Identified transition challenges and potential responses.
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"2216",leadTitle:null,fullTitle:"Pesticides - Advances in Chemical and Botanical Pesticides",title:"Pesticides",subtitle:"Advances in Chemical and Botanical Pesticides",reviewType:"peer-reviewed",abstract:"Pesticides are considered as potential molecules to combat insects, pests, diseases and weeds in agricultural, horticultural cropping system as well as health management systems. 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Career development is not a linear and continuous process. Many workers face challenges and disruptions to their careers linked to the nature of their work (for example, seasonal work); the disruption caused by health, disability and caring for children and relatives; and the short duration of many careers that require a change (for example in professional sports). Whilst the general concept of a ‘career’ is currently undergoing significant change due to the implementation of new disruptive technologies and the emergence of a global ‘gig’ economy, it can be effectively captured in all its variations as ‘the sequence of jobs that individuals hold during their work histories regardless of their occupations or organisational levels’ [1]. The literature is conflicted about whether organisations or individual employees have the key responsibilities for career management and career development [2]. Disrupted and career re-development is extensive in the workforce. Mass layoffs associated with plant closures, technological change and global competitive pressures force many workers to search for jobs in new regions or industries, or to retrain for new occupations. Typical transitional challenges are from graduation to work [3], and from full time caring to work. The concept of transitional labour markets [4, 5] captures the adjustment process of moving from one position to another where the shifts involve challenges and access linked to securing job entry and sustaining a career.
\nThe transition from military to civilian life is a challenging one, impacting personal growth, life satisfaction, psychological well-being, and the physical health of many veterans after their deployment [6]. Many veterans struggle with managing their psychological health, and as such, returning to work can be difficult as mental health symptoms can influence individuals’ abilities to gain or maintain employment [7]. Some research suggests a correlation between employment status and various mental health conditions, including post-traumatic stress disorder (PTSD), anxiety disorder, depression, alcohol and drug abuse [8]. While many successfully transition from military services into civilian employment, there remain a residual of ex-military employees that find accessing the civilian labour market difficult. In this chapter the obstacles and challenges to civilian employment are identified, rather than those who have successfully transitioned into civilian employment.
\nMilitary personnel returning to civilian life face an array of psychological, physical and social challenges that are not typically addressed during their service periods [9]. The Australian Senate Inquiry into the mental health of defence personnel [10] found that one of the key issues contributing to military personnel stress and anxiety was the difficulty of accessing a civilian job, with claims that the unemployment rate for veterans was around five times the national average, at 30% [11]. In combination with mental and physical disabilities, unemployment contributes to a vicious circle of social exclusion for veterans. Disabilities and other factors contribute to difficulties in accessing jobs, including employer stereotyping of ex-defence personnel [12], and in turn being unable to secure employment contributes to their stress. In this context, it is important that the relationship between military service and post-service access to suitable employment is evaluated, as the concerns facing ex-defence personnel are complex, and impact a multitude of different areas in civilian life (health care, employment, disability), and therefore they require more specialist case-management services [13].
\nThis chapter discusses these transitional challenges from military to civilian employment, largely based on United States studies. Specific transitional challenges including health, skills recognition and employer stereotyping are identified. Then follows a discussion of the processes and programs that can potentially support the transition and the establishment of a civilian career.
\nThe processes and experiences of transition for veterans to civilian life and employment are not well understood, and it is often a transition with concomitant challenges related to identity, employment, and lifestyle [14, 15]. Veterans, especially those who have had extended periods of service or lack experience in job search processes, can experience numerous challenges when seeking post-service employment [16], and may create unrealistic expectations regarding salary and job search time-frames. Some veterans experience financial struggles, while others have relationship problems and/or substance abuse issues. When compounded with the challenges associated with securing post-military employment, these can lead to less overall stability upon return to civilian life [17].
\nThe transition process is also often viewed as being difficult due to associated learning or relearning to live outside the highly organised, regimented and controlled way of life experienced during military service. Many veterans may have begun their military careers immediately following high school, so another challenge in this transition process is gaining civilian employment for the first time and becoming familiar with the associated practices of job search [16]. They will need to seek employment in non-military fields and transferring their status can prove stressful [18]. They are not only leaving the military as a job, but also as a way of life. This can also lead to a higher rate of mental health disorders [13, 19], as there is a mismatch between veterans’ expectations and reality. Many veterans will feel they are returning to a “normal” way of life, but in reality, due to the nature of military service and the emotional and physical scars veterans endure during their deployment, they can often feel isolated or alienated upon return to civilian life [20]. As such, the nature of the transition is far more complex psychologically than often recognised, and this needs to be considered when discussing the transition process [18]. Potential employer stereotyping that veterans are too regimented, inflexible, and unable to adapt to civilian work situations [21] further exacerbate their employment-seeking challenges.
\nAnother reason why many veterans struggle to readjust to civilian life is in part due to the socioeconomic and educational challenges they may have experienced prior to individual military service [22], for example, entering military service without possessing any formal post school qualifications and because of the decline in direct supervision in post-military life. Many individuals do not have plans for employment post-military service; and may also lack a sustainable plan for living arrangements upon completion of their service given that accommodation is usually provided by the military, thus potentially leading to poverty and homelessness. Military establishments are often located in remote regions, placing a physical and financial barrier to accessing jobs in large urban areas with expensive property markets. In addition research suggests that some veterans have experienced challenges with anger upon returning to civilian life, strained family relationships, and post-traumatic stress disorder (PTSD). If not treated, these issues can lead to poor coping strategies that can result in an increase in substance abuse and which may have originated during active duty. According to the US Department of Defence Health Related Behavior Survey, 84.5% of active duty personnel across all military branches reported using alcohol and 25% reported moderate to heavy substance use, which is significantly higher than in non-military civilians (16.6%) [23].
\nThe Pentagon has reported that around 1.6 million military personnel who returned from the Afghanistan war in late 2001 struggled to find employment [24, 25]. US soldiers aged between 22 and 24 years old were three times more likely to be unemployed when compared with non-US soldiers in the same age bracket [25]. Due to the young age of enlistment by military personnel, many do not have college degrees when they join the military, thus making it even more difficult to find employment post-service. For example, in 2008, the year with the highest deployment of US military overseas, 52% of military personnel were 25 years old or younger, and only 4.5% had a bachelor’s degree [26].
