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Mayrovitz HN, Aoki KC, Colon J. Chronic Venous Insufficiency With Emphasis on the Geriatric Population. Cureus 2023; 15:e40687. [PMID: 37485203 PMCID: PMC10358300 DOI: 10.7759/cureus.40687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/13/2023] [Indexed: 07/25/2023] Open
Abstract
The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.
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Affiliation(s)
- Harvey N Mayrovitz
- Medical Education and Simulation, Nova Southeastern University's Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Kawaiola C Aoki
- Medicine, Nova Southeastern University's Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Jessica Colon
- Medicine, Nova Southeastern University's Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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2
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Bernatchez SF, Eysaman-Walker J, Weir D. Venous Leg Ulcers: A Review of Published Assessment and Treatment Algorithms. Adv Wound Care (New Rochelle) 2022; 11:28-41. [PMID: 33848433 PMCID: PMC8573799 DOI: 10.1089/wound.2020.1381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Significance: Chronic venous disease (CVD) is prevalent in the aging population and leads to venous leg ulcers (VLUs). These wounds can last and recur for years, significantly impacting quality of life. A large body of literature exists on CVD and VLU diagnosis and treatment. Multiple algorithms, guidelines, and consensus documents have been published on this topic, highlighting the importance of this issue in clinical practice. However, these documents are not fully aligned with each other. Recent Advances: The latest update of the internationally used classification system for CVD was recently published. Our review aims to summarize the existing information to provide an educational tool for clinicians new to this topic, and to highlight the commonalities between the published recommendations. Critical issues: VLUs need to be treated with consideration for the extent of venous disease present in the patient. This requires a good understanding of the various components involved and the possible additional concomitant conditions by the first-line clinician who encounters the patient. A multidisciplinary team is necessary for a successful overall treatment plan, and this plan should be tailored to each patient's specific needs and lifestyle. Future Directions: Compression is still the mainstay of treatment for CVD and VLUs. Compression is needed long term, but it does not suffice by itself to prevent recurrences without interventional correction. Venous intervention should be offered early to prevent or slow disease progression and reduce recurrence.
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Affiliation(s)
| | | | - Dot Weir
- Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, New York, USA
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3
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Pan J, Hu X, Yin H, Zhang C, Yan Z. Effectiveness of different types of skin grafting for treating venous leg ulcers: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2021; 100:e25597. [PMID: 33847692 PMCID: PMC8052075 DOI: 10.1097/md.0000000000025597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) are the most common ulcer on the lower extremity, with 4% of patients over the age of 65 suffering from VLUs worldwide. As a recurrent, chronic, disabling disease, VLUs are associated with prolonged disability, substantial socioeconomic impact, and significant psychosocial morbidity. At present, Skin grating is one of the most effective treatments for non-healing ulcers. However, there are still no new studies based on the latest research and new research methods to evaluate and compare the effect of different types of skin grafts for treating venous leg ulcers. Therefore, a Bayesian network meta-analysis (NMA) will be conducted to systematically assess skin grafting efficacy for VLUs. METHODS We will include randomized controlled trials (RCTs) involving patients with VLUs treated by skin grafts. Electronic databases and clinical trials registries will be searched from their inception until June 2021, without language or publication restrictions on status. The search strategy mainly includes Medical Subject Headings (MeSH) and free-text terms. Two review authors will independently perform data extraction and assessment of study quality. And We will use Bayesian NMA to evaluate all available evidence in STATA 14.0 and WinBUGS software. RESULTS This protocol will use Bayesian NMA to assess the effectiveness of different types of skin grafting for treating venous leg ulcers. CONCLUSION This study aims to synthesize the available evidence from RCTs in a network meta-analysis to summarize the best research available and provide consistency among treatment protocols given to patients, resulting in improved efficacy and the quality of care and reduced cost.
