MIXED CHRONIC LEG ULCER
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MIXED CHRONIC LEG ULCER Palliative treatment results on 132 patients Enrique G. Bertranou José Antonio Olivencia Sergio E. Gonorazky PowerPoint PPT Presentation


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MIXED CHRONIC LEG ULCER Palliative treatment results on 132 patients Enrique G. Bertranou José Antonio Olivencia Sergio E. Gonorazky Hospital Privado de Comunidad. Mar del Plata, Argentina Iowa Vein Center. Des Moines, Iowa. INTRODUCTION. The similar clinical features of

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MIXED CHRONIC LEG ULCER Palliative treatment results on 132 patients Enrique G. Bertranou José Antonio Olivencia Sergio E. Gonorazky

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Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

MIXED CHRONIC LEG ULCER

Palliative treatment results on 132 patients

Enrique G. Bertranou

José Antonio Olivencia

Sergio E. Gonorazky

Hospital Privado de Comunidad. Mar del Plata, Argentina

Iowa Vein Center. Des Moines, Iowa


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

INTRODUCTION

The similar clinical features of

a group of chronic leg ulcer,

permit its inclusion under

a distinct group called:

“mixed chronic leg ulcer” (MCLU)

for its better management.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

BRIEF DEFINITION OF

THE NEW CLINICAL ENTITY

Leg ulcer resulting of chronic,

progressive and irreversible impairment

of the venous, arteriolar and lymphatic

circulation, in aged patients with

unbearable pain and remote possibilities

of cure.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

OBJECTIVES

  • Description of mixed chronic leg ulcer

  • (MCLU).

  • Description of the leg ulcer palliative

  • care program (LUPC).

  • Evaluation of 12 year – leg ulcer palliative

  • care program (LUPC).

  • Determination of mixed chronic leg ulcer

  • survival rate.

  • Survival rate comparison between MCLU

  • and matched control group.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

CLINICAL FEATURES

Elderly patients.

Frequently women.

Background of venous and/or arteriolar ulcer.

Extensive, profound, necrotic, transudating ulcer.

Unbearable pain (mostly by night).

Torpid evolution.

No peripheral pulses.

No foot gangrene.

Arterial hypertension.

No cognitive deterioration.

Remote possibilities of cure.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

Mixed chronic leg ulcer

Venous ulcer in origin


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

Mixed chronic leg ulcer

Martorell’s arteriolar hypertensive ulcer in origin


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

PATHOGENESIS

A) SVI and/or DVI chronic venous ulcer physiologic

senescence arteriosclerosis arterial hypertension

arteriolosclerosis diabetes (?) extreme impairment of

macro and micro circulation skin hypoxia of foot

and leg mixed chronic leg ulcer.

B) Chronic Martorell’s arteriolar hypertensive ulcer without

venous pathology physiologic senescence

arteriosclerosis arterial hypertension arteriolosclerosis

diabetes (?) extreme impairment of macro and micro

circulation skin hypoxia of foot and leg

mixed chronic leg ulcer.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

RECENT WORK CONCERNING ULCER HEALING

  • Increased leukocyte activation

  • Metalloproteinase inhibitors

  • Fibroblasts senescence

  • Degradation of angiogenic mediators

  • (growth factor ß1)

  • Antiendothelian cell antibodies

  • Plasminogen activation with proteolitic activity

  • High rate of antithrombin deficiency.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

LEG ULCER PALLIATIVE CARE (LUPC) PROGRAM

  • Oral and written information to patient and family about

  • the disease and its remote possibility of cure.

  • Self ulcer dressing at home: silver sulfadiazine or chloranfenicol

  • ointments alternatively twice a day, 30 mmHg elastic bandage.

  • Weekly visit to the Ulcer Clinic: necrotic tissue debridement,

  • denudated tendon resection (if any), medical treatment control.

  • Treatment of pain (progressive steps following pain intensity).

  • Avoid complex and vain diagnostic and therapeutic methods.

  • Eliminate unrealistic expectation of healing.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

PATIENTS

Study period: April 1990 – October 2002

Patients Number Age on entering Standard Error

the program

Total 132

Women 93 74,5 years 1,4 years

p = NS

Men 37 71,7 years 1,4 years


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

PATIENTS

SURVIVAL RATE

Actuarial analysis (Kaplan-Meier)

Patients: 132

Deceased: 58

Censored: 74

amputees: 5

lost in the follow-up: 46

end of study: 23


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

PATIENTS

CASE-CONTROL STUDY

FROM RANDOMIZED CAPTIVE POPULATION

Actuarial analysis (Kaplan-Meier, Wilcoxon)

Study group: 78 patients.

Control group: 78 individuals matched by

gender and age on entering

the palliative program.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

p = NS


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

RESULTS

  • Satisfactory patient/family treatment compliance.

  • Adequate pain management.

  • Cellulitis with hospitalization: 11 patients (8,3%).

  • Desertion from program with ulterior reentry:

  • 11 patients (8,3%).

  • Actuarial survival: 1st year: 93%, 6th year: 53%,

  • 12th year 0%.

  • Median survival: 7,2 years.

  • Treatment cost: $152 patient/month.

  • No survival difference between patients with

  • mixed leg ulcer and general population.


Mixed chronic leg ulcer palliative treatment results on 132 patients enrique g bertranou jos antonio oli

CONCLUSIONS

  • Patient/family compliance of leg ulcer

  • palliative care program resulted in adequate

  • ulcer maintenance and satisfactory pain control.

  • 2) The patient survival rate was high despite

  • the presence of MCLU.

  • 3) No survival rate difference between patients

  • and controls.

  • 4) Leg ulcer palliative care program offer quality of life

  • on these incurable patients.

  • 5) MCLU management with complex diagnostic

  • and therapeutic methods is futile.


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