Cellulitis in chronic oedema of the lower leg: an international cross-sectional study.

BACKGROUND: Cellulitis and chronic oedema are common conditions with considerable morbidity. The number of studies designed to assess the epidemiology of cellulitis in chronic oedema is scarce. OBJECTIVES: To investigate the prevalence and risk factors of cellulitis in chronic leg oedema, including lymphoedema. METHODS: A cross-sectional study included 40 sites in nine countries during 2014-17. Adults with clinically proven unilateral or bilateral chronic oedema (oedema > 3 months) of the lower leg were included. The main outcome measures were frequency and risk factors for cellulitis within the last 12 months. RESULTS: Out of 7477 patients, 15·78% had cellulitis within the last 12 months, with a lifetime prevalence of 37·47%. The following risk factors for cellulitis were identified by multivariable analysis: wounds [odds ratio (OR) 2·37, 95% confidence interval (CI) 2·03-2·78], morbid obesity (OR 1·51, 95% CI 1·27-1·80), obesity (OR 1·21, 95% CI 1·03-1·41), midline swelling (OR 1·32, 95% CI 1·04-1·66), male sex (OR 1·32, 95% CI 1·15-1·52) and diabetes (OR 1·27, 95% CI 1·08-1·49). Controlled swelling was associated with a reduced risk (OR 0·59, 95% CI 0·51-0·67). In a subgroup analysis, the risk increased with the stage of oedema [International Society of Lymphology, stage II OR 2·04 (95% CI 1·23-3·38) and stage III OR 4·88 (95% CI 2·77-8·56)]. CONCLUSIONS: Cellulitis in chronic leg oedema is a global problem. Several risk factors for cellulitis were identified, of which some are potentially preventable. Our findings suggest that oedema control is one of these. We also identified that advanced stages of oedema, with hard/fibrotic tissue, might be an important clinical indicator to identify patients at particular risk.

The campylobacteriosis conundrum - examining the incidence of infection with Campylobacter sp. in Australia, 1998-2013.

Campylobacter sp. are a globally significant cause of gastroenteritis. Although rates of infection in Australia are among the highest in the industrialized world, studies describing campylobacteriosis incidence in Australia are lacking. Using national disease notification data between 1998 and 2013 we examined Campylobacter infections by gender, age group, season and state and territory. Negative binomial regression was used to estimate incidence rate ratios (IRRs), including trends by age group over time, with post-estimation commands used to obtain adjusted incidence rates. The incidence rate for males was significantly higher than for females [IRR 1·20, 95% confidence interval (CI) 1·18-1·21], while a distinct seasonality was demonstrated with higher rates in both spring (IRR 1·18, 95% CI 1·16-1·20) and summer (IRR 1·17, 95% CI 1·16-1·19). Examination of trends in age-specific incidence over time showed declines in incidence in those aged <40 years combined with contemporaneous increases in older age groups, notably those aged 70-79 years (IRR 1998-2013: 1·75, 95% CI 1·63-1·88). While crude rates continue to be highest in children, our findings suggest the age structure for campylobacteriosis in Australia is changing, carrying significant public health implications for older Australians.

A large outbreak of Campylobacter jejuni infection in a university college caused by chicken liver pâté, Australia, 2013.

In October 2013, public health authorities were notified of a suspected outbreak of gastroenteritis in students and guests following a catered function at a university residential college. A retrospective cohort study was undertaken to examine whether foods served at the function caused illness. A total of 56 cases of gastroenteritis, including seven laboratory-confirmed cases of Campylobacter jejuni infection, were identified in 235 eligible respondents. Univariate analysis showed a significant association with a chicken liver pâté entrée [relative risk (RR) 3·64, 95% confidence interval (CI) 2·03-6·52, P < 0·001], which retained significance after adjustment for confounding via multivariable analysis (adjusted RR 2·80, 95% CI 1·26-6·19, P = 0·01). C. jejuni and C. coli were also isolated in chicken liver pâté recovered from the college's kitchen. Subsequent whole genome multilocus sequence typing (wgMLST) of clinical and food-derived C. jejuni isolates showed three genetically distinct sequence types (STs) comprising ST528, ST535 (both clinically derived) and ST991 (food derived). The study demonstrates the value of utilizing complementary sources of evidence, including genomic data, to support public health investigations. The use of wgMLST highlights the potential for significant C. jejuni diversity in epidemiologically related human and food isolates recovered during outbreaks linked to poultry liver.