\nDue to the hazardous and life-threatening nature associated with military employment, returning veterans may suffer either physical and/or psychological challenges, as indicated by the increasing rate of disability claims [27]. Many US veterans are also at risk of severe life-threatening issues, with data indicating that, in 2014 around 20 veterans committed suicide every day [28]. While some knowledge and skills possessed by military personnel are transferrable to the civilian workplace (for example, administrative, computer and problem-solving skills), an inability to illustrate how these skills are transferrable is one of the primary reasons for veterans’ unemployment. In addition, the current population is more educated today than ever before, and this has led to veterans having to face a more competitive marketplace when seeking employment [29].
\nIn the following sections we briefly outline some of the key institutional and structural challenges that contribute to the veteran’s post service career access in civilian employment.
\nSeveral studies have examined veterans’ employment outcomes when confronted with a primary diagnosis of post-traumatic stress disorder (PTSD), although primarily in the United States. Savoca and Rosenheck’s study [30], for example, found that Vietnam-era veterans with combat-related PTSD were significantly less likely to be employed than those without PTSD, and a PTSD diagnosis was also associated with a lower hourly wage for those in a civilian job. Increased severity of PTSD was associated with a decreased likelihood of fulltime employment in another cross-section study of veterans with PTSD [31]. Resnick and Rosenheck’s study [32] observed that veterans with PTSD were 19% less likely to be employed on discharge.
\nUnaddressed associated mental health and substance abuse issues manifest themselves in several ways in relation to civilian employment [33]. Army veterans with health challenges (physical and psychological) may face employment concerns especially in finding and maintaining work [34]. Moreover, in some cases, the psychological effects of deployment tend to limit veterans’ ability to work, and they are often hesitant to seek assistance, feeling that documented mental health issues may limit their employment options [35]. Further, due to negative pre-conceived notions of self-stigmas associated around their health, it becomes difficult for them to participate in employment preparation and screening processes [36]. Finally, physical and psychological concerns can affect veterans’ access to education and training, thus further reducing the chances of employment [36].
\nThe skills transferability of army veterans, in terms of equating military skills and experiences with civilian job qualifications, is reported as one of the most significant employment-related challenges [37]. For successful civilian employment army veterans are required to re-interpret the skills developed in their military jobs (e.g. planning, leadership, risk mitigation, decision-making, communicating, and military intelligence capabilities), and to articulate them effectively in the civilian employment marketplace [38]. The US Society of Human Resource Management (SHRM), Prudential, the RAND Corporation, the Center for New American Security (CNAS), and Pew Research, have all identified these gaps in translating military skills to post- military service careers as either the number one or number two issue in effective military career transition and career development [21].
\nAlthough many employment programs acknowledge the various skills gained by veterans during their army careers, there is disparity among employers regarding recognition of these skills [39]. As an example, a study by Harrell and Berglass [37] identified leadership and teamwork skills, character, discipline, expertise, resilience and loyalty to be some of the reasons for hiring the veterans. However, the same study reported that skill transferability, negative stereotyping, skills mismatches, repeated deployments, and acclimatisation to the civilian world were listed as risks and challenges for hiring veterans. It is also noted in the literature that many employers perceive veterans as either a mismatch for civilian employment, and further, employers often considered veterans as being unsuited to civilian employment [40]. According to Castro et al. [40], post-9/11 veterans reported that civilian employers did not understand their needs, did not think military veterans have the necessary skills, considered veterans to be dangerous and physically broken, and did not want to hire them.
\nEmployers were found to often hold false stereotypical perspectives about army veterans, their skills and experiences, and their estimated “employability” based on political ideology, assumptions of poor skills or presumptions of mental or emotional dysfunction [40]. There is a reported lack of research in understanding the difficulties experienced by employers and veterans regarding suitable positions in civilian environments and workplaces [37]. Moreover, given the employment problems experienced by veterans and many employers’ unwillingness to recruit them, few research studies have examined the factors that affect such hiring decisions [39].
\nMuch extant literature has observed that the lack of preparation and understanding for finding civilian employment when leaving the military is a large contributor to veteran unemployment [40]. It has been observed that some veterans have unrealistic expectations of their civilian job prospects, and some employers are hesitant to hire them due to their poor interviewing skills and inadequate resumes [41]. This unpreparedness has been linked to limited initiative, lack of appropriate planning and lack of motivation, as observed by Keeling, Kintzle and Castro [42] - ‘
Military identity and values (for example, duty, honour, loyalty; and commitment to comrades, unit, and nation) conflict with materialistic, individualistic and libertarian civilian values, which can create a ‘civil-military cultural gap’. These identity crises impact upon their chances of finding suitable employment, as veterans often maintain a continuity of “military identity” due to “military institutionalisation” which may adversely affect their transition to civilian life [43]. This further suggests that due to this institutionalisation, the skills many civilians are accustomed to using (the ability to conduct job searches or tailor communication methods) are under-developed in veterans [44]. Previous literature also indicates that to maintain their military identity, veterans tend to seek work within other “masculinised” and military like institutions (for example, prisons and security work) or prefer to travel around in order to relive the experience of temporary postings in the military [44]. Preconceived notions of differences in civilian and military organisational cultures may also be related to hiring decisions about veterans for civilian jobs [39].
\nSomewhat related to the role of military identity and the presence of a ‘civil-military cultural gap’, veterans may face cultural adjustment issues in civilian jobs. Previous research reports on challenges faced by army veterans suggest that transitioning veterans experience a “culture shock” when re-entering civilian life [15], and the major reason for this is related to the army culture of selfless service [45]. The career transition involves moving away from not being in charge or making decisions (or being the subordinate) and requires changes in mindsets, adapting, and in what may influence persistence, effort, interest, and career goals [46]. Employers expect that veterans must bring the ability to demonstrate adaptive performance, employability, adaptability, functionalism, and flexibility – often capabilities they do not possess.
\nIt has been observed that military service can decrease civilian wages, and the longer the duration in the military, the greater the wage differential faced by veterans relative to civilians [47]. Finding acceptance in a new organisation can be a challenge for veterans to adapt to a career change and a new kind of organisation. There are suggestions that the realities of the military-to-civilian career transition may become fraught with adversities, frustrations, inequities, and setbacks in the workplace with supervisors or co-workers.
