Venous ulcers

Qualidade de vida de pessoas com feridas crônicas

Resumo Objetivo: Avaliar a qualidade de vida de pessoas com feridas crônicas. Métodos: Estudo transversal realizado com 176 pessoas com feridas crônicas em acompanhamento ambulatorial e domiciliar em um serviço público de saúde. Foram utilizados: formulário para a caracterização sociodemográfica, clínica e terapêutica e o questionário Cardiff Wound Impact Schedule para a mensuração da qualidade de vida. As análises foram descritivas e inferenciais empregando-se os testes t de Student, ANOVA, Mann Whitney e Kruskal-Wallis. Resultados: Dentre as pessoas acompanhadas em domicílio, predominaram lesões de origem vasculogênicas, com tempo de existência superior a 12 meses e área de até 25 cm2. No ambiente ambulatorial, prevaleceram feridas vasculogênicas e traumáticas, com tempo máximo de seis meses e extensão de até 25 cm2. Os fatores clínicos associados à qualidade de vida foram: tempo de duração da lesão, etiologia da lesão, grande extensão, aspecto do exsudato, presença de odor e de dor. O domínio de QV “bem-estar” apresentou maior impacto negativo decorrente da presença de lesão. Conclusão: Os fatores clínicos influenciaram diretamente os domínios de QV, sendo necessária a utilização de estratégias diferenciadas com o intuito de reduzir o impacto na QV por se tratarem de aspectos que poderiam ser atenuados ou evitados mediante a avaliação da lesão e a escolha do tratamento adequado.

Autologous Smashed Follicular Dermal Graft with Epidermal Cell Suspension in Chronic Nonhealing Leg Ulcers

Wound healing is a multifaceted process. Restoration of the epithelium may occur either by migration of activated epithelial keratinocytes from the adjoining epithelium or by centrifugal migration of putative stem cells found in the bulge region of the hair follicle. Dermal collagen and glycosaminoglycans also play a key role in laying down the scaffold for vascular in-growth and population of the matrix with host fibroblasts. Despite the availability of a wide range of treatment modalities, chronic nonhealing leg ulcers remain a therapeutic challenge and cause significant patient morbidity. Hence, there is a further need to develop novel techniques which would be effective, safe, easily available, and affordable for the patient.

Extracorporeal shock wave therapy for the healing and management of venous leg ulcers

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.

Upregulation of epidermal gap junctional proteins in patients with venous disease

Background

Leg ulceration is a feared complication of venous insufficiency. It is not known whether varicose veins predispose skin to poor wound healing. The expression pattern of gap junctional protein connexin, a known marker of poor wound healing, was investigated across various stages of venous disease.

Methods

Patients undergoing intervention for varicose veins were assessed according to the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification of varicose veins. Paired 4-mm punch biopsies were taken from above the ankle (pathological) and above the knee (control). Tissues were stained with haematoxylin and eosin, and for connexin 43, connexin 30 and connexin 26.

Results

Forty-eight paired biopsies were taken (12 each for CEAP class C0, C2, C4 and C6). The pathological skin showed progressive epithelial hyperthickening, an increase in the number and depth of rete ridges, increased inflammation and loss of dermal architecture with disease progression from C4 onwards. The overall absolute connexin expression and mean connexin expression per cell in the pathological skin similarly increased across the CEAP classes from as early as C2. Increasing levels of connexin in control skin were also noted, indicating progression of the disease proximally. Connexin 43 expression showed the strongest positive correlation between pathological and control skin.

Conclusion

Connexins were overexpressed in patients with simple varicose veins, with a stepwise increased expression through venous eczema to ulceration. Connexin 43 is a potential biomarker for venous disease. This finding suggests that varicose veins predispose skin to poor wound healing. Surgical relevanceThe overexpression of connexins, a family of gap junctional proteins, is known to cause poor healing in venous leg ulceration. It is not known whether there is any association with superficial venous disease. Here, connexin proteins were overexpressed in patients with uncomplicated varicose veins, before histological skin changes. Connexin could be a biomarker of venous disease progression.

