The thesis explores chronic leg ulceration experienced by young people who inject drugs (PWID). The applied health research study, in two phases, used a sequential explanatory mixed methods design. Phase 1 involved a survey of 200 people who injected drugs to investigate the prevalence of skin problems and leg ulceration, together with the identification of risk factors for ulceration. Phase 2 involved a series of fifteen qualitative semi-structured interviews that explored the results relating to risk factors with a sample of PWID who had experienced leg ulceration, and investigated participants’ perceptions of appropriate harm reduction methods. Main findings There were three research questions in this study: 1) What is the extent of skin problems and chronic leg ulceration in young people who inject drugs? The study identified a high prevalence of leg ulceration as 15%. 60% of the sample had experienced a skin problem. Each reported skin complication is clearly defined. 2) What causes chronic leg ulceration in young people who inject drugs? Leg ulceration experienced by PWID in this study was directly linked to deep vein thrombosis (DVT), as well as injecting in the groin and the leg. DVT was strongly associated with groin and leg injecting. The acceptance amongst injectors of the groin and leg as a site of choice has occurred with a lack of awareness of the long-term consequences of damage to the limb. 3) What are appropriate harm reduction measures in young people who inject drugs? Harm reduction methods related to the development of leg ulceration have been absent across schools and drug services. Training for healthcare workers which enables them to identify risk factors should be developed, and harm reduction information related to leg ulceration should be included in drug education within schools, and instigated within drugs services. This applied health research has led to a number of practice-focused recommendations surrounding clinical care including early detection of venous insufficiency and accessible services to prevent, assess, and treat venous disease in PWID. The original contribution to knowledge is three-fold: 1. Leg ulcers have been found to be highly prevalent in young people who inject drugs. 2. Ulceration is predominantly caused by venous thrombosis due to injecting in the legs or groin. 3. Harm reduction related to the development of venous disease has lacked impact and effect.

Chronic venous disease (CVD) affects about 0.5 to 3.0% of the population. The venous ulcer (UV) is the most advanced stage of CVD and affects the patient-age, worsening their quality of life and burdens the welfare system. Venous reflux is related to the genesis, development and maintenance of UV. To evaluate venous reflux in patients with UV. A cross-sectional study was performed, observational Vascular Surgery Service at the Federal University of Sergipe - Aracaju-SE, in a sample of 162 patients with active UV divided into two groups for evaluation of reflux: G1 (primary etiology) and G2 ( etiopathogenesis secondary) seen consecutively in the period of 03 / 2009-10 / 2010. Five patients were excluded because they had chronic ischemia, because they have two non-recanalized vein thrombosis and one for being pregnant. We investigated the age, gender, distribution of venous reflux in the superficial venous system (SVS), the deep venous system (DVS) and perforating veins (PVs), location of reflux in the SVS, types of reflux in the saphenous vein (GSV ) and saphenous vein (VSP) and distribution of reflux in the DVS. Statistical method: the database and statistical analysis were performed using the SPSS 18.0. Quantitative variables were summarized as mean and standard deviation. Categorical variables were described by simple frequency and percentages with their respective confidence intervals for 95%. The mean age was 53.7 years with a predominance of women (79%). The distribution of reflux was observed that all patients in G1 had reflux in the SVS without reflux in the DVS, VPs with 92% in G2 and 83.3% had reflux in the SVS, with 100% DVS and 92.3% in the VPs. Regarding the location of reflux in the SVS group G1 showed reflux in 96% in GSV and 14% VSP and G2 showed reflux in GSV 70% and 13% in VSP. Considering the types of saphenous vein reflux in G1 90% of the type I had reflux in the GSV and 71.5% type IV in VSP in G2 while 84% of reflux in the GSV type I and type IV 85.7% in VSP. In Group G2 approximately 70% of patients had reflux in these veins of the legs and 54% in the popliteal veins. The superficial system reflux was present in all patients with primary venous insufficiency and in most patients with secondary failure. The finding most often found in the superficial venous system was the GSV reflux. The