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Eur J Vasc Endovasc Surg 24, 249±254 (2002) doi:10.1053/ejvs.2002.1650, available online at http://www.idealibrary.com on

Outcome of Venous Stasis Ulceration when Complicated by Arterial Occlusive Disease

W. T. Bohannon, R. B. McLaffertyÃ, S. T. Chaney, M. A. Mattos, L. A. Gruneiro, D. E. Ramsey and K. J. Hodgson

Division Vascular Surgery, Department of Surgery, Southern Illinois University, School of Medicine, Springfield, Illinois, U.S.A.

Objective: to report the outcome of patients with venous stasis ulceration (VSU) and severe arterial occlusive disease (AOD). Design: retrospective study. Methods: using the International Classification of Diseases (ICD-9), codes for VSU and AOD were cross-matched to identify patients from 1989 to 1999 at two tertiary hospitals. Entry into the study required the presence of a VSU and an ipsilateral procedure to improve AOD or major amputation during the same hospitalisation. Results: fourteen patients (15 extremities) with a mean age of 80 years (range: 47±93) were identified as having VSU and AOD. Mean duration of VSU up to the time of revascularisation or amputation was 6.4 years (range: 4 months±21 years). The mean number of VSUs per extremity was 2.1 and mean wound area was 71 cm2. Mean ankle±brachial index was 0.46 (range: 0.10±0.78). Nine extremities (60%) had a bypass procedure, 3 (20%) had an interventional procedure, 1 (0.6%) had a lumbar sympathectomy, and 2 (13%) had an amputation. Over a mean follow-up of 2.8 years, 3 extremities (23%) healed of which 2 recurred. On last review, 11 patients with 12 afflicted extremities had expired. Nine of the remaining 10 extremities were not healed at the time of death. Eight of nine bypass grafts remained patent in follow-up or at death and subsequent limb salvage was 100%. Conclusions: combined VSU and AOD represents a rare condition predominantly found in elderly patients with multiple comorbidities. Few patients had complete healing despite an arterial inflow procedure and mortality was high over the short term.

Key Words: Venous stasis ulcer; Arterial occlusive disease; Outcome.

Introduction therapy for VSU may not be possible until improved arterial perfusion is provided.18,19 Knowledge as to Lower extremity ulceration arising from chronic ven- the outcome of patients with VSU and AOD necessi- ous insufficiency afflicts as much as one per cent of tating a procedure to improve arterial inflow remains the adult population.1±3 Although various surgical limited. Herein, we report the long-term outcome of interventions are available for treatment,4±11 the large patients with these two morbid conditions. majority of patients are prescribed some form of elastic compression.12,13 Healing often occurs with compliance but unfortunately recurrence rates for venous stasis ulceration (VSU) remain as high as Patients and Methods 60%.12,14 Other factors such as poor nutrition, immunosuppression, and ulcer size, may contribute A retrospective chart review was performed at to VSUs becoming recalcitrant.15,16 Additionally, the Memorial Medical Center and St John's Hospital in presence of arterial occlusive disease (AOD) from Springfield, Illinois. Each hospital functions as may further complicate healing.17,18 tertiary referral center for Central and Southern Depending on the severity of AOD, compression Illinois as well as the primary teaching hospitals for Southern Illinois University, School of Medicine. Patients were identified by using the International à Please address all correspondence to: R. B. McLafferty, Assistant Professor of Surgery, Division of Vascular Surgery, PO Box 19638, Classification of Diseases, 9th Revision (ICD-9). As Springfield, Illinois 62794-9638, U.S.A. required by the Centers for Medicare and Medicaid

1078±5884/02/030249 ‡ 06 $35.00/0 # 2002 Published by Elsevier Science Ltd 250 W. T. Bohannon et al.

