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Mixed-etiology leg ulcers in a patient on long-term glucocorticoid therapy. Reumatologia 2019; 57:173-177. [PMID: 31462834 PMCID: PMC6710843 DOI: 10.5114/reum.2019.86429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/28/2019] [Indexed: 12/31/2022] Open
Abstract
Chronic leg ulceration is a frequent condition in elderly patients. Chronic wounds that are nonresponsive to 3-month therapy affect approximately 6.5 million people in the United States with a prevalence of 1% and costs estimated at 25 billion dollars per year. Although the main causes are venous insufficiency, lower extremity arterial disease and diabetes, in many cases the etiology is multi-factorial. Approximately 20–23% of non-healing wounds that are refractory to vascular intervention have other etiologies including vasculitis, rheumatoid arthritis and Sjögren syndrome. Adverse drug interactions are the least commonly considered, especially those which involve disease-modifying anti-rheumatic drugs. The authors present a report on a female patient with reported Sjögren syndrome, multiple morbidities and non-healing lower limb ulceration that developed during treatment with methotrexate, and no significant improvement after discontinuation of the drug and after vascular surgery. Microvascular deterioration caused by beta-blockers was considered decisive. Calcium-blocker replacement brought complete healing in the follow-up.
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Çaytemel C, Topaloğlu Demir F, Büyükbabani N, Türkoğlu Z, Uzuner EG. Multifactorial Painful Leg Ulcers Due to Hyperhomocysteinemia, Plasminogen Activator Inhibitor-1 4G/5G Heterozygote Gene Mutation, and Beta Thalassemia Minor: A Case Report. INT J LOW EXTR WOUND 2019; 18:339-341. [PMID: 31409160 DOI: 10.1177/1534734619861584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Leg ulcers may occur due to many autoimmune, hereditary, inflammatory, and infectious causes including venous, arterial, and neuropathic ulcers. Hyperhomocysteinemia is a metabolic disorder caused by various enzyme defects in methionine metabolism. The most common cause is methylenetetrahydrofolatreductase (MTHFR) enzyme gene mutations. Hyperhomocysteinemia is an independent risk factor for deep vein thrombosis and peripheral arterial disease. The effects of endothelial cell damage on smooth muscle hypertrophy, platelet aggregation, coagulation, and fibrinolysis cause atherogenesis and thrombosis, leading to venous and arterial lower extremity ulcers. In this article, we report the case of a 47-year-old male patient who was admitted to our clinic due to painful leg ulcers that started 1 year ago. He had a history of vena cava inferior thrombosis, deep vein thrombosis, and 40 pack-year smoking. Histopathological examination of punch biopsy taken from ulcerative lesion showed intense inflammatory infiltration in the middle dermis, erythrocyte extravasation, leukocytoclasia, and thrombus formation in a small diameter venule lumen. There were nonspecific findings in direct immunofluorescence examination. He was found as having MTHFR C677T homozygote and plasminogen activator inhibitor-1 4G/5G heterozygote gene mutation with high homocysteine level of 22.90 µmol/L, and he was diagnosed as hyperhomocysteinemia. He was recommended to quit smoking because it triggered thrombosis in hyperhomocysteinemia. Herein, we present a case of hyperhomocysteinemia due to MTHFR mutation, which is one of the rare hereditary thrombophilia causes.
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Affiliation(s)
- Ceyda Çaytemel
- Dermatology Department, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey
| | - Filiz Topaloğlu Demir
- Dermatology Department, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey
| | - Nesimi Büyükbabani
- School of Medicine, Pathology Department, Istanbul University, Istanbul, Turkey
| | - Zafer Türkoğlu
- Dermatology Department, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey
| | - Esen Gül Uzuner
- Pathology Department, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey
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Monsuur HN, Weijers EM, Gibbs S, van den Broek LJ. Skin substitutes are more potent than dermal or epidermal substitutes in stimulating endothelial cell sprouting. BMC Biomed Eng 2019; 1:18. [PMID: 32903380 PMCID: PMC7422578 DOI: 10.1186/s42490-019-0018-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/11/2019] [Indexed: 12/01/2022] Open
Abstract
Background Therapy resistant ulcers are wounds that remain open for a long time period and often arise from chronic venous disease, prolonged pressure or diabetes. For healing of chronic wounds, revitalization of the inert wound bed, which is achieved by angiogenic sprouting of new blood vessels is of great importance. An alternative treatment option to conventional therapies is the use of skin substitutes: dermal (DS), epidermal (ES) or bi-layered skin substitutes (SS). The aim of this study was to determine the mode of action of an autologous SS, ES and DS with regards to endothelial cell proliferation, migration and angiogenic sprouting into a fibrin hydrogel. Results SS consists of a fully differentiated epidermis expanding over the acellular donor dermis (AD) which has become repopulated with fibroblasts. DS is the same construct as SS but without the epidermis and ES is the same construct as SS but without the fibroblasts. As a control, AD was used throughout. It was found that the bi-layered SS was the most potent substitute in inducing migration and sprouting of endothelial cells. The cross talk between dermis and epidermis resulted in the strongest induction of sprouting via VEGF and uPAR. ES stimulated sprouting more than DS again via VEGF and uPAR. The slight induction of sprouting mediated by DS was not mediated by VEGF, but was in part stimulated through uPAR. Conclusion This in vitro study supports our clinical observations that a bi-layered SS is a strong stimulator of angiogenesis and therefore has the potential to revitalize an inert wound bed.
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Affiliation(s)
- Hanneke N Monsuur
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ester M Weijers
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Susan Gibbs
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Oral Cell Biology, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdan and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lenie J van den Broek
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Abstract
Patients with severe diabetic foot ulcerations that fail to heal with standard conventional therapies may be candidates for hyperbaric oxygen therapy; these patients also should be evaluated for atypical wound etiologies. Medical evaluation includes thorough history, physical examination, screening laboratory tests, and ulcer biopsy. During hyperbaric oxygen therapy, patients breathe 100% oxygen at 2 times to 3 times atmospheric pressure while enclosed in a hyperbaric chamber. Over time, administration of hyperbaric oxygen therapy can result in wound neovascularization and enhanced limb salvage. In patients with suspected atypical ulceration, referral to a multidisciplinary wound healing center is considered standard of care.
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Affiliation(s)
- Carol Deane Benedict Mitnick
- Division of Rheumatology, Immunology and Allergy, Center for Wound Healing, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, 3PHC, Suite 3004, Washington, DC 20007, USA
| | - Kelly Johnson-Arbor
- MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA.
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55
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Duschek N, Trautinger F. [Chronic leg ulcers in older patients]. Z Gerontol Geriatr 2019; 52:377-390. [PMID: 31187184 DOI: 10.1007/s00391-019-01567-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/20/2019] [Indexed: 01/13/2023]
Abstract
Chronic ulcers of the lower extremities are one of the most common medical problems encountered in western societies. The prevalence of leg ulcers is estimated to be 0.5-1.0% of the German population and is clearly associated with age. Therefore, in an aging society chronic leg ulcers are an important health issue with respect to increased morbidity and healthcare costs. The most frequent causes of leg ulcers are chronic venous insufficiency, peripheral arterial occlusive disease and diabetes mellitus. Efficient treatment necessitates an exact diagnosis and a close interdisciplinary collaboration. Affected patients often require instructions regarding self-help and support for competent nursing and prophylaxis. Therapeutic strategies, especially in the geriatric setting, aim to maintain the quality of life through preservation of patient mobility and autonomy.
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Affiliation(s)
- N Duschek
- Klinische Abteilung für Haut- und Geschlechtskrankheiten, Universitätsklinikum St. Pölten, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dunant-Platz 1, 3100, St. Pölten, Österreich.
| | - F Trautinger
- Klinische Abteilung für Haut- und Geschlechtskrankheiten, Universitätsklinikum St. Pölten, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Dunant-Platz 1, 3100, St. Pölten, Österreich
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56
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Bui UT, Finlayson K, Edwards H. The diagnosis of infection in chronic leg ulcers: A narrative review on clinical practice. Int Wound J 2019; 16:601-620. [PMID: 30697930 PMCID: PMC7948879 DOI: 10.1111/iwj.13069] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/20/2018] [Accepted: 12/28/2018] [Indexed: 12/17/2022] Open
Abstract
This literature review aimed to provide a narrative review of evidence on validity of clinical and microbial indicators of infection and to gain insights into the diagnosis of infection in chronic leg ulcers (CLUs). A search was conducted in Cinahl, Medline, the Cochrane Library databases, Embase, Web of Science, ScienceDirect, Pubmed, PsycINFO, ProQuest dissertations, and Google Scholar from January 1990 to July 2017. The inclusion criteria were original studies, systematic reviews, and consensus documents focused on "infection" in CLUs, English language, clinical and community settings, and human. The reviewed studies were inconsistent in criteria for infection between investigated wound types and lack of specificity regarding wound types. There were few studies investigating the criteria for diagnosis of infection in leg ulcers. The identification of leg ulcer infection still remains problematic and relies on out-of-date and not uniform evidence. Literature in this area was mostly limited to level III and IV evidence based on The Australian National Health and Medical Research Council Levels of Evidence, or expert opinion. This literature review showed seven clinical signs and symptoms that could be diagnostic for infection in CLUs, including: new, increased, or altered ulcer pain; malodour; increased ulcer area; wound breakdown, delayed or non-healing; and erythema and increased local temperature, whilst the microbial indicators used to diagnose infected leg ulcers were varied and regarded as less important.