PredyCLU: a prediction system for chronic leg ulcers based on fuzzy logic; part I - exploring the venous side

Chronic leg ulcers (CLUs) are a common occurrence in the western population and are associated with a negative impact on the quality of life of patients. They also cause a substantial burden on the health budget. The pathogenesis of leg ulceration is quite heterogeneous, and chronic venous ulceration (CVU) is the most common manifestation representing the main complication of chronic venous disease (CVD). Prevention strategies and early identification of the risk represent the best form of management. Fuzzy logic is a flexible mathematical system that has proved to be a powerful tool for decision-making systems and pattern classification systems in medicine. In this study, we have elaborated a computerised prediction system for chronic leg ulcers (PredyCLU) based on fuzzy logic, which was retrospectively applied on a multicentre population of 77 patients with CVD. This evaluation system produced reliable risk score patterns and served effectively as a stratification risk tool in patients with CVD who were at the risk of developing CVUs.

Serum homocysteine is associated with the severity of primary chronic venous disease

Objective

This study was conducted to assess whether serum homocysteine concentration was associated with the severity of primary chronic venous disease.

Design

Cross-sectional study.

Methods

A total of 282 primary chronic venous disease patients were enrolled from outpatient vascular services. The severity of venous disease was graded using the Clinical Etiology Anatomy Pathophysiology classification system. The association of serum homocysteine concentration with advanced primary chronic venous disease (C4-6) was assessed using the Mann Whitney U test and logistic regression analysis.

Results

Median (interquartile range) serum homocysteine concentrations were 9.10 µM (7.55–10.75) and 10.40 µM (8.85–13.10) in patients with primary chronic venous disease classified by C1-3 (n = 209) and C4-6 (n = 73) grades, respectively, p < 0.001. Serum homocysteine concentration was positively associated with clinical grade 4–6 after adjusting for other risk factors including age, diabetes, male sex, hypertension, recurrent varicose veins and stroke. Patients with serum homocysteine in the third (odds ratio, 2.76, 95% confidence interval, 1.01–7.54) and fourth (odds ratio 3.29, 95% confidence interval 1.15–9.43) quartiles were more likely to have grade C4-6 chronic venous disease than subjects with serum homocysteine in the first quartile.

Conclusions

Serum homocysteine is positively associated with the severity of primary chronic venous disease and therefore could play a role in promoting chronic venous disease complications.

Regulation of cell-based therapeutic products intended for human applications in the EU

AIMS

Recent developments in the field of cell-based therapeutic products (CBTPs) have forced the EU to revise its legislation on therapeutic products by enacting several new legal instruments. In this study, we investigate how CBTPs are regulated and what determines their regulatory classification. Furthermore, we compare the regulatory burden between CBTPs in different product categories.

MATERIALS & METHODS

Product categories covering CBTPs were identified and characteristics critical for the regulatory classification of a CBTP were determined in each category. The effect of the critical characteristics on the classification was evaluated by constructing a decision tree that covers all possible combinations of the critical characteristics. Differences in the regulatory burden between CBTPs were evaluated by comparing regulations crucial for placing a therapeutic product on the EU market between the product categories.

RESULTS

Regulation of CBTPs has been divided between the main product categories of the EU legal framework for therapeutic products on the basis of the characteristics of the cells that the CBTPs contain. The regulatory burden is lowest for CBTPs regulated as blood, cells or tissues, and highest for CBTPs regulated as medicinal products.

CONCLUSION

CBTPs exist in all product categories of the EU legal framework for therapeutic products. However, the current framework does not cover all possible CBTPs. Furthermore, our results indicate that the regulatory burden of a CBTP is related to the risk it may pose to the health and safety of recipients.

