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.     

Leg ulcers in Portugal: an underestimated health care problem

To determine the prevalence and aetiology of leg ulceration in a population of patients registered with five health centres within Lisbon, a study was undertaken to identify patients receiving care from community and hospital. Identification of patients was through health professionals, with a simple questionnaire completed for all patients identified who were registered with the five health centres. In 263 patients were identified in a population of 186,000 (total prevalence 1.41/1,000 population). The prevalence was similar between men and women (1.3 and 1.46/1,000, respectively). As expected this was highly age dependent, being most common in patients aged over 80 years (6.5 and 4.9/1,000, respectively). The ulceration was highly chronic in nature, with median ulceration of 18 months. Of the 240 with ulcer duration recorded, 158 (66%) had the present ulcer for longer than one year, and 40 (17%) for longer than five years. The cause of ulceration was unknown to the health professional treating the patient in 86 (33%) of the cases. Of those with a cause, most commonly this was venous (80%) with 10% mixed arterial/venous ulceration and 3% frank arterial disease. Most care was provided by community services, with 145 (55%) treated in health centres and 77 (29%) treated in the patient's home. The mean number of treatments per week was 3.0, with 21 (9%) of patients being seen on a daily basis. Most patients (80%) had seen a specialist doctor for their ulceration, most often a dermatologist (48%) and a vascular surgeon (33%). 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. This produces a high burden on both hospital and community services.     

Prevalence of lower limb ulceration in an urban health district.

Before establishing a community leg ulcer programme, a survey was performed to assess the incidence and prevalence of lower limb ulceration in the Newcastle Health District. The prevalence was 1.9 per 1000 in patients over the age of 45 years, and the annual incidence 3.5 per 1000 in the same age group. Recurrent ulcers represented 47 per cent of the total and 50 per cent of all ulcers had been present for > 6 months. District nurses spent 190 h per week in the community dressing leg ulcers, making a total number of 25,922 visits each year. In the treatment of leg ulcers 35 different types of dressing were used and only 14 per cent of ulcerated limbs were treated by appropriate compression. Of all patients with leg ulcers, 35 per cent had been seen by a hospital specialist but only 7 per cent had been examined by a vascular surgeon at any time.     

Epidemiology of chronic venous ulcers

A metropolitan population of 238,000 in Perth, Western Australia, was screened for chronic ulceration of the leg. Patients with a chronic leg ulcer and a venous abnormality comprised 57 per cent of all patients with a chronic leg ulcer, giving a prevalence of 0.62 per 1000 population. There was an increasing prevalence with age; 90 per cent of patients were 60 years and older. This group comprised 16.7 per cent of the population, and had a prevalence of 3.3 per 1000. Although chronic venous ulcers were more common in women there was no difference in age related prevalence. In 36 per cent of patients with a venous abnormality, there was at least one other aetiological factor contributing to chronic ulceration of the leg; 96 per cent had either a history of deep venous thrombosis or a condition known to predispose to deep venous thrombosis.     

Health economic burden that different wound types impose on the UK's National Health Service

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to the management of different wound types by the UK's National Health Service (NHS) in 2012/2013 and the annual costs incurred by the NHS in managing them. This was a retrospective cohort analysis of the records of 2000 patients in The Health Improvement Network (THIN) Database. Patients' characteristics, wound‐related health outcomes and all health care resource use were quantified, and the total NHS cost of patient management was estimated at 2013/2014 prices. The NHS managed an estimated 2·2 million patients with a wound during 2012/2013. Patients were predominantly managed in the community by general practitioners (GPs) and nurses. The annual NHS cost varied between £1·94 billion for managing 731 000 leg ulcers and £89·6 million for managing 87 000 burns, and associated comorbidities. Sixty‐one percent of all wounds were shown to heal in an average year. Resource use associated with managing the unhealed wounds was substantially greater than that of managing the healed wounds (e.g. 20% more practice nurse visits, 104% more community nurse visits). Consequently, the annual cost of managing wounds that healed in the study period was estimated to be £2·1 billion compared with £3·2 billion for the 39% of wounds that did not heal within the study year. Within the study period, the cost per healed wound ranged from £698 to £3998 per patient and that of an unhealed wound ranged from £1719 to £5976 per patient. Hence, the patient care cost of an unhealed wound was a mean 135% more than that of a healed wound. Real‐world evidence highlights the substantial burden that wounds impose on the NHS in an average year. Clinical and economic benefits to both patients and the NHS could accrue from strategies that focus on (a) wound prevention, (b) accurate diagnosis and (c) improving wound‐healing rates.     