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Affiliation(s)
- Ut T. Bui
- School of Nursing, Institute of Health and Biomedical Innovation, Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
| | - Kathleen Finlayson
- School of Nursing, Institute of Health and Biomedical Innovation, Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
| | - Helen Edwards
- School of Nursing, Institute of Health and Biomedical Innovation, Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
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Isoherranen K, O'Brien JJ, Barker J, Dissemond J, Hafner J, Jemec GBE, Kamarachev J, Läuchli S, Montero EC, Nobbe S, Sunderkötter C, Velasco ML. Atypical wounds. Best clinical practice and challenges. J Wound Care 2019; 28:S1-S92. [DOI: 10.12968/jowc.2019.28.sup6.s1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kirsi Isoherranen
- Helsinki University Central Hospital and Helsinki University, Wound Healing Centre and Dermatology Clinic, Helsinki, Finland
| | | | - Judith Barker
- Nurse Practitioner - Wound Management, Rehabilitation, Aged and Community Care., Adjunct Associate Professor, University of Canberra, Canberra, Australia
| | - Joachim Dissemond
- University Hospital of Essen, Department of Dermatology, Venerology and Allergology, Hufelandstraße 55, Essen, Germany
| | - Jürg Hafner
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland
| | - Gregor B. E. Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark
| | - Jivko Kamarachev
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland
| | - Severin Läuchli
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland
| | | | - Stephan Nobbe
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland Department of Dermatology, Cantonal Hospital of Frauenfeld, Switzerland
| | - Cord Sunderkötter
- Chair, Department of Dermatology and Venerology, University and University Hospital of Halle, Ernst-Grube-Strasse 40, Halle, Germany
| | - Mar Llamas Velasco
- Department of Dermatology, Hospital Universitario De La Princesa, Madrid, Spain
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Rousselle P, Braye F, Dayan G. Re-epithelialization of adult skin wounds: Cellular mechanisms and therapeutic strategies. Adv Drug Deliv Rev 2019; 146:344-365. [PMID: 29981800 DOI: 10.1016/j.addr.2018.06.019] [Citation(s) in RCA: 248] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/28/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022]
Abstract
Cutaneous wound healing in adult mammals is a complex multi-step process involving overlapping stages of blood clot formation, inflammation, re-epithelialization, granulation tissue formation, neovascularization, and remodelling. Re-epithelialization describes the resurfacing of a wound with new epithelium. The cellular and molecular processes involved in the initiation, maintenance, and completion of epithelialization are essential for successful wound closure. A variety of modulators are involved, including growth factors, cytokines, matrix metalloproteinases, cellular receptors, and extracellular matrix components. Here, we focus on cellular mechanisms underlying keratinocyte migration and proliferation during epidermal closure. Inability to re-epithelialize is a clear indicator of chronic non-healing wounds, which fail to proceed through the normal phases of wound healing in an orderly and timely manner. This review summarizes the current knowledge regarding the management and treatment of acute and chronic wounds, with a focus on re-epithelialization, offering some insights into novel future therapies.
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59
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Naik G, Ivins NM, Harding KG. A prospective pilot study of thigh-administered intermittent pneumatic compression in the management of hard-to-heal lower limb venous and mixed aetiology ulcers. Int Wound J 2019; 16:940-945. [PMID: 31016851 DOI: 10.1111/iwj.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/18/2019] [Indexed: 01/16/2023] Open
Abstract
This was a prospective observational pilot study of a unique intermittent pneumatic compression (IPC) device designed to be applied in the thigh region of the affected limb in patients with lower limb ulceration of both venous and mixed (venous and arterial) aetiologies. This compression system consists of a circumferential three-chamber thigh garment and an electronic pneumatic compression pump operating over a repeated 4-minute cycle. Patients were recruited from outpatient wound clinics. Those recruited were treated with standard therapy in addition to IPC, which was applied for 2 hours per day, and followed up for a total of 8 weeks. The primary objective of the study was to examine the effects of IPC on wound healing over an 8-week period. The other objectives were to assess patients' experiences of pain and the acceptability of IPC device. Twenty-one patients were recruited, and wounds progressed towards healing in 95.24% (20/21) of the patients. Pain scores decreased in 83.33% (15/18) of the patients. Most patients felt that the thigh-applied IPC device was comfortable and easy to apply and remove. The thigh-administered IPC device can be recommended for use in routine clinical practice, especially when other treatment options are limited.
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Affiliation(s)
- Gurudutt Naik
- Welsh Wound Innovation Centre, Pontyclun, UK.,Vauxhall Practice, Chepstow, UK
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60
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Lelli D, Pedone C, Frezzotti E, Pennazza G, Santonico M, Grasso S, Antonelli Incalzi R. Use of voltammetric analysis for fast and objective discrimination of the etiology, evolution, and bacterial infection of lower limb ulcers. Wound Repair Regen 2019; 27:288-291. [PMID: 30663822 DOI: 10.1111/wrr.12696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 12/13/2022]
Abstract
The timely recognition of leg ulcers (LU) etiology and infection is pivotal to optimize management and accelerate healing. The objective of this proof-of-concept study was to test the diagnostic performance of voltammetric analysis (VA) on ulcer exudate to identify LU etiology, infection, and predict clinical course. We enrolled 25 patients aged ≥60 years, affected by 42 venous/arterial LU. Clinical examination (Leg Ulcer Measurement Tool score, LUMT), swab culture, and VA were performed at baseline and 30 days. The ability of VA to predict outcomes was tested using partial least square-discrimination analysis. Mean age was 75 years (SD 11.1), 9/25 were male. The accuracy, sensitivity, and specificity vs. etiology were 97.4, 100%, and 94.1%, respectively; the corresponding figures were 95.2%, 100%, 88.9%, for infection and 94%, 84.6%, 100% for predicted objective LUMT worsening. VA is a promising diagnostic/prognostic tool for management of LU that may allow a more timely targeted therapy.
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Affiliation(s)
- Diana Lelli
- Geriatric Unit, Campus Bio-Medico University Hospital, via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Claudio Pedone
- Geriatric Unit, Campus Bio-Medico University Hospital, via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Elena Frezzotti
- Geriatric Unit, Campus Bio-Medico University Hospital, via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Giorgio Pennazza
- Unit of Electronics for Sensor Systems, Faculty of Engineering, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Marco Santonico
- Unit of Electronics for Sensor Systems, Faculty of Engineering, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Simone Grasso
- Unit of Electronics for Sensor Systems, Faculty of Engineering, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128 Rome, Italy
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61
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Avishai E, Golubnitschaja O. Flammer Syndrome in the Context of Healing Impairments – Facts and Hypotheses for Multi-professional Consideration. FLAMMER SYNDROME 2019. [DOI: 10.1007/978-3-030-13550-8_12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Efficacy of a Chinese Herbal Medicine Compound Zhangpi Ointment against Hydroxyurea-Induced Leg Ulcers: A Prospective, Randomized, Open-Label, Controlled Clinical Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:9329465. [PMID: 30643539 PMCID: PMC6311290 DOI: 10.1155/2018/9329465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/23/2018] [Indexed: 02/03/2023]
Abstract
Objective. The randomized controlled trial was to evaluate the efficacy of topical Chinese herbal Zhangpi Ointment for hydroxyurea-induced leg ulcers in patients with myeloproliferative neoplasms. Patients and Methods. This single-center, prospective, randomized, open-label, controlled clinical trial conducted at Shanghai Ninth People's Hospital enrolled 54 patients with hydroxyurea-induced leg ulcers. Patients were randomly assigned to the control group (n = 27) treated with chlorhexidine dressing or the intervention group (n = 27) treated with the Zhangpi Ointment. Finally, 26 patients in the control group and 23 patients in the intervention group completed 8 weeks of observation. Results. The rate of complete healing was 100% for the intervention group, which was significantly higher than that of the control group (96.15%) (P<0.05). Furthermore, the intervention group achieved a significantly higher rate of wound healing (95.56%) than the control group (69.02%) at week 4 (P<0.01). The intervention group took 34 ± 5 days to achieve complete healing while the control group took 41 ± 7 days (P < 0.01). Moreover, grade 3/4 side effects were observed in neither group. Conclusion. The Zhangpi Ointment is effective in promoting the healing of hydroxyurea-induced leg ulcers in patients with myeloproliferative neoplasms, providing a therapeutic option for a condition that is recalcitrant to conventional therapy.
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63
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Bui UT, Finlayson K, Edwards H. Risk factors for infection in patients with chronic leg ulcers: A survival analysis. Int J Clin Pract 2018; 72:e13263. [PMID: 30239088 DOI: 10.1111/ijcp.13263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 07/30/2018] [Accepted: 08/27/2018] [Indexed: 12/25/2022] Open
Abstract
AIM This study aimed to validate the relationships between possible predictive factors and clinically diagnosed infection in adult patients with chronic leg ulcers. METHODS This study used a sample of 636 adult participants whose ulcers were diagnosed as either venous, arterial or mixed aetiology leg ulcers and had no clinical signs of infection at recruitment. Data were extracted from recruitment to 12 weeks from six longitudinal prospective studies from 2004 to 2015. Survival analysis was used to investigate mean time-to-infection, including the Kaplan-Meier method and the Cox proportional-hazards regression model. RESULTS The sample included 74.7% venous, 19.6% mixed and 5.7% arterial leg ulcers. There were 101 (15.9%) participants diagnosed with infection at least once within 12 weeks of follow-up. Mean time-to-infection was 10.89 weeks (95% CI = 10.66-11.12). After adjustment for potential confounders, a Cox proportional hazards regression model found that depression, using walking aids, calf ankle ratio <1.3, wound area ≥10 cm2 and ulcers with slough tissue at recruitment were significant risk factors for wound infection. CONCLUSION This study has validated the predictive ability of factors which have been found in a cross-sectional study to be significantly associated with infection in patients with leg ulcers, including venous leg ulcers, arterial leg ulcers and mixed aetiology leg ulcers. Results showed that patients with chronic leg ulcers, who either presented with depression, used walking aids, had a calf ankle ratio <1.3, a wound area ≥10 cm2 or an ulcer with slough tissue, had greater likelihood of developing infection compared to those without these factors.
