Charles McCollum

Management of venous leg ulcers.

Leg ulcers are a big problem for both patients and health service resources.1–3 Most ulcers are associated with venous disease, but other causes or contributing factors include immobility, obesity, trauma, arterial disease, vasculitis, diabetes, and neoplasia (box 1). In the United Kingdom, venous leg ulceration alone has been estimated to cost the NHS £400m (

Community leg ulcer clinics : a comparative study in two health authorities

720m; €600m) a year.1–3 Much of this cost is accounted for by community nursing services; district nurses spend up to half of their time caring for patients with ulcers.1 4 Most venous leg ulcers could be healed if patients were admitted to hospital for continuous leg elevation. Shortage of hospital beds, the high cost of inpatient care, and the need to maintain independence in this elderly population of patients mean that this once popular approach is now rarely practical.2 Furthermore, ulcers often recur when the patient returns home and resumes a lifestyle in which most of the day is spent with the legs in dependency.w1 Outpatient systems of care that maintain mobility and avoid the complications of bed rest are more cost effective and appropriate. Outpatient and community based care also maintain independence and quality of life. Care for patients with leg ulcers has improved in the past two decades as research based approaches have been adopted. Community leg ulcer clinics using compression bandaging have dramatically improved healing rates and reduced costs, but close supervision by leg ulcer nurse specialists is essential if standards are to be maintained.1 2 5 We have reviewed the evidence for this approach and on new treatments that may improve care of leg ulcers in the future. We compiled material for this review from published literature located by online searches of Medline, PubMed, and Embase using the terms “leg ulcer management,” …

Influence of smoking and plasma factors on patency of femoropopliteal vein grafts.

Abstract Objective: To compare the outcome and cost of care for leg ulcers in community leg ulcer clinics in Stockport District Health Authority with Trafford District Health Authority as a control. Design: Detailed cost and efficacy studies conducted prospectively over a three month period in both districts both before and one year after the introduction of five leg ulcer clinics in Stockport. Setting: Two large district health authorities of broad socioeconomic mix and total population of 540 000. Patients: All patients receiving treatment for an active leg ulcer, irrespective of the profession or location of their carer. Main outcome measures: The proportion of ulcerated limbs completely healed within three months and total cost of leg ulcer care. Results: The introduction of community clinics in Stockport improved healing of leg ulcers from 66/252 (26%) in 1993 to 99/233 (42%) in 1994 (P<0.001) compared with in Trafford, where 47/203 (23%) healed in 1993 and only 43/213 (20%) in 1994. This improved result in Stockport was achieved while the annual expenditure on care of leg ulcers was reduced from £409 991 to only £253 371. In the same year the cost of leg ulcer care in Trafford increased from £556 039 to £673 318. Conclusion: In the first year after the introduction of community clinics, before most patients in Stockport had access to these clinics, healing of leg ulcers was already improved whereas costs were reduced. Key messages The introduction of community leg ulcer clinics improved care and resulted in lower costs than the traditional approach that the clinics replaced Planned and coordinated programmes of care can reduce costs substantially while improving healing rates Community units and general practitioners should be encouraged to seek alternatives to the standard care for leg ulcers

Antiplatelet drugs in femoropopliteal vein bypasses: A multicenter trial

OBJECTIVE--To determine the effects of smoking, plasma lipids, lipoproteins, apolipoproteins, and fibrinogen on the patency of saphenous vein femoropopliteal bypass grafts at one year. DESIGN--Prospective study of patients with saphenous vein femoropopliteal bypass grafts entered into a multicentre trial. SETTING--Surgical wards, outpatient clinics, and home visits coordinated by two tertiary referral centres in London and Birmingham. PATIENTS--157 Patients (mean age 66.6 (SD 8.2) years), 113 with patent grafts and 44 with occluded grafts one year after bypass. MAIN OUTCOME MEASURE--Cumulative percentage patency at one year. RESULTS--Markers for smoking (blood carboxyhaemoglobin concentration (p less than 0.05) and plasma thiocyanate concentration (p less than 0.01) and plasma concentrations of fibrinogen (p less than 0.001) and apolipoproteins AI (p less than 0.04) and (a) (p less than 0.05) were significantly higher in patients with occluded grafts. Serum cholesterol concentrations were significantly higher in patients with grafts that remained patent one year after bypass (p less than 0.005). Analysis of the smoking markers indicated that a quarter of patients (40) were untruthful in their claims to have stopped smoking. Based on smoking markers, patency of grafts in smokers was significantly lower at one year by life table analysis than in non-smokers (63% v 84%, p less than 0.02). Patency was significantly higher by life table analysis in patients with a plasma fibrinogen concentration below the median than in those with a concentration above (90% v 57%, p less than 0.0002). Surprisingly, increased plasma low density lipoprotein cholesterol concentration was significantly associated with improved patency at one year (85%) at values above the median compared with patency (only 68%) at values in the lower half of the range (p less than 0.02). CONCLUSIONS--Plasma fibrinogen concentration was the most important variable predicting graft occlusion, followed by smoking markers. A more forceful approach is needed to stop patients smoking; therapeutic measures to improve patency of vein grafts should focus on decreasing plasma fibrinogen concentration rather than serum cholesterol concentration.