Doxycycline speeds up healing of chronic venous ulcers

Venous ulcers are common, with an overall prevalence of up to 2% in the general population of western countries, and have significant socioeconomic impact. Matrix metalloproteinases (MMPs) are involved in the alteration of extracellular matrix that could lead to venous ulceration. Sixty-four patients with venous ulcers were recruited in a 22-month period. All patients were subjected to the most appropriate treatment considering also the patient's wishes (compression therapy followed or not by vein surgery). Patients were randomised into two groups of 32 persons in each (groups A and B). Patients of group A in addition to the basic treatment, described above, received the administration of oral low doses of doxycycline 20 mg b.i.d. for 3 months, whereas patients of group B received basic treatment only. Healing was assessed by means of direct ulcer tracing with computerised planimetry. Group A showed a higher healing rate compared with group B. In group B, the lower healing rate was related to higher levels of MMP-9; neutrophil gelatinase-associated lipocalin and vascular endothelial growth factor, documented in plasma; wound fluid and biopsies executed and compared between both groups. Pharmacological treatments, as doxycycline administration, which by means of its immunomodulatory and anti-inflammatory actions, through the inhibition of MMP, could improve extracellular matrix functioning and represent a possible solution to support wound healing.

Chronic venous leg ulcers are associated with high levels of metalloproteinases-9 and neutrophil gelatinase-associated lipocalin

Venous ulcers are related to dysfunctions in extracellular matrix. Both matrix metalloproteinases (MMP) and neutrophil gelatinase-associated lipocalin (NGAL) could play a role in the healing process in patients with chronic venous ulcers. We evaluated the role of MMP-9 and NGAL in the healing process in venous ulceration. We performed an open-label, parallel groups, single clinical center study. Patients with chronic venous leg ulcers represented the test group (Group I), whereas patients without chronic ulcers represented the control group (Group II). In Group I plasma and wound fluid samples were collected at the time of admission, at the time of the surgery, and at the follow-up, while ulcer tissues were taken at the time of the surgery. In Group II, plasma and wound fluid were collected at admission and at the time of the surgery, whereas skin tissues were collected at the time of the surgery. Enzyme-linked immunosorbent assay test was used to evaluate the levels of MMP-9 and NGAL in plasma and wound fluid, whereas Western blot analysis was performed to estimate the expression of MMP-9 and NGAL in tissues. Enzyme-linked immunosorbent assay tests revealed significantly higher levels of MMP-9 and NGAL in both plasma and wound fluid of patients with ulcers compared to patients without ulcers (p < 0.01). Moreover, Western blot analysis documented an increased expression of MMP-9 and NGAL in biopsy tissue of patients with ulcers compared to patients without ulcers (p < 0.01). In conclusion MMP-9 and NGAL may correlate with the clinical course of venous ulcers.

Low molecular weight heparin improves healing of chronic venous ulcers especially in the elderly

Venous ulcers are common, especially in the elderly, accounting for more than 50% of all lower extremity ulcers with important socioeconomic problems. Improving extracellular matrix functioning, by heparin administration, seems to be a way to support wound healing. A total of 284 patients with venous ulcers were recruited in a 4-year period. All patients were subjected to the most appropriate treatment after considering their preference (compression therapy followed or not by vein surgery). Patients were randomised into two groups of 142 persons in each (group A and group B as cases and controls, respectively). Patients of group A, in addition to the basic treatment as described earlier, received administration of nadroparin 2850 IU/0.3 ml through subcutaneous injection once a day for 12 months, whereas group B patients received basic treatment alone. Healing was assessed by means of direct ulcer tracing with computerised planimetry. Group A showed a healing rate of 83·80% at 12 months, whereas that of group B was 60·56%. Results by age group surprisingly showed that the group of older patients took the most advantage from long-term treatment with low molecular weight heparin; this group also had lowest recurrence rate.

Hyperhomocysteinaemia and chronic venous ulcers

Chronic venous ulceration (CVU) is the major cause of chronic wounds of lower extremities, and is a part of the complex of chronic venous disease. Previous studies have hypothesised that several thrombophilic factors, such as hyperhomocysteinaemia (HHcy), may be associated with chronic venous ulcers. In this study, we evaluated the prevalence of HHcy in patients with venous leg ulcers and the effect of folic acid therapy on wound healing. Eighty-seven patients with venous leg ulcers were enrolled in this study to calculate the prevalence of HHcy in this population. All patients underwent basic treatment for venous ulcer (compression therapy ± surgical procedures). Patients with HHcy (group A) received basic treatment and administered folic acid (1·2 mg/day for 12 months) and patients without HHcy (group B) received only basic treatment. Healing was assessed by means of computerised planimetry analysis. The prevalence of HHcy among patients with chronic venous ulcer enrolled in this study was 62·06%. Healing rate was significantly higher (P < 0·05) in group A patients (78·75%) compared with group B patients (63·33%). This study suggests a close association, statistically significant, between HHcy and CVU. Homocysteine-lowering therapy with folic acid seems to expedite wound healing. Despite these aspects, the exact molecular mechanisms between homocysteine and CVU have not been clearly defined and further studies are needed.