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Affiliation(s)
- Ut T Bui
- Faculty of Health, School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld, Australia
- Wound Management Innovation Cooperative Research Centre, West End, Qld, Australia
| | - Kathleen Finlayson
- Faculty of Health, School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld, Australia
- Wound Management Innovation Cooperative Research Centre, West End, Qld, Australia
| | - Helen Edwards
- Faculty of Health, School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld, Australia
- Wound Management Innovation Cooperative Research Centre, West End, Qld, Australia
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Bambaradeniya YTB, Karunaratne WAIP, Rakinawasam SV, Tomberlin JK, Goonerathne I, Kotakadeniya RB. Myiasis incidences reported in and around central province of Sri Lanka. Int J Dermatol 2018; 58:336-342. [PMID: 30460994 DOI: 10.1111/ijd.14291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Myiasis, or the invasion of living tissues of humans and other mammals by dipterous larvae, is considered the world's fourth most common travel-associated skin disease after cutaneous larval migrants, pyodermas, and pruritic arthropod-reactive dermatitis. METHOD The present study recorded the cause, anatomical position, and severity of the wounds of myiasis patients admitted to 11 hospitals located in the central region of Sri Lanka from February 2016 to July 2017. RESULTS Altogether, 28 myiasis incidences were noted within the study period. Of the total identified myiasis patients, nine were female while the remainder were male. The greatest number of patients was recorded from the Mawanella Base Hospital and Peradeniya Teaching Hospital (seven patients each). The ages of recorded patients ranged between 30 and 92 years with the average being 59.4 years. The greatest number of myiasis cases was diagnosed in wounds located in lower limbs (24). In addition, scalp, urogenital, and umbilical infestations were recorded. Eighteen out of the total patients had diabetes mellitus, and two patients suffered from filarial lymphedema. Psychiatric illnesses were a predisposing factor of larval infestation of six patients including the recorded scalp and two urogenital myiasis patients. Of the 28 myiasis cases, 27 were caused by the old world screwworm, Chrysomya bezziana Villeneuve (Diptera: Calliphoridae), and one by the blowfly, Chrysomya megacephala Fabricius (Diptera: Calliphoridae). CONCLUSION The awareness of patients with ulcers about this disease helps to decrease further risk of being infected by fly larvae.
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Affiliation(s)
- Yasas Tharindu B Bambaradeniya
- Faculty of Science, Department of Zoology, University of Peradeniya, Kandy, Sri Lanka.,Postgraduate Institute of Science, University of Peradeniya, Kandy, Sri Lanka
| | | | | | | | - Induwara Goonerathne
- Faculty of Medicine, Department of Forensic Medicine, University of Peradeniya, Kandy, Sri Lanka
| | - Rasika B Kotakadeniya
- Faculty of Medicine, Department of Surgery, University of Peradeniya, Kandy, Sri Lanka
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Xie T, Ye J, Rerkasem K, Mani R. The venous ulcer continues to be a clinical challenge: an update. BURNS & TRAUMA 2018; 6:18. [PMID: 29942813 PMCID: PMC6003071 DOI: 10.1186/s41038-018-0119-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/11/2018] [Indexed: 01/18/2023]
Abstract
Venous ulcers are a common chronic problem in many countries especially in Northern Europe and USA. The overall prevalence of this condition is 1% rising to 3% in the over 65 years of age. Over the last 25 years, there have been many developments applicable to its diagnosis and treatment. These advances, notwithstanding healing response and recurrence, are variable, and the venous ulcer continues to be a clinical challenge. The pathogenesis of venous ulcers is unrelieved or ambulatory venous hypertension resulting mostly from deep venous thrombosis leading to venous incompetence, lipodermatosclerosis, leucocyte plugging of the capillaries, tissue hypoxia and microvascular dysfunction. It is not known what initiates venous ulcers. Triggers vary from trauma of the lower extremity to scratching to relieve itchy skin over the ankle region. Venous ulcers can be painful, and this condition presents an increasing burden of care. A systematic analysis of the role of technology used for diagnosis and management strongly supports the use of compression as a mainstay of standardised care. It further shows good evidence for the potential of some treatment procedures to accelerate healing. This article reviews the pathogenetic mechanisms, current diagnostic methods and standard care and its limitations.
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Affiliation(s)
- Ting Xie
- 1Wound Healing Centre at Emergency Department, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junna Ye
- 2Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kittipan Rerkasem
- 3NCD Centre of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand.,4NCD Centre and Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rajgopal Mani
- 4NCD Centre and Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,5Academic Division of Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK.,6Shanghai Jiao Tong University, Shanghai Jiao Tong School of Medicine, Shanghai, China
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66
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Abstract
OBJECTIVE: Wound dressings that use biosynthetic cellulose may be a good alternative to dressings currently used to treat chronic and acute ulcers because their nanostructure is similar to collagen. The objective of this study was to evaluate a wound dressing created with a new material that is composed of a fibrillary network of biosynthetic cellulose. METHODS: A case series of 8 patients in primary healthcare centers in Östergötland county council, Sweden, with chronic and acute lower limb wounds were treated with a wound dressing based on eiratex (S2Medical AB, Linköping, Sweden). The dressing was applied to traumatic (n = 5) and venous ulcers (n = 3). All ulcers were considered healed at the end of the treatment. MAIN OUTCOME MEASURE: The wounds were examined at regular intervals by a physician to determine healing time, number of dressing changes, and number of visits. MAIN RESULTS: Mean healing time was 43 ± 6 days after the first application of the dressing. The mean number of visits was 5.7 ± 0.6, and the mean number of dressings used per patient was 1.7 ± 0.2. CONCLUSIONS: These results demonstrate the efficacy of a wound dressing made of eiratex to heal chronic and acute ulcers. The data show that the number of dressings used and dressing changes needed to heal the ulcers are lower than what have been reported in the literature for other dressing materials.
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Cooper B, Bachoo P. Extracorporeal shock wave therapy for the healing and management of venous leg ulcers. Cochrane Database Syst Rev 2018; 6:CD011842. [PMID: 29889978 PMCID: PMC6513251 DOI: 10.1002/14651858.cd011842.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Leg ulcers are chronic wounds of the lower leg, caused by poor blood flow, that can take a long time to heal. The pooling of blood in the veins can damage the skin and surrounding tissues, causing an ulcer to form. Venous leg ulcers are associated with impaired quality of life, reduced mobility, pain, stress and loss of dignity. The standard treatment for venous leg ulcers is compression bandages or stockings. Shock wave therapy may aid the healing of these wounds through the promotion of angiogenesis (the formation and development of blood vessels) and reduction of inflammation, though this process is poorly understood at present. OBJECTIVES To assess the effects of extracorporeal shock wave therapy on the healing and management of venous leg ulceration. SEARCH METHODS In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. We applied no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We considered all published and unpublished randomised controlled trials (RCTs) assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias of included studies, extract study data and rate the certainty of the evidence using GRADE. MAIN RESULTS We found no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS We found no RCTs assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration. The lack of high-quality evidence in this area highlights a gap in research and may serve to justify the need for further research and evidence to provide guidance concerning the use of this treatment option for this condition. Future trials should be of clear design and include concomitant use of the current best practice treatment, multilayer compression therapy. Recruitment should aspire to best represent patients seen in clinical practice and patient-related outcome measures should be included in study design.
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Affiliation(s)
- Ben Cooper
- NHS GrampianDepartment of Vascular SurgeryForesterhill RoadAberdeenUKAB25 2ZN
| | - Paul Bachoo
- NHS GrampianDepartment of Vascular SurgeryForesterhill RoadAberdeenUKAB25 2ZN
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Abstract
Aging results in both anatomic and physiologic changes in the skin's structure and vascular system. These vascular changes result in a wide array of dermatologic findings, ranging from the benign to the highly morbid. Herein, we review the impact of both intrinsic and common extrinsic factors of aging on cutaneous vasculature and highlight the manifestations of microvascular, venous, arterial, lymphatic, and neuropathic alterations in the geriatric population.
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Affiliation(s)
- Laura Buford
- Section of Dermatology, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Rebecca Kaiser
- Section of Dermatology, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Vesna Petronic-Rosic
- Section of Dermatology, The University of Chicago Pritzker School of Medicine, Chicago, Illinois.
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Assis S, Henderson CY, Casimiro S, Alves Cardoso F. Is differential diagnosis attainable in disarticulated pathological bone remains? A case-study from a late 19th/early 20th century necropolis from Juncal (Porto de Mós, Portugal). INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2018; 20:26-37. [PMID: 29496213 DOI: 10.1016/j.ijpp.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/18/2017] [Accepted: 10/27/2017] [Indexed: 06/08/2023]
Abstract
Differential diagnosis is a fundamental step in every palaeopathological study. It is a challenging exercise since many intrinsic and extrinsic factors may negatively impact the accurate interpretation of bone changes in human skeletal remains. Among these, the completeness and preservation of skeletal elements plays a significant role. This study aims to explore the limits of differential diagnosis in the analysis of disarticulated, fragmented bones. The sample consists of twelve adult bone fragments with noticeable changes. The remains were identified in a dis-articulated skeletal assemblage from the former necropolis of Juncal (Porto de Mós, Portugal), which probably closed in the late 19th century/early 20th century. They were analysed visually and with X-radiography, and the changes carefully described prior to differential diagnosis. Six bones presented signs of healed bone trauma and one showed features compatible with leg amputation. Periosteal reactions were observed in several bones, one of them resembling changes consistent with an overlying skin ulcer. Two bone fragments were identified as belonging to the same individual due to the matching bone changes. Despite the incomplete remains, a broader diagnosis was possible for most cases, which facilitated a discussion of health, medical and social care among the inhabitants of the region.
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Affiliation(s)
- Sandra Assis
- LABOH - Laboratório de Antropologia Biológica e Osteologia Humana, CRIA/FCSH, Universidade Nova de Lisboa, Portugal; CRIA - Centro em Rede de Investigação em Antropologia, Faculdade de Ciências Sociais e Humanas, FCSH, Universidade Nova de Lisboa, 1069-061 Lisboa, Portugal.
| | - Charlotte Yvette Henderson
- CIAS - Research Centre for Anthropology and Health, Department of Life Sciences, University of Coimbra, 3001-401 Coimbra, Portugal.
| | - Sílvia Casimiro
- LABOH - Laboratório de Antropologia Biológica e Osteologia Humana, CRIA/FCSH, Universidade Nova de Lisboa, Portugal; CRIA - Centro em Rede de Investigação em Antropologia, Faculdade de Ciências Sociais e Humanas, FCSH, Universidade Nova de Lisboa, 1069-061 Lisboa, Portugal.
| | - Francisca Alves Cardoso
- LABOH - Laboratório de Antropologia Biológica e Osteologia Humana, CRIA/FCSH, Universidade Nova de Lisboa, Portugal; CRIA - Centro em Rede de Investigação em Antropologia, Faculdade de Ciências Sociais e Humanas, FCSH, Universidade Nova de Lisboa, 1069-061 Lisboa, Portugal.
