Chapter 1 Introduction In I wrote a speculative biomedical paper suggesting that the immune system is the key to understanding a broad range of mental illnesses, including depression, schizophrenia, hyperactivity, anxiety and manic-depressive disorder. These cytokines have powerful effects on the brain:
It was published there in September. Venous leg ulcers VLUs most often occur in the gaiter region of the lower leg, from just below the ankle up to mid-calf. They are defined as any break in the skin that has been present for at least six weeks or occurs in someone with a previous history of venous leg ulceration Norman et al, Repeated cycles of ulceration, healing and recurrence are common.
Venous leg ulcers are painful, distressing and have a considerable impact on quality of life. They are also expensive to treat. In the UK, most people with leg ulcers are treated in the community and require frequent visits from nurses to care for their wounds Ashby et al, Recent research on what matters most to people with ulcers, and other complex wounds, has found that complete wound healing is a high priority Cullum et al, There is a clear need for evidence-based strategies and services to prevent and treat VLUs.
The expert working committee responsible for the joint document on Management of Patients with Venous Leg Ulcers from the European Wound Management Association EWMA and Wounds Australia, highlight variations in the evidence and guidelines which, with differences in healthcare structures in different countries, potentially cause confusion Franks et al, This document focuses on implementation of best practice and provides clinical practice statements which go beyond the scope of this article.
This article will focus on evidence from Cochrane Reviews, several of which have informed the EWMA document and international guidelines.
Treatments for venous leg ulcers Cleansing Wound cleansing is an integral part of managing venous ulcers, recommended in many international guidelines, but it is unclear which is the best method or solution.
A guideline published in by the Scottish Intercollegiate Guidelines Network SIGN,along with others, recommends that venous ulcers should be washed with tap water, informed by a Cochrane Review Fernandez and Griffiths, that found that infection rates were comparable for chronic wounds washed with safe tap water or saline.
Some guidelines recommend the use of a neutral, non-toxic solution. A new Cochrane Review is being prepared to assess the effects of wound cleansing solutions and techniques on healing rates of VLUs McLain and Moore, Debridement Best practice documents and expert opinion suggest that debridement, removing dead or dying tissue from the ulcer surface, can promote VLU healing, but is there good evidence underpinning this?
Is debridement effective, and how do the methods compare? There are six methods of debridement: A Cochrane Review Gethin et al, looked at the impact of debridement on venous ulcer healing and the comparative effectiveness of different methods.
Although ten small RCTs were included, no meta-analysis was possible and the review reveals a very limited evidence base for debridement. Compression Compression therapy, with bandages or stockings, promotes healing through aiding venous return and is the first-line treatment for venous leg ulcers.
The most recent version of the review, published inincludes 48 randomised controlled trials RCTs reporting 59 comparisons. The review authors note that the methodological quality of the evidence is variable, with all trials but one being at high or unclear risk of bias, but also that trial quality is improving over time.
They found that compression increases the healing rate compared with no compression and that multi-component systems are more effective than single-component systems. Two-component systems appear equivalent to the 4LB in terms of healing. The review highlighted areas of continued uncertainty, including the relative effectiveness of compression stockings and the 4LB.
They found no difference in venous ulcer healing between the 4LB, the current gold standard treatment for venous leg ulcers, and two layer hosiery HHbelow the knee stockings.
These two systems deliver the same amount of pressure, but HH is easier to put on and less bulky to wear, which might encourage its use and improve ulcer healing rates.
However, the investigators caution that there is too little evidence to draw firm conclusions about relative effectiveness. There is very little evidence on the use of compression to prevent recurrence of venous ulcers Nelson and Bell-Syer SEM, Compression is better than none for healing venous leg ulcers, but it is unclear whether it can help prevent a recurrence Dressings and topical agents Dressings are usually applied to open ulcers.
As well as offering protection, dressings may be chosen for other reasons, such as antimicrobial properties or absorption of exudate. As well as a wide range of types of dressings available, there are a number of topical products, used to reduce infection risk, aid exudate absorption or promote wound healing by other means, as well as topical painkilling agents.
Having reliable evidence to guide choices is important, and not only for healthcare professionals.Journal of Clinical and Experimental Dermatology Research discusses the latest research innovations and important developments in this field. Preventing Pressure Ulcers in Hospitals 3.
What are the best practices in pressure ulcer prevention that we want to use?
Deep Tissue Injury Overview Deep tissue injury is a term proposed by NPAUP to describe a unique form of pressure ulcers. These ulcers have been described by clinicians for many years with terms. The edition of the Emergency Severity Index Implementation Handbook provides the necessary background and information for establishing ESI-a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from least to most urgent based on patient acuity and resource needs.
Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well. This article for nurses, on venous leg ulcers, is one of a series of evidence reviews written by Sarah Chapman for the British Journal of Community Nursing.