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MIXED CHRONIC LEG ULCER Palliative treatment results on 132 patients Enrique G. Bertranou José Antonio Oliven

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 Oliven

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  1. 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

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. Mixed chronic leg ulcer Venous ulcer in origin

  7. Mixed chronic leg ulcer Martorell’s arteriolar hypertensive ulcer in origin

  8. 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.

  9. 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.

  10. 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.

  11. 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

  12. 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

  13. 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.

  14. p = NS

  15. 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.

  16. 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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