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71
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Lurie F, Bittar S, Kasper G. Optimal Compression Therapy and Wound Care for Venous Ulcers. Surg Clin North Am 2017; 98:349-360. [PMID: 29502776 DOI: 10.1016/j.suc.2017.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Venous leg ulcers remain a major public health issue with significant economic impact. Two main components of the management of patients with venous leg ulcers are compression therapy and wound care. This article addresses principles and specific aspects of compression therapy and focal wound care for patients with venous leg ulcers.
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Affiliation(s)
- Fedor Lurie
- ProMedica Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH 43606, USA; University of Michigan, Ann Arbor, MI, USA.
| | - Samir Bittar
- ProMedica Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH 43606, USA
| | - Gregory Kasper
- ProMedica Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH 43606, USA
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72
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Affiliation(s)
- Adam J Singer
- From Departments of Emergency Medicine and Vascular Surgery, Stony Brook University, Stony Brook, NY (A.J.S., A.T.); and the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami (R.S.K.)
| | - Apostolos Tassiopoulos
- From Departments of Emergency Medicine and Vascular Surgery, Stony Brook University, Stony Brook, NY (A.J.S., A.T.); and the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami (R.S.K.)
| | - Robert S Kirsner
- From Departments of Emergency Medicine and Vascular Surgery, Stony Brook University, Stony Brook, NY (A.J.S., A.T.); and the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami (R.S.K.)
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73
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Sundby ØH, Høiseth LØ, Mathiesen I, Jørgensen JJ, Sundhagen JO, Hisdal J. The effects of intermittent negative pressure on the lower extremities' peripheral circulation and wound healing in four patients with lower limb ischemia and hard-to-heal leg ulcers: a case report. Physiol Rep 2017; 4:4/20/e12998. [PMID: 27798353 PMCID: PMC5099962 DOI: 10.14814/phy2.12998] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/19/2016] [Indexed: 11/24/2022] Open
Abstract
Peripheral circulation is severely compromised in the advanced stages of peripheral arterial disease. Recently, it was shown that the application of -40 mmHg intermittent negative pressure (INP) to the lower leg and foot enhances macro- and microcirculation in healthy volunteers. In this case report, we describe the effects of INP treatment on four patients with lower limb ischemia and hard-to-heal leg and foot ulcers. We hypothesized that INP therapy may have beneficial hemodynamic and clinical effects in the patients. Four patients (age range: 61-79 years) with hard-to-heal leg and foot ulcers (6-24 months) and ankle-brachial pressure indices of ≤0.60 on the affected side were included. They were treated with an 8-week intervention period of -40 mmHg INP (10 sec negative pressure and 7 sec atmospheric pressure) on the lower limbs. A custom-made vacuum chamber was used to apply INP to the affected lower leg and foot for 2 h per day. After 8 weeks of INP therapy, one ulcer healed completely, while the other three ulcers were almost completely healed. These cases suggest that INP may facilitate wound healing. The theoretical foundation is that INP assists wound healing by improving blood flow to the small blood vessels in the affected limb, increasing the flow of oxygen and nutrients to the cells.
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Affiliation(s)
- Øyvind H Sundby
- Section of Vascular Investigations, Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Otivio AS, Oslo, Norway
| | - Lars Ø Høiseth
- Section of Vascular Investigations, Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway.,Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | - Jørgen J Jørgensen
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Jon O Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
| | - Jonny Hisdal
- Section of Vascular Investigations, Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway
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Arase N, Tanimura K, Jin H, Yamaoka T, Kishibe M, Nishioka M, Kiyohara E, Tani M, Matsuoka S, Ohmura K, Takasugi K, Yamamoto T, Murota H, Arase H, Katayama I. Novel autoantibody against the β2‐glycoprotein I/human leucocyte antigen–
DR
complex in patients with refractory cutaneous ulcers. Br J Dermatol 2017; 178:272-275. [DOI: 10.1111/bjd.15571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- N. Arase
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
- Department of Immunochemistry Research Institute for Microbial Diseases Osaka University Suita Osaka Japan
| | - K. Tanimura
- Department of Obstetrics and Gynecology Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - H. Jin
- Department of Immunochemistry Research Institute for Microbial Diseases Osaka University Suita Osaka Japan
- Laboratory of Immunochemistry WPI Immunology Frontier Research Center Osaka University Suita Osaka Japan
| | - T. Yamaoka
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
| | - M. Kishibe
- Department of Dermatology Asahikawa Medical University Asahikawa Hokkaido Japan
| | - M. Nishioka
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
| | - E. Kiyohara
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
| | - M. Tani
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
| | - S. Matsuoka
- Department of Immunochemistry Research Institute for Microbial Diseases Osaka University Suita Osaka Japan
| | - K. Ohmura
- Department of Rheumatology and Clinical Immunology Kyoto University Graduate School of Medicine Kyoto Kyoto Japan
| | - K. Takasugi
- Department of Internal Medicine Center for Rheumatic Diseases Dohgo Spa Hospital Matsuyama Ehime Japan
| | - T. Yamamoto
- Department of Dermatology Fukushima Medical University Fukushima Fukushima Japan
| | - H. Murota
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
| | - H. Arase
- Department of Immunochemistry Research Institute for Microbial Diseases Osaka University Suita Osaka Japan
- Laboratory of Immunochemistry WPI Immunology Frontier Research Center Osaka University Suita Osaka Japan
| | - I. Katayama
- Department of Dermatology Osaka University Graduate School of Medicine Suita Osaka Japan
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75
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Kaplan ST, Hemsinli D, Kaplan S, Arslan A. Amputation predictors in diabetic foot ulcers treated with hyperbaric oxygen. J Wound Care 2017; 26:361-366. [PMID: 28704149 DOI: 10.12968/jowc.2017.26.7.361] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Although hyperbaric oxygen therapy (HBOT) has long been used for diabetic foot ulcers (DFUs), its effectiveness is still controversial. The aim of this study was to investigate the efficacy of HBOT in the management of DFUs and identify amputation predictors. METHOD Patients with chronic DFUs (Wanger grade 2-5) were included in the study, which took place between January 2010 and December 2012. HBOT, 100% oxygen, 2.4 atmosphere absolute (ATA) for 120 minutes, was administered to all patients in addition to standard treatment. DFUs were monitored for at least 3 years, or until healing or amputation occurred. RESULTS Patients with a total of 146 chronic DFUswere recruited. Complete healing (69.6%) and significant improvement (17.9%) was observed in 87.5% of the patients. The cases with no improvement resulted in amputation (minor amputation: 15.0%; major amputation: 8.2%). The duration of diabetes (p=0.037), new wound formation (p=0.045), C-reactive protein (p=0.001) and Wagner grade (p=0.0001) were correlated with amputation in multiple regression analysis. Mortality was higher in the amputation group than in the non-amputation group (47.1 % versus 21.4 %, p=0.007). CONCLUSION The inclusion of HBOT with standard treatment and a multidisciplinary approach may be useful in the treatment of DFUs. We found the most important predictors of amputation to be Wagner grade and wound infection. Multicentre, prospective, randomised studies are needed to provide more evidence.
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Affiliation(s)
- S T Kaplan
- Department of Internal Medicine, Trabzon Kanuni Education and Research Hospital, Trabzon, Turkey
| | - D Hemsinli
- Department of Cardiovascular Surgery, Trabzon Kanuni Education and Research Hospital, Trabzon, Turkey
| | - S Kaplan
- Department of Cardiology, KTU, Faculty of Medicine, Trabzon, Turkey
| | - A Arslan
- Department of Underwater and Hyperbaric Medicine, Faculty of Meram Medicine, Necmettin Erbakan University, Konya, Turkey
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76
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Shannon R, Nelson A. A single-arm trial indirect comparison investigation: a proof-of-concept method to predict venous leg ulcer healing time for a new acellular synthetic matrix matched to standard care control. Int Wound J 2017; 14:729-741. [PMID: 27868341 PMCID: PMC7949811 DOI: 10.1111/iwj.12687] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/21/2016] [Accepted: 10/06/2016] [Indexed: 11/27/2022] Open
Abstract
To compare data on time to healing from two separate cohorts: one treated with a new acellular synthetic matrix plus standard care (SC) and one matched from four large UK pragmatic, randomised controlled trials [venous leg ulcer (VLU) evidence network]. We introduce a new proof-of-concept strategy to a VLU clinical evidence network, propensity score matching and sensitivity analysis to predict the feasibility of the new acellular synthetic matrix plus SC for success in future randomised, controlled clinical trials. Prospective data on chronic VLUs from a safety and effectiveness study on an acellular synthetic matrix conducted in one wound centre in the UK (17 patients) and three wound centres in Australia (36 patients) were compared retrospectively to propensity score-matched data from patients with comparable leg ulcer disease aetiology, age, baseline ulcer area, ulcer duration, multi-layer compression bandaging and majority of care completed in specialist wound centres (average of 1 visit per week), with the outcome measures at comparable follow-up periods from patients enrolled in four prospective, multicentre, pragmatic, randomised studies of venous ulcers in the UK (the comparison group; VLU evidence network). Analysis using Kaplan-Meier survival curves showed a mean healing time of 73·1 days for ASM plus SC (ASM) treated ulcers in comparison with 83·5 days for comparison group ulcers treated with SC alone (Log rank test, χ2 5·779, P = 0·016) within 12 weeks. Sensitivity analysis indicates that an unobserved covariate would have to change the odds of healing for SC by a factor of 1·1 to impact the baseline results. Results from this study predict a significant effect on healing time when using a new ASM as an adjunct to SC in the treatment of non-healing venous ulcers in the UK, but results are sensitive to unobserved covariates that may be important in healing time comparison.