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Affiliation(s)
- Junqing Pan
- Jiangxi University of Traditional Chinese Medicine
| | - Xiangjun Hu
- Jiangxi University of Traditional Chinese Medicine
| | - Hongwei Yin
- Jiangxi University of Traditional Chinese Medicine
| | | | - Zhangren Yan
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, Jiangxi Province, China
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4
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Wu X, Liu R, Lao TT. Therapeutic compression materials and wound dressings for chronic venous insufficiency: A comprehensive review. J Biomed Mater Res B Appl Biomater 2019; 108:892-909. [PMID: 31339655 DOI: 10.1002/jbm.b.34443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/06/2019] [Accepted: 06/28/2019] [Indexed: 01/15/2023]
Abstract
Chronic venous insufficiency (CVI) is a common disorder worldwide. Related pathophysiological mechanisms reportedly involve venous pooling and reduced venous return, leading to heaviness, aching, itchiness, tiredness, varicosities, pigmentation, and even lower limb ulceration. Approaches adopted to manage CVI at various stages of clinical-etiology-anatomy-pathophysiology include compression therapy, pharmacological treatment, ultrasound treatment, surgery, electrical or wireless microcurrent stimulation, and pulsed electromagnetic treatment. Among these, polymer-based therapeutic compression materials and wound dressings play increasingly key roles in treating all stages of CVI because of their unique physical, mechanical, chemical, and biological functions. However, the characteristics, working mechanisms, and effectiveness of these CVI treatment materials are not comprehensively understood. The present systematic review examines the structures, properties, types, and applications of various polymer-based compression materials and wound dressings used in prophylaxis and treatment of CVI. Existing problems, limitations, and future trends of CVI treatment materials are also discussed. This review could contribute to the design and application of new functional polymer materials and dressings to enhance the efficiency of CVI treatments, thereby facilitating patients' self-care ability and long-term health improvement.
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Affiliation(s)
- Xinbo Wu
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Rong Liu
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Terence T Lao
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
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Rosen AC, Goh C, Lacouture ME, Mehrara BJ, Cordeiro PG, Myskowski PL. Post-reconstruction dermatitis of the breast. J Plast Reconstr Aesthet Surg 2017; 70:1369-1376. [PMID: 28602267 DOI: 10.1016/j.bjps.2017.05.012] [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] [Received: 12/26/2016] [Revised: 04/16/2017] [Accepted: 05/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Approximately one-third of women diagnosed with breast cancer undergo mastectomy with subsequent implant-based or autogenous tissue-based reconstruction. Potential complications include infection, capsular contracture, and leak or rupture of implants with necessity for explantation. Skin rashes are infrequently described complications of patients who undergo mastectomy with or without reconstruction. METHODS A retrospective analysis of breast cancer patients referred to the Dermatology Service for diagnosis and management of a rash post-mastectomy and expander or implant placement or transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. Parameters studied included reconstruction types, time to onset, clinical presentation, associated symptoms, results of microbiologic studies, management, and outcome. RESULTS We describe 21 patients who developed a rash on the skin overlying a breast reconstruction. Average time to onset was 25.7 months after expander placement or TRAM flap reconstruction. Clinical presentations included macules and papules or scaly, erythematous patches and plaques. Five patients had cultures of the rash, which were all negative. Skin biopsy was relatively contraindicated in areas of skin tension, and was reserved for non-responding eruptions. Treatments included topical corticosteroids and topical antibiotics, which resulted in complete or partial responses in all patients with documented follow-ups. CONCLUSION Our findings suggest that tension and post-surgical factors play a causal role in this hitherto undescribed entity: "post-reconstruction dermatitis of the breast." This is a manageable condition that develops weeks to years following breast reconstruction. Topical corticosteroids and antibiotics result in restoration of skin barrier integrity and decreased secondary infection.
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Affiliation(s)
- A C Rosen
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave, RMSB 2023A, Miami, FL 33139, USA.
| | - C Goh
- Department of Medicine, Dermatology Division, David Geffen School of Medicine at UCLA, UCLA Dermatology Center, Peter Morton Medical Building, 200 UCLA Medical Plaza, Ste 465, Los Angeles, CA 90095, USA
| | - M E Lacouture
- Department of Medicine, Dermatology Service, Memorial Sloan Kettering Cancer Center, 16 E 60th Street, New York, NY 10022, USA
| | - B J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgical Service, Memorial Sloan Kettering Cancer Center, 160 East 53rd Street, New York, NY 10022, USA
| | - P G Cordeiro
- Department of Surgery, Plastic and Reconstructive Surgical Service, Memorial Sloan Kettering Cancer Center, 160 East 53rd Street, New York, NY 10022, USA
| | - P L Myskowski
- Department of Medicine, Dermatology Service, Memorial Sloan Kettering Cancer Center, 16 E 60th Street, New York, NY 10022, USA
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Zhao R, Liang H, Clarke E, Jackson C, Xue M. Inflammation in Chronic Wounds. Int J Mol Sci 2016; 17:ijms17122085. [PMID: 27973441 PMCID: PMC5187885 DOI: 10.3390/ijms17122085] [Citation(s) in RCA: 519] [Impact Index Per Article: 64.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/30/2016] [Accepted: 12/05/2016] [Indexed: 12/26/2022] Open
Abstract
Non-healing chronic wounds present a major biological, psychological, social, and financial burden on both individual patients and the broader health system. Pathologically extensive inflammation plays a major role in the disruption of the normal healing cascade. The causes of chronic wounds (venous, arterial, pressure, and diabetic ulcers) can be examined through a juxtaposition of normal healing and the rogue inflammatory response created by the common components within chronic wounds (ageing, hypoxia, ischaemia-reperfusion injury, and bacterial colonisation). Wound bed care through debridement, dressings, and antibiotics currently form the basic mode of treatment. Despite recent setbacks, pharmaceutical adjuncts form an interesting area of research.