The use of topical phenytoin for healing of chronic venous ulcerations

BACKGROUND

Many topical agents have been used for promotion of healing of chronic venous ulcers. One such agent that has been tried is phenytoin. The effect of phenytoin on cutaneous healing has been suggested. This study was designed to evaluate the efficacy of topical phenytoin in healing of venous ulcerations.

METHODS

One hundred and four patients with chronic venous ulcers were recruited in this study. They were divided into study group and control group. The study group was 54 patients while control group was 50 patients. Patients in the study group were subjected to dressing of their ulcers with topical phenytoin once daily while patients in the control group were subjected to dressing with normal saline. All patients were followed up for eight weeks and assessed for their ulcer status and recorded as: complete healing, partial healing, no improvement or worsening of the condition.

RESULTS

By the end of the eight weeks, complete healing was evident in 35/54 of the patients (64.8%) in the study group and 26/50 of the patients (52%) in the control group. It was statistically significant (p = .04). The rate of reduction in the mean surface area of the ulcers was faster in the study group than control group. Minor side effects were reported among 4 patients (7.4%) of the study group in the form of burning sensation.

CONCLUSION

Topical phenytoin can be used to enhance healing of chronic venous ulcers in conjunction with the established treatment. It has favorable results and tolerable local side effects.

Efficacy and tolerance of a hydrocolloid dressing containing hyaluronic acid for the treatment of leg ulcers of venous or mixed origin

OBJECTIVE

This study was aimed at comparing efficacy and tolerance of a new hydrocolloid dressing containing hyaluronic acid (HC + HA) to a reference hydrocolloid not containing hyaluronic acid (HC) in the treatment of leg ulcers of venous or mixed origin.

RESEARCH DESIGN AND METHODS

This was an open, prospective study, randomized in parallel groups, in which 125 patients were enrolled and treated for up to 42 days. The primary efficacy criterion was the reduction of the wound area; other efficacy criteria were the condition of the wound bed, and of the surrounding skin, and presence and severity of symptoms such as pain and itching.

RESULTS

After 42 days of treatment the median reduction of ulcer area was -42.6% (95% confidence interval [CI]: -66.6; -5.7) and -31.0% (95% CI: -51.6; -8.8) in the HC + HA group and in the reference HC group, respectively. The difference between treatments was not statistically significant. A reduction > or = 90% of the initial ulcer area was seen in 15 patients in the HC + HA dressing group and in only seven patients in the HC dressing group. Changes in wound bed condition in the two groups were not significantly different, except for a more marked reduction of fibrinous tissue in the HC + HA dressing group (p = 0.04), at Day 28. Both treatments were well tolerated.

CONCLUSIONS

The HC + HA dressing was equally well tolerated and with a trend to be more effective than the reference HC dressing in the treatment of leg ulcers of venous or mixed origin. Further research is needed to confirm these findings.

Endovenous laser ablation for persistent and recurrent venous ulcers after varicose vein surgery

A 75-year-old woman presented with painful recurrent venous ulcers (VU) continuously for the past 33 months on a background of frequent intermittent problems for the last 16 years. She had previously been treated with varicose vein surgery and trials of compression bandaging. Subsequently, she underwent endovenous laser ablation (EVLA) targeting the distal incompetent remnant of her great and small saphenous veins. This resulted in complete healing of her ulcers within four weeks. The dramatic response demonstrated in this case suggests that EVLA may represent an effective intervention in the management of postsurgery refractory VU.