Efficacy of two compression systems in the management of VLUs: results of a European RCT.

OBJECTIVE: To evaluate the efficacy, tolerance and acceptability an innovative two-layer system (KTwo; Laboratoires URGO) versus an established four-layer bandage system (Profore; Smith & Nephew) in the local management of venous leg ulcers. METHOD: A non-inferiority European randomised controlled trial, conducted in 37 centres, in three countries (France, U.K. and Germany), on patients presenting with venous leg ulcers (VLUs). Participants were adult, non-immunosuppressed patients who presented with non-infected, non-malignant leg ulcers, predominantly of venous origin (ABPI > 0.8), with a surface area of 2-50 cm2 and duration 1-24 months. Patients were followed-up every 2 weeks for a period of 12 weeks, or until full closure. Visits included a clinical examination, wound area tracings and photographic evidence. The primary endpoint was the percentage of leg ulcers healed after the 12 weeks, with secondary endpoints of relative wound area reduction (RWAR), absolute wound area reduction (AWAR) and the percentage of wounds with RWAR > or = 40%. RESULTS: In total, 187 patients were randomised to either the two-layer bandage (2LB, n=94) or four-layer bandage (4LB; n=93) system. The two groups were comparable,with regard to wound and patient characteristics, at baseline. By week 12, 44% of VLUs in the 2LB group and 39% in the 4LB group had healed (intention-to-treat [ITT] analysis). The per-protocol (PP) analysis showed that complete wound closure was obtained in 48% and 38% of the 2LB and 4LB groups, respectively. A non-inferiority margin within -10% is considered as demonstrating a 95% and 97.5% confidence interval (p = 0.001). The AWAR was 6.6 cm2 in the test and 4.9 cm2 in the control group. The percentage of wounds with a RWAR > OR =40% was 47% and 44% for the 2LB and 4LB systems, respectively. Pain between dressing changes was reported in 27% of the test and 40% of the control group, and the incidence of adverse events was 17% and 25%, respectively. The 2LB compression system was considered to be significantly easier to apply than the 4LB (p = 0.038). CONCLUSION: The 2LB system (KTwo) was not seen to be any less effective than a well-known 4LB system (Profore) in the management of VLUs. Furthermore, the 2LB system was considered to be easier to apply, representing an alternative to the conventional treatment with 4LB currently available. DECLARATION OF INTEREST: This study was sponsored by a grant from Laboratoires URGO, manufacturers of KTwo. S. Bohbot and A. Sauvadet are employees of Laboratoires Urgo. S. Meaume has received monetary compensation as a speaker for Laboratoires Urgo. Data management and statistical analyses were conducted by Vertical (J. C. Kerihuel; Paris, France).

A preliminary randomized controlled study to determine the application frequency of a new lymphoedema bandaging system.