\nComplementing academic knowledge with veterans’ skills developed in the military through educational attainment is one effective way of making a transition from army service to civilian employment [48]. Previous research has linked educational attainment to employment mobility [49]. However, veterans face additional challenges that make it difficult for them to succeed in higher education - for example, understanding what benefits they are eligible for, finding campus administrators who understand government support/assistance complexities, obtaining academic credit for military training, and finding services on campus that support their integration into civilian student life [50]. Moreover, veterans as students are different from traditional students and may be raising families and maintaining full-time employment or part-time enrollment, which may result in a higher risk for course non-completions [49, 50]. Another challenge is the difficulty in meeting academic expectations (for example, balancing work and family while studying; independent study and analysis; relating to fellow students; meeting lecturers’ expectations) that are significantly different from what veterans have encountered in military courses [50].
\nFurther, for educational attainment, it is important for the veterans to seek academic credit for coursework and training received in the military. This poses a strong challenge for educational institutions, as military transcripts in the US context consist of indecipherable acronyms—the “military alphabet”, rattling off a list of numbered and lettered forms and courses—and some are even officially classified – so the knowledge or participation could not be acknowledged or certified [48]. Difficulties lie in maintaining consistencies in credit transfers [50, 51] and determining whether given credit applies to unit requirements, general education or graduation requirements, or major and major preparation requirements [51].
\nWhile most studies of the difficulties facing veterans in the transition to civilian employment have highlighted mental disability, many veterans also face physical disability. Serving in the defence forces, especially on active duty, involves facing potential life-threatening risks on a daily basis. Veterans who suffer physical disability are able to access rehabilitation, counselling and welfare support services during and post service. However, many disabilities are permanent or have associated effects such as pain, disability and limited attention spans [52]. There is also an interaction between physical and mental stress [52]. Having a permanent injury may contribute to anxiety and impacts on the ability to engage in effective job search activities [48]. As with mental disability, there are also many documented barriers to those with physical disabilities in accessing employment and workplaces [53].
\nIn the case of job search for ex-service personnel there are a number of distinct challenges. The first is spatial, that is being removed from locations where there are jobs. Job search requires access and resources. Many military establishments are located outside capital cities, often in remote regions, and this imposes physical and financial barriers to effective job search. In addition, military personnel often have limited networks that support job access. Many nations, including the US, Australia, UK and New Zealand, have special services and outplacement arrangements for ex service personnel [54]. There are several job search support services available for Australian ex-military personnel to support job search – these include The Career Transition Access Scheme (CTAS) [55] and the Veterans’ Employment Program [56]. Linked to physical separation are the associated costs and disruption of physical relocation. This may involve new schools for children; job search for spouses; and accessing accommodation in expensive capital cities. For those ex-servicepersons with families the challenges and disruption are collective; the transition to civilian life presents problems for the entire family, often moving from a military town dominated by the military, and moving to multi-cultural and cosmopolitan cities with diverse populations, industries and networks [48].
\nWhere there are barriers to career transition and to developing a new career, addressing the challenges requires informed, flexible and complementary remedial measures. In the case of the transition from university and college graduation to a career position, there a range of stakeholders who have an interest in ameliorating the identified problems that prevents transition. These include students/graduates; employers; universities and governments [3] since there are large private and public investments in education that a predicated on the ability to transition from graduation to employment and generate private and public returns from the investment [3]. Responses range from better informed course and institutional selection; education programs that incorporate required job skills; improving job search processes; public funding of university programs on the basis of successful job placements; and providing articulation arrangements, such as traineeships [3].
\nIn the military transition context the challenges are more profound than in the case of the education transition. Veterans are seeking to transition from one career to a different career; they often have few formal qualifications; they have not been preparing for the transition and in many cases they have personal attributes such as health problems that further limit their employability. In terms of the barriers, policy responses have to encompass the multitude of challenges discussed above, and the different market and non-market sources of these challenges [48–51]. The articulation of ‘process’ and the holistic approach to resilience, acculturation and identity also allows us a deeper understanding of the different assistance programs countries have in place to address these challenges. In the UK, the Ministry of Defence formulated a Strategy for Veterans and Armed Forces Covenant [54]. In the USA, Congress established a Transition Assistance Program (TAP) [56].
\nThe transition experiences of veterans are often complex, and a successful transition requires a portfolio of supports and programs, encompassing action from many stakeholders, including the military, government, employer groups, non-government organisations such as veteran’s associations, education and training institutions to address potential risks and protective factors [57]. As with education to employment transitions, the remedial process is not homogeneous in terms of the personal characteristics of those transitioning (education, skills, age, years of service, disability, location) [3], and requires co-ordination across many authorities and stakeholder groups. The following table (Table 1) shows the different challenges and some of the potential strategies that have been outlined in the literature, along with the intervention time-frame (before, during or after transition).
\n\n | Challenges | \nPotential strategies | \nTime phase | \n
---|---|---|---|
1 | \nMental health and substance abuse | \nCounselling and social support | \nDuring transition and afterwards | \n
2 | \nSkills transferability | \nCertification for skills; preparation for civilian employment | \nOn-going | \n
3 | \nEmployers’ perceptions | \nEducate HR professionals and employer associations | \nOn-going | \n
4 | \nPreparation for civilian employment | \nTransition Assistance Programs (TAP) | \nBefore and during transition | \n
5 | \nMilitary identity and cultural adjustment | \nRealignment and adaption of new behaviours | \nTraining workshops during transition and afterwards | \n
6 | \nAcceptance challenges | \nIndustry orientation workshops | \nTraining workshops before and during transition | \n
7 | \nEducational enhancement | \nRecognition of prior leaning/training to higher education community/education assistance programs Formal accreditation procedures for training programs. | \nOn-going | \n
8 | \nPhysical disability challenges | \nReserved positions for disabled veterans in federal jobs | \nOn-going | \n
9 | \nJob search challenges | \nJob search support programs | \nOngoing | \n
Identified transition challenges and potential responses.
The strategies included in the table include the US transition assistance programs (TAP) which support veterans by providing pre-separation counselling and transition assistance workshops to aid in the transition from military service to civilian life; career assessments (regarding career interests, self-efficacy, and career resilience); and in Australia, the ‘Career Transition Assistance Scheme - CTAS which provides phased benefits, tools and services in support of this obligation [55]. The CTAS [55] supports the career transition of members from the service to suitable civilian employment, with the minimum involuntary break in continuity of employment; enhances the ability of members to competitively market themselves for suitable civilian employment; and attempts to make the best use of members’ existing skills gained from ADF service.