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Affiliation(s)
- Ruilong Zhao
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney, NSW 2065, Australia.
| | - Helena Liang
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney, NSW 2065, Australia.
| | - Elizabeth Clarke
- Murray Maxwell Biomechanics Laboratory, Kolling Institute of Medical Research, University of Sydney, NSW 2065, Australia.
| | - Christopher Jackson
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney, NSW 2065, Australia.
| | - Meilang Xue
- Sutton Arthritis Research Laboratory, Kolling Institute of Medical Research, University of Sydney, NSW 2065, Australia.
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Toledo RR, Santos MERDC, Schnaider TB. Effect of Pycnogenol on the Healing of Venous Ulcers. Ann Vasc Surg 2016; 38:212-219. [PMID: 27521821 DOI: 10.1016/j.avsg.2016.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/30/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Venous ulcers are common complications of chronic venous insufficiency that result in severe physical and mental suffering to patients. The oral administration of diosmin/hesperidin has been used as adjuvant therapy in the treatment of chronic venous insufficiency. The purpose of this study was to evaluate and compare the effect of pycnogenol and diosmin/hesperidin on the healing of venous ulcers. METHODS This longitudinal, prospective, randomized clinical trial was conducted with 30 adult patients with venous ulcers from a vascular surgery outpatient clinic of a university hospital. The patients were randomly allocated to 2 groups: Group 1 (n = 15) was treated with pycnogenol (50 mg orally, 3 times daily) and Group 2 (n = 15) was treated with diosmin/hesperidin (450/50 mg orally, twice daily). They were assessed every 15 days for 90 days. During follow-up visits, photo-documentation was obtained and the ulcer area and circumference of the affected limb were measured. Friedman's test and Mann-Whitney test were used to compare ulcer areas and circumference of affected limbs between and within groups at different time points. The level of significance was set at 5% (P < 0.05) for all tests. RESULTS Both the pycnogenol and diosmin/hesperidin treatments had a similar effect on the healing of venous ulcers and led to a significant decrease in the circumference of affected limbs (P < 0.0001). CONCLUSION The results suggest that pycnogenol has an adjuvant effect on the healing of venous ulcers, similar to diosmin/hesperidin.
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Affiliation(s)
- Renato Riera Toledo
- Professional Master's Program in Applied Health Sciences, Department of Surgery, Universidade do Vale do Sapucaí, Pouso Alegre, Brazil.
| | | | - Taylor Brandão Schnaider
- Professional Master's Program in Applied Health Sciences, Department of Surgery, Universidade do Vale do Sapucaí, Pouso Alegre, Brazil
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Martis G, Laczik R. The role of radical surgery in the management of CEAP C5/6 and lipodermatosclerosis. Phlebology 2016; 31:753-768. [PMID: 27257053 DOI: 10.1177/0268355516652011] [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: 11/17/2022]
Abstract
Aim Analysis of the radical removing of the dermatosclerotic tissues and ulcer(s) with perforator veins dissection as well as local wound and standard compression treatment of CEAP C5/6 stage in a prospective comparative cohort study. Primary endpoint is to compare the results of the one-year follow-up regarding quality of life, vein clinical severity score, and ulcer healing process. Secondary endpoint is the precise presentation of the surgical technique. Tertiary endpoint is to demonstrate the photo-documented results of the postoperative wound treatment protocol. Method Clinical and statistical comparison of radical surgery versus solely wound care and compression in a cohort of 15 patients in each group (Groups 1, 2). In Group 1, radical removing of the dermatosclerotic pannicule and leg ulcer, perforator vein dissection, great saphenous vein, or small saphenous vein was performed. Quality of life , pain intensity, vein clinical severity score and patients' load capacity were compared. The tissue oxygen saturation changes were monitored via near infra-red spectroscopy. Results Both groups were statistically comparable. Wound healing in the operated group was 100% versus 60% in the second one, the difference was significant, p = 0.006. The quality of life: 45.33 versus 36.8, p < 0.001, intensity of leg restless and pain: 2.28 versus 5.3, p < 0.001, changes of vein clinical severity score: 5.27 versus 20.93, p < 0.001, changes of tO2sat: 19.00 versus 6.07 in the upper third of the leg p < 0.001, proved significantly better in group 1 compared to 2. Load capacity was significantly better in group 1 than 2 at the end of the study. The average wound healing time was 113 days in group 1. Conclusion The radical surgery provides significantly better results, considering quality of life, vein clinical severity score, load capacity than the conservative treatment in this study.
