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Venous Ulcer
Venous Ulcer—a normal vein has valves that prevent the backflow of blood. When these valves become incompetent, the backflow of venous blood causes venous congestion. Hemaglobin from the red blood cells escapes and leaks into the extravascular space, causing the brownish discoloration commonly noted.
Venous Ulcers: Pathophysiology and Treatment Options?Part 2
In Kirsner et al? Cultured grafts. Platelet-derived wound healing factor.
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Development of a Content-Validated Venous Ulcer Guideline
Evidence-based practice for venous ulcers may improve healing and reduce costs of care. The Association for the Advancement of Wound Care Government and Regulatory Task Force developed a content-validated venous ulcer guideline based on best available evidence supporting each aspect of venous ulcer care. After compiling all-inclusive lists of elements in venous ulcer algorithms published before August 2002, the Task Force objectively rated and summarized up to five best references from MEDLINE, CINAHL, and EMBASE literature searches covering each aspect of care. Sixteen multidisciplinary wound care professionals and educators used judgment quantification to content validate all steps. A 2004 email survey of AAWC members (N = 1,514) clarified effects of under-reimbursement on evidence-based venous practice. The Venous Ulcer Guideline containing all elements with A-level evidence plus those with a Content Validity Index >0.75 now resides on the AAWC and the Agency for Healthcare Research and Quality National Guideline Clearinghouse websites. However, a review of US healthcare environment components, including reimbursement policies, and the results of the survey identified many barriers to implementation of A-level evidence supported steps (sustained graduated high compression, autolytic debridement, and moist wound environments) in practice. Sufficient evidence supports improved venous ulcer care in the US but inadequate and/or inconsistent reimbursement policies impede quality evidence-based venous ulcer practice, delaying healing and increasing the burden of venous ulcers on society.
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Venous Ulcers: Pathophysiology and Treatment Options?Part 1
Venous ulcers affect approximately 1% of the world?s population, increasing healthcare expenditures and decreasing quality of life. Several hypotheses may help explain their origin. Incompetent veins or valves or impaired muscle function may lead to abnormal calf muscle pump function that can elevate ambulatory venous pressure (venous hypertension). This hypertension subsequently results in local venous dilatation and pooling, concomitantly trapping leukocytes that may release proteolytic enzymes that destroy tissues. Venous pooling also induces interendothelial pore widening and deposition of fibrin and other macromolecules that ?trap? growth factors within them, rendering them unavailable for wound repair. Compression therapy, the mainstay treatment, reduces edema, reverses venous hypertension, and improves calf muscle pump function. Several treatment options can be employed as adjuvants to compression ? eg, systemic therapy with pentoxifylline or aspirin, autologous grafts, tissue-engineered skin, growth factor therapy, and/or vein surgery. The epidemiology, pathophysiology, diagnosis, and management options regarding venous ulcers are reviewed. KEYWORDS: venous ulcer, wound healing, venous insufficiency, compression, leg ulcer
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Use of the PUSH Tool to Measure Venous Ulcer Healing
Currently, no instrument is available to provide an accurate and simple method of monitoring venous ulcer healing in clinical practice. The Pressure Ulcer Scale for Healing (PUSH) tool was developed and validated to monitor the healing of pressure ulcers. During a 2-month study involving 27 venous ulcer patients visiting a chronic wound clinic of a major university, the feasibility of using the PUSH tool to monitor healing was evaluated. The patients were assessed by two Wound Ostomy Continence Nurses using the PUSH tool, where 0 = healed and 17 = worst possible score. The mean score at the initial clinic visit was 12. One month and 2 months later, the mean scores were 9 and 8, respectively. Of the 27 participating patients, 23 had a decrease in their PUSH score over the 2-month period of the study; four of the 23 patients had PUSH scores of zero after 2 months because their venous ulcers had healed. One ulcer did not change and three ulcers worsened and their PUSH scores increased. Based on this study, the PUSH tool appears to be an effective way to monitor healing trends in venous ulcers as well as pressure ulcers. KEYWORDS: PUSH tool, venous ulcers, wound healing, NPUAP, pressure ulcer scale for healing
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Illness Behavior and Social Support in Patients with Chronic Venous Ulcers
Venous ulcers are a chronic and costly condition for providers and payors, as well as for patients, particularly the elderly. To examine the association between chronic venous ulceration, illness behavior, and levels of social support, patients drawn from a separate clinical trial (N = 74) were interviewed using the Illness Behaviour Questionnaire and the Social Support Questionnaire. Results indicate that women had higher hypochondriasis (1.70 versus 1.03, P = 0.19), affective disturbance (2.70 versus 1.42, P = 0.08), and number of supports (Social Support Questionnaire, 2.41 versus 1.81, P = 0.056) than men, although no score achieved a standard level of statistical significance. Patients under 70 years of age had significantly higher hypochondriasis (1.96 versus 1.17, P = 0.021) and irritability (1.38 versus 0.90, P = 0.026) scores than those older than 70 years, although denial was significantly higher in those older than 70 years (3.97 versus 3.46, P = 0.045). The level of satisfaction with social support was significantly higher in those under 70 years of age (5.13 versus 4.97, P = 0.042). These results underscore the psychological and social cost imposed by chronic venous ulceration on older women. They also support previous studies implying a greater psychological burden on younger patients. The association between illness behavior and social support remains unclear, but examining the association between illness behavior and social support among patients with venous ulceration provides an opportunity to increase understanding of the psychological, physical, and social dynamics of this chronic condition.