\nIn response to the transition challenges identified in the above discussion, there are six key complementary imperatives which might be provided by human resource management (HRM) professionals for the mutual benefit of veterans and their organisations. First, in order to overcome the stereotyped beliefs and self-adopted stigmas of veterans [36, 39], one important strategy is to alter these preconceived notions of employers [39]. Human resource professionals might take the lead in providing career development, learning and development, and hiring support to create a better understanding about veterans in the civilian workplace [15]. They need to consciously understand the application of military frameworks to current business practices and develop an understanding how the skills of veterans can be utilised to create a more viable, innovative, creative, and leadership-ready workforce [58]. Moreover, recruiters need tools and associated training to help them understand the benefits of hiring veterans [59].
\nHRM professionals can assist veteran recruits to transition to new civilian work identities by addressing the three phases that every individual making a transition encounters: (a) letting go of old ways and old identities, (b) moving out of a “neutral zone” and experiencing psychological realignment, and (c) exiting the transition and beginning anew with a new identity and sense of purpose. HRM professionals can design strategies to support veterans in their psychological realignment and establish a new identity with a clear sense of purpose [48, 50].
\nThrough recognition of prior learning (RPL) mechanisms, veterans might be given academic credit for coursework and training received in the army [49]. The nature of military expertise and the knowledge accumulated while in service may have different connotations in course curriculum. Although some veterans have completed academic qualifications and applied training during their military service, some educational institutions do not award credit for military training [49]. Bergman and Herd [60], for example, strongly advocated assisting veterans with academic credit for prior learning in the military and recommended a program of portfolio development for prior learning assessment (PLA) method provided by the Council for Adult and Experiential Learning [CAEL] in 2010. Veterans tend to be of mature age, and consequently their success often depends on their ability to make rapid progress and build on the knowledge they have established in the services. Establishing consistent credit transfer guidelines and transparency about those guidelines can go a long way to help veterans attain education for smoothly transitioning into civilian employment.
\nAs many higher education providers do not understand military cultures or the challenges veterans face when transitioning to an academic setting [61], it is imperative that higher education personnel develop awareness of the complex and multiple identities of students so that they can introduce effective programming initiatives [49]. Providing training to faculty and staff about military culture and veterans’ unique needs and transitional issues [62] can help improve the situation. These initiatives could be complemented with educational assistance programs that can prevent the unemployment of veterans, assist their adjustment to civilian life, reward their military service, and make education affordable [63]). The GI Bill (US Education and Training Benefit), for example, provides monetary aid to help cover college tuition, housing, books, and other educational fees for vocational training, on-the-job training, flight training, correspondence training, licencing, national testing programs, entrepreneurship training, and tutorial assistance [63].
\nFinally, and most controversially, in the US veterans are given preferences in appointments to federal government jobs [64]. Public policies in the US have also attempted to boost the demand for veteran labour through federal hiring preferences and private employer tax credits [63]). Veterans who are disabled or who serve on active duty in the US Armed Forces during certain specified time periods or in military campaigns are also entitled to preference over non-veterans both in federal hiring practices and in retention during reductions in force [63].
\nThe concept of a single career with linear and sequential development, and long periods of tenure with a single employer has been disrupted by technological and structural changes that undermine the marketability of skills, qualifications and experience [1]. Career development is for many a disrupted process, involving transition challenges and shifts in career orientation, and often involving structural and institutional barriers [5]. Moving out of military to civilian employment captures many of the structural, institutional and market barriers that those who seek to change careers face, but as indicated the challenges and the barriers to the transition process are systemic and considerable [40]. This chapter reports on the challenges faced by army veterans in their transitions into civilian employment, largely in the US context. The main challenges that have been highlighted in extant research are based around mental health and substance abuse; skills transferability; negative employer perceptions towards veterans; the lack of preparation for entry into the civilian workforce; the negative military identity (and stereo-typing); the cultural challenge of civilian employment; insufficient educational attainment; physical disability; and job search challenges [29–34]. The challenges are not homogenous and require tailored support programs to assist veterans. These may range from job search and training programs; through to rehabilitation programs to assist those with physical and mental health challenges. There is need for multiple stakeholder responses that include support for transition while in military service; and support from a range of stakeholders across the range of identified impediments from NGOs, through to governments and employer groups in the post transition phase. Developing a career is challenging when you enter the civilian workforce at an age where existing participants have civilian employment experience and recognised skills and credentials.
\nFurther research could examine the differences in the transitional challenges across countries and across different defence services such as the navy and air force. Here contextual factors such as the conditions and forms of service in different countries, and the skills required to perform different service tasks could affect the ability to transition to civilian employment. Moreover, studies that examine successful transition can identify those conditions that contribute to supporting the transition and career development process.
\nVenous leg ulcer (VLU) represent a pathological tissue change in the form of a defect in the lower leg which occurs as a complication of chronic venous insufficiency (CVI) [1]. Chronic ulceration is defined as ulceration on the lower leg that lasts (does not heal) within 6 weeks, and is caused by various etiopathogenetic factors [2].
Venous leg ulcers often heal slowly and result in long-term suffering and intensive use of health care resources [3, 4]. A VLUs represent a growing health problem, and they are a condition that is very expensive to treat for both the health system and patients.
A VLUs endangers the patient’s normal life. Treatment of VLUs requires dedication and cooperation between the patient and the doctor. The health-related impact of VLUs is increasingly recognized as a valuable outcome measure for assessing interventions, especially when complete cure is unlikely [5]. Adults with VLUs often have multiple disabling symptoms, including pain, sleep disturbance, depression, swelling of the lower extremities, fatigue and symptoms associated with inflammation of lower leg (redness, localized heat, discomfort due to high exudate levels and itching) [6].
The prevalence of VLU varies between 1.5–3% in the total population and 4–5% in persons over the age of 80 [1]. Studies have shown that 1–2% of the adult population either has or has had venous ulceration [7]. The prevalence of VLU in Western European countries in the population over the age of 18 is 0.1–0.3% [1].