Cerebral emboli as a potential cause of Alzheimer's disease and vascular dementia: Case-control study

To evaluate the influence of antiplatelet drugs on patency in femoropopliteal vein bypasses, 48 vascular surgeons recruited 549 patients to a randomized double-blind trial of aspirin (300 mg) + dipyridamole (150 mg) or placebo twice daily starting 2 days before surgery and continuing indefinitely. Graft occlusion measured objectively by independent coordinators and cardiovascular events (myocardial infarction or stroke) were studied, expressed by life table, and analyzed statistically by log rank and confidence intervals (95% CI). Randomization achieved comparable groups with 60% of grafts inserted for rest pain or gangrene. Operative complications on aspirin plus dipyridamole included 18 reoperations for bleeding and 12 hematomas compared with 9 and 14, respectively, on placebo (NS). Most of the 172 graft failures occurred early with failure rates of 43/1000 patient-months in the first 3 months, reducing to 17/1000 at 6 to 12 months, and under 10/1000 in subsequent years. Cumulative graft patency on placebo was 72%, 62%, and 60% at 1, 2, and 3 years, respectively, compared with 78%, 70%, and 61% on aspirin plus dipyridamole. The difference in patency of 6.1% (95% CI, -3% to 15.5%) at 1 year and 8.0% (95% CI, -5% to 21%) at 2 years failed to achieve significance (p = 0.43). On mean follow-up of 34 months, 53 (132/1000 patient-years) cardiovascular events (myocardial infarction or cerebrovascular accident) occurred in patients on placebo compared with only 35 (73/1000) on aspirin plus dipyridamole, a significant difference of 59/1000 (p = 0.004). Antiplatelet therapy had little influence on femoropopliteal vein patency, but subsequent myocardial infarction and stroke was reduced in these patients with peripheral vascular disease.

The influence of acute smoking on leucocytes, platelets and the endothelium

Abstract Objective To compare the occurrence of spontaneous cerebral emboli and venous to arterial circulation shunts in patients with Alzheimers disease or vascular dementia and controls without dementia. Design Cross sectional case-control study. Setting Secondary care old age psychiatry services, Manchester. Participants 170 patients with dementia (85 with Alzheimers disease, 85 with vascular dementia) and 150 age and sex matched controls. Patients on anticoagulant treatment, patients with severe dementia, and controls with marked cognitive impairment were excluded. Main outcome measures Frequencies of detection of spontaneous cerebral emboli during one hour monitoring of the middle cerebral arteries with transcranial Doppler and venous to arterial circulation shunts by a transcranial Doppler technique using intravenous microbubbles as an ultrasound contrast. Results Spontaneous cerebral emboli were detected in 32 (40%) of patients with Alzheimers disease and 31 (37%) of those with vascular dementia compared with just 12 each (15% and 14%) of their controls, giving significant odds ratios adjusted for vascular risk factors of 2.70 (95% confidence interval 1.18 to 6.21) for Alzheimers disease and 5.36 (1.24 to 23.18) for vascular dementia. These spontaneous cerebral emboli were not caused by carotid disease, which was equally frequent in dementia patients and their controls. A venous to arterial circulation shunt indicative of patent foramen ovale was found in 27 (32%) Alzheimers disease patients and 25 (29%) vascular dementia patients compared with 19 (22%) and 17 (20%) controls, giving non-significant odds ratios of 1.57 (0.80 to 3.07) and 1.67 (0.81 to 3.41). Conclusion Spontaneous cerebral emboli were significantly associated with both Alzheimers disease and vascular dementia. They may represent a potentially preventable or treatable cause of dementia.

