Christine Moffatt

Community clinics for leg ulcers and impact on healing.

OBJECTIVE--To evaluate the effectiveness of community clinics for leg ulcers. DESIGN--All patients with leg ulceration were invited to community clinics that offered treatment developed in a hospital research clinic. Patients without serious arterial disease (Doppler ankle/brachial index > 0.8) were treated with a high compression bandage of four layers. SETTING--Six community clinics held in health centres in Riverside District Health Authority supported by the Charing Cross vascular surgical service. PATIENTS--All patients referred to the community services with leg ulceration, irrespective of cause and duration of ulceration. MAIN OUTCOME MEASURES--Time to complete healing by the life table method. RESULTS--550 ulcerated legs were seen in 475 patients of mean (SD) age 73.8 (11.9) years. There were 477 venous ulcers of median size 4.2 cm2 (range 0.1-117 cm2), 128 being larger than 10 cm2. These ulcers had been present for a median of three months (range one week to 63 years) with 150 present for over one year. Four layer bandaging in the community clinics achieved complete healing in 318 (69%) venous ulcers by 12 weeks and 375 (83%) by 24 weeks. There were 56 patients with an ankle/brachial arterial pressure index < 0.8, indicating arterial disease. The 50 patients with pressure index < 0.8 > 0.5 were treated with reduced compression, and 24 (56%) healed by 12 weeks and 31 (75%) by 24 weeks. The figures for overall healing for all leg ulcers were 351/550 (67%) at 12 weeks and 417/550 (81%) at 24 weeks, compared with only 11/51 (22%) at 12 weeks before the community clinics were set up. CONCLUSIONS--Community clinics for venous ulcers offer an effective means of achieving healing in most patients with leg ulcers.

Classification of Compression Bandages: Practical Aspects

BACKGROUND Compression bandages appear to be simple medical devices. However, there is a lack of agreement over their classification and confusion over the use of important terms such as elastic, inelastic, and stiffness. OBJECTIVES The objectives were to propose terms to describe both simple and complex compression bandage systems and to offer classification based on in vivo measurements of subbandage pressure and stiffness. METHODS A consensus meeting of experts including members from medical professions and from companies producing compression products discussed a proposal that was sent out beforehand and agreed on by the authors after correction. RESULTS Pressure, layers, components, and elastic properties (P-LA-C-E) are the important characteristics of compression bandages. Based on simple in vivo measurements, pressure ranges and elastic properties of different bandage systems can be described. Descriptions of composite bandages should also report the number of layers of bandage material applied to the leg and the components that have been used to create the final bandage system. CONCLUSION Future descriptions of compression bandages should include the subbandage pressure range measured in the medial gaiter area, the number of layers, and a specification of the bandage components and of the elastic property (stiffness) of the final bandage.

Health‐related quality of life with lymphoedema: a review of the literature

This article reviews qualitative and quantitative studies that evaluate health‐related quality of life (HRQoL) in lymphoedema. Qualitative studies reveal a number of factors that can affect HRQoL. These include a lack of understanding of lymphoedema by health professionals and poor information provided to patients. Emotional responses include shock, fear, annoyance, frustration and negative body image. Treatment can be costly in terms of time and disruption to lifestyle. Quantitative studies show that patients with lymphoedema experience greater levels of functional impairment, poorer psychological adjustment, anxiety and depression than the general population. Increased limb volume is poorly related to the impact of lymphoedema on the patient. Factors leading to deficits in quality of life include the frequency of acute inflammatory episodes, the presence of pain, skin quality, lymphoedema in the dominant hand and reduced limb mobility. There is some evidence that the adoption of patient‐centred guidelines can improve quality of life in patients with breast‐cancer‐related lymphoedema. HRQoL is an important outcome in the management of patients with lymphoedema. Further studies must examine how lymphoedema impacts on patients other than those with breast‐cancer‐related lymphoedema and the consequences to patients of different approaches to care.

Lymphoedema: estimating the size of the problem

Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.

Randomized trial of four-layer and two-layer bandage systems in the management of chronic venous ulceration

To compare a four‐layer bandage system with a two‐layer system in the management of chronic venous leg ulceration, a prospective randomized open parallel groups trial was undertaken. In total, 112 patients newly presenting to leg ulcer services with chronic leg ulceration, screened to exclude the presence of arterial disease (ankle brachial pressure index <0.8) and causes of ulceration other than venous disease, were entered into the trial. Patients were randomized to receive either four‐layer (Profore™) or two‐layer (Surepress™) high‐compression elastic bandage systems. In all, 109 out of 112 patients had at least one follow‐up. After 24 weeks, 50 out of 57 (88%) patients randomized to the four‐layer bandage system with follow‐up had ulcer closure (full epithelialization) compared with 40 out of 52 (77%) on the two‐layer bandage, hazard ratio = 1.18 (95% confidence interval 0.69–2.02), p = 0.55. After 12 weeks, 40 out of 57 (70%) patients randomized to the four‐layer bandage system with follow‐up had ulcer closure compared with 30 out of 52 (58%) on the two‐layer bandage, odds ratio = 4.23 (95% confidence interval 1.29–13.86), p = 0.02. Withdrawal rates were significantly greater on the two‐layer bandage (30 out of 54; 56%) compared with the four‐layer bandage system (8 out of 58; 14%), p < 0.001, and the number of patients with at least one device‐related adverse incident was significantly greater on the two‐layer bandaging system (15 out of 54; 28%) compared with four‐layer bandaging (5 out of 54; 9%), p = 0.01. The higher mean cost of treatment in the two‐layer bandaging system arm over 24 weeks (

Randomized trial of cohesive short-stretch versus four-layer bandaging in the management of venous ulceration

1374 [£916] vs.