BACKGROUND: Bandaging plays an important role in the treatment of lymphoedema. OBJECTIVE: To investigate efficacy and safety of the 3M™ Coban™ 2 compression system (Coban 2 system) with different application frequencies in comparison to short-stretch bandaging. METHODS: A multicentre, randomized, prospective study was performed with 82 patients suffering from arm or leg lymphoedema stage II or late stage II. Patients were allocated to traditional short-stretch bandaging five times per week or to the Coban 2 system applied two, three or five times per week for 19 days. Limb volume and adverse events were recorded at each study visit. The primary endpoint was percentage volume reduction. RESULTS: The highest lymphoedema volume reduction was achieved with the Coban 2 system applied two times per week. A mean reduction of 18·7% (SD 14·5) in legs and 10·5% (SD 8·3) in arms was achieved. More frequent bandage changes of three and five times per week did not demonstrate additional benefits. Short-stretch bandaging five times per week showed a mean volume reduction of 10·9% (SD 5·2) and 8·2% (SD 3·1) for legs and arms, respectively. Bandage slippage was low for all treatment groups. A relevant change in overall mobility was achieved during the use of the Coban 2 system. The adverse reactions were in agreement with already known side-effects and did not differ remarkably between the treatment groups. CONCLUSION: The 3M™ Coban™ 2 compression system applied twice weekly demonstrated a high rate of volume reduction and a good safety profile. Oedema reduction was still effective with 4 days between bandage change, which allows a constant therapeutic effect in routine practice. This should give the patient a high degree of independence and mobility.

Filifactor alocis interactions with gingival epithelial cells.

An association between the gram-positive anaerobe Filifactor alocis and periodontal disease has recently emerged; however, possible pathogenic mechanisms have not been investigated. In this study we examined the responses of primary cultures of gingival epithelial cells (GECs) to infection with F. alocis. Secretion of the pro-inflammatory cytokines interleukin-1ß, interleukin-6 and tumor necrosis factor-α from GECs was stimulated by F. alocis infection. F. alocis also induced apoptosis in GECs through pathways that involved caspase-3 but not caspase-9. Apoptosis was coincident with inhibition of mitogen-activated protein kinase kinase (MEK) activation. These results show that F. alocis has characteristics in common with established periodontal pathogens and has the potential to contribute to periodontal tissue destruction.

Interaction of oral bacteria with gingival epithelial cell multilayers.

Primary gingival epithelial cells were cultured in multilayers as a model for the study of interactions with oral bacteria associated with health and periodontal disease. Multilayers maintained at an air-liquid interface in low-calcium medium displayed differentiation and cytokeratin properties characteristic of junctional epithelium. Multilayers were infected with fluorescently labeled Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum or Streptococcus gordonii, and bacterial association was determined by confocal microscopy and quantitative image analysis. Porphyromonas gingivalis invaded intracellularly and spread from cell to cell; A. actinomycetemcomitans and F. nucleatum remained extracellular and showed intercellular movement through the multilayer; whereas S. gordonii remained extracellular and predominantly associated with the superficial cell layer. None of the bacterial species disrupted barrier function as measured by transepithelial electrical resistance. P. gingivalis did not elicit secretion of proinflammatory cytokines. However, A. actinomycetemcomitans and S. gordonii induced interleukin-1ß (IL-1ß), tumor necrosis factor-α (TNF-α), IL-6 and IL-8 secretion; and F. nucleatum stimulated production of IL-1ß and TNF-α. Aggregatibacter actinomycetemcomitans, F. nucleatum and S. gordonii, but not P. gingivalis, increased levels of apoptosis after 24 h infection. The results indicate that the organisms with pathogenic potential were able to traverse the epithelium, whereas the commensal bacteria did not. In addition, distinct host responses characterized the interaction between the junctional epithelium and oral bacteria.

The experience of patients with complex wounds and the use of NPWT in a home-care setting.

OBJECTIVE: To explore the experience of patients living with complex wounds and the impact of undergoing negative pressure wound therapy (NPWT) as part of their treatment. METHOD: Qualitative data were collected from eight patients, using semi-structured interviews. A purposive, stratified sampling approach was used to identify participants with a range of wound types, as well as age and gender. Participants were recruited from one primary care trust and were interviewed, following 10 days of treatment with NPWT. The matrix-based 'Framework' approach, from the National Centre for Social Research, was used to structure the analysis. RESULTS: Of the eight participants recruited, five were female and three male, with an age range of 46-77 years. Five overarching categories, with their constituent themes, were identified from the data. The first, developing a wound through crisis, has three themes: a failing body, missed diagnosis and failed professional intervention. The second category, decreased control, has four related themes: poor communication; failed wound healing; poor discharge planning and failure to recover. The third category, increased control, has four themes: understanding what is happening; symptom control; positive professional relationships and returning to health. The fourth category, using NPWT, has two themes: information and understanding of NPWT and expectations and experience of NPWT. The final category sets out participant recommendations about the device and has two themes: device issues and improving professional practice. CONCLUSION: This study investigated the experience of patients undergoing NPWT for complex wounds in the home setting and reveals a number of the psychosocial effects of using this therapy in this environment. Participants saw NPWT as an active intervention, associated with improved wound healing and symptom control. The participant experience described in this study, and the recommendations they make, provide a valuable resource to inform service improvement programmes and wound research. DECLARATION OF INTEREST: This study was supported by a research grant from Smith & Nephew Ltd.