Prognostic value of increased soluble thrombomodulin and increased soluble E-selectin in ischaemic heart disease

Cigarette smoking is a risk factor for the development of atherosclerosis. Possible mechanisms for this include leucocytes and platelet activation, and/or damage to the endothelium, any of which may contribute to changes in thrombosis and haemostasis. We examined the acute effects of smoking on these systems by obtaining blood before, immediately after, and at 10 and 30 min after the rapid smoking of two cigarettes in sequence by 20 smokers. Blood samples taken at the same time points from ten non-smokers acted as control material. In the smokers there was a transient rise in leucocyte count and neutrophil activation, but von Willebrand factor (VWF--marking endothelial damage) increased steadily at each time point (P <0.05). There were no changes in neutrophil elastase, soluble intercellular adhesion molecule-1 (sICAM-1 normally increased in smokers), fibrinogen, platelet count or soluble P-selectin (marking platelet activation, also normally increased in smokers). We conclude that the acute smoking of two cigarettes in succession will activate leucocytes and cause endothelial cell damage, but will not immediately influence platelet activity.

Autologous versus allogeneic transfusion in aortic surgery: a multicenter randomized clinical trial.

Abstract: Endothelial cell dysfunction is likely to be important in the pathophysiology of ischaemic heart disease and increased levels of endothelial cell markers soluble E‐selectin and soluble thrombomodulin may reflect this damage. To determine whether increased levels of these markers were predictive of disease progression, we obtained plasma from 54 patients who had survived a myocardial infarction. Soluble E‐selectin and soluble thombomodulin were measured by ELISA. After 49 months, 24 patients had suffered an additional cardiovascular event such as a second myocardial infarction or requirement for arterial surgery. Soluble E‐selectin was 60±30 ng/mL in patients who suffered an end‐point and was 54±23 ng/mL in those without an end‐point (p = 0.43). Soluble thrombomodulin was 65±24 ng/mL in patients who suffered an end‐point and was 49±19 ng/mL in patients who were free of an end‐point (p = 0.009). The major risk factors for atherosclerosis (hypercholesterolaemia, hypertension, smoking) or peak creatinine kinase levels were unable to predict the development of an end‐point. Using life tables, soluble thrombomodulin had a significant effect on survival free of an end‐point (p = 0.011). We conclude that the measurement of soluble E‐selectin is of limited value in epidemiological studies, and that raised soluble thrombomodulin is a new marker for the progression of atherosclerosis in patients with ischaemic heart disease.

Evaluation of the HemoCue® for measuring intra‐operative haemoglobin concentrations: a comparison with the Coulter Max‐M®

ObjectiveTo evaluate the efficacy of acute normovolemic hemodilution (ANH) and intraoperative cell salvage (ICS) in blood-conservation strategies for infrarenal aortic surgery. Summary Background DataRecent concerns over the risks of transfusion-related infection have resulted in sharp rises in the cost of blood preparations. Autologous transfusion may be a safe alternative to allogeneic transfusion, which has been associated with immune modulation and postoperative infection. MethodsThis multicenter prospective randomized trial compared standard transfusion practice with autologous transfusion combining ANH with ICS in 145 patients undergoing elective aortic surgery. The primary outcome measures were the proportion of patients requiring allogeneic blood and the volume of allogeneic transfusion. The secondary outcome measures were the frequency of complications, including postoperative infection, and postoperative hospital stay. ResultsThe combination of ANH and ICS reduced the volume of allogeneic blood transfused from a median of two units to zero units. The proportion of patients transfused was 56% in allogeneic and 43% in autologous. There were no significant differences in complications or length of hospital stay. ConclusionsBoth ANH and ICS were safe and reduced the allogeneic blood requirement in patients undergoing elective infrarenal aortic surgery.

von Willebrand Factor, Endothelial Cell Damage and Atherosclerosis

We compared haemoglobin concentration values obtained using a portable haemoglobinometer, the HemoCue, in the operating theatre with the results obtained by the Coulter Max‐M in the laboratory. Haemoglobin concentrations were measured on 52 arterial blood samples obtained from 13 patients during aortic surgery, in theatre with the HemoCue and again by the Coulter Max‐M. Twenty routine samples from the laboratory were also analysed by both methods. There was no significant difference between results, with a mean of 10.94 gdl−1 and 10.90 gdl−1 for the HemoCue and Coulter, respectively (p = 0.12, t = −1.99, df = 70). The limits of agreement of the two methods (mean difference ± 2 SD) were −0.37 and +0.45 gdl−1. The coefficients of repeatability of the 20 samples analysed in duplicate on each device were 0.26 gdl−1 and 0.33 gdl−1, respectively. The coefficients of variance were 0.74% (HemoCue) and 0.93% (Coulter). With adequate training and monitoring, the HemoCue provides comparable haemoglobin results for near‐patient testing in theatre.