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Affiliation(s)
| | - Andrea Nelson
- Head of School, School of HealthcareUniversity of LeedsLeedsUK
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77
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Park JW, Hwang SR, Yoon IS. Advanced Growth Factor Delivery Systems in Wound Management and Skin Regeneration. Molecules 2017; 22:E1259. [PMID: 28749427 PMCID: PMC6152378 DOI: 10.3390/molecules22081259] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/21/2017] [Accepted: 07/25/2017] [Indexed: 01/18/2023] Open
Abstract
Growth factors are endogenous signaling molecules that regulate cellular responses required for wound healing processes such as migration, proliferation, and differentiation. However, exogenous application of growth factors has limited effectiveness in clinical settings due to their low in vivo stability, restricted absorption through skin around wound lesions, elimination by exudation prior to reaching the wound area, and other unwanted side effects. Sophisticated systems to control the spatio-temporal delivery of growth factors are required for the effective and safe use of growth factors as regenerative treatments in clinical practice, such as biomaterial-based drug delivery systems (DDSs). The current review describes the roles of growth factors in wound healing, their clinical applications for the treatment of chronic wounds, and advances in growth factor-loaded DDSs for enhanced wound healing, focusing on micro- and nano-particulate systems, scaffolds, hydrogels, and other miscellaneous systems.
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Affiliation(s)
- Jin Woo Park
- Department of Pharmacy, College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Muan-gun, Jeonnam 58554, Korea.
| | - Seung Rim Hwang
- Department of Pharmacy, College of Pharmacy, Chosun University, Dong-gu, Gwangju 61452, Korea.
| | - In-Soo Yoon
- College of Pharmacy, Pusan National University, Geumjeong-gu, Busan 46241, Korea.
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Athanerey A, Patra PK, Kumar A. Mesenchymal stem cell in venous leg ulcer: An intoxicating therapy. J Tissue Viability 2017; 26:216-223. [PMID: 28619238 DOI: 10.1016/j.jtv.2017.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 05/19/2017] [Accepted: 06/02/2017] [Indexed: 12/11/2022]
Abstract
Venous leg ulcers (VLU) are a prevalent and reoccurring type of complicated wound, turning as a considerable public healthcare issue, with critical social and economic concern. There are both medical and surgical therapies to treat venous leg ulcers; however, a cure does not yet exist. Mesenchymal stem cells (MSC) are capable and proved of accelerating wound healing in vivo and their study with human chronic wounds is currently awaited. MSCs are a promising source of adult progenitor cells for cellular therapy and have been demonstrated to differentiate into various mesenchymal cell lineages. They have a crucial and integral role in native wound healing by regulating immune response and inflammation. Improved understanding of the cellular and molecular mechanisms at work in delayed wound healing compels to the development of cellular therapy in VLU. This review focuses on the current treatment option of VLU and further emphasizing the role of MSCs in accelerating the healing process. With further understanding of the mechanism of action of these cells in wound improvement and, the involvement of cytokines can also be revealed that could be used for the therapeutic purpose for VLU healing. Clinical uses of MSCs have been started already, and induced MSCs are surely a promising tool or compelling therapy for VLU.
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Affiliation(s)
- Anjali Athanerey
- Department of Biotechnology, National Institute of Technology Raipur, Chhattisgarh, India
| | - Pradeep Kumar Patra
- Department of Biochemistry, Pt. JNM Medical College, Raipur, Chhattisgarh, India
| | - Awanish Kumar
- Department of Biotechnology, National Institute of Technology Raipur, Chhattisgarh, India.
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Serra R, Rizzuto A, Rossi A, Perri P, Barbetta A, Abdalla K, Caroleo S, Longo C, Amantea B, Sammarco G, de Franciscis S. Skin grafting for the treatment of chronic leg ulcers - a systematic review in evidence-based medicine. Int Wound J 2017; 14:149-157. [PMID: 26940940 PMCID: PMC7949524 DOI: 10.1111/iwj.12575] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 12/31/2015] [Accepted: 02/04/2016] [Indexed: 12/13/2022] Open
Abstract
Skin grafting is one of the most common surgical procedures in the area of non-healing wounds by which skin or a skin substitute is placed over a wound to replace and regenerate the damaged skin. Chronic leg ulcers are an important problem and a major source of expense for Western countries and for which many different forms of treatment have been used. Skin grafting is a method of treatment that decreases the area of chronic leg ulcers or heals them completely, thus improving a patient's quality of life. Skin grafting is an old technique, rediscovered during the first and second world wars as the main treatment for wound closure. Nowadays, skin grafting has a pivotal role in the context of modern wound healing and tissue regeneration. The aim of this review was to track and to analyse the specific outcomes this technique achieved, especially in the last decade, in relation to venous, arterial, diabetic, rheumatoid and traumatic leg ulcers. Our main findings indicate that autologous split-thickness skin grafting still remains the gold standard in terms of safety and efficacy for chronic leg ulcers; skin grafting procedures have greater success rates in chronic venous leg ulcers compared to other types of chronic leg ulcers; skin tissue engineering, also supported by genetic manipulation, is quickly expanding and, in the near future, may provide even better outcomes in the area of treatments for long-lasting chronic wounds.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental BiotechnologyUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Antonia Rizzuto
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Alessio Rossi
- Department of Medicine and Health Sciences “Vincenzo Tiberio”University of MoliseCampobassoItaly
| | - Paolo Perri
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Andrea Barbetta
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Karim Abdalla
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Santo Caroleo
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Chiara Longo
- Department of Physical Medicine and RehabilitationHospital of Saint‐FlourSaint‐FlourFrance
| | - Bruno Amantea
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Giuseppe Sammarco
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental BiotechnologyUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Department of Medical and Surgical SciencesUniversity of CatanzaroCatanzaroItaly
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80
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Parker CN, Finlayson KJ, Edwards HE. Ulcer area reduction at 2 weeks predicts failure to heal by 24 weeks in the venous leg ulcers of patients living alone. J Wound Care 2017; 25:626-634. [PMID: 27827277 DOI: 10.12968/jowc.2016.25.11.626] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Chronic wounds are costly and affect approximately 1-2% of the population. Venous disease is responsible for about 60% of all chronic leg ulcers and these ulcers can be debilitating, with evidence of a decreased quality of life. Unfortunately, up to 30% of venous leg ulcers (VLUs) fail to heal, despite best practice treatment. This study aimed to identify risk factors associated with delayed healing in participants with VLUs and in particular, whether psychosocial factors play a part in this process. METHOD A secondary analysis was conducted of a large data set of clinical, wound healing, health, social, economic and psychological data collected in previous prospective studies of participants with VLUs. Generalised linear mixed modelling was used to identify independent predictors of failure to heal after 24 weeks. RESULTS We recruited 247 participants with 318 VLUs from hospital and community settings. Findings revealed that four early predictors were independently significantly associated with failure to heal by 24 weeks. These were: participants who lived alone (OR 2.3, 95%CI [1.13-4.61], p=0.03); had less than 25% reduction in ulcer area within two weeks of treatment (OR 10.07, 95%CI [4.60-22.19], p<0.001); had higher ulcer severity scores (OR 5.1, 95%CI [2.33-11.88], p=0.001); and participants who were not treated with high level compression therapy (i.e.>30 mmHg) at the time of assessment (OR 4.18, 95% CI [1.95-8.97], p=0.002). CONCLUSION Identified risk factors offer an opportunity for clinicians to determine realistic outcomes for their patients and to guide decisions on early referral and implementation of tailored adjunctive interventions. Additionally, findings from this study suggest health professionals need to assess and address not only clinical risk factors but also social risk factors, when planning interventions to promote healing.
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Affiliation(s)
- C N Parker
- Assistant Dean (International and Engagement), School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD, 4059 Australia.,Assistant Dean (International and Engagement), Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue Kelvin Grove, QLD, 4059 Australia.,Assistant Dean (International and Engagement), Faculty of Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059 Australia.,Assistant Dean (International and Engagement), Wound Management Innovation Cooperative Research Centre, Oxley House, Level 2, 25 Donkin Street West End, QLD 4101 Australia
| | - K J Finlayson
- Assistant Dean (International and Engagement), School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD, 4059 Australia.,Assistant Dean (International and Engagement), Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue Kelvin Grove, QLD, 4059 Australia.,Assistant Dean (International and Engagement), Faculty of Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059 Australia.,Assistant Dean (International and Engagement), Wound Management Innovation Cooperative Research Centre, Oxley House, Level 2, 25 Donkin Street West End, QLD 4101 Australia
| | - H E Edwards
- Assistant Dean (International and Engagement), Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue Kelvin Grove, QLD, 4059 Australia.,Assistant Dean (International and Engagement), Faculty of Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059 Australia.,Assistant Dean (International and Engagement), Wound Management Innovation Cooperative Research Centre, Oxley House, Level 2, 25 Donkin Street West End, QLD 4101 Australia
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81
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Järbrink K, Ni G, Sönnergren H, Schmidtchen A, Pang C, Bajpai R, Car J. The humanistic and economic burden of chronic wounds: a protocol for a systematic review. Syst Rev 2017; 6:15. [PMID: 28118847 PMCID: PMC5259833 DOI: 10.1186/s13643-016-0400-8] [Citation(s) in RCA: 257] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 12/19/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic non-healing wounds present a substantial economic burden to healthcare system; significant reductions in quality of life for those affected, and precede often serious events such as limp amputations or even premature deaths. This burden is also likely to increase with a larger proportion of elderly and increasing prevalence of life-style diseases such as obesity and diabetes. Reviews of the evidence on the burden of illness associated with chronic wounds have not been comprehensive in scope and have not provided an assessment of the distribution of the health care costs across categories of resource use. METHODS/DESIGN This study is a systematic review of multiple databases for studies on adult patients with chronic wounds and with the primary objective to assess the impact on health-related quality of life by category of ulcers, and associated direct and indirect costs. Eligible studies will primary be empirical studies evaluating, describing or comparing measurement of quality of life and economic impact. Two reviewers will independently screen titles and abstracts and select studies involving adults with chronic wounds. These investigators will also independently extract data using a pre-designed data extraction form. Differences in applied methodologies and uncertainties will clearly be accounted for. Conservative valuations of costs and impact on health-related quality of life will be prioritised. Variations that may depend on age distribution, the categorisation of ulcer, healthcare system etc. will be described clearly. DISCUSSION The proposed systematic review will yield a comprehensive assessment of the humanistic and economic burden of chronic wounds in an adult population. A better understanding of the humanistic and economic burden of chronic wounds is essential for policy and planning purposes, to monitor trends in disease burden and not at least in order to estimate the real-world cost-effectiveness of new treatments and therapies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037496.