Assessment of health-related quality of life in patients with lymphedema of the lower limb.

1314 [£876]) was explained by the increased mean number of bandage changes (1.5 vs. 1.1 per week) with the two‐layer system. In conclusion, the four‐layer bandage offers advantages over the two‐layer bandage in terms of reduced withdrawal from treatment, fewer adverse incidents, and lower treatment cost. (WOUND REP REG 2003;11:166–171)

Variability of pressure provided by sustained compression

A multicenter prospective randomized clinical trial was undertaken to compare a generic four‐layer bandage system with a cohesive short‐stretch system (Actico, Activa Healthcare) in the management of venous leg ulceration. Both systems are designed to produce sufficient pressure to counteract venous hypertension. Patients in leg ulcer services with leg ulceration were screened for inclusion in this trial. Patients with arterial disease (ankle brachial pressure index < 0.8) and causes of ulceration other than venous disease were excluded. For patients with bilateral ulceration, the limb with the larger area of ulceration was studied. Patients were randomized to receive either type of compression bandage and simultaneously randomized to one of two foam dressings that were changed weekly unless more frequent changes were clinically required. In all, 156 patients met entry criteria and were randomized from the 12 clinical centers with median (range) ulcer size of 4.33 (0.33–123.10) cm2. Analysis revealed that after 24 weeks a total of 111 (71%) of patients had complete ulcer closure, 32 (21%) had withdrawn from the trial, 12 (8%) remained with open ulceration, and one patient had died. Of the 74 patients randomized to the four‐layer bandage, 51(69%) had ulcer closure on treatment compared with 60/82 (73%) on the cohesive short‐stretch system. Intention‐to‐treat analysis produced a hazard ratio for healing of 1.08 (95 percent CI 0.63–1.85, p= 0.79). Withdrawal rates were similar between groups (15, 20% four‐layer bandage; 17, 21% cohesive short‐stretch system). Ulcer closure rates for patients treated with the cohesive short‐stretch system were similar to those for patients managed by the four‐layer bandage system in this trial.

Do Clinical and Social Factors Predict Quality of Life in Leg Ulceration

The purpose of this study was to examine the use of a number of tools in the evaluation of health‐related quality of life in patients with lower limb lymphedema, and to determine the consequences of cancer history and concurrent leg ulceration. Patients in one health trust having lower limb lymphedema were identified and interviewed at entry and after 24 weeks. The short form‐36 (SF‐36), modified Barthel scale, McGill short form pain questionnaire, and Euroqol were administered at both time points. Of the 164 (median age=76.9 years, 70.7% women) patients who comprised the study population, 15.2% had a history of cancer and 30.4% had coexisting current leg ulceration. Internal consistencies were high for all scales (Cronbachs α >0.80). There were high ceiling effects for a number of SF‐36 scores, and high floor effects in these and the McGill short form pain questionaire, scales. Despite these limitations, there was strong evidence that treatment led to significant improvements in six of eight scores of the SF‐36, three of three scores of the McGill short form pain questionnaire and the modified Barthel scale (all p<0.05). The improvement in physical functioning was significantly greater for patients who entered the study with a leg ulcer (mean different=9.1, 95% confidence interval 2.1–16.1, p=0.011). Patients treated with compression bandaging had significantly greater improvements for physical functioning (10.2) than those treated with compression hoisery (−1.5) or no treatment (−2.0), p=0.001. Of the tools assessed, the SF‐36, appears to be the most appropriate for use in this patient group.

Sociodemographic factors in chronic leg ulceration

Compression therapy is the cornerstone of treatment for patients with venous leg ulcers (VLUs). Although it is generally accepted that the therapeutic outcomes are directly related to the quality of compression therapy, delivering precise and sustained compression therapy is an ongoing challenge for health care professionals. Several factors influence quality of compression therapy: physical structure and elastomeric properties of the compression system, size and shape of the leg, skill and technique of the bandager and physical activity undertaken by the patient. Graduated compression is achieved by applying a bandage at the same tension from ankle to knee, providing the shape of the leg is normal. Many patients with VLUs have distorted legs, challenging the delivery of a desired pressure gradient. Poor bandaging technique can result in little or no benefit or may deliver too high a pressure causing a detrimental effect to the wearer. If the wearer is unable to tolerate the compression, patient concordance and effectiveness are affected. Training has been shown to reduce variability of sub‐bandage pressure. Sub‐bandage pressure increases during standing and walking. These pressure changes are related to the elastomeric properties of the compression systems. Health care professionals need to understand the properties of the available compression systems and how their application technique must be adjusted.