Healing of Venous ulcers and cost of therapy


The treatment of venous leg ulcers (VLU) represents 23% of new patient visits and 36% of all patient visits in vascular surgery practice. Depending on the age of the patient cohort, VLU affects between 0.2% and 1% of the population.1 In first world countries, the treatment of VLU may represent a maximum of 3% of health care expenditures.2 Presently, the standard of care for VLU remains compression therapy, in many cases Unna’s boot, but ideally multilayer wraps.3 With this current treatment, healing rates in patients with normal arterial perfusion is reported to be between 63% at 10 weeks retrospectively and 33% at 12 weeks prospectively.[4] and [5] Overall, annual direct costs for the treatment of VLU are in the range of $30,000 per patient per annum, with only 60-80% of them healing at 6 months. Dr O’Donnell has accurately pointed out that “any treatment modality improving VLU healing time or proportion healed would reduce the burden of VLU care.”6


Others have noted that a maximum of 15% of the limbs affected by VLU observed in large volume vascular practices have an ankle–brachial index (ABI) of <0.8.4 Patients with an ABI of <0.8 were noted to take 19 weeks to heal 50% of their ulcers as compared with 9 weeks taken by the normally perfused group. In another study, which evaluated the closure rate of mixed arterial venous ulcers, the closure rate for the standard of care arm at 16 weeks was 46.2% as compared with the 82.6% in the cohort treated with porcine-derived intestinal submucosa (SIS) (Cook Medical Inc., Bloomington IN).7 A 2004 study conducted in the United Kingdom reported that 13.6% of patients presenting with VLU had an ABI of 0.5-0.85 and 2.2% had an ABI of <0.5.8 M.L. Humphreys, A.H. Stewart and M.S. Gohel et al., Management of mixed arterial and venous leg ulcer, Br J Surg 94 (2007), pp. 1104–1107. View Record in Scopus Cited By in Scopus (9)8 Therefore, to assess the effect of intervening percutaneously on the arterial circulation of patients with mixed arterial venous disease who were dependent on compression therapy. This therefore excluded the few patients who had mixed arterial venous disease with easily correctable, superficial-only venous reflux. The hypothesis was that improving or “normalizing” the lower extremity perfusion, as assessed by ABI and pulse volume recordings (PVRs), would normalize the healing trajectory of this hard-to-close patient subset. Few others have applied this protocol selectively but with a large proportion of patients who underwent arguably more morbid open procedures.8

Second - hand smoking and mortality

Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. This exposure was estimated to have caused 379 000 deaths from ischaemic heart disease, 165 000 from lower respiratory infections, 36 900 from asthma, and 21 400 from lung cancer. 603 000 deaths were attributable to second-hand smoke in 2004, which was about 1·0% of worldwide mortality. 47% of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men. DALYs lost because of exposure to second-hand smoke amounted to 10·9 million, which was about 0·7% of total worldwide burden of diseases in DALYs in 2004. 61% of DALYs were in children. The largest disease burdens were from lower respiratory infections in children younger than 5 years (5 939 000), ischaemic heart disease in adults (2 836 000), and asthma in adults (1 246 000) and children (651 000).

The Lancet, Volume 377, Issue 9760, Pages 139 - 146, 8 January 2011