Aetiology of chronic leg ulcers.

This study was undertaken to determine the relative prevalence of the factors causing chronic ulceration of the leg in the general population. Two hundred and fifty-nine patients with chronic ulceration of the leg were found on screening a Western Australian population of 238,000. (The prevalence of chronic ulceration of the leg was 1.1 per 1000 population.) Two hundred and forty-two of these patients (93%) with 286 chronically ulcerated limbs were fully assessed to determine the factors contributing to ulceration. In 239 limbs (84%) ulceration involved the leg; in these limbs venous disease was the most prevalent cause of ulceration (160 limbs). Arterial disease was found in 66 limbs, with both venous and arterial disease present in 35 limbs. Rheumatoid arthritis was a causative factor in 27 limbs and diabetes was found with 29 limbs with ulceration involving the leg. In 47 limbs (16%) ulceration was confined to the foot; arterial disease (35 limbs) and diabetes (23 limbs) were the most prevalent causes of ulceration in these limbs. Venous disease was infrequent (three limbs). No disorder of the circulation was found in 48 limbs (20%) with ulceration involving the leg, and in 58 (20%) of all ulcerated limbs. More than one aetiological factor was present in 93 limbs (33%). A cause for ulceration was not found in 10 limbs (3.5%).     

Prevalence and incidence rates of pressure ulcers in an Emergency Department

Older patients represent an increasing population in emergency department (ED) with underlying diseases and longer ED length of stay, which are potential risk factors of pressure ulcers (PUs). The aim of the study was to determine the prevalence and incidence rates of PUs in an Emergency Department and to analyse variables related to PUs occurrence. The study was carried out in the Emergency Department of Bordeaux (France), and included 602 patients from 1 to 15 June 2010. All the potential body sites of pressure were examined at admission and discharge for all the patients by trained nurses. Comorbidity score, list of treatment, length of stay (hours), PUs (including stage I) and C‐reactive protein (CRP) level were systematically recorded. A total of 47 (7·8%) patients had prevalent PUs at admission and 74 (12·3%) at discharge. The cumulative incidence was 4·9% and the incidence density was 5·4 per 1000 patients per hour. In multivariate analysis, higher comorbidities (OR 1·3; P = 0·014) and CRP levels (OR 1·005; P = 0·017) were both independent risk factors for developing PU. In conclusion, these data show that even a very short stay to the ED is sufficient to induce PUs especially stage I.     

Hyperhomocysteinaemia and chronic venous ulcers

Chronic venous ulceration (CVU) is the major cause of chronic wounds of lower extremities, and is a part of the complex of chronic venous disease. Previous studies have hypothesised that several thrombophilic factors, such as hyperhomocysteinaemia (HHcy), may be associated with chronic venous ulcers. In this study, we evaluated the prevalence of HHcy in patients with venous leg ulcers and the effect of folic acid therapy on wound healing. Eighty‐seven patients with venous leg ulcers were enrolled in this study to calculate the prevalence of HHcy in this population. All patients underwent basic treatment for venous ulcer (compression therapy ± surgical procedures). Patients with HHcy (group A) received basic treatment and administered folic acid (1·2 mg/day for 12 months) and patients without HHcy (group B) received only basic treatment. Healing was assessed by means of computerised planimetry analysis. The prevalence of HHcy among patients with chronic venous ulcer enrolled in this study was 62·06%. Healing rate was significantly higher (P < 0·05) in group A patients (78·75%) compared with group B patients (63·33%). This study suggests a close association, statistically significant, between HHcy and CVU. Homocysteine‐lowering therapy with folic acid seems to expedite wound healing. Despite these aspects, the exact molecular mechanisms between homocysteine and CVU have not been clearly defined and further studies are needed.     