reflux in the GSV type I and type IV reflux in VSP findings were more often found in the superficial venous system of patients in both groups. Approximately 70% of deep venous reflux was located in the leg, the popliteal vein being the most frequently affected. / A doença venosa crônica (DVC) atinge cerca de 0,5 a 3,0% da população. A úlcera venosa (UV) é o estágio mais avançado da DVC e atinge o paciente em idade produtiva, piora a sua qualidade de vida e onera o sistema previdenciário. O refluxo venoso está relacionado com a gênese, desenvolvimento e manutenção da UV. Avaliar o refluxo venoso nos portadores de UV. Realizado estudo de corte transversal, observacional no Serviço de Cirurgia Vascular da Universidade Federal de Sergipe - Aracaju SE, em amostra de 162 pacientes com UV em atividade dividida em dois grupos para avaliação do refluxo: G1 (etiopatogenia primária) e G2 (etiopatogenia secundária) atendidos consecutivamente no período de 03/ 2009 a 10/ 2010. Foram excluídos cinco pacientes por apresentarem isquemia crônica, dois por apresentarem trombose venosa não recanalizada e um por estar gestante. Foram pesquisadas as variáveis idade, gênero, distribuição do refluxo venoso no sistema venoso superficial (SVS), no sistema venoso profundo (SVP) e em veias perfurantes (VPs); localização do refluxo no SVS; tipos de refluxo na veia safena magna (VSM) e em veia safena parva (VSP) e distribuição do refluxo no SVP. Método estatístico: o banco de dados e a análise estatística foram efetuados no programa SPSS 18.0. As variáveis quantitativas foram sumarizadas como média e desvio-padrão. As variáveis categóricas foram descritas mediante frequência simples e porcentagens com seus respectivos intervalos de confiança para 95%. A idade média foi de 53,7 anos com predomínio de mulheres (79%). Quanto a distribuição do refluxo observou-se que no G1 todos pacientes apresentaram refluxo no SVS, sem refluxo no SVP, com 92% em VPs e no grupo G2 83,3% tinham refluxo no SVS, com 100% no SVP e 92,3% VPs. Em relação a localização do refluxo no SVS do grupo G1 96% apresentaram refluxo em VSM e 14% em VSP e do G2 70% apresentaram refluxo em VSM e 13% em VSP. Considerando os tipos de refluxo em veias safenas no G1 90% apresentaram refluxo do tipo I em VSM e 71,5% do tipo IV em VSP enquanto que no G2 84% de refluxo do tipo I em VSM e 85,7% do tipo IV em VSP. No Grupo G2 aproximadamente 70% dos pacientes apresentaram refluxo em veias de pernas e destes 54% em veias poplíteas. O refluxo no sistema superficial esteve presente em todos os pacientes com insuficiência venosa primária e na maioria dos pacientes com insuficiência secundária. O achado mais frequentemente encontrado no SVS foi o refluxo VSM. O refluxo tipo I em VSM, bem como o refluxo tipo IV em VSP foram os achados mais frequentemente encontrados no SVS de pacientes dos dois grupos. Aproximadamente 70% do refluxo venoso profundo estava localizado na perna, sendo a veia poplítea a mais frequentemente acometida.

Objetivo: Comparar o tratamento cirúrgico convencional das varizes de membros inferiores com a escleroterapia com espuma ecoguiada nos pacientes com úlcera venosa. Como objetivo secundário, foi comparada a incidência de complicações com os métodos empregados e a melhora na qualidade de vida após a realização dos procedimentos. Casuística e Métodos: Foi realizado um estudo randomizado e prospectivo de 49 pacientes com úlceras ativas (C6), que foram submetidos ao tratamento cirúrgico (28 membros) ou escleroterapia espuma (23 membros), tendo como desfechos a cicatrização de úlceras de origem venosa, complicações do tratamento e qualidade de vida,. Os pacientes completaram o Questionário Aberdeen Veias Varicosas (QAVV), o escore de severidade clínica venoso (ESCV) e o Escore de Incapacidade Venosa (EIV). Resultados: A média e desvio padrão de acompanhamento foi de 502 ± 220 dias. A úlcera cicatrizou em 100% e 91,3% dos doentes tratados com cirurgia ou escleroterapia espuma, respectivamente (P > 0,05). QAVV, ESCV e EIV melhoraram em ambos os grupos após o tratamento. Não houve diferenças significativas no resultado final do QAVV, ESCV e EIV entre os dois grupos, vários meses após os procedimentos (p = 0,45, 0,58 e 0,66, respectivamente; Mann- Whitney U). As complicações ocorreram em 14,2% e 13,0% nos grupos cirúrgico e escleroterapia com espuma, respectivamente. Conclusão: A escleroterapia com espuma não foi inferior ao tratamento cirúrgico de úlceras venosas. Portanto a escleroterapia é uma alternativa ao tratamento cirúrgico, particularmente adequada para pacientes de alto risco cirúrgico que apresentam insuficiência venosa avançada e úlcera ativa / Objective: To compare the results of varicose vein treatment using ultrasoundguided foam sclerotherapy versus