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Affiliation(s)
- Krister Järbrink
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Gao Ni
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Henrik Sönnergren
- Department of Dermatology, Skåne University Hospital, Lasarettsgatan 15, 221 85 Lund, Sweden
| | - Artur Schmidtchen
- Dermatology and Innate Immunity Laboratory, Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Caroline Pang
- Medical Library, Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 308232 Singapore
| | - Ram Bajpai
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, 3rd Floor Reynolds Building, St Dunstan’s Road, London, W6 8RP UK
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82
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Davies HOB, Popplewell M, Bate G, Kelly L, Darvall K, Bradbury AW. Impact of UK NICE clinical guidelines 168 on referrals to a specialist academic leg ulcer service. Phlebology 2017; 33:84-88. [DOI: 10.1177/0268355516688357] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management. Aim Determine the impact of CG168 on referrals to a leg ulcer service. Methods Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012–June 2013) and an 18-month period commencing six months after (January 2014–June 2015) publication of CG168 were compared. Results There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006). Conclusions Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.
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Affiliation(s)
- Huw OB Davies
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | - Matthew Popplewell
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | - Gareth Bate
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | - Lisa Kelly
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
| | | | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Netherwood House, Solihull Hospital, Birmingham, UK
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83
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Hemsinli D, Kaplan ST, Kaplan S, Yildirim F. Hyperbaric Oxygen Therapy in the Treatment of Fontaine Stage IV Thromboangiitis Obliterans. INT J LOW EXTR WOUND 2016; 15:366-370. [PMID: 27647524 DOI: 10.1177/1534734616666866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ischemic wounds unresponsive to standard treatment in thromboangiitis obliterans are associated with amputation, morbidity, and mortality. In this study, hyperbaric oxygen therapy was added to standard treatment of 36 patients with thromboangiitis obliterans with ischemic ulcerated wounds in the extremities. Full recovery was observed in 52.7% of cases (25% at discharge, 27.7% during follow-up). Resting pain after treatment decreased significantly compared to pretreatment levels based on visual analog scale scores (7.1 ± 1.7 vs 2.2 ± 3.0, P = .0001). Mean wound area also decreased significantly after treatment (22.6 ± 17.5 vs 13.02 ± 16.5, P = .0001). The number of patients requiring no assistance during routine daily activities increased significantly (25% vs 55.5%, P = .001). All patients were at Fontaine stage IV before hyperbaric oxygen therapy. The number of patients at stage IIB increased significantly after treatment, while that of patients at stage IV decreased significantly (0% vs 47.2%, P = .0001, and 100% vs 47.2%, P = .0001, respectively). None of our patients was able to walk without pain before treatment; however, walking distance was significantly extended in 16 patients who were capable of walking (0 vs 190.6 ± 129.4 meters, P = .0001). In addition, 11.1% of patients underwent major amputation during follow-up.
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Affiliation(s)
- Dogus Hemsinli
- 1 Kanuni Research and Training Hospital, Trabzon, Turkey
| | | | - Sahin Kaplan
- 2 Karadeniz Technical University, Trabzon, Turkey
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84
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Järbrink K, Ni G, Sönnergren H, Schmidtchen A, Pang C, Bajpai R, Car J. Prevalence and incidence of chronic wounds and related complications: a protocol for a systematic review. Syst Rev 2016; 5:152. [PMID: 27609108 PMCID: PMC5017042 DOI: 10.1186/s13643-016-0329-y] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/31/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic wounds impose a significant and often underappreciated burden to the individual, the healthcare system and the society as a whole. Preliminary literature search suggests that there are at present no reliable estimates on the total prevalence of chronic wounds for different settings and categories of chronic wounds. Such information is essential for policy and planning purposes as the increasing number of elderly and the prevalence of lifestyle diseases point in the direction of an increased burden. Knowledge about the prevalence and incidence of chronic wounds in relation to population characteristics is important for informing healthcare planning and resource allocation. The objective is to present a transparent process for how to review the existing literature on the prevalence and incidence rates of chronic wounds and resulting implications. METHODS/DESIGN We will search electronic bibliographic databases (MEDLINE, EMBASE, the EBM Reviews and Cochrane, Cumulative Index to Nursing and allied Health Literature (CINAHL), PsycINFO, Global Health) and reference lists of included articles. Two investigators will independently screen titles and abstracts and select studies involving adults with chronic wounds. These investigators will also independently extract data using a pre-designed data extraction form that will cover information on demographics, diagnostics including disease prevalence, medical history, hospital and community-based management and outcomes. Subgroup analysis and sensitivity analysis will be performed to address the heterogeneity across studies. Meta-analysis will also be performed if homogeneous group of studies will be found. The collective evidence will be further stratified according to the important background variables if allowed. DISCUSSION This study will describe the available epidemiological evidence and summarise prevalence and incidence rates of chronic wounds and related complications. A better understanding of the relationship between population profile and the prevalence of chronic wounds and related complications will be helpful in the development of guidelines for patient management. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037355.
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Affiliation(s)
- Krister Järbrink
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Gao Ni
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Henrik Sönnergren
- Department of Dermatology, Skåne University Hospital, Lasarettsgatan 15, 221 85 Lund, Sweden
| | - Artur Schmidtchen
- Dermatology and Innate Immunity Laboratory, Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Caroline Pang
- Medical Library, Lee Kong Chian School of Medicine, 11 Mandalay Road, Singapore, 636921 Singapore
| | - Ram Bajpai
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
| | - Josip Car
- Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Experimental Medicine Building, Singapore, 636921 Singapore
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, 3rd Floor Reynolds Building, St Dunstan’s Road, London, W6 8RP UK
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85
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Affiliation(s)
- Raghu Kolluri
- Prairie Vascular Institute, St John's Hospital, Springfield, IL USA, rkolluri@ prairieheart.com
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86
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Lazarides M, Giannoukas A. The Role of Hemodynamic Measurements in the Management of Venous and Ischemic Ulcers. INT J LOW EXTR WOUND 2016; 6:254-61. [DOI: 10.1177/1534734607306878] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a need for quantitative investigations in the vascular laboratory to manage lower extremity ulcers. The majority of leg ulcers are of venous (45%-60%) or arterial origin (10%-20%). Despite the increasing complexity of new devices used in vascular surgical practice, the anklebrachial pressure index (ABPI) remains the cornerstone for the differential diagnosis of ischemic ulcers. The toe-brachial pressure index and the pole test represent attractive alternative tests especially in patients with diabetes. Color flow Doppler imaging (CFDI) is advantageous over ABPI in cases in which wounds and ulcers prevent the use of a cuff by virtue of their size or location; additionally CFDI technology can detect nonflow limiting lesions, lesions to nonaxial arteries such as the deep femoral artery, or lesions limited to a single tibial artery. Continued improvements in the accuracy of CFDI have prompted some vascular surgeons to replace contrast arteriography in distal bypass procedures. Transcutaneous partial oxygen tension measurement (TcPO2) is another noninvasive method that is reliable to select the level of amputation and recommended to determine tissue viability in critically ischemic limbs and in the management of the diabetic foot. CFDI has revolutionized the diagnostic approach to venous disorders and it is considered the gold standard for the assessment of the venous system of the lower limb, causes minimal inconvenience to patients, and is easily repeatable, but it is considered highly operator dependent. Various plethysmography techniques are of limited application in ulcer investigations, because of their difficulty to calibrate signal, unless time measurements such as the postexercise refilling time are used.
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Affiliation(s)
- M.K. Lazarides
- Department of Vascular Surgery, Demokritos University,
Alexandroupolis,
| | - A.D. Giannoukas
- Department of Vascular Surgery, University of Thessaly,
Larissa, Greece
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87
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Morton LM, Phillips TJ. Wound healing and treating wounds. J Am Acad Dermatol 2016; 74:589-605; quiz 605-6. [DOI: 10.1016/j.jaad.2015.08.068] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/03/2015] [Accepted: 08/14/2015] [Indexed: 11/26/2022]
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88
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Boink MA, Roffel S, Nazmi K, van Montfrans C, Bolscher JGM, Gefen A, Veerman ECI, Gibbs S. The Influence of Chronic Wound Extracts on Inflammatory Cytokine and Histatin Stability. PLoS One 2016; 11:e0152613. [PMID: 27018788 PMCID: PMC4809600 DOI: 10.1371/journal.pone.0152613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 03/16/2016] [Indexed: 12/26/2022] Open
Abstract
Chronic ulcers represent a major health burden in our society. Despite many available therapies, a large number of ulcers do not heal. Protein based therapies fail in part due to proteolytic activity in the chronic wound bed. The aim of this in vitro study was to determine whether typical inflammatory cytokines and human salivary histatins remain stable when incubated with chronic wound extracts. Furthermore we determined whether a short exposure of histatins or cytokines was sufficient to exert long term effects on fibroblast migration. Stability of human recombinant cytokines IL-6 and CXCL8, and histatin variants (Hst1, Hst2, cyclic Hst1, minimal active domain of Hst1) in the presence of chronic wound extracts isolated from non-healing ulcers, was monitored by capillary zone electrophoresis. Migration-stimulating activity was assessed using a dermal fibroblast wound healing scratch assay. Histatins and cytokines stayed stable in saline for > 24 h at 37°C, making them ideal as an off-the-shelf product. However, incubation with chronic wound extracts resulted in serious breakdown of Hst1 and Hst2 (~50% in 8 h) and to lesser extent cyclic Hst1 and the minimal active domain of Hst1 (~20% in 8 h). The cytokines IL-6 and CXCL8 were more stable in chronic wound extracts (~40% degradation in 96 h). An initial 8-hour pulse of histatins or cytokines during a 96-hour study period was sufficient to stimulate fibroblast migration equally well as a continuous 96-hour exposure, indicating that they may possibly be used as novel bioactive therapeutics, exerting their activity for up to four days after a single exposure.