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Affiliation(s)
- Gábor Martis
- 1 Department of Vascular Surgery, Clinical and Health Science Centre, Institute of Surgery, University of Debrecen, Debrecen, Hungary
| | - Renáta Laczik
- 2 Department of Angiology, Clinical and Health Science Centre, Institute of Medicine, University of Debrecen, Debrecen, Hungary
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External Application of Traditional Chinese Medicine for Venous Ulcers: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:831474. [PMID: 26435725 PMCID: PMC4576005 DOI: 10.1155/2015/831474] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/14/2015] [Accepted: 08/23/2015] [Indexed: 01/22/2023]
Abstract
Objective. To evaluate the effectiveness of external application of traditional Chinese medicine (EA-TCM) on venous ulcers. Methods. Seven databases were searched until April 2015 for randomized controlled trials (RCTs) of EA-TCM for venous ulcers. Risk of bias was assessed using Cochrane Handbook guidelines. Study outcomes were presented as risk ratios (RRs) for dichotomous data or mean differences (MDs) for continuous data. Results. Sixteen of 193 potentially relevant trials met the inclusion criteria; however, their methodological qualities were low. Comparison of the same intervention strategies revealed significant differences in total effectiveness rates between EA-TCM and conventional therapy groups (RR = 1.22, 95% confidence interval [CI] = 1.16–1.29, and P < 0.00001). Compared to conventional therapy, EA-TCM combined with conventional therapy had a superior total effectiveness rate (RR = 1.11, 95% CI = 1.04–1.19, and P = 0.003). There were no significant differences in recurrence rates during followup and final pain measurements between the experimental and those in the control groups (RR = 0.86, 95% CI = 0.31–2.39, and P = 0.85; MD −0.75, 95% CI = −2.15–0.65, and P = 0.29). Conclusion. The evidence that EA-TCM is an effective treatment for venous ulcers is encouraging, but not conclusive due to the low methodological quality of the RCTs. Therefore, more high-quality RCTs with larger sample sizes are required.
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Valle MF, Maruthur NM, Wilson LM, Malas M, Qazi U, Haberl E, Bass EB, Zenilman J, Lazarus G. Comparative effectiveness of advanced wound dressings for patients with chronic venous leg ulcers: A systematic review. Wound Repair Regen 2014; 22:193-204. [DOI: 10.1111/wrr.12151] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/10/2013] [Indexed: 11/27/2022]
Affiliation(s)
| | - Nisa M. Maruthur
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Epidemiology; Johns Hopkins University Bloomberg School of Public Health; Baltimore Maryland
| | - Lisa M. Wilson
- Department of Health Policy and Management; Johns Hopkins University Bloomberg School of Public Health; Baltimore Maryland
| | - Mahmoud Malas
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Umair Qazi
- Department of Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Elisabeth Haberl
- Department of Health Policy and Management; Johns Hopkins University Bloomberg School of Public Health; Baltimore Maryland
| | - Eric B. Bass
- Department of Medicine; Johns Hopkins University School of Medicine; Baltimore Maryland
- Department of Health Policy and Management; Johns Hopkins University Bloomberg School of Public Health; Baltimore Maryland
- Department of Health Systems and Outcomes; Johns Hopkins University School of Nursing; Baltimore Maryland
| | - Jonathan Zenilman
- Department of Epidemiology; Johns Hopkins University Bloomberg School of Public Health; Baltimore Maryland
- Division of Infectious Diseases; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Gerald Lazarus
- Department of Dermatology; Johns Hopkins University School of Medicine; Baltimore Maryland
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Ma W, Yang X, Ma L, Wang X, Zhang L, Yang G, Han C, Gou Z. Fabrication of bioactive glass-introduced nanofibrous membranes with multifunctions for potential wound dressing. RSC Adv 2014. [DOI: 10.1039/c4ra10232k] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Bioactive glass-introduced gelatin/chitosan nanofibrous dressings were developedviaelectrospinning to endow improved antibacterial activity, adjustable bioactivity and water uptake capacity for enhancing chronic wound healing.