EPIDEMIOLOGY OF CHRONIC LEG ULCERS IN AUSTRALIA

The aim of this study was to determine the point prevalence of ulceration of the leg in an Australian community. This was a population-based epidemiological study. Two hundred and fifty-nine patients with leg ulceration were identified by health care professionals of all types working in hospitals and private practices, as well as by self referral from patients. The base population in the study area was 238000. The following data were recorded: age, sex, site of ulceration. duration of ulceration, history of previous ulceration and patient mobility. The point prevalence was 0.11%. The male: female ratio was 1:1.9; however the age related prevalence was similar for both sexes. The age related prevalence of ulceration was similar to that found in two similarly conducted studies in the United Kingdom. The ulcers were a chronic problem with 24% having been present for more than 1 year. Thirty-five per cent of patients had had a problem of ulceration for more than 5 years and 20% had suffered 10 or more episodes of ulceration. Related immobility was a prominent factor with 45% of patients being housebound. Chronic ulceration of the leg is a common recurrent problem in the elderly population and is likely to increase as the population grows. There is a definite need to improve the method of treating this problem.     

Association of diabetic foot care and amputation rates in Germany

Podologists are nurses who care for the diabetic foot (orthotics, offloading devices, blisters, calluses, treatment of fungus infection and patient education). In contrast to podiatrists, they are not qualified to perform any surgical treatment or wound care. We analysed whether there is an association between the decrease in major amputations and the number of podologic foot care (PFC) visits prescribed in Germany. Detailed list of all major lower limb amputations (OPS 5‐864) performed from 2007 to 2011 was provided by the Federal Statistical Office. Data were separated for the 16 federal states in Germany. Detailed lists of the number of PFC treatments for each of the 5 years were derived from the federal report of the statutory health insurance. The total numbers of hospitalised cases per year having diabetes mellitus documented as an additional diagnosis were used to adjust for the different rates of people with diabetes in each federal state. Within a 5‐year time period, population‐based major amputations per 100 000 people dropped from 21·7 in 2007 to 17·5 in 2011 (?18·5%); whereas the number of PFC treatments per 1000 insured increased from 22 in 2007 to 60 in 2011 (+172·7%). The total number of major amputations divided by the total number of hospitalised cases with the additional diagnosis of diabetes mellitus (DM) shows an inverse correlation with the number of PFC treatments per 1000 insured (Pearson's correlation factor is ?0·52049). The five countries with the highest increase in PFC compared with the five countries with the lowest increase (35·6 versus 15·4 per 1000 insured) will have only small differences in the decrease in major amputation rates in this period (?5·1 versus ?3·4 per 100.000). There is a strong association between increasing utilisation PFC and decreasing major amputations in Germany. Further study is required to document the cost‐effectiveness of this service.     

Kidney health in the Middle East

Chronic kidney disease (CKD) is a common and costly health problem in the Middle East. The incidence of CKD is still unknown, and the incidence of end-stage renal disease (ESRD) is estimated at 100 - 140 incident cases per million population in the Middle East countries. Most of the available statistics about prevalence are of treated ESRD. Published population-based studies for incidence and prevalence of CKD and ESRD are still lacking in most of the Middle East countries. This negatively affects the health planning and effectiveness of preventive and therapeutic measures in the region. The prevalence of renal replacement therapy varies among the different countries in the Middle East. The infrastructure for these services is also variable among these countries and affects the outcome, which as yet cannot be measured accurately. The low gross national income of the Middle East countries is a major factor in negating the implementation of research, planning, and improvement of the services for CKD patients. To overcome the obstacles for the renal services in the Middle East countries, the constraints on health expenditure need to be surmounted, which is not an easy task, and related appropriately to the gross national income. Awareness within the medical community and the public at large about the advances of therapeutic and preventive measures is also an important factor for progress toward better kidney health in the Middle East.     