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Affiliation(s)
- Mireille A. Boink
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- Department of Dermatology, VU University medical center, Amsterdam, The Netherlands
| | - Sanne Roffel
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
- Department of Dermatology, VU University medical center, Amsterdam, The Netherlands
| | - Kamran Nazmi
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | | | - Jan G. M. Bolscher
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | - Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Enno C. I. Veerman
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | - Susan Gibbs
- Department of Dermatology, VU University medical center, Amsterdam, The Netherlands
- Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University, MOVE Research Institute Amsterdam, Amsterdam, The Netherlands
- * E-mail:
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89
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Fujimoto M, Asano Y, Ishii T, Ogawa F, Kawakami T, Kodera M, Abe M, Isei T, Ito T, Inoue Y, Imafuku S, Irisawa R, Ohtsuka M, Ohtsuka M, Kadono T, Kawaguchi M, Kukino R, Kono T, Sakai K, Takahara M, Tanioka M, Nakanishi T, Nakamura Y, Hashimoto A, Hasegawa M, Hayashi M, Fujiwara H, Maekawa T, Matsuo K, Madokoro N, Yamasaki O, Yoshino Y, Le Pavoux A, Tachibana T, Ihn H. The wound/burn guidelines - 4: Guidelines for the management of skin ulcers associated with connective tissue disease/vasculitis. J Dermatol 2016; 43:729-57. [PMID: 26972733 DOI: 10.1111/1346-8138.13275] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 11/21/2015] [Indexed: 11/27/2022]
Abstract
The Japanese Dermatological Association prepared guidelines focused on the treatment of skin ulcers associated with connective tissue disease/vasculitis practical in clinical settings of dermatological care. Skin ulcers associated with connective tissue diseases or vasculitis occur on the background of a wide variety of diseases including, typically, systemic sclerosis but also systemic lupus erythematosus (SLE), dermatomyositis, rheumatoid arthritis (RA), various vasculitides and antiphospholipid antibody syndrome (APS). Therefore, in preparing the present guidelines, we considered diagnostic/therapeutic approaches appropriate for each of these disorders to be necessary and developed algorithms and clinical questions for systemic sclerosis, SLE, dermatomyositis, RA, vasculitis and APS.
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Affiliation(s)
- Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Takayuki Ishii
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Fumihide Ogawa
- Department of Dermatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tamihiro Kawakami
- Department of Dermatology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masanari Kodera
- Department of Dermatology, Japan Community Health Care Organization Chukyo Hospital, Aichi, Japan
| | - Masatoshi Abe
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Taiki Isei
- Department of Dermatology, Kansai Medical University, Osaka, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Hyogo, Japan
| | - Yuji Inoue
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinichi Imafuku
- Department of Dermatology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryokichi Irisawa
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Masaki Ohtsuka
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Mikio Ohtsuka
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Takafumi Kadono
- Department of Dermatology, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - Masakazu Kawaguchi
- Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Ryuichi Kukino
- Department of Dermatology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takeshi Kono
- Department of Dermatology, Nippon Medical School, Tokyo, Japan
| | - Keisuke Sakai
- Intensive Care Unit, Kumamoto University Hospital, Kumamoto, Japan
| | - Masakazu Takahara
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Miki Tanioka
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Nakanishi
- Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Akira Hashimoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masahiro Hayashi
- Department of Dermatology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hiroshi Fujiwara
- Department of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takeo Maekawa
- Department of Dermatology, Jichi Medical University, Tochigi, Japan
| | - Koma Matsuo
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Madokoro
- Department of Dermatology, Mazda Hospital, Hiroshima, Japan
| | - Osamu Yamasaki
- Department of Dermatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | | | - Takao Tachibana
- Department of Dermatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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90
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Lehnen M, Kohaus S, Körber A, Hillen U, Grabbe S, Dissemond J. Kontaktsensibilisierungen von Patienten mit chronischen Wunden. Hautarzt 2016; 57:303-6, 308. [PMID: 16317553 DOI: 10.1007/s00105-005-1053-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Patients with chronic wounds frequently acquire clinically relevant contact sensitization. We examined the results of the skin patch tests in patients with chronic wounds, who were treated between 1999-2004 in the Department of Dermatology, University School of Medicine, Essen, Germany. Altogether 105 patients with chronic wounds underwent patch testing. In 68 individuals, contact sensitization to at least one substance was detected. The most frequent contact allergens were to balsam of Peru, Amerchol L-101, fragrance mix, wool wax alcohols and rosins. Contact sensitization to wound dressing materials was also identified in 4 patients. Our results demonstrate the current spectrum of contact sensitization of patients with chronic wounds. Our results show the importance of paying attention to the ingredients in wound dressings and performing patch testing if there is any clinical suggestion of allergic contact dermatitis.
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Affiliation(s)
- M Lehnen
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen
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91
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Apollonio A, Antignani PL, Di Salvo M, Failla G, Guarnera G, Mosti G, Ricci E. A large Italian observational multicentre study on vascular ulcers of the lower limbs (Studio Ulcere Vascolari). Int Wound J 2016; 13:27-34. [PMID: 24618175 PMCID: PMC7949669 DOI: 10.1111/iwj.12216] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/15/2013] [Accepted: 12/19/2013] [Indexed: 11/28/2022] Open
Abstract
An observational study of 2 years was promoted by the Italian Association for Cutaneous Ulcers (AIUC) in order to monitor the epidemiology of leg ulcers, the trend of healing and the more frequent therapeutic approaches in lower limb ulcers. Fifty-nine sites in 14 different Italian regions involved in the study, with 1333 enrolled patients (1163 patients fully evaluated and followed up for 9 months). A prevalence of females (62%) was observed with a mean age of 70 years and a high rate of hypertension (62%), diabetes (38%) and obesity (29%). Venous ulcer was most frequent (55%), followed by mixed (25%) and diabetic (8·3%) ulcers. Basically, all patients received a local therapy (LT) (compression and advanced local therapies), while 63% of patients have an associated systemic pharmaceutical treatment. Ulcer healing rates progressively increased throughout the study and despite the type of observational study does not allow conclusions on the treatment, it was observed that the patients receiving additional systemic drugs were associated with a more rapid acceleration of healing rates of ulcers compared to LT alone (3 months: 39·7% versus 29·2%; 6 months: 62·0% versus 47·0%; 9 months: 74·7% versus 63·8%). In particular, the Studio Ulcere Vascolari (SUV) study showed that a combination treatment with sulodexide and compression therapy allows for a greater increase in the healing rates in venous ulcers.
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92
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Blagojevic J, Piemonte G, Benelli L, Braschi F, Fiori G, Bartoli F, Guiducci S, Bellando Randone S, Galluccio F, Cometi L, Castellani S, Boddi M, Moggi Pignone A, Rasero L, Epifani F, Matucci-Cerinic M. Assessment, Definition, and Classification of Lower Limb Ulcers in Systemic Sclerosis: A Challenge for the Rheumatologist. J Rheumatol 2016; 43:592-8. [PMID: 26834223 DOI: 10.3899/jrheum.150035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate pathogenesis and clinical features of lower limb ulcers in systemic sclerosis (SSc) and to propose a classification that could be used in clinical practice. METHODS Charts of 60 patients with SSc who had lower limb cutaneous lesions were reviewed. All patients had videocapillaroscopy and arterial and venous lower limb color Doppler ultrasonography (US). Arteriography was performed if occlusive peripheral arterial disease was suspected. RESULTS The 554 lesions were classified as hyperkeratosis, ulcers, and gangrenes. There were 341 (61.6%) hyperkeratoses, 208 (37.5%) ulcers, and 5 (0.9%) gangrenes. Ulcers were divided into pure ulcers, ulcers associated with hyperkeratosis, and ulcers secondary to calcinosis. Involvement of arterial and venous macrocirculation as determined by color Doppler US was observed in 17 (18.3%) and 18 (30%) patients, respectively. Seventeen out of 37 patients with pure ulcers (45.9%) presented neither venous insufficiency nor hemodynamically significant macrovascular arterial disease. In these patients, pure ulcers were most likely caused by isolated SSc-related microvascular involvement (pure microvascular ulcers). The only significant risk factor for development of pure microvascular ulcers in the multivariate analysis was the history of lower limb ulcers (OR 26.67, 95% CI 2.75-259.28; p < 0.001). CONCLUSION Results of our study indicate that lower limb ulcers in SSc often have a multifactorial pathogenesis that may be difficult to manage. Further studies are needed to validate the proposed classification and to assess the most appropriate management of lower limb ulcers in SSc.
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Affiliation(s)
- Jelena Blagojevic
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Guya Piemonte
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Laura Benelli
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Francesca Braschi
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Ginevra Fiori
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Francesca Bartoli
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Serena Guiducci
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Silvia Bellando Randone
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Felice Galluccio
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Laura Cometi
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Sergio Castellani
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Maria Boddi
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Alberto Moggi Pignone
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Laura Rasero
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Francesco Epifani
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Marco Matucci-Cerinic
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
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Ayuk SM, Abrahamse H, Houreld NN. The Role of Matrix Metalloproteinases in Diabetic Wound Healing in relation to Photobiomodulation. J Diabetes Res 2016; 2016:2897656. [PMID: 27314046 PMCID: PMC4893587 DOI: 10.1155/2016/2897656] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/03/2016] [Accepted: 05/08/2016] [Indexed: 01/25/2023] Open
Abstract
The integration of several cellular responses initiates the process of wound healing. Matrix Metalloproteinases (MMPs) play an integral role in wound healing. Their main function is degradation, by removal of damaged extracellular matrix (ECM) during the inflammatory phase, breakdown of the capillary basement membrane for angiogenesis and cell migration during the proliferation phase, and contraction and remodelling of tissue in the remodelling phase. For effective healing to occur, all wounds require a certain amount of these enzymes, which on the contrary could be very damaging at high concentrations causing excessive degradation and impaired wound healing. The imbalance in MMPs may increase the chronicity of a wound, a familiar problem seen in diabetic patients. The association of diabetes with impaired wound healing and other vascular complications is a serious public health issue. These may eventually lead to chronic foot ulcers and amputation. Low intensity laser irradiation (LILI) or photobiomodulation (PBM) is known to stimulate several wound healing processes; however, its role in matrix proteins and diabetic wound healing has not been fully investigated. This review focuses on the role of MMPs in diabetic wound healing and their interaction in PBM.