It is very important to point out that a certain number of VLUs heal very slowly or not at all. In a period of about 4 months with the application of adequate therapy, about 50% of VLUs heals [8, 9]. However, about 20% of VLUs do not heal even after 2 years from the beginning of treatment, and about 8% even after 5 years from the beginning of treatment [1]. At the annual level, the recurrence rate of VLUs ranges from 6–15% [1]. The risk of recurrence over a period of 1 year ranged from 30–57% [1].
Risk factors for VLUs are numerous, and most patients have more than one. Most of these factors are immutable and this group includes being female, elderly, having previous venous thrombosis of the legs, pulmonary embolism, multiparity, musculoskeletal and joint diseases [7, 10]. Obesity and sedentarianism are risk factors that can be influenced on [11]. The genetic traits of an individual can also be emphasized as a predisposing factor [7, 12], but the specific gene or set of genes responsible for the occurrence of this disease has not been determined so far. In people with varicose veins, Forkhead box C2, located on chromosome 16q24 [13], was isolated.
Despite the application of different standard treatment modalities for VLUs, a certain percentage of venous ulcers do not heal. Studies have shown that prolonged healing time or refractoriness to applied therapy may be due to an increase of T lymphocytes and granulocytes, lack of oxygen, growth factor and cytokine imbalance [10]. For this reason, we are working on the development of modern therapeutic modalities, while the number of new techniques for the VLUs care has increased in recent years and is constantly improving [14].
Venous ulcer is usually localized on the inner side of the lower third of the leg, oval, circular or irregular in shape. The surface of the ulcer depends more on the degree of development than on the etiology. It is usually fibrous or covered with fresh granules that bleed heavily to the touch (Figure 1).
Typical venous ulceration.
The ulcer area is thickened, pigmented and induced, together with subcutaneous adipose tissue. These changes correspond to lipodermatosclerosis, which is in fact a pre-ulcerative condition [15].
The absence of lipodermatosclerosis in the vicinity of the ulcer surface suggests that the ulcer may not be of venous origin. The presence of dilated venules, most often around the maleolus, below the ulcer surface, is also significant as a consequence of the transmission of increased venous tension through insufficient communicating veins. The presence of larger, dilated incompetent communicating veins is very significant for venous ulcers. An ulcer localized on the lateral side of the lower leg is often associated with an incompetent saphenous vein [16]. The presence of edema, lipodermatosclerosis and varicose superficial veins also supports the venous ulcer genesis. When examining ulcers, it is necessary to always examine the condition of the arterial circulation [17].
Although simple at first glance, the diagnosis of venous disorders is essentially difficult due to specific hemodynamic conditions in the venous bloodstream.
A well-taken anamnesis can greatly help us in making an adequate diagnosis, and just the taking of anamnesis is considered to be a special skill, but for now there are no adequately conducted studies on the value of specific items for anamnesis. It is necessary to take data related to [18]: major symptoms exhibited and experienced, previous medical history, varicosity and treatment of varices, superficial and deep venous thrombosis, leg ulcer, peripheral arterial vascular disorder, diabetes mellitus, rheumatoid arthritis, extensive leg trauma, nutritional status, patient mobility, family anamnesis and specific leg ulcer aspects (duration, pain, previous treatment, symptoms of ulcer infection, the ankle joint mobility).
Today, the following diagnostic procedures are used to examine the venous system: Color-flow duplex ultrasound in the diagnosis of vascular diseases is widespread today, both because of its high sensitivity and accuracy, and the fact that it is a simple and safe diagnostic procedure. This method measures the diameter of the blood vessel, the duration of reflux, the presence of flow and the compressibility of the vein. The examination is performed in a standing position [19]. When examining the deep venous system up to the inferior vena cave, the patient is placed in a supine position [20]. The duration of reflux in normal proximal veins of the legs is <1 s while in distal veins <0.5 s.
Direct venous pressure measurement is an invasive diagnostic method where venous pressure is directly measured using a cannula in the superficial vein of the foot [21]. It was found that there is a direct correlation between the height of the pressure in the vein of the foot and the height of the pressure in the deep veins at the height of the ankle. Direct measurement of venous pressure is rarely used today because it is an invasive diagnostic technique and is not recommended as a routine diagnostic method in patients with venous ulcers.
Ankle-brachial pressure index (ABPI) is used to evaluate adequate arterial blood flow. A large number of studies have shown that about 30% of patients with VLUs also have a disease of the peripheral arterial system. Ulcers that occur in these patients may be due to diseases of the peripheral arterial system or occur in combination with venous insufficiency. Normal ABPI values range from 0.91–1.20. If ABPI is >0.8 arterial abnormality on the arteriogram is generally ruled out (chance >95%) [22].
Plethysmography, phlebodynamometry and phlebography, are less used methods due to inferior accuracy and associated risks [23, 24].
Application of bacteriological examination or biopsy of ulceration and patho-histological examination will be applied in case of suspicion of infection or malignant etiology of ulceration.
The success of the treatment of venous ulcers of the lower extremities depends on the accuracy of the diagnosis. Infectious ulcers are mostly found in the tropics, while neoplastic ones are relatively rare. Ulcers associated with rheumatic disease or diabetes are also common in everyday clinical practice [7]. There is a whole range of etiological causes of ulcers on the lower extremities (Table 1).
Differential diagnosis of leg ulcers | |
---|---|
Vascular | venous, ischemic, mixed arterovenous, arteriovenous fistulas, venous malformations, vasculitis, diabetic ulcers, etc. |
Traumatic | after sclerotherapy, after surgical interventions, accidental |
Edema | lymphedema, renal, cardiac |
Infection | tropical ulcers, cutaneous tuberculosis, syphilis, leprosy, parasitic and fungal infections |
Malignant disease | Marjolin ulcer, primary squamous cell carcinoma, lymphoma, basal cell carcinoma, malignant melanoma |
Other | immunodeficiency, contact dermatitis, nutrition disorder |
Differential diagnosis of leg ulcers.
The therapy of VLUs is complex and is determined on the basis of: etiology, clinical picture, echosonographic findings, thrombotic status, laboratory findings, comorbidities, nutritional deficiencies, risk factors, economic and medical possibilities for diagnosis and therapy. The goal of therapy is complete restitution (reconstruction) of the tissue defect and prevention of recurrence [25]. Improvement of hemodynamic status (reduction of venous hypertension and venous stasis) is the primary therapeutic goal. The three basic elements of VLUs therapy are [26]:
local therapy
compression therapy
surgical treatment
Adequate VLUs therapy should reduce venous hypertension in the micro and macro circulation [26].