Clinical trials needed to evaluate compression therapy in breast cancer related lymphedema (BCRL). Proposals from an expert group.

AIM: A mainstay of lymphedema management involves the use of compression therapy. Compression therapy application is variable at different levels of disease severity. Evidence is scant to direct clinicians in best practice regarding compression therapy use. Further, compression clinical trials are fragmented and poorly extrapolable to the greater population. An ideal construct for conducting clinical trials in regards to compression therapy will promote parallel global initiatives based on a standard research agenda. The purpose of this article is to review current evidence in practice regarding compression therapy for BCRL management and based on this evidence, offer an expert consensus recommendation for a research agenda and prescriptive trials. Recommendations herein focus solely on compression interventions. METHODS: This document represents the proceedings of a session organized by the International Compression Club (ICC) in June 2009 in Ponzano (Veneto, Italy). The purpose of the meeting was to enable a group of experts to discuss the existing evidence for compression treatment in breast cancer related lymphedema (BCRL) concentrating on areas where randomized controlled trials (RCTs) are lacking. RESULTS: The current body of research suggests efficacy of compression interventions in the treatment and management of lymphedema. However, studies to date have failed to adequately address various forms of compression therapy and their optimal application in BCRL. We offer recommendations for standardized compression research trials for prophylaxis of arm lymphedema and for the management of chronic BCRL. Suggestions are also made regarding; inclusion and exclusion criteria, measurement methodology and additional variables of interest for researchers to capture. CONCLUSION: This document should inform future research trials in compression therapy and serve as a guide to clinical researchers, industry researchers and lymphologists regarding the strengths, weaknesses and shortcomings of the current literature. By providing this construct for research trials, the authors aim to support evidence-based therapy interventions, promote a cohesive, standardized and informative body of literature to enhance clinical outcomes, improve the quality of future research trials, inform industry innovation and guide policy related to BCRL.

The burden of infectious gastroenteritis in elderly residents and staff of long-term care facilities, Australia.

We estimated the incidence of gastroenteritis in 16 Australian long-term care facilities. During 12 months' surveillance, 245 (96%) of 254 episodes of gastroenteritis among long-term care residents were associated with 17 outbreaks in 11 facilities. Incidence in long-term care residents was 0.64 episodes per 1,000 bed-days (95% confidence interval, 0.29-1.42).

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.

Surveillance for outbreaks of influenza-like illness in the institutionalized elderly.

Respiratory outbreaks are common in aged-care facilities (ACFs), are both underreported and frequently identified late, and are often associated with considerable burden of illness and death. There is emerging evidence that active surveillance coupled with early and systematic intervention can reduce this burden. Active surveillance for influenza-like illness and rapid diagnosis of influenza were established in 16 ACFs in Sydney, Australia, prior to the winter of 2006. A point-of-care influenza test and laboratory direct immunofluorescence tests for common respiratory viruses were used for diagnosis. We achieved early identification of seven respiratory disease outbreaks, two of which were caused by influenza. For the influenza outbreaks, antiviral treatment and prophylaxis were initiated 4-6 days from symptom onset in the primary case. A simple active surveillance system for influenza was successfully implemented and resulted in early detection of influenza and other respiratory disease outbreaks. This enabled earlier implementation of prevention and control measures and increased the potential effectiveness of anti-influenza chemoprophylaxis.