Services for the purposes of reimbursement and data Patients with concomitant severe AOD were collection for each hospital, all ICD-9 codes are defined as those undergoing a procedure to improve applied to every patient's discharge by registered arterial circulation or having an amputation. Add- health information technicians in the Department of itionally, at least one objective test documenting the Medical Records. In order to identify patients with severity of AOD prior to the procedure was required concomitant VSU and AOD at the same hospital for inclusion. These included ankle±brachial index discharge, a list of patients was computer generated (ABI), toe pressures, arterial duplex mapping, or (St. John's Hospital: Chart Stat, SoftMed; Memorial arteriography. Pulse examination was not considered Medical Center: Crystal Applications, Seagate) where- an objective assessment. Demographic data, risk fac- by ICD-9 codes applicable to chronic venous insuffi- tors, functional status, and other signs and symptoms ciency and atherosclerosis of the lower extremity pertinent to AOD were recorded. were cross-matched in all combinations for hospital Follow-up information was obtained by continued discharges between 1989 and 1999. Multiple codes review of subsequent inpatient and outpatient were used in order to maximise the ability to find records. Final follow-up was performed by telephone patients with both conditions at the same hospital interview with the patient. If the patient was deceased discharge. Table 1 shows the ICD-9 codes used for or not able to be interviewed, persons noted in the cross-matching. medical record as a patient contact were interviewed if After patient identification by having at least one possible. Follow-up information included ulcer heal- ICD-9 code related to venous insufficiency and ath- ing and recurrence, durability of arterial inflow pro- erosclerosis of the lower extremity, charts were com- cedure, functional status, and disposition. pletely reviewed by the senior author (R.B.M.) or the vascular surgery fellow (W.T.B) for patients hospita- lised with an active VSU and the presence of AOD Results during the same hospitalisation. VSU was defined by the presence of ulceration at or near the medial or From 1989 to 1999, a total of 456 199 patients were lateral malleoli. Information as to the presence of discharged from Memorial Medical Center and edema, hyperpigmentation, stasis , and St. John's Hospital. Of these, ICD-9 cross-matching lipodermatosclerosis was sought. To increase the identified 367 patients with concomitant codes related likelihood of a clinical diagnosis of VSU, at least two to chronic venous insufficiency and atherosclerosis of these additional signs had to be present. Other of the lower extremity. Review of these charts re- information obtained regarding the patient's venous vealed 14 patients (15 extremities) as having VSU disease included pertinent demographic data, risk and an arterial inflow procedure or amputation for factors, and ulcer size and duration. Patients with severe AOD during the same hospitalisation. Mean ulcers secondary to trauma, caused by primary infec- age was 80 years (range: 47±93) and nine patients tion, or thought to be solely related to diabetes melli- (64%) were female. Four patients (29%) had a remote tus were excluded. history of lower extremity deep venous , 3 (21%) had a remote history of varicose stripping, and 4 (29%) had a remote history of lower extremity trauma. Nine patients (64%) smoked, 12 (86%) had , 5 (36%) had diabetes mellitus, 4 (29%) Table 1. ICD-9Ã codes applicable to chronic venous insufficiency had hyperlipidaemia, 2 (12%) had chronic renal insuf- and atherosclerosis of the lower extremity. ICD-9 codes were ficiency (baseline creatinine 4 2.5 mg/dl), and 10 cross-matched in all combinations. (71%) had coronary disease. Mean duration of ICD-9 codes: chronic venous insufficiency VSU up to the time of arterial inflow procedure or Varicose of lower extremity with ulcer 454.0 amputation was 6.4 years (range: 4 months±21 of lower extremity with 454.1 Postphlebitic syndrome 459.1 years). Mean VSUs per extremity was 2.1 with a Venous insufficiency 459.81 mean wound area of 71 cm2 (range: 1.8±360 cm2). Chronic ulcer of skin, lower limb, except decubitus 707.1 Four extremities (27%) had ipsilateral toe ulceration. Chronic ulcer of other specified site 707.8 Chronic ulcer of unspecified site 707.9 Objective measurement of AOD prior to arterial in- ICD-9 codes: atherosclerosis of the lower extremity flow procedure or amputation included ABI in Atherosclerosis of native of the extremities 440.2 12 extremities, toe pressures in 9 and arteriography Atherosclerosis of bypass graft of the extremities 440.3 in 13. Table 2 shows results of tests measuring arterial Peripheral vascular disease, unspecified 443.9 insufficiency before and after arterial inflow proced- Ã ICD-9 International Classification of Diseases, 9th revision. ure or amputation.

Eur J Vasc Endovasc Surg Vol 24, September 2002 Venous Stasis Ulceration and Arterial Occlusive Disease 251

Table 2. Diabetes status, non-invasive vascular testing, arteriogram findings, and type of arterial inflow procedure or amputation for each patient with concomitant venous stasis ulcer and severe atherosclerotic occlusive disease of the lower extremity. Patient LJ is shown twice because both extremities were affected.