Local VLUs therapy is based on the application of the TIME treatment principle [27]:
Tissue management
Inflammation and infection control
Moisture balance
Epithelial (edge) advancement
Chronic wounds can traditionally be bandaged with gauze, antiseptics, topical antibiotics and adsorbents. This type of therapy requires daily bandaging, making the treatment expensive and ineffective [28].
By wound cleaning, we mean the removal of necrosis, fibrin or other deposits. Necrotic tissue can be removed surgically or treated with an enzymatic wound cleanser. The wound cleans itself by autolysis, if none of these methods is chosen. When performing surgical debridement of ulceration, debridement should be performed to avoid damage to healthy tissue [29]. Antiseptics such as povidone-iodine, chlorhexidine, acetic acid etc. are often used today in the VLUs treatment.
The use of dressings in the treatment of VLUs is efficient and pharmacoeconomically justified. The use of dressings in the treatment of VLUs has shown a significant advantage over the classic gauze bandage in a large number of studies. The advantages of dressing applying in the treatment of VLUs are reflected in [30]:
faster wound healing (allow constant temperature and humidity, which allows faster cell migration).
reducing the risk of infection (achieved by releasing silver ions or creating an impermeable barrier to bacteria and viruses).
greater comfort and cost-effectiveness (do not require daily dressing, reduce painful sensitivity of the wound, and provide significantly better quality of life).
Dressings are divided into primary and secondary. Primary dressings are in direct contact with the wound surface, while secondary dressings have the role of fixing and holding the primary dressing, which also protects the wound surface from the external environment. Today, dressings have the role of both primary and secondary [31, 32].
The division of dressings according to the mode of action on wound healing is shown in Table 2.
Type of dressings | Mode of operation |
---|---|
Gels, alginate dressings with additives (Ringer, 0,9%Nacl) | Activation of autolysis |
Hydrocolloids, foam, hydrocapillary or silicone coatings | Granulation, creating a moist environment and absorbing secretions |
Membranes, acrylates, therapeutic dressings (non-resorbable / resorbable) collagen coatings, cellulose hydrobalanced dressings, nets, films | Reepithelialization |
Dressings with the addition of silver, iodine, medical honey, polyhexanide | Anti-inflammatory action |
Type and mode of dressings action.
Compression therapy is the most effective form of VLUs conservative treatment. The advantage of this therapy is that it is used on an outpatient basis, patients are able to work during treatment and it is also cheaper compared to surgical treatment [33]. This method of treatment can be applied continuously or intermittently. Before applying the compression bandage, it is necessary to perform local treatment of the ulcer surface, cover the ulcer surface with sterile gauze, after which a compressive bandage is placed. The application of external compression reduces transmural pressure and improves skin changes. Compression bandage compresses the extremities, thus reducing the effect of venous hypertension. Depending on the stage of the vein disease, different degrees of compression therapy are applied.
Compression therapy can be achieved with short-elastic and long-elastic bandages, as well as various compression systems (compression gloves, socks and clothing) [34] The materials used to make compressive agents have different extensibility, and create different pressures under the applied compressive agents both at rest and while walking.
In relation to the degree of compression, compression means are divided into four classes (Table 3) [35].
Class | Levels of compression | Indications |
---|---|---|
Class 1 | <25 mmHg | Prevention of DVT, Mild oedema, Tired-aching legs |
Class 2 | 25–35 mmHg | Mild VV, Mild to moderate oedema, VV during and after pregnancy |
Class 3 | 35–45 mmHg | Venous ulcers (including healed ulcers) DVT, Superficial thrombophlebitis, Following venous surgery and sclerotherapy, VV with severe oedema, Post-thrombotic syndrome, Mild lymphoedema |
Class 4 | 45–60 mmHg | Severe lymphoedema, Severe CVI |
Levels of compression and indications.
These compression values refer to in vivo measurements in the medial B1 area (end of the Achilles tendon / calf muscle insertion) measured while lying down [36].
Compression systems may contain elastic and inelastic materials. Multilayer systems (two-layer and four-layer) function as inelastic systems even if they contain mainly elastic components. An inelastic bandage is known to have high stiffness compared to an elastic bandage. The stiffness of the compression therapy system can be determined by determining the static stiffness index (SSI). This index is determined by measuring the values of the pressure between the compression system and the patient’s skin (subband pressure). Pressure is measured first when the patient is lying down and then in a standing position. The difference between these two measurements is SSI. If SSI is >10, the compression system is characterized as inelastic, while if SSI is <10, the compression system is marked as elastic [37].
Compression therapy systems in which SSI is high (inelastic or multilayer compression system) give higher pressure during standing and lower pressures when the patient is lying down compared to a system with lower SSI (elastic compression system).
Contraindications to the use of compression therapy are shown in Table 4 [38]:
Contraindications | |
---|---|
Absolute | Relative |
Advanced peripheral artery disease (critical ischemia) | Mild to moderate peripheral artery disease |
Decompensated heart failure | Advanced peripheral polyneuropathy |
Septic phlebitis | Chronic compensated heart failure |
Phlegmasia cerulea dolens | Intolerance or allergy to the materials used |
Advanced peripheral artery disease (critical ischemia) | Treatment-related pain |
Florid infectious diseases (initial phase of erysipelas/cellulitis) |
Absolute and relative contraindications for the application of compressive therapy.
The use of compression therapy may be associated with the appearance of certain signs and symptoms that indicate the appearance of complications. The most common complications of compression therapy are necrosis, skin trauma, discoloration, pain, paresthesia, burning sensation, etc. [39].
Surgical treatment of VLUs is one of the types of treatment. Today, surgical procedures are performed on the superficial venous system, deep venous system and venous perforators. It should also be noted that surgical procedures on these three venous systems can be combined [40]. One of the ways of VLUs surgical treatment is the Vigoni-Schmeller procedure. This method involves excision of ulcers and surrounding altered tissue with removal of compartment syndrome of the lower leg by the Hach method [41].
The modern approach to the treatment of VLUs today is based on the application of various biophysical interventions such as electromagnetic therapy, phototherapy, electrical stimulation and ultrasound therapy. The modern method of treatment today includes the use of stem cell therapies, biological skin equivalents (such as bilayered living cellular construct (BLCC), or 3D-printed hydrogel dressing [42, 43].
