In the article, "Association of Sociodemographic Factors with Hope for Cure, Religiosity, and Spirituality in Patients with Venous Ulcers" in the February 2015 issue of Advances in Skin & Wound Care, Salome et al1 investigated whether there was any association of sociodemographic factors with hope for cure and levels of religiosity and spirituality in patients with venous leg ulcers (VLUs). They identified that most patients with VLUs in their sample had lower levels of spirituality, religious activities, and hope for a cure. Because VLUs are frequently accompanied by arterial disease, it appears that the authors excluded subjects with arterial or mixed-type ulcers by not enrolling subjects with an ankle brachial index (ABI) of less than 0.8 to better test whether VLUs without any arterial etiology were associated with their outcomes. Although this approach was true for correctly classifying subjects with venous ulcers, the authors did not include subjects with an ABI of greater than 1.0, as they noted that only individuals who had ABI values of 0.8 to 1.0 were enrolled. A low ABI (<0.9) is consistent with the presence of peripheral arterial occlusive disease2 and indicative of arterial occlusive diseases in other vascular beds; however, the normal ABI range is actually defined as 1.0 to 1.4, and ABI values of 0.91 to 0.99 are considered "borderline."3 Thus, in order to make sure that the ulcers were primarily caused by venous insufficiency but not arterial obstruction or occlusion, enrollment of subjects with an ABI value of 1.0 to 1.4 would be more appropriate (rather than 0.8-1.0), particularly in research works. With the present approach, the authors of this letter estimate that there were still participants in the study group with ABI values compatible with the diagnosis of peripheral arterial occlusive disease.2 Moreover, it should be acknowledged that even subjects with an ABI of greater than 0.9 may frequently have trophic changes in their lower extremities.4

In addition, the authors recently reported that patients with diabetic foot ulcers had stronger feelings of powerlessness regarding their condition and less hope of recovery compared with patients with VLUs.5 Because diabetic foot ulcers are associated with underlying arterial disease, the authors' study outcome findings suggested that prevalent arterial comorbidity was more important than venous-type ulcers, which were similar to the current study. Moreover, many years ago, Everson et al6 found in a large cohort that the presence of atherosclerotic diseases, including myocardial infarction, was significantly associated with high hopelessness, even more than cancer, suggesting that psychological and social comorbidities are frequently encountered in people with atherosclerotic diseases.

Therefore, to identify whether venous pathologies affect an individual's hope for cure and levels of religiosity and spirituality, subjects with arterial pathologies should have been excluded by robust methods.

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Ilker Tasci, MD, and Kenan Saglam, MD

Gulhane School of Medicine, Ankara, Turkey

-Bilgin Bahadir Basgoz, MD

Army Hospital, Golcuk, Kocaeli, Turkey

References