The Slow Art & Science of Healing Leg Ulcers

Simon Curtis - Wednesday, October 18, 2017

Getting Mary Back to Goa

It is great when patients show their appreciation and they often do, but sometimes the difference that we have made is tangible. It took about 4 months to heal Mary’s leg wound and when it healed I was as pleased as she was. She gave me a hug and some tomatoes and courgettes from her garden. She is 80 years old and a widow, full of life and adventure. She had injured her leg in Goa while on holiday, a traumatic wound from an accident as she stepped onto a boat, an L shaped skin flap laceration that stretched from below her knee to just above the ankle. She presented about 10 days after the accident with black sutures, like liquorice bootlaces holding the wound together.

My colleague called me in to have a look, with her back to the patient she pulled a face that suggested ‘OMG!’ The sutures were holding the vertical part of the wound but the horizontal was covered with black eschar and beginning to gape, a number of the sutures were flapping about doing nothing. The wound didn’t look infected but the leg was swollen. I told Mary that I wasn’t sure we could heal this in primary care and that plastics might be an option. I explained to Mary that I thought we should try to treat this with compression, it didn’t look like a venous leg ulcer but I was hopeful that the mechanism that allowed compression to heal venous leg ulcers might work here. Mary, bless her, had faith in us!

The doppler result gave us an ABPI of 0.9 so, with the sutures out, we started short stretch compression, over a simple non adhesive dressing with some padding to absorb the exudate. We were seeing her twice a week. After four weeks we had some improvement but the lower part of the wound was sloughy and the black eschar, although reduced ,in size was still there. Actiform Cool® (marmalade to Mary) helped hydrate the eschar and de slough the wound. It took weeks but there was a little improvement each time. We got to a point when the exudate was minimal and we changed to the Activa® hosiery kit which give the same amount of compression as a two layer bandage but meant Mary could share the management of the wound but more importantly enabled her to shower without an ungainly cover to protect her leg. We moved to weekly appointments with Mary replacing the primary dressing and stockings in between. The Venus IV study (2014) found that this hosiery kit healed ulcers at the same rate as 4 layer compression and that recurrence rates were lower.

Progress was painfully slow and although Mary didn’t say that she was discouraged her face let us know. Then finally the day came, my colleague who had shared the management of this wound with me called me in for Mary to declare that her wound was healed. This is when we got the garden produce and the hug. “By the way’ said Mary ‘ I have booked to go back to Goa next year!”

Lucy Hamilton

Nurse Practitioner and Educator on the NB Medical Primary Care Nurses Course


Subclinical Hypothyroidism in the Elderly - A Small Victory in Addressing Overdiagnosis

Hot Topics - Thursday, October 12, 2017
New England Journal of Medicine June 2017

 

Florence is 82. She’s starting to get a bit frail, lives out in the countryside and getting to the surgery can be difficult. She’s on a couple of antihypertensives and a couple of inhalers for her COPD and has had some blood tests for mild cognitive impairment. She sleeps a bit more in the day time (so will I if I get to 82). Her TSH comes back at 7.5 with a normal T4. What do we do? First thought ‘rats, why did I do the TFT in the first place’.

I’m sure we have all been reading a lot about overdiagnosis and overtreatment over the past cou- ple of years, and one of the aspects that has really hit home with me is the idea of the ‘treatment burdens’ we place on patients. Not just medications, but testing, appointments etc. We have for many years been pushed down the path of ever increasing testing, monitoring and treatment, mainly based on evidence that was often not really applicable to the real world patients we are seeing in General Practice. We have known for some time we are just doing too much ‘stuff’ to our patients for minimal gains but have felt duty bound to ‘follow the guidelines’.

However, the recent NICE guideline on multimorbidity has been a total game changer in my view. It has given us the backing to make those judgement calls on whether testing or treating the patient in front of us is really going to improve their quality of life or not. One of the difficulties though is that the evidence base on when NOT to treat is still in it’s infancy.

However, one small victory came in the shape of an RCT published in the NEJM in June 2017 looking at subclinical hypothyroidism in the elderly. Richard Lehman in his blog nicely suggested that ‘the thyroid gland could be described as the playground of overdiagnosis’. It was an RCT of >700 patients >65 years old with subclinical hypothyroidism (TSH 4.6 to <20 with normal T4). They were randomised to treatment aiming for normal TSH levels, or placebo (which also had sham blood tests and dose adjustments). At 1 year there was no difference in either hypothyroid symptom score or tiredness score.

So back to Florence and what we do about her subclinical hypothyroidism. Previously I would have been tempted to treat it just in case it was causing the cognitive impairment, but let’s be honest, it’s much more likely to be age related and/or vascular as she was a heavy smoker. Given the backing of the multimorbidity guideline I’m now not going to increase her treatment burden by adding more pills, and the hassle of another half a dozen appointments for blood tests and follow- ups, for something that is highly unlikely to improve her quality of life. I’m going to suggest we just watch and wait and check it again as part of her annual review next year.


Dr. Rob Walker

Locum Organiser