Patient (age) Diabetes Pre-ABI/ Arteriogram findings Inflow procedure/ Post-ABI/ toe pressureà amputation toe pressuresy

FA (86) yes 0.61/31 Popliteal artery occlusion Femoral±popliteal bypass none/67 WB (77) no None/none Superficial femoral artery occlusion Femoral±popliteal bypass none/none KB (47) no 0.48/30 Common iliac , 90% PTAz 1.08/80 VB (91) no 0.55/28 Superficial femoral artery stenosis, 70% Femoral±popliteal bypass none/66 popliteal artery stenosis, 50% diffuse tibial artery stenoses BG (83) yes 0.0/14 Diffuse tibial artery stenoses PTA (failed) 1.06/84 popliteal±tibial bypass LJ (82) no 0.3/none Common femoral artery stenosis, 50% Femoral±tibial bypass 1.20/100 superficial femoral artery occlusion diffuse tibial artery stenoses LJ (82) no 0.3/none Common femoral artery stenosis, 30% Femoral±tibial bypass 1.10/90 superficial femoral artery stenosis, 90% diffuse tibial artery stenoses RK (63) no 0.83/0 Superficial femoral artery occlusion Femoral±popliteal bypass 0.94/60 MK (91) no None/none Superficial femoral artery stenosis, 90% Lumbar sympathectomy None/none popliteal artery stenosis, 90% LM (76) yes 0.4/30 Diffuse tibial artery stenoses Femoral±tibial bypass 0.55/24 JR (77) no 0.45/15 Superficial femoral artery stenosis, 90% Femoral±popliteal bypass None/none BW (77) yes 0.78/76 Common iliac stenosis, 70% PTAz 0.80/85 DW (83) yes NC/none Superficial femoral artery stenosis, 95% PTAz, lumbar sympathectomy NCx/63 diffuse tibial artery stenoses CW (88) no 0.4/24 Superficial femoral artery stenosis, 95% Above knee amputation Not applicable MZ (93) no 0.5/none None Above knee amputation Not applicable

à pre-ABI ˆ ankle±brachial index prior to arterial inflow procedure or amputation, toe pressures measured in mmHg. y post-ABI ˆ ankle±brachial index after arterial inflow procedure or amputation (same hospitalisation), toe pressures measured in mmHg. z PTA ˆ percutaneous transluminal angioplasty. x NC ˆ non-compressible.

Twelve patients had a procedure to improve postoperatively and failed thrombolysis. Of those arterial inflow and 2 patients underwent above patients undergoing only PTA, one had a repeat knee amputation. Of the 12 patients (13 extremities) superficial femoral artery PTA one month later. No having an arterial inflow procedure, 9 had a bypass patient who had an arterial inflow procedure went (7 with vein, 2 with synthetic graft), 4 had a percutan- on to amputation at last follow-up or death. At last eous transluminal angioplasty (PTA), and 2 had a follow-up, 11 of 14 patients were dead and of those lumbar sympathectomy. One patient failed PTA of 12 who had an arterial inflow procedure, only one the tibioperoneal trunk and underwent bypass. had permanent VSU healing. This patient died with One patient had a lumbar sympathectomy following a healed extremity and no recurrence. Mean time to PTA during the same hospitalisation. Table 2 shows death was 33 months (range: 3±132 months). Causes of the type of bypass and location of PTA for each death included myocardial infarction in 3 patients, patient. congestive heart failure in 2 patients, pulmonary em- Over a mean follow-up of 2.8 years (range: 0.25±11 bolism in one patient, stroke in one patient, and years), complete VSU healing occurred in only sepsis from an infected VSU in one patient. Cause of 3 extremities (3 patients, 21%). Two of these extrem- death in the remaining 3 patients could not be ities experienced recurrent ulceration. The patient determined. The youngest patient who underwent who remained healed at last follow-up had moderate a common iliac artery PTA was lost to follow-up arterial insufficiency and underwent common iliac (patient KB, Table 2). artery PTA (patient BW, Table 2). At last follow-up or Prior to arterial inflow procedure or amputation, death (mean: 2.8 years), 8 of 9 bypasses were patent. 12 of 14 patients were ambulatory of which 8 required Two bypasses occluded in follow-up. One bypass a walker or cane. Following recovery from an arterial occluded 4 months postoperatively and underwent inflow procedure, two patients no longer required successful thrombolysis and PTA of a common iliac a walker or cane and one patient who could walk stenosis and the other bypass occluded 10 months independently required a walker. At last follow-up