In addition to the application of standard methods of treating VLUs, the following are also used: oxygen therapies, negative pressure wound therapy and platelet-rich plasma therapy. The use of a muscle pump activator or device with occasional pneumatic compression in a number of patients with VLUs has been shown to be very successful [44, 45].
Electromagnetic therapy (EMT) also has a significant place in VLUs therapy. EMT devices generate a pulsed electromagnetic field (PEMF). PEMF increases the number of fibroblasts and macrophages in the wound, which results in rapid wound healing. Studies have shown that PEMF increases the deposition of fibrin and collagen and reduces the inflammatory process [46].
Low-level light therapy (LLLT) as a variant of phototherapy has a prominent place in the treatment of VLUs [47, 48]. The use of LLLT devices activates cells through a photochemical effect. There is an increase in cellular activity [43] resulting in accelerated tissue healing, granulation tissue formation, increased protein synthesis, increased cell proliferation, anti-inflammatory modulation and pain reduction [43, 49]. This method is a non-contact method of treating VLUs, and LLLT devices usually direct a beam of light around the entire surface of the wound [48].
Electrical stimulation (ES) stimulates angiogenesis by activating mitogen-activated protein kinase (MAPK) and increasing vascular endothelial growth factor (VEGF). The application of ES leads to increased fibroblast proliferation by stimulating the production of fibroblast growth factors (FGF). The application of ES has been shown to be effective in reducing the inflammatory process and regulating bacterial growth [50].
Ultrasound therapy (UT) has found a significant place in the treatment of VLUs as one of the auxiliary therapeutic modalities [51, 52]. The effect of ultrasound on tissues is reflected in the increase of blood flow in the tissue and the induction of physical changes in the structure of collagen. This type of therapy promotes cell proliferation, angiogenesis and protein synthesis. UT also accelerates the formation of granulation tissue, has anti-inflammatory and anti-edematous effects [51, 52]. However, previous research on the application of UT has not given a clear answer on the in vivo healing process [51].
Clinical studies have shown that stem cell therapy (SCT) promotes wound healing in each wound repair phase. The application of SCT accelerates the healing process of VLUs, with a significant reduction in wound area and quality tissue regeneration [53, 54].
Oxygen therapy has a prominent place in the treatment of VLUs. Chronic wound tissues have a very small amount of oxygen, and due to hypoxia, the wound healing process is slowed down. This is particularly pronounced if a transcutaneous oxygen partial pressure (pO2) is lower than 40 mmHg [55]. Oxygen therapy accelerates wound healing and does not reveal relevant cell damage risk [55, 56]. Today, the following methods of oxygen therapy are used: hyperbaric oxygen therapy and topical oxygen therapy.
Negative pressure wound therapy (NPWT) accelerates the healing process of VLUs. This is achieved through several mechanisms: reduction of local edema as well as reduction of the number of bacteria, inflammatory mediators and wound exudates. NPWT promotes angiogenesis, promotes tissue perfusion, stimulates tissue granulation, causes wound shrinking, and contraction of its edges [47, 57].
Platelet-rich plasma (PRP) or autologous platelet-rich plasma is a suspension of platelets obtained from whole blood [58]. The concentration of platelets in PRP is two to six times higher than that in the blood [59]. To form a liquid or gel that contains multiple growth factors, PRP is most commonly mixed with thrombin. PRP supplies not only a number of growth factors but also signaling cytokines that also play a key role in new tissue synthesis, angiogenesis, or inflammation regulation [58].
The role of growth factors in wound healing is very complex. Certain growth factors (e.g. TGF-beta) play different roles in different phases of healing. To date, in spite of many years of research, only one growth factor (Becaplermin, PDGF) is registered for the treatment of diabetic foot ulcers and not for venous ulcers [60].
Venous leg ulcers occur as a complication of CVI. With the aging of the world’s population, an increase in the number of obese people with various chronic diseases, the number of patients with VLUs will increase. These patients’ performance will be a significant burden on the health care system [61].
Venous leg ulcers are significantly more common in the elderly. In 13% of people, VLUs first appears before the age of 30, and 22% before the age of 40. For this reason, patients with VLUs have a reduced quality of life and varying degrees of physical disabilities. These patients suffer varying degrees of acute and chronic pain [62].
The application of modern diagnostic and therapeutic modalities in the treatment of VLUs in combination with available evidence-based data will reduce the number of patients who will not heal VLUs and who will relapse. Therefore, the use of standard methods of treatment and the use of expensive advanced therapeutic agents is of particular importance.
It is very important to have a comprehensive clinical examination at the very beginning. Subsequent non-invasive and sometimes invasive tests may be indicated for diagnosis and treatment planning. Inadequate diagnosis results in inadequate therapy.
The application of objective tests aims to confirm the diagnosis, determine the etiology of the disease, locate the anatomical site of the venous disease (superficial, deep, and perforating venous system) and the severity of the disease, or identify coexisting peripheral arterial disease [63].
Taking a good medical history is imperative of a good clinical examination. Patients with VLUs have a rich medical history and a number of concomitant comorbidities. Unfortunately, there are not enough studies that have shown the value of specific items for the anamnesis [25]. In practice, it has been shown to be very important to take all data related to the previous medical history as well as the family history and the specific aspects of the ulcer [18].
In order to monitor the healing rate of ulcers, it is very important to perform an accurate and consistent wound measurement. Wound location, area, and characteristics should be documented. Traditionally, length and width are measured in perpendicular distances of wound borders (the longest length with the greatest width at right angles). This measurement can be done manually or via digital photography. These wound measurement methods are inconsistent and sometimes inaccurate. The use of digital software is recommended. The study of Cardinal et al. showed that oval or circular ulcers initially heal better than wounds with large indentations, multiple segments and skin swellings at the edges. VLUs documentation is important for estimating the healing rates. If in the period from 4 weeks there is no reduction in wound area by 30%, it is unlikely that VLUs will heal by week 12 [64]. Patients with VLUs that heal slowly are ideal candidates for advanced therapy.
In order to make a diagnosis, the following diagnostic procedures are recommended: ABPI and duplex venous mapping. If duplex venous mapping cannot be used to make a valid diagnosis, phlebography, venous angiotomography, and venous angioresonance are recommended [64].
