Clinical predictors of leg ulcer healing.

Background Identification of factors associated with healing can help in understanding the causes of delayed healing in chronic leg ulceration, and can allow for programmes to be developed to modify these factors to improve patient outcomes. Objectives To determine factors associated with healing in patients with chronic leg ulceration of all types within a defined patient population. Methods The patients were identified within the combined acute/community leg ulcer service within Wandsworth Primary Care Trust. All identified patients agreed to be interviewed and those who were able underwent clinical and noninvasive testing to determine the cause of the ulceration. Follow ups were to a maximum of 48 weeks, with time to healing given as the principal outcome measure. Analysis was by the Cox proportional hazards model for both univariate and multivariate analysis. Results were expressed as hazard ratio with 95% confidence intervals derived from the models. Results In total, 113 patients took part in this study. Univariate analysis revealed statistically significant differences for delayed healing according to the ulcer duration (P = 0.002), complexity of the ulcer aetiology (P = 0.035), presence of lipodermatosclerosis (P = 0.02), history of deep vein thrombosis (DVT) (P = 0.03) and thrombophlebitis (P = 0.03). Multivariate analysis showed that ulcer duration (P = 0.014), DVT (P = 0.008) and a lack of Pseudomonas on wound swab (P = 0.005) were independently associated with delayed healing. Conclusions The results indicate the complexity of determining risk factors for poor healing in patients with chronic leg ulceration. There appears to be little scope for interventions to improve healing from the factors identified.

Psychological factors in leg ulceration: a case-control study.

BACKGROUND: There is increasing recognition of the role that psychological status plays in the development and outcomes of chronic disease, but little understanding of its importance in chronic leg ulceration. OBJECTIVES: To examine psychological health and perceived social support in patients with chronic leg ulceration. METHODS: Patients with leg ulceration within a defined population were matched for age and gender (1:1) with community controls in a matched case-control study. Analysis was by conditional logistic regression and matched t-test analysis. RESULTS: Ninety-five patients (60 women and 35 men; 59% aged over 75 years) were identified and matched to the same number of controls. Cases had significantly poorer health-related quality of life in all domains of the Nottingham Health Profile (all P < or = 0.001), compared with controls. Levels of depression (Hospital Anxiety and Depression Scale) were significantly greater in the patient group (mean 5.3 vs. 3.6, P < 0.001). Social support (Medical Outcomes Study Social Support Survey scale) showed significantly fewer social networks and less perceived social support in patients than controls (P = 0.008). Patients used significantly fewer coping strategies (COPE scale) than controls, particularly with regard to problem-focused coping strategies. CONCLUSIONS: Patients with leg ulceration experience poor psychological health with a greater risk of depression, less perceived social support and greater social isolation. Systems of care should offer an environment that reduces social isolation and increases support to this patient group.

Sociodemographic factors in chronic leg ulceration.

BACKGROUND: While there is a commonly held belief that leg ulceration is associated with social factors, the evidence to support this is mainly anecdotal. OBJECTIVES: To determine deficits in sociodemographic status in patients with chronic leg ulceration. In a matched case-control study carried out in community leg ulcer clinics and participants' homes within Wandsworth Primary Care Trust, patients with chronic leg ulceration were compared with age- and sex-matched community controls drawn from general practitioner registers. Main outcome measures were the prevalence of social class, ethnicity, marital status, living status and social support. Data were analysed by conditional logistic regression. RESULTS: In all, 113 patients were identified and matched to controls. Patients had a mean age of 75 years (range 31-94), with 72 (64%) being women. The ulcer had been present for a median of 8 months (range 0.8-144), and 29% of patients had an area of ulceration >10 cm(2) (range 0.5-171.5). Being Afro-Caribbean increased the risk of leg ulceration eightfold (95% confidence interval, CI 1.83-34.75; P < 0.001) compared with the white population. There was a gradient with social class, with patients with leg ulcers being more likely to come from social class IV and V (odds ratio, OR 2.82, 95% CI 1.19-6.74; P = 0.015). Never having married (OR 2.98, 95% CI 1.15-7.74; P = 0.025), living in rented housing (P < 0.001) and having a mobility deficit (P < 0.001) more often occurred in the ulcer patients, while living with a spouse was protective (OR 0.46, 95% CI 0.21-0.99; P = 0.048). Patients with ulceration experienced significantly poorer social support than their controls for most subscales of the medical outcomes study social support questionnaire (all P < 0.05). CONCLUSIONS: Chronic leg ulceration is associated with poorer socioeconomic status, and factors which relate to social isolation. At present it is not possible to determine whether these associations are causative or are a consequence of the ulceration.