Eur J Vasc Endovasc Surg Vol 24, September 2002 252 W. T. Bohannon et al. or death, 5 patients were ambulatory of which inflow procedure. Thirty-six week healing rates in 3 required a walker. these two groups were 64% and 23% respectively. Prior to arterial inflow procedure or amputation, The large majority of patients in our study had severe 10 patients lived at home, 2 resided in an assisted arterial insufficiency as defined by Ghauri et al. living facility resided, and 2 were cared for in a skilled and healing was equally poor. Other studies have nursing facility. Both patients who underwent shown a similar prevalence of AOD complicating amputation lived in a skilled nursing facility before VSU. Callam et al. demonstrated in a large study and after the procedure. During recovery after an population that 19% of proximal leg ulcers had con- arterial inflow procedure (n ˆ 12 patients), 3 patients comitant arterial insufficiency (ABI 5 0.9) and of required a skilled nursing facility and 4 had profes- those patients with arterial impairment and ulcer- sional home health care. The two patients who were ation, 52% had other physical signs of chronic venous in an assisted living facility prior to the procedure insufficiency.22 Nelzen et al., in a large cross-sectional were discharged to a skilled nursing facility. At last population study designed to determine the aetiology follow-up or death, 8 of 14 resided in a skilled of chronic leg ulceration (n ˆ 463 extremities), found nursing facility of which 6 patients declined in their that 72% had venous insufficiency and 40% had arter- disposition status. ial insufficiency (ABI 5 0.9), thus representing an overlap of 12%.3 Compared to other studies examining the natural Discussion history of VSU,6,13±15 patients in this study with com- bined disease were predominantly older (mean age: Treatment of VSU can be time consuming, expensive, 80 years) with a higher mortality (mean time to death and frustrating for both the patient and physician.15,20 of 11/14 patients: 33 months). Interestingly, patients Although various surgical procedures are avail- solely with limb-threatening AOD also are younger able to assist in healing a VSU,4±11,21 the mainstay of with better survival than this small cohort of pat- therapy remains elastic compression because of ients with combined disease.22 Callam et al. noted in equivalent results in healing.12 Patients with concom- the aforementioned study that the probability of itant arterial insufficiency may not tolerate compres- having a chronic leg ulcer associated with arterial sion secondary to exacerbation of inadequate arterial insufficiency rises sharply with age.23 By the ninth perfusion that may lead to increased pain and poor decade, 50% of patients had associated arterial insuf- healing.18 Little is known about the outcome of ficiency. Another predominant feature of our pat- patients who have a VSU and severe AOD. The pur- ients was the relatively high frequency of risk factors pose of this study was to examine the patient charac- for the development of chronic venous insufficiency teristics and outcome of those with a presumed and atherosclerosis, thus supporting the potential clinical diagnosis of VSU and concomitant severe pathogenesis of both conditions over time. Diabetes AOD requiring an intervention, be it an arterial was evenly distributed among the 14 patients inflow procedure or amputation. (Table 2). Two patients had an ABI 5 0.5 while Although patients presenting solely with VSU or 2 patients had ABI 4 0.5 and 5 0.8, and 1 patient AOD of the lower extremity represent relatively had non-compressible arteries. Similarly, there was common conditions, patients afflicted with VSU and no trend as to patients with diabetes having larger severe AOD seem to be an extremely rare cohort, as ulcers and no patient with diabetes required amputa- exemplified in this study. Patients with these two tion as the initial treatment. Three patients underwent conditions represented 0.08% of all discharges at arterial bypass surgery and two had percutaneous two large tertiary care hospitals over a ten-year time transluminal angioplasty. period. Knowledge of how many patients in the com- Given the older age and multiple comorbidities of munity had VSU over the same time frame would this patient group, the poor outcome of ulcer healing provide a more accurate denominator of how fre- and high mortality over the short term is not sur- quently severe ipsilateral AOD occurs. Nevertheless, prising. Limb salvage for those patients undergoing 14 patients represent a very small group of patients an arterial inflow procedure was 100%. Ironically, having both conditions whereby a procedure was after recovery over the short term, patients continued performed for AOD. Ghauri et al. showed that of to ambulate with or without assistance. These mixed 267 consecutive extremities with VSU, 33 (12%) had results present a dilemma in deciding whether some moderate arterial insufficiency (ABI 4 0.5 and 5 0.85) patients would be better served with an amputation and 13 (5%) had severe arterial insufficiency (ABI 5 instead of an arterial inflow procedure, particularly 0.5).17 Of these 46 patients, 14 required an arterial when that procedure is bypass surgery. Defining the