The success and sensitivity of the color-flow duplex ultrasound depend on the researchers and the coefficient of variation of reflux measurements ranges from 30–45% [65]. Studies have shown that duplex diagnostics has high sensitivity and specificity in the diagnosis of superficial and deep venous leg systems [65, 66]. Today, this method represents the gold standard in the diagnosis of venous diseases, enables further classification of chronic venous insufficiency and selection of the optimal treatment of venous diseases.
ABPI test is widely applied in the diagnosis of peripheral occlusive artery disease, because of its accessibility, affordable price, lack of risk, a sensitivity of 95% and a specificity of 99% [64]. Determination of ABPI is not the most reliable in patients with diabetes mellitus because compression of the arteries may not be possible due to medial sclerosis.
Taking an ulcer biopsy is a quick, easy, and effective way to identify less common etiologies in ulcers that are unusual in appearance and where there is a reasonable suspicion of a malignant etiology. Sometimes it is necessary to take multiple biopsy specimens to get an accurate diagnosis [67].
Standard sampling for bacterial colonization has no therapeutic consequence and thus is meaningless. Wound swabs should only be taken if there are signs of infection, prior to initiating therapy, and for MSRA detection. Cultivation and eventual use of antibiotics is only indicated if there are signs of VLUs infection [68].
Successful treatment of VLUs requires a multidisciplinary team to make an adequate diagnosis, assess the condition of the vascular system and determine other factors that affect the healing of ulceration.
The basis of VLUs treatment is to reduce or eliminate the effect of venous hypertension. This is achieved through the use of compression therapy, surgical treatment of venous abnormalities, local ulcer treatment, systemic medications that aid healing and complementary measures [64].
There is relatively little data in the medical literature regarding the cleansing of venous ulcers. The results of a number of prospective and retrospective studies related to surgical debridement of VLUs have shown that this method has a certain place in treatment. The results of a prospective study showed that the presence of dense fibrosis and high levels of mature collagen in ulcer tissue samples directly positively correlates with the speed and success of VLUs healing [26].
Extensive and deep debridement of VLUs that were refractory to therapy until the absence of dense fibrosis and mature collagen in the ulceration is recommended.
The results of a number of studies have shown that there are no justifiable reasons for the use of antiseptics, in principle, cytotoxic agents. Cleaning with ordinary clean water has the same result as cleaning with isotonic sodium solution [26].
The use of dressings in the treatment of VLUs has shown a significant advantage over the classic gauze bandage in a large number of studies. Proper use of dressings is based on clinical protocols containing the etiology of ulceration, clinical assessment of ulceration (depth, size, degree of purity, contamination, surrounding skin condition, amount of exudate), presence of infection, and general patient condition [30].
Modern dressings today provide optimal physio-chemical conditions necessary for normal wound healing, preventing the development of infection, controlling exudates, reducing the number of debridements and reducing the need for more painful dressings [69, 70].
Effective compression is achieved by precise application of the bend system, which should provide mild compression at rest, but also effective compression during all types of activities. All compression therapy systems achieve this to some extent, and the choice of a bandage or socks requires selection on an individual basis.
The two main principles on which compression therapy is based are [71]:
creating a closed system that allows internal pressures to be evenly distributed in the leg.
variation of subbandage pressure according to limb shape and bend tension.
Understanding the principles of compression therapy allows us to define the ideal compression system. The characteristics of an ideal compression system are: includes inelastic component, provides good anatomical grip, enables smooth operation and mobility, provides comfort at rest, easy to apply and adapts to the size and shape of the limbs and does not cause an allergic reaction and shows endurance.
Compression therapy systems must be compatible so that they can be effectively applied in different limb sizes and shapes, while providing therapeutic levels of compression without the risk of damage. The use of multicomponent compression systems has shown significantly better efficiency in the healing of venous ulcers compared to the use of one-component compression systems. Multicomponent compression greater than 30 mm/Hg showed, in addition to high efficiency in wound healing, a reduction in the recurrence of venous ulcerations [72, 73].
After the ulcer has healed, elastic stockings with graduated compression of the appropriate size are used, with a pressure of 30–40 mmHg. In most patients, knee pads are sufficient. In fact, socks above the knee or other compression devices that exceed the height of the knee are uncomfortable to wear and occlude the popliteal vein during knee flexion. Ankle compression >40 mmHg is rarely required. If the patient is associated with arterial insufficiency, socks that produce less pressure around the ankle joint are needed, so as not to lead to skin necrosis [71].
It should be noted that it is very important to apply surgical therapy in order to treat the underlying venous disease whenever possible. The use of surgery can improve and accelerate healing, as well as reduce the risk of recurrence [64].
Unfortunately, up to this date, no randomized studies have been performed on the use of this treatment for VLUs. The problem with the application of surgical therapy in the treatment of VLUs is the lack of valid randomized, controlled studies. Previous studies have had an uneven number of patients and different surgical techniques have been applied. None of the previous studies has shown the advantage of surgical therapy over VLUs conservative treatment.
Based on the recommendations of the Scottish guidelines, surgical therapy should not be the method of choice in the VLUs treatment (an active ulcer). Surgical therapy is also not recommended as a secondary prevention after VLUs healing [74]. The data obtained from the ESHAR study showed that there is no advantage of surgery over compression therapy in the treatment of patients with varicose veins of the lower extremities. However, this study showed that in relation to the occurrence of disease recurrence, surgical therapy proved to be more successful [75].
The number of new technologies and use of grafting techniques used in the treatment of VLUs has increased in recent years. The future may hold micro- and pixel-grafts, spray on cells and the use of 3D printing to prefabricate vascularized grafts to assist in wound coverage.
Some of the new technologies used in the treatment of VLUs require broader evidence of clinical efficacy and can be considered as experimental therapies [76].
Venous leg ulcers occur as a complication of CVI. Venous leg ulcers are significantly more common in the elderly. A VLUs represent a growing health problem, and they are a condition that is very expensive to treat for both the health system and patients. The application of modern diagnostic and therapeutic modalities in the treatment of VLUs in combination with available evidence-based data will reduce the number of patients who will not heal and who will relapse. Therefore, the use of standard treatment methods and the use of expensive advanced therapeutic agents is of particular importance.
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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. 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