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.

Leg ulceration in Portugal: prevalence and clinical history.

OBJECTIVE: To determine the prevalence and clinical history of leg ulceration in Portugal. DESIGN: Case identification of patients through health professionals providing care for patients with leg ulceration. SETTING: Clinical areas in hospital, community centres and patients' homes. PARTICIPANTS: Patients registered with five health centres within Lisbon suffering from ulceration of the leg receiving care from hospital and community staff. METHODS: Patients identified by health care professionals working in one area of Lisbon were asked to complete a simple proforma on each patient with leg ulceration. Patients were followed up prospectively to determine healing rates during this baseline period of evaluation. RESULTS: In total 263 patients were identified in a population of 186,000 (total prevalence 1.41 (95%CI 1.25-1.59) per 1000 population). The prevalence was similar between men and women (1.3 and 1.46 per 1000, respectively). As expected this was highly age dependent being most common in the patients aged over 80 years (6.5 and 4.9 per 1000, respectively). Median duration of ulceration was 18 months, with 158/240 (66%) present for longer than 1 year, and 40 (17%) for longer than 5 years. The cause of ulceration was unknown to the health professional treating the patient in 86 (33%) patients. Diagnosis of aetiology was usually on the basis of clinical examination alone (145, 56%), with 21 (8%) having undergone ankle to brachial pressure index (ABPI) measurements and a further eight undergoing either echo-Doppler or arteriography. Most care was provided by community services, with 145 (55%) treated in health centres and 77 (29%) treated in the patient's home. CONCLUSIONS: The prevalence of chronic leg ulceration is similar to other reported studies in western Europe, and indicates that approximately 14,000 patients suffer from leg ulceration at any one time in Portugal. Leg ulceration causes a considerable burden on both hospital and community services.

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.

Implementation of a leg ulcer strategy.

BACKGROUND: The care of patients with leg ulceration has developed over the past 15 years, although there is little information available to determine how these changes have affected clinical and patient defined outcomes. OBJECTIVES: To describe and evaluate the implementation of a leg ulcer strategy. PATIENTS/METHODS: This study used a pre- and postimplementation evaluation within population-based services within the boundaries of community services providing leg ulcer care. Evidence-based leg ulcer services were developed, including standardized assessment using Doppler ultrasound, rationalization of treatment using multilayer elastic high compression, development of referral criteria and acute service support. Complete ulcer healing rates, health-related quality of life and use of health resources were evaluated after 12 weeks in both pre- and postimplementation cycles. RESULTS: A total of 955 patients were evaluated (518 preimplementation, 437 postimplementation). The levels of assessment and treatment were poor prior to the change in practice with just one patient having evidence of correct assessment and 49 (11%) receiving high compression therapy. Postimplementation, this improved to 412 of 437 (94%) having evidence of measurement of the ankle brachial pressure index, and 85% receiving compression. Twelve-week healing rates preimplementation ranged between 9% and 24%, and postimplementation rose from 19% to 39%. Combined overall healing rates improved from 71 of 518 (14%) to 160 of 437 (37%), odds ratio =3.53, P < 0.001. Frequency of treatment visits reduced from a mean (SD) of 24.0 (16.1) over 12 weeks to 13.5 (8.6), P < 0.001. Intervention led to major improvements in health-related quality of life (measured using the Nottingham Health Profile), with significant improvements for energy, pain, sleep and mobility (P < 0.01). CONCLUSIONS: Rationalization of leg ulcer services through a total service change results in improvements in professional practice, better patient outcomes, and efficient use of current resources. This study highlights the importance of a multifaceted approach to improve practice focused on the needs of individual organizational settings.

Perspectives on concordance in leg ulcer management.

Non-concordance is all too often blamed on the patient. In reality it is more likely to reflect the relationship between the patient and practitioner. The second article in this series on leg ulceration explores issues surrounding concordance.

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.