Eur J Vasc Endovasc Surg Vol 24, September 2002 Venous Stasis Ulceration and Arterial Occlusive Disease 253 patient's preprocedure ambulatory status and avail- are elderly, have multiple comorbidities, and a high able ancillary support services becomes paramount in mortality during the short term. With the treatment recommending the most appropriate therapy. With of arterial inflow in this study, ulcer healing is infre- regard to ulcer healing, Marston et al. in a prospective quent but limb salvage remains high. Preprocedure study determined that the only factors to independ- ambulatory status, available ancillary services, and ently affect healing time were initial ulcer size and the patient desires may represent the most important fac- presence of moderate arterial insufficiency (ABI 4 0.5 tors in deciding whether to recommend amputation or and 5 0.8).15 Patients with severe ischaemia provide a surgical bypass. The minimal invasiveness (ABI 5 0.5) underwent revascularisation as is recom- and low risks associated with endoluminal therapies mended in our practice. Average ulcer size in should direct the physician to aggressively pursuing their study was 24.6 cm2 compared to 71 cm2 in our this treatment to improve arterial inflow if possible. study. Given that VSU healing may be dependent upon the presence of arterial occlusive disease, all patients should undergo a pulse examination. If a pedal pulse cannot be easily detected, which is not References uncommon given the possible presence of oedema 1 Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. and/or lipodermatosclerosis, an ABI should be per- Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992; 6: 245±251. formed. Taking into account other comorbidities, 2 Nelzen O, Bergqvis D, Lindhagen A. Leg ulcer etiology ± A cross sectional population study. J Vasc Surg 1991; 14: 557±564. patients with VSU and severe ischaemia (ABI 5 0.5) 3 Nelzen O, Bergqvist D, Lindhagen A. Venous and non-venous should undergo revascularisation whereas those with leg ulcers: clinical history and appearance in a population moderate ischaemia (ABI 4 0.5 and 5 0.8) require se- study. Br J Surg 1994; 81: 182±187. 4 Pierik EG, van Urk H, Hop WC, Wittins CH. Endoscopic lective revascularisation depending on VSU recalci- verses open subfascial division of incompetent perforating trance and size. veins in the treatment of venous leg ulceration: a randomized The reliability of the ICD-9 coding system to accur- trial. J Vasc Surg 1997; 26: 1049±1054. 5 DePalma R, Kowallek D. Venous ulceration: a cross-over study ately identify all patients with both diseases at dis- from nonoperative to operative treatment. J Vasc Surg 1996; 24: charge may represent one weakness of the study. 788±792. Indeed, all patients discharged with VSU were not 6 Ghauri A, Nyamekeye I, Grabs A et al. Influence of a special- ized leg ulcer service and venous surgery on the outcome of routinely evaluated for the presence of AOD. Our venous leg ulcers. Eur J Vasc Endovasc Surg 1998; 16: 238±244. goal was to examine the natural history of those 7 Masuda EM, Kistner RL. Long-term results of venous valve patients with VSU who additionally underwent arter- reconstruction: a four- to twenty-one-year follow-up. J Vasc Surg 1994; 19: 391±403. ial revascularisation or amputation because of AOD. 8 Raju S, Fredericks RK, Neglen PN, Bass JD. Durability of Other studies have used the ICD-9 coding system venous valve reconstruction techniques for ``primary'' and to identify patients with reliable results.24±26 The lack postthrombotic reflux. J Vasc Surg 1996; 23: 357±366. 9 Darke SG, Penfold C. Venous ulceration and saphenous of objective testing to measure venous insufficiency ligation. Eur J Vasc Surg 1992; 6: 4±9. such as the measurement of venous valve closure 10 Padberg FT. Surgical intervention in venous ulceration. J Cardio- times or venous refill times remains a shortcoming vasc Surg 1999; 7: 83±90. 11 Raju S, Neglen P, Doolittle J, Meydrech EF. Axillary vein of the study. Nevertheless, older reports examining transfer in trabeculated postthrombotic veins. J Vasc Surg 1999; the clinical science of VSU often relied on physical 29: 1050±1062. examination alone as non-invasive vascular labora- 12 Mayberry JC, Monetta GL, Taylor LM, Porter JM. Fifteen- 12,27,28 year results of ambulatory compression therapy for chronic tory testing was not developed. Because of the venous ulcers. Surgery 1991; 109: 575±581. retrospective nature of the study, patients were 13 Arnold T, Stanley J, Fellows E, Moncada G et al. Pros- required to have at least two other physical signs pective, multicenter study of managing lower extremity venous ulcers. Ann Vasc Surg 1994; 8: 356±362. of chronic venous insufficiency documented in the 14 Erickson CA, Lanza DJ, Karp DL et al. Healing of venous medical record in addition to the presence of a mal- ulcers in an ambulatory care program: the roles of chronic leolar ulcer and a discharge diagnosis of VSU. Lastly, venous insufficiency and patient compliance. J Vasc Surg 1995; 22: 629±636. little insight can be made as to the treatment of the 15 Martson W, Carlin R, Passman M, Farber M, Keagy B. VSU after the arterial inflow procedure was per- Healing rates and cost efficiency of outpatient compression formed and whether wound complications occurred treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999; 30: 491±498. after bypass surgery. There was no physician uniform- 16 Phillips TJ, Machado F, Trout R et al. Prognostic indicators ity as the study examined two entire hospital popula- in venous ulcers. J Am Acad Dermatol 2000; 43: 627±630. tions over a ten-year period. 17 Ghauri A, Nyamekeye I, Grabs A, Farndon J, Poskitt K. The diagnosis and management of mixed arterial/venous leg In summary, patients with VSU and severe AOD ulcers in community-based clinics. Eur J Vasc Endovasc Surg who need an arterial inflow procedure or amputation 1998; 16: 350±355.

