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Colin E. Davies MSc BSc(Hons) FAETC RGN Gloucestershire Leg Ulcer Service Cheltenham General Hospital Management of Leg Ulcers The Role of the Gloucestershire.

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Presentation on theme: "Colin E. Davies MSc BSc(Hons) FAETC RGN Gloucestershire Leg Ulcer Service Cheltenham General Hospital Management of Leg Ulcers The Role of the Gloucestershire."— Presentation transcript:

1 Colin E. Davies MSc BSc(Hons) FAETC RGN Gloucestershire Leg Ulcer Service Cheltenham General Hospital Management of Leg Ulcers The Role of the Gloucestershire Leg Ulcer Service

2 Introduction Common Low healing High recurrence Poor assessment Irrational treatment Chronic problem Expensive

3 Causes of Leg Ulcers Venous 70% Arterial 10% Arterial + venous 10-15% Non- vascular 5% Non-Vascular Co-Morbidities Malignancy Trauma Diabetes Rheumatoid Arthritis Vasculitis Blood disorders Metabolic disorders 95% OF LEG ULCERS WILL BE VASCULAR

4 Cause of Tissue Breakdown Skin Capillary Oxygen Nutrients Oxygen Nutrients Carbon dioxide Waste metabolites Water Fibrinogen Carbon dioxide Chronic Venous Hypertension

5 Cause of Tissue Breakdown Fibrin cuff deposition White cell entrapment Growth factor entrapment Fibrin Leucocytes

6 Chronic Venous Hypertension Oedema Haemosiderin staining Atrophy blanche Ankle flare Lipodermatosclerosis Varicose veins Varicose eczema

7 Non-Vascular Co-Morbidities Malignancy 1 – 2% Trauma Diabetes Rheumatoid Arthritis Vasculitis Blood disorders Metabolic disorders Non-Vascular Causes

8 Ankle brachial pressure index Colour venous duplex ultrasound Arterial ultrasound scan Assessment

9 Re-vascularisation ABPI Full compression Full compression ABPI Modified compression ABPI <0.5 Refer to vascular surgeon Deterioration Healed Incompressible Leg Ulcer Management

10 CompressionElevationExercise Compression + Elevation + Exercise = Optimum Healing XXX Delayed Healing Evidence-Based Approach

11 However recurrence rates are high Compression is lifelong Concordance is poor Venous Ulcers Treatment Pathways

12 Ulcerated limb ABPI >0.85 Compression Compression + Surgery Monthly review 3 monthly review ESCHAR Trial

13 Superficial Venous Reflux Months Healed limbs % Surgery + compression Compression alone p< % 12% ESCHAR Results

14 Mixed superficial and segmental deep reflux Months Healed limbs % Surgery + compression Compression p= % 9% ESCHAR Results

15 Lancet 2004 Jn 5; 363(9424): % refused surgery ESCHAR Results

16 n = 500 Barwell et al, 2004 Isolated superficial reflux 61% 24% Superficial & segmental deep reflux 15% Superficial & total deep Suitability for Further Intervention

17 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service Healing 24 Weeks Recurrence 12 Months P<0.01 Ghauri ASK, et al (1998) Eur J Endovasc Surg 16,

18 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service General Practitioners Leg Ulcer Service Community Nurses Dermatologists Patient Self-Referral Ward Nurses Other Specialists Practice Nurses

19 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service

20 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service

21 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service GLOUCESTER Cinderford CHELTENHAM Bourton-on-the-Water Cirencester Tewkesbury Stroud Moreton-in –the-Marsh

22 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service Community Leg Ulcer Clinics Home Specialist Nurses Primary Care Teams Hospital Vascular Lab Vascular Surgeon

23 Established in 1995 Referral system One-stop assessment Nurse specialists Community clinics Vascular Unit link Management Protocol The Leg Ulcer Service

24 Well Leg Clinic Management Strategies Foam Biopsy Multilayer Compression + Hosiery One-Stop Assessment ClinicPinch Skin Grafting RCT Superficial Venous Surgery ESCHAR Larvae Therapy RCT

25 Improvement in Outcomes Prospective database November 1995 – December 2010 Healing Recurrence

26 7481 legs on database Excluded (n=2085)  Arterial, malignant, diabetic, rheumatoid, others  Lost to follow up Data analysed prospectively for:  24 week healing rates  12 month recurrence rates Improvement in Outcomes 5396 legs

27 24 Week Healing Weeks Healed (%) – – – – % 63% 29 %

28 12 Month Recurrence – – – – Recurrence (%) Weeks 20.1% 13.5% 33%

29 Conclusions Improved healing Improved healing % healed at 24 weeks % healed at 24 weeks Before Service 29% healed at 24 weeks Audit Prospective 179%

30 Conclusions Reduced recurrence Reduced recurrence % recurrence at 12 months % recurrence at 12 months Before Service 54% recurrence at 12 months Audit Prospective - 75%

31 Conclusions Secondary care assessment Specialist vascular-led clinics Clearly defined, evidence-based protocols Further intervention Leg ulcer management benefits from…

32 Thank you


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