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Affiliation(s)
- Sandra Matabi Ayuk
- Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, P.O. Box 17011, Doornfontein 2028, South Africa
| | - Heidi Abrahamse
- Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, P.O. Box 17011, Doornfontein 2028, South Africa
| | - Nicolette Nadene Houreld
- Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, P.O. Box 17011, Doornfontein 2028, South Africa
- *Nicolette Nadene Houreld:
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94
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Sonter JA, Chuter VH. Cross-sectional correlations between the toe brachial index and lower limb complications in older people. Int Wound J 2015; 14:74-78. [PMID: 26663492 DOI: 10.1111/iwj.12552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/01/2015] [Accepted: 11/02/2015] [Indexed: 11/29/2022] Open
Abstract
The aim of the study was to investigate the relationship between the toe brachial index (TBI) and foot ulceration and amputation in older people. Two hundred and sixty-one participants meeting guidelines for lower limb vascular assessment had their toe and brachial blood pressure measured, medical records audited and signs and symptoms of peripheral arterial disease (PAD) recorded. Pearson's correlation and linear regression analyses were performed to determine the strength of relationships between variables. Significant correlations were found between the TBI and painful symptoms (r = -0·35, P < 0·05) and foot complications (r = -0·31, P < 0·05). After adjusting for traditional risk factors for foot complications, participants with a TBI <0·70 were 19 times more likely to have a history of foot wounds or amputation (odds ratio = 19·20, 95% confidence interval (CI): 2·36-155·96, P < 0·001) than those with higher TBI values (>0·70). This preliminary study supports a TBI threshold of 0·70 for PAD diagnosis and indicates that lower values are associated with painful symptoms, history of ulceration and amputation. Future longitudinal investigation of the predictive capacity is now warranted.
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Affiliation(s)
- Jennifer A Sonter
- School of Health Sciences, University of Newcastle, Ourimbah, Australia.,School of Science and Health, Western Sydney University, Campbelltown, Australia
| | - Vivienne H Chuter
- School of Health Sciences, University of Newcastle, Ourimbah, Australia.,Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Newcastle, Australia
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95
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Modulation of matrix metalloproteinases MMP-2 and MMP-9 activity by hydrofiber-foam hybrid dressing - relevant support in the treatment of chronic wounds. Cent Eur J Immunol 2015; 40:391-4. [PMID: 26648787 PMCID: PMC4655393 DOI: 10.5114/ceji.2015.54605] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/26/2015] [Indexed: 01/04/2023] Open
Abstract
Success in chronic wound therapy requires careful selection of appropriate dressing, which enables effective management of wound exudate. According to current knowledge, exudate may contain large quantities of proteases, including matrix metalloproteinases, MMP-2 and MMP-9, which are responsible for delay in wound healing. Therefore, neutralization of MMPs may be beneficial for treatment efficacy. The aim of the study was to test whether AQUACEL Foam, a novel, technologically advanced hydrofiber-foam hybrid dressing (HFHD), may interfere with proteolytic activity of MMPs in vitro. The assessment included in vitro tests of liquid retention and measurement of human recombinant MMP-2 and MMP-9 activity. The MMPs activity was measured before and after their interaction with HFHD, using a fluorescent gelatinase assay kit and Real-Time PCR device. The in vitro tests have shown that the hydrofiber layer of HFHD revealed significant potential to decrease the activity of MMPs in the experimental system. The mentioned modulatory properties of AQUACEL Foam may contribute to a composed mechanism of its beneficial action. Furthermore, our finding may explain clinical effectiveness of HFHD observed in clinical settings.
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96
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Amato B, Compagna R, Amato M, Butrico L, Fugetto F, Chibireva MD, Barbetta A, Cannistrà M, de Franciscis S, Serra R. The role of adult tissue-derived stem cells in chronic leg ulcers: a systematic review focused on tissue regeneration medicine. Int Wound J 2015; 13:1289-1298. [PMID: 26399452 DOI: 10.1111/iwj.12499] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/10/2015] [Accepted: 08/16/2015] [Indexed: 12/12/2022] Open
Abstract
Wound healing is an articulated process that can be impaired in different steps in chronic wounds. Chronic leg ulcers are a special type of non-healing wounds that represent an important cause of morbidity and public cost in western countries. Because of their common recurrence after conventional managements and increasing prevalence due to an ageing population, newer approaches are needed. Over the last decade, the research has been focused on innovative treatment strategies, including stem-cell-based therapies. After the initial interest in embryonic pluripotent cells, several different types of adult stem cells have been studied because of ethical issues. Specific types of adult stem cells have shown a high potentiality in tissue healing, in both in vitro and in vivo studies. Aim of this review is to clearly report the newest insights on tissue regeneration medicine, with particular regard for chronic leg ulcers.
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Affiliation(s)
- Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Rita Compagna
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Lucia Butrico
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Francesco Fugetto
- School of Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Mariia D Chibireva
- School of Medicine, Kazan State Medical University, Kazan, Tatarstan Republic, Russian Federation
| | - Andrea Barbetta
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Marco Cannistrà
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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97
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Cooper B, Bachoo P, Brittenden J. Extracorporeal shock wave therapy for the healing and management of venous leg ulcers. Hippokratia 2015. [DOI: 10.1002/14651858.cd011842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ben Cooper
- NHS Grampian; Department of Vascular Surgery; Foresterhill Road Aberdeen UK AB25 2ZN
| | - Paul Bachoo
- NHS Grampian; Department of Vascular Surgery; Foresterhill Road Aberdeen UK AB25 2ZN
| | - Julie Brittenden
- Aberdeen Royal Infirmary; University of Aberdeen, c/o Vascular Unit - Ward 36; Foresterhill Aberdeen Scotland UK AB25 2ZN
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98
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Hedayati N, Carson JG, Chi YW, Link D. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med 2015. [DOI: 10.1177/1358863x15594683] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mixed arterial venous disease is estimated to affect up to 26% of patients with lower extremity ulcerations. However, its clinical significance and pathophysiology are incompletely understood. Furthermore, there is no consensus on the optimal treatment modality, whether conservative or operative. In this review paper, we describe the current understanding of the pathophysiology of mixed arterial venous lower extremity ulcers. Guidelines for diagnostic tests for patients with mixed arterial venous diseases are discussed. We review some of the newer biological skin substitutes for conservative wound care. Finally, we propose a treatment algorithm based on current available data.
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Affiliation(s)
- Nasim Hedayati
- Division of Vascular and Endovascular Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - John G Carson
- Division of Vascular and Endovascular Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - Yung-Wei Chi
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California, USA
| | - Daniel Link
- Department of Radiology, University of California, Davis Medical Center, Sacramento, California, USA
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99
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Krasowski G, Jawień A, Tukiendorf A, Rybak Z, Junka A, Olejniczak-Nowakowska M, Bartoszewicz M, Smutnicka D. A comparison of an antibacterial sandwich dressing vs dressing containing silver. Wound Repair Regen 2015; 23:525-30. [DOI: 10.1111/wrr.12301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 04/06/2015] [Indexed: 11/30/2022]
Affiliation(s)
| | - Arkadiusz Jawień
- Department of Vascular Surgery and Angiology Collegium Medium in Bydgoszcz; University Hospital nr 1 Bydgoszcz
| | | | - Zbigniew Rybak
- Department of Experimental Surgery and Biomaterials Research
| | - Adam Junka
- Department of Pharmaceutical Microbiology and Parasitology; Wrocław Medical University, Wroclaw
| | | | | | - Danuta Smutnicka
- Pharmaceutical Microbiology and Parasitology; Wrocław Medical University, Wroclaw, Poland
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100
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Hu ZC, Chen D, Guo D, Liang YY, Zhang J, Zhu JY, Tang B. Randomized clinical trial of autologous skin cell suspension combined with skin grafting for chronic wounds. Br J Surg 2015; 102:e117-23. [PMID: 25627123 DOI: 10.1002/bjs.9688] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/03/2014] [Accepted: 09/29/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Treatment of chronic wounds using traditional surgical procedures is challenging because of the low graft take rates. This study investigated the combination approach of split-thickness autografts with harvested skin cell suspension for chronic wound treatment. METHODS This randomized clinical trial enrolled patients with chronic wounds between March 2012 and December 2013. Patients who were assigned randomly to the active treatment received a split-thickness autograft combined with harvested skin cell suspension. Control patients received the split-thickness autograft alone. The primary outcome was the rate of complete wound closure by postoperative day 28. Analysis was by intention to treat. Patients who achieved wound closure were followed up for a minimum of 6 months to evaluate the quality of healing. RESULTS A total of 88 patients were included, 44 in each group. More patients achieved complete wound closure in the skin cell group than in the control group (41 versus 34 patients; P = 0·035). Complete wound closure was observed at a median of 14 (95 per cent c.i. 12·0 to 16·0) days in the skin cell group and 20 (15·7 to 24·3) days in the control group (P = 0·001). The skin cell group had significantly fewer complications (4 versus 11 patients; P = 0·047). The autografted sites displayed better physical attributes and a reduced tendency for wound recurrence in the skin cell group. CONCLUSION Complementary split-thickness autologous skin grafting with autologous skin cells harvested using ReCell® (Avita Medical, Cambridge, UK) technology improved the healing rate of chronic wounds. REGISTRATION NUMBER UMIN000011966 (http://www.umin.ac.jp/ctr).
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Affiliation(s)
- Z-C Hu
- Department of Burn Surgery, Guangzhou, China
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