A technique for the computation of lower leg muscle volume from MRI images in the context of venous return

A technique to automatically calculate the volume of a patient's calf muscle using MRI scans in the context of venous insufficiency is presented. Rather than giving a quantifiable measurement of volume, the technique provides a pixel count which can be used to compare the calf muscle volume of one leg of a patient against the other in the context of unilateral leg ulcers or to compare one patient's calf muscle volume against another patient. A custom MATLAB program reads the MRI scans (in the form of JPEG images) and determines the number of pixels (right and left limbs separately) that fall within a user defined gray-scale band, designated as being muscle. The output from the MATLAB program was compared with a manual counting method. The pixel counting algorithm was found to have an acceptable accuracy with results indicating a percentage difference from the manual method of between 2 and 9.5%.

Measurement of venous leg ulcers with a laser-based three-dimensional method: comparison to computer planimetry with photography

A lack of reproducible and practical methods to assess venous leg ulcer healing is a major problem encountered by investigators evaluating various treatments. We aimed to compare a new laser-based three-dimensional (3D) measuring device with computer planimetry with photography for the assessment of venous leg ulcers, and to estimate the reliability of measurements by the methods. Sixty measurements of perimeter and area of 15 venous leg ulcers, < 10 cm in diameter (eight patients; six females; mean age 71 years; range 52-90 years), were made with both methods. Two independent investigators performed the measurements at the first visit and 2-4 weeks later. The precision and accuracy of the methods were determined and compared. The accuracies for computer planimetry with photography in comparison with the laser-based 3D measuring method were 8.4% for perimeter and 16.0% for area measurements. The precisions of ulcer area and perimeter measurements did not differ significantly between the two methods (p=0.993 and 0.201, respectively). The main advantage of the laser-based measuring method is the 3D ulcer measurement with a precision of 7.5%, which also takes into account distortions created by the limb convexity. The system is accurate, inexpensive, user-friendly, and appropriate for everyday practice.

Sudden increase in skin temperature predicts venous ulcers: a case study

Venous ulcers affect approximately 2.5 million adults with chronic venous disease (CVD). Venous ulcers are a significant health problem with a reoccurrence rate as high as 72%. There is a critical need for a prediction/prevention model of venous ulcers that includes objective methods to assess the skin. Among individuals affected by CVD, skin temperature is elevated in the lower extremities. This case study of a patient with CVD highlights the potential predictive usefulness and feasibility of measuring skin temperature with an infrared dermal thermometer as part of the standard of care for venous ulcer prevention.

Venous leg ulcer treatment and practice--part 1: the causes and diagnosis of venous leg ulcers

This article, the first of a series of four on venous leg ulceration, discusses theories relating to the pathophysiology underlying the condition, and the range of diagnostic procedures undertaken to establish that ulceration is of venous origin.

Incompetent Great Saphenous Veins Treated with Endovenous 1,320-nm Laser: Results for 71 Legs and Morphologic Evolvement Study

BACKGROUND

Endovenous lasers with various wavelengths have been utilized with good outcomes in treating leg varicose veins. The natural history and evolution of treated veins after endovenous procedures, however, have seldom been addressed.

OBJECTIVE

This study determines the efficacy vein ablation and serial venous morphologic evolution of incompetent great saphenous veins (GSVs) after endovenous 1,320-nm laser treatment.

METHODS

Fifty patients with symptomatic varicose veins secondary to GSV insufficiency treated with 1,320-nm endovenous laser ablation were enrolled. The treated varicose veins in each limb were mapped and sized before laser treatment. Vein wall diameters were measured with duplex ultrasound at follow-up visits.

RESULTS

Seventy-one limbs in 50 patients were enrolled. During the mean 13.1-month follow-up, closure of GSVs was observed in 94% of limbs (67/71). Vein diameters at 3 cm below saphenofemoral junction level were reduced to 81% at 2 days, 75% at 1 month, 48% at 3 months, and 39% at 5 months. Average mean duration for treated GSVs to narrow as fibrotic cords (internal diameter,<2.5 mm) was 5.8 months.

CONCLUSION

The endovenous 1,320-nm laser ablation procedures have excellent efficacy in treating incompetent GSVs. This excellent shrinkage behavior may be the basis for nice long-term results of patients treated with 1,320-nm Cooltouch endovenous laser.