Primary health care strategies for the prevention of end-stage renal disease in Cuba

End-stage renal disease (ESRD) is a major health problem in the world, including Cuba. There is an increasing trend in both the incidence and prevalence of ESRD. Global projections consistently show an increase of patients in maintenance dialysis, and also an epidemic trend in diabetes mellitus and hypertension, two diseases that are leading causes of ESRD in most countries. A new paradigm is necessary to handle this major health problem, such as a public health model that integrates health promotion and disease prevention. In 1996, the Ministry of Public Health of Cuba launched a national program for the prevention of chronic renal failure (CRF). The progressive implementation of this program follows several steps: the analysis of the resources and health situation in the country; epidemiological research to define the burden of CRF; continuing education for nephrologists, family doctors, and other health professionals; and reorientation of primary health care toward increased nephrology services, intervention, and surveillance. The main outcomes of the program have been: a rational redistribution of nephrology services in corresponding health areas of primary health care; nephrologists being brought closer to the community; an improvement in the knowledge and ability of family doctors and nephrologists in the prevention of chronic renal disease; an increase in the number of patients with CRF (serum creatinine > or = 133 micromol/L or > or = 1.5 mg/dL, or a glomerular filtration rate < 60 mL/min) who are registered in primary health care every year, from a prevalence of 0.59 per 1,000 inhabitants at the beginning of the program in 1996 to 0.92 per 1,000 inhabitants in 2002, with a mean prevalence growth of 9.2% per year; a significant reduction (0.1%) in the incidence of viral hepatitis B in dialysis patients after the implementation of vaccination against viral hepatitis B in CRF patients who are registered in primary health care; and the implementation of CRF surveillance in primary health care, which provides periodic information on CRF burden, patterns, and trends to assist evidence-based public-health decision making, and measures the impact of interventions in the population. Primary health care is an essential tool, and the community is an appropriate social space for health promotion and the prevention of CRF and ESRD.     

Venous leg ulcer management in clinical practice in the UK: costs and outcomes

The aim of this study was to estimate the patterns of care and annual levels of health care resource use attributable to managing venous leg ulcers (VLUs) in clinical practice by the UK's National Health Service (NHS) and the associated costs of patient management. This was a retrospective cohort analysis of the records of 505 patients in The Health Improvement Network (THIN) Database. Patients' characteristics, wound‐related health outcomes and health care resource use were quantified, and the total NHS cost of patient management was estimated at 2015/2016 prices. Overall, 53% of all VLUs healed within 12 months, and the mean time to healing was 3·0 months. 13% of patients were never prescribed any recognised compression system, and 78% of their wounds healed. Of the 87% who were prescribed a recognised compression system, 52% of wounds healed. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 30% of all the VLUs may have been clinically infected at the time of presentation, and only 22% of patients had an ankle brachial pressure index documented in their records. The mean NHS cost of wound care over 12 months was an estimated £7600 per VLU. However, the cost of managing an unhealed VLU was 4·5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU). This study provides important insights into a number of aspects of VLU management in clinical practice that have been difficult to ascertain from other studies and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.     

Pressure ulcer prevalence across Welsh orthopaedic units and community hospitals: surveys based on the European Pressure Ulcer Advisory Panel minimum data set

The survey used the European Pressure Ulcer Advisory Panel (EPUAP) methodology for the collection of pressure ulcer prevalence data. The orthopaedic survey was conducted across all National Health Service Trusts in Wales between 2 and 6 July 2007 while the community hospital survey covering 25% of all community hospital beds was conducted between 21 April 2008 and 2 May 2008. Data were gathered upon 1196 patients (581, 48·6% within orthopaedic units with 615 located in community hospitals). Of these patients, 81 (13·9%) and 162 (26·7%) had pressure ulcers in orthopaedic and community hospitals, respectively. Where patients presented with multiple pressure ulcers, the most severe pressure ulcer was recorded. Across both surveys, most pressure ulcers were reported to be either category I or II with 91 category I wounds (33 in orthopaedic units and 58 in community hospitals). Severe (categories III and IV) pressure ulcers affected 78 patients (19 in orthopaedic units and 59 in community hospitals). Adoption of the EPUAP pressure ulcer prevalence methods can help achieve consistent data upon pressure ulcer prevalence in different health care organisations and specialities. The adoption of a consistent data collection capture methodology is a clear prerequisite for the compilation of meaningful pressure ulcer prevalence data sets at a national level.     