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Subfascial Endoscopic Perforating Vein Surgery (SEPS) for the Treatment of Venous Ulcers
Lower extremity ulcerations that result from venous hypertension are a significant cause of disability in Western nations. Venous ulcers, highly related to lower extremity venous valvular incompetence and post-thrombotic syndrome, demonstrate a protracted course of healing with a high recurrence rate when managed conservatively. Effective treatment includes correcting the elevated lower extremity venous pressure using non-invasive (compression therapy) or invasive modalities (removal or correction of incompetent venous segments, most commonly the greater saphenous vein). Minimally invasive subfascial endoscopic perforating vein surgery, performed on an outpatient basis, allows ligation of incompetent Cockett perforating veins. Venous ulcer healing rates of 88% and infrequent wound complications have been reported using this technique. Using 5-mm cameras and trocars that are available for other endoscopic surgeries could further improve this technique; creating ports smaller than the traditional 15-mm incisions would subsequently reduce tissue disruption. In addition, the etiology of recurrent ulceration and the failure of the primary ulcer to heal are not completely understood. If these poor outcomes can be further defined, even higher rates of wound healing may be attained using this procedure. Significant efforts have been devoted to elucidating the exact mechanism of skin breakdown from venous hypertension but the pathophysiology of this process is still not understood. Keywords: review, clinical, venous ulcers, minimally invasive surgery. Ostomy/Wound Management 2005;51(9):26?31
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Epidermoid Cancers that Masquerade as Venous Ulcer Disease
Many lesions originally diagnosed as venous ulcers exhibit characteristics that are strikingly similar to skin cancers and might represent sites of primary carcinomas. To ascertain the frequency of malignancy in patients previously diagnosed with venous ulcer disease, a retrospective cohort review of patients evaluated at a Wound Healing Center in Florida was conducted. Charts of all patients with IDC-9 codes for varicose veins with stasis ulcer, varicose veins with ulcer and inflammation, and venous peripheral insufficiency were reviewed. Only charts of patients with one of these diagnoses and documented clinical varicosities, hemosiderosis, brawny edema, and lesions located at the medial or lateral lower leg were included. Sixty (60) patients were identified. Of these, 20 had lesions that were clinically suspicious for epidermoid skin cancers (ie, showing raised borders and chronic scaling). Biopsies confirmed malignancy in 15 of the 60 ulcers (25%). Of these, eight were squamous cell cancers. Given the high rate of malignancies in this cohort of patients, it is postulated that primary epidermoid cancers may mimic venous ulcers in appearance, location, and symptoms; that Marjolin's ulcers are rare despite their propensity to develop in many different types of wounds; and that patients with a history of venous ulcers and prolonged exposure to ultraviolet rays may benefit from lesion biopsies to test for epidermoid cancers.
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Using Horsechestnut Seed Extract in the Treatment of Venous Leg Ulcers: A Cost-Benefit Analysis
Venous leg ulcers affect approximately 0.6% of the western population, consuming millions of healthcare dollars every year. To determine whether an alternative venous ulcer treatment using horsechestnut seed extract ? Aesculus hippocastanum? and conventional therapy involving dressings and compression was more cost-effective than using conventional therapy alone, a 12-week cost-benefit analysis of horsechestnut seed extract therapy was conducted. The study, using data from a 12-week prospective, randomized, placebo-controlled trial conducted in South Australia in 2002?2004, involved 54 patients with venous ulceration who received treatment through a large South Australian district nursing service. Taking into account the cost of horsechestnut seed extract, dressing materials, travel, staff salaries, and infrastructure for each patient, horsechestnut seed extract therapy combined with conventional therapy was found to be more cost-effective than conventional therapy alone with an average savings of AUD $95 in organizational costs and AUD $10 in dressing materials per patient. This study confirms that dressing change frequency has a significant impact on the total cost of wound care and suggests that district nursing service operation efficiency may be enhanced through the use of horsechestnut seed extract as a result of less frequent nursing visits. Further study of this treatment modality is warranted.
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Evaluation of Two Calcium Alginate Dressings in the Management of Venous Ulcers
Calcium alginate dressings facilitate the management of highly exudating wounds such as venous ulcers. To evaluate and compare the performance of two calcium alginate dressings in the management of venous ulcers, a prospective, randomized, controlled clinical study was conducted among 19 outpatients at two wound clinics in California. Ten patients (53%) were treated with Alginate A and nine patients (47%) with Alginate B. Dressings were changed weekly and patients were followed for a maximum of 6 weeks or until the venous ulcer no longer required the use of an alginate dressing. At each dressing change, the wound was assessed and dressing performance evaluated. Absorbency of exudate, patient comfort during wear, ease of removal, adherence to wound bed, dressing residue following initial irrigation, patient comfort during removal, ease of application, and conformability were assessed. Patients using Alginate A experienced significantly less foul odor (P = 0.02) and less denuded skin (P = 0.04) than Alginate B at follow-up wound assessments. With the exception of conformability, Alginate A was rated significantly better than Alginate B (P less than or equal to 0.05) in all dressing performance assessments. No significant healing differences were observed. As the different performance characteristics of various calcium alginate dressings become more obvious in clinical practice, further study is warranted to determine their optimal effectiveness.
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Wound Bed Preparation: Future Approaches
Cellular and Biochemical Abnormalities in Chronic Wounds One of the barriers to healing and proper wound bed preparation consists of the cellular abnormalities within the wound (see Figure 1). Figure 1Schematic representation of wound bed preparation. In the context of wound bed preparation, how senescence of cells, their possible unresponsiveness to growth factors, and impaired healing are related becomes an...
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