Assessing community nurses' level of knowledge of lymphoedema.

As part of a major project to develop a primary care trust-based framework of lymphoedema management, the educational needs of community nurses regarding the care of patients with lymphoedema were assessed using focus groups and questionnaires. Community nurses assessed their current knowledge and skill in the care and management of patients with lymphoedema as adequate or poor. They were concerned about their lack of knowledge and skill and were uncertain regarding their role relative to other professions involved in the care of this patient group. At the same time they understood the importance of their role in providing ongoing care, recognizing problems, offering sound advice and referring on to a specialist practitioner when necessary. Any education provision that prepares community nurses for their role within a framework of lymphoedema management should emphasize the important place they occupy in providing long-term care for this patient group.

Prevalence of leg ulceration in a London population.

BACKGROUND: Current prevalence estimates of chronic leg ulceration are frequently based on studies from the 1980s. During the last decade, major changes have occurred in the application of evidence-based practice to this condition. AIM: To determine the prevalence and cause of leg ulceration in a defined geographical population after 8 years of providing standardized evidence based protocols of care. DESIGN: Prospective survey. METHODS: Patients with leg ulceration of >4 weeks duration) within an integrated acute and community leg ulcer service were ascertained, interviewed and clinically assessed, using a standardized questionnaire on medical history, ulcer details and non-invasive vascular investigation to describe causes. Ulcers were classified by aetiology. RESULTS: We identified 113 patients in a population of 252 000, giving a crude prevalence of 0.45/1000 (95%CI 0.37-0.54/1000): 0.34/1000 in men, 0.54/1000 in women. Rates were highly dependent on age, increasing to 8.29 (men) and 8.06/1000 (women) in those aged >85 years. Of the responders, 62/113 (55%) had their ulcer for >1 year. Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs; a further 21 had ulceration primarily due to arterial disease. Complex causes were present in 48 (35%) limbs, mostly venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%). DISCUSSION: Our prevalence of chronic leg ulceration is approximately one-third of that predicted by previous studies using similar methodologies in the 1980s. Patients with ulceration have more complex aetiologies than previously recognized, which may be a consequence of both increasing ulcer chronicity and age.

Lymphoedema: an underestimated health problem.

BACKGROUND: Lymphoedema/chronic oedema is an important cause of morbidity in the population, but little is known of its epidemiology and impact on patients or health services. AIM: To determine the magnitude of the problem of chronic oedema in the community, and the likely impact of oedema on use of health resources, employment and patient's quality of life. DESIGN: Questionnaire-based survey. METHODS: Health professionals from dedicated lymphoedema services, specific out-patient clinics, hospital wards and community services (GP clinics and district nurses) were contacted to provide information on patients from within South West London Community Trust. A subset of the identified patients was interviewed. RESULTS: Within the catchment area, 823 patients had chronic oedema (crude prevalence 1.33/1000). Prevalence increased with age (5.4/1000 in those aged > 65 years), and was higher in women (2.15 vs. 0.47/1000). Only 529 (64%) were receiving treatment, despite two specialist lymphoedema clinics within the catchment area. Of 228 patients interviewed, 78% had oedema lasting > 1 year. Over the previous year, 64/218 (29%) had had an acute infection in the affected area, 17/64 (27%) being admitted for intravenous antibiotics. Mean length of stay for this condition was 12 days, estimated mean cost pound 2300. Oedema caused time off work in > 80%, and affected employment status in 9%. Quality of life was below normal, with 50% experiencing pain or discomfort from their oedema. DISCUSSION: Chronic oedema is a common problem in the community with at least 100 000 patients suffering in the UK alone, a problem poorly recognized by health professionals. Lymphoedema arising for reasons other than cancer treatment is much more prevalent than generally perceived, yet resources for treatment are mainly cancer-based, leading to inequalities of care.

"Heparin-free" cardiopulmonary bypass: first reported use of heparinoid (Org 10172) to provide anticoagulation for cardiopulmonary bypass.

Org 10172 provided adequate anticoagulation for this patient. An excellent correlation between anti-factor Xa activity and ACT was observed at the doses used for CPB. If high-dose Org 10172 is used, these data suggest that it may be possible to circumvent the measurement of anti-factor Xa activity by using the ACT as an index of this heparinoid's anticoagulant effect. Because postoperative bleeding may be excessive, however, development of a method of reversal of Org 10172 is desirable. Although the optimal ACT, dose, plasma concentration, and means of reversal (e.g., protamine vs. heparinase) remains to be determined, heparinoids provide an alternate means of anticoagulation for CPB in patients unable to receive standard heparin.