom

Venous ulcers of the lower limbs complicated by infection or chronicity represent a serious public health problem. The elevated number of those afflicted burdens the health services, interferes in quality of life and causes absenteeism. Although there are 2,500 items on the market, ranging from the simplest dressing up to the most complex types of dressing, treatment remains a challenge. Among the substances used, fibrin sealant is the one that promotes diminution of bacterial colonization and of edema, controls hemorrhaging, alters the pain threshold by protecting the nerve endings, hydrates the wound bed and forms granulation tissue that favors healing. Its disadvantages include higher cost and utilization of human fibrinogen that can transmit infectious diseases. The Center for the Study of Venoms and Venomous Animals (CEVAP) at São Paulo State University (UNESP) developed a new sealant made up of fibrinogen extracted from large animals and from an enzyme obtained from snake venom. The present study, developed in the Health Education Clinic (CEPS) of Sacred Heart University (USC) aimed to evaluate the effect of the new sealant on the healing process of venous ulcers in 24 adult patients, seven of whom were male and 17 female. Two study groups were formed as follows: Group 1 (G1) - control group of 11 patients treated with essential fatty acid (EFA) and Unna's boot, and Group 2 (G2) - 13 patients treated with essential fatty acid (EFA), fibrin sealant and Unna's boot. The follow-up lasted eight weeks and the sealant was applied at only the first and fourth weeks. The results showed that Group 2 presented worse lesion conditions as to healing, but, when comparing the two groups, it was noteworthy that the the sealant was effective in healing venous ulcers...

A Study of Prevalence of Activated Protein C Resistance and Leiden Mutation among Korean Patients with Venous Ulcers / 대한피부과학회지

BACKGROUND: Recently, resistance to activated protein C(APC) is known to be an important risk factor for venous leg ulcers. Leiden mutation in clotting factor V is the most common genetic defect leading to APC resistance in western countries. Until now, the prevalence of APC resistance and Leiden mutation in Korean patients with venous ulcers has been ill defined. OBJECTIVE: We performed this study in order to investigate the prevalence of APC resistance and Leiden mutation in Korean patients with venous ulcers. METHODS: The functional analysis for APC resistance(APC resistance ratio) and genetic study for Leiden mutation were conducted in 40 patients with venous ulcers. RESULTS: 1. Of the 40 patients with venous ulcers, resistance to APC was documented in 11 individuals (27.5%). 2. We could not find factor V Leiden mutation in 40 patients. 3. Patients with APC resistance more frequently represented recurrence of venous ulcers and venous thrombosis than in their non-APC resistant counterparts. CONCLUSION: APC resistance may be one of the thrombophilic defects in relation with venous ulcers in Korea. However, Leiden mutation may be rare in Korean patients with venous ulcers than in Caucasians. These findings suggested that the other genetic or non-genetic factors may be involved in the pathogenesis of APC resistance in Korea.