conventional surgery in patients with venous ulcers. As a secondary outcome, we compared the incidence of complications related to the employed technique and improvements in quality of life after the procedures. Methods: A randomized and prospective study was conducted in 49 patients with active venous ulcers (C6), submitted to surgical treatment (28 limbs) or foam sclerotherapy (23 limbs). The primary outcomes analysed included healing of venous ulcer, treatment complications and improvements in quality of life. All patients completed the Aberdeen Varicose Veins Questionnaire (AVVQ), the Venous Clinical Severity score (VCSS) and Venous Disability Score (VDS). Results: The mean and standard deviation follow-up was 502 ± 220 days. Ulceration healing was observed in 100% and 91.3% of patients treated with surgery or foam sclerotherapy, respectively (P > 0.05). AVVQ, VCSS and VDS improved in both groups following treatment. There were no significant differences in AVVQ, VCSS and VDS between the two groups several months after the procedures (p = 0,45, 0.58 and 0.66, respectively; Mann-Whitney U test). Complications occurred in 14.2% and 13.0% in the surgical and foam sclerotherapy groups, respectively. Conclusion: Sclerotherapy was non-inferior to surgical treatment in the management of venous ulcers. Therefore sclerotherapy can be considered an alternative to surgical treatment, especially in high surgical risk patients presenting with advanced venous insufficiency and an active ulcer

Objetivo: Comparar o tratamento cirúrgico convencional das varizes de membros inferiores com a escleroterapia com espuma ecoguiada nos pacientes com úlcera venosa. Como objetivo secundário, foi comparada a incidência de complicações com os métodos empregados e a melhora na qualidade de vida após a realização dos procedimentos. Casuística e Métodos: Foi realizado um estudo randomizado e prospectivo de 49 pacientes com úlceras ativas (C6), que foram submetidos ao tratamento cirúrgico (28 membros) ou escleroterapia espuma (23 membros), tendo como desfechos a cicatrização de úlceras de origem venosa, complicações do tratamento e qualidade de vida,. Os pacientes completaram o Questionário Aberdeen Veias Varicosas (QAVV), o escore de severidade clínica venoso (ESCV) e o Escore de Incapacidade Venosa (EIV). Resultados: A média e desvio padrão de acompanhamento foi de 502 ± 220 dias. A úlcera cicatrizou em 100% e 91,3% dos doentes tratados com cirurgia ou escleroterapia espuma, respectivamente (P > 0,05). QAVV, ESCV e EIV melhoraram em ambos os grupos após o tratamento. Não houve diferenças significativas no resultado final do QAVV, ESCV e EIV entre os dois grupos, vários meses após os procedimentos (p = 0,45, 0,58 e 0,66, respectivamente; Mann- Whitney U). As complicações ocorreram em 14,2% e 13,0% nos grupos cirúrgico e escleroterapia com espuma, respectivamente. Conclusão: A escleroterapia com espuma não foi inferior ao tratamento cirúrgico de úlceras venosas. Portanto a escleroterapia é uma alternativa ao tratamento cirúrgico, particularmente adequada para pacientes de alto risco cirúrgico que apresentam insuficiência venosa avançada e úlcera ativa / Objective: To compare the results of varicose vein treatment using ultrasoundguided foam sclerotherapy versus conventional surgery in patients with venous ulcers. As a secondary outcome, we compared the incidence of complications related to the employed technique and improvements in quality of life after the procedures. Methods: A randomized and prospective study was conducted in 49 patients with active venous ulcers (C6), submitted to surgical treatment (28 limbs) or foam sclerotherapy (23 limbs). The primary outcomes analysed included healing of venous ulcer, treatment complications and improvements in quality of life. All patients completed the Aberdeen Varicose Veins Questionnaire (AVVQ), the Venous Clinical Severity score (VCSS) and Venous Disability Score (VDS). Results: The mean and standard deviation follow-up was 502 ± 220 days. Ulceration healing was observed in 100% and 91.3% of patients treated with surgery or foam sclerotherapy, respectively (P > 0.05). AVVQ, VCSS and VDS improved in both groups following treatment. There were no significant differences in AVVQ, VCSS and VDS between the two groups several months after the procedures (p = 0,45, 0.58 and 0.66, respectively; Mann-Whitney U test). Complications occurred in 14.2% and 13.0% in the surgical and foam sclerotherapy groups, respectively. Conclusion: Sclerotherapy was non-inferior to surgical treatment in the management of venous ulcers. Therefore sclerotherapy can be considered an alternative to surgical treatment, especially in high surgical risk patients presenting with advanced venous insufficiency and an active ulcer