Effectiveness of an acellular synthetic matrix in the treatment of hard‐to‐heal leg ulcers

Hard‐to‐heal leg ulcers are a major cause of morbidity in the elderly population. Despite improvements in wound care, some wounds will not heal and they present a significant challenge for patients and health care providers. A multi‐centre cohort study was conducted to evaluate the effectiveness and safety of a synthetic, extracellular matrix protein as an adjunct to standard care in the treatment of hard‐to‐heal venous or mixed leg ulcers. Primary effectiveness criteria were (i) reduction in wound size evaluated by percentage change in wound area and (ii) healing assessed by number of patients healed by end of the 12 week study. Pain reduction was assessed as a secondary effectiveness criteria using VAS. A total of 45 patients completed the study and no difference was observed between cohorts for treatment frequency. Healing was achieved in 35·6% and wound size decreased in 93·3% of patients. Median wound area percentage reduction was 70·8%. Over 50% of patients reported pain on first visit and 87·0% of these reported no pain at the end of the study. Median time to first reporting of no pain was 14 days after treatment initiation. The authors consider the extracellular synthetic matrix protein an effective and safe adjunct to standard care in the treatment of hard‐to‐heal leg ulcers.     

Impact of bladder,bowel and sexual dysfunction on health status of people with thoracolumbar spinal cord injuries living in the community

Objective. The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.

Methods. Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.

Results. Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.

Conclusion. Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.     

End stage renal disease in Brunei Darussalam – report from the first Brunei Dialysis Transplant Registry (BDTR)

Abstract

The Brunei Dialysis and Transplant Registry (BDTR) was established in 2011 to collect data from patients undergoing renal replacement therapy (RRT) in Brunei Darussalam. The chief aims of the registry are to obtain general demographic data for RRT patients and to determine disease burden attributable to End Stage Renal Disease (ESRD). The registry population comprises of all ESRD patients treated in Brunei Darussalam. Data domains include general demographic data, medical history, ESRD etiological causes, laboratory investigations, dialysis treatment and outcomes. There were 545 prevalent RRT patients in Brunei at the end of 2011. The incidence and prevalence of ESRD were 265 and 1250 per million population. Hemodialysis (HD), Peritoneal Dialysis (PD) and Transplant comprised of 83%, 11% and 6% of the RRT population, respectively. Diabetes mellitus accounted for 57% of all new incident cases. The mean serum hemoglobin, phosphate, calcium and iPTH were 11.0?±?1.6?g/dL, 1.9?±?0.5?mmol/L, 2.3?±?0.2?mmol/L and 202.5?±?323.4?ng/mL. Dialysis adequacy for HD and PD were 65.1 (urea reduction ratio) and 2.0?±?0.3 (Kt/v). 71 % of all prevalent HD had functioning AV fistulae and the peritonitis incidence was one in 24.5 patient-month/episode. The first BDTR has identified some deficiencies in the renal services in Brunei. However, it signals an important milestone for the establishment of benchmarked renal practice in the country. We hoped to maintain and improve our registry for years to come and will strive to align our standards to acceptable international practice.     

The prevalence of locomotor disability and handicap in the Cape Peninsula. Part III. The white population of Fish Hoek

A door-to-door survey to identify the locomotor-disabled was carried out on 24.2% of the population living in a white middle-class residential area of the Cape Peninsula (2391 people). This coastal resort is a popular place for retirement and has a large elderly population (23.3%). The prevalence rate of locomotor disability was 13/1000. Illness caused 74.2% of the disability, and in 34.5% of cases this was identified as arthritis. Most of the disabled were aged 60 years or more (77.4%), while 22.6% were 16-59 years old. Fifty per cent of those in the working-age group were employed; one-third competed in the open labour market and the rest were in sheltered employment. Few people were in contact with health, geriatric or social services.