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18 Hallin R. Venous stasis ulcers of the lower extremity com- pneumonia for incidence and vaccine efficacy studies. Am plicated by arterial insufficiency. American Surgeon 1971; 17: J Epidemiol 1999; 149: 282±289. 495±497. 25 Henry OA, Gregory KD, Hobel CJ, Platt LD. Using ICD-9 19 Callam MJ, Ruckley CV, Dale JJ, Harper DR. Hazards of codes to identify indications for primary and repeat cesarean compression treatment of the leg: an estimate from Scottish sections: agreement with clinical records. Am J Public Health surgeons. Br Med J 1987; 295: 1382. 1995; 85: 1143±1146. 20 Olin JW, Beusterien KM, Childs MB et al. Medical costs of 26 Carson JL, Strom BL, Duff A et al. The feasibility of studying treating venous stasis ulcers: evidence from a retrospective drug-induced acute hepatitis with use of Medicaid data. Clin cohort study. J Vasc Med 1999; 4: 1±7. Pharmacol Ther 1992; 52: 214±219. 21 Cikrit DF, Nichols WK, Silver D. Surgical management of 27 Kitahama A, Elliot LF, Kerstein MD, Menendez CV. refractory venous stasis ulceration. J Vasc Surg 1988; 7: 473±478. Leg ulcer: conservative management or surgical treatment. 22 Taylor LM Jr,Edwards JM, Porter JM. Present status of JAMA 1982; 247: 197±199. reversed vein bypass grafting: Five-year results of a modern 28 Depalma RG. Surgical therapy for venous stasis: results of series. J Vasc Surg 1990; 11: 193±206. a modified Linton operation. Amer J Surg 1979; 137: 810±813. 23 Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial disease in chronic leg ulceration: an underestimated hazard? Lothian and Forth Valley leg ulcer study. Br Med J 1987; 294: 929±931. 24 Guevara RE, Butler JC, Marston BJ et al. Accuracy of ICD-9- CM codes in detecting community-acquired pneumococcal Accepted 25 March 2002

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