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Affiliation(s)
- Weibin Ma
- Zhejiang-California International Nanosystems Institute
- Zhejiang University
- Hangzhou 310058, China
| | - Xianyan Yang
- Zhejiang-California International Nanosystems Institute
- Zhejiang University
- Hangzhou 310058, China
| | - Liang Ma
- Zhejiang-California International Nanosystems Institute
- Zhejiang University
- Hangzhou 310058, China
| | - Xingang Wang
- Department of Burns
- The 2nd Affiliated Hospital
- College of Medicine of Zhejiang University
- Hangzhou 310009, China
| | - Lei Zhang
- Rui’an People’s Hospital & the 3rd Affiliated Hospital to Wenzhou Medical University
- Rui’an 325200, China
| | - Guojing Yang
- Rui’an People’s Hospital & the 3rd Affiliated Hospital to Wenzhou Medical University
- Rui’an 325200, China
| | - Chunmao Han
- Department of Burns
- The 2nd Affiliated Hospital
- College of Medicine of Zhejiang University
- Hangzhou 310009, China
| | - Zhongru Gou
- Zhejiang-California International Nanosystems Institute
- Zhejiang University
- Hangzhou 310058, China
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Malas MB, Qazi U, Lazarus G, Valle MF, Wilson LM, Haberl EB, Bass EB, Zenilman J. Comparative effectiveness of surgical interventions aimed at treating underlying venous pathology in patients with chronic venous ulcer. J Vasc Surg Venous Lymphat Disord 2013; 2:212-25. [PMID: 26993193 DOI: 10.1016/j.jvsv.2013.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/30/2013] [Accepted: 10/10/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Chronic venous ulcers (CVUs) remain the leading causes for nonhealing wounds in the lower extremities. Although multilayer compression dressing remains the treatment gold standard, there are various surgical procedures aimed at healing CVUs with little or no evidence on the efficacy of these treatment methods. We conducted a systematic review of the effects of various surgical treatments for CVUs, in terms of ulcer healing rates, complete time to heal, recurrence rates, mortality, pain, and quality of life. METHODS We searched MEDLINE, EMBASE, the Cochrane Central Register for Controlled Trials, and the Cumulative Index for Nursing and Allied Health Literature databases from January 1980 through July 2012. We included studies that compared a surgical procedure with multilayer compression therapy or another surgical procedure among patients with CVUs. We also included studies without a comparison group if they were of sufficient quality. Two independent reviewers screened titles, abstracts, and articles for eligibility. Two reviewers extracted data on study design, applicability, results, and quality. RESULTS We identified 10,676 citations, of which 22 studies (23 publications) were included. Eight studies (six randomized controlled trials, two cohorts) compared a surgical procedure with compression. Fourteen studies evaluated different surgical interventions. Adding superficial vein ligation and stripping to compression did not improve wound-healing rate. However, the recurrence rate was 50% reduced when surgery corrected the underlying superficial venous pathology (moderate to high strength of evidence [SOE]). Adding subfascial endoscopic perforator surgery with superficial vein surgery to compression does not improve the healing rate of venous ulcers or reduce the recurrence rate except for medial and large ulcers (high SOE). The SOE was insufficient to support a conclusion about the effects of sclerotherapy when added to compression in healing CVUs. There was insufficient evidence on the surgical treatment of CVUs secondary to deep venous reflux and venous obstruction. We are unable to draw conclusions about the effects of surgical procedures on mortality, pain, and quality of life. CONCLUSIONS Our ability to draw conclusions on most surgical techniques is limited due to poorly designed and executed studies, with no uniformity of treatment methods, follow-up or reporting, and lack of randomization. We found some evidence to suggest superficial vein ligation and stripping may reduce the risk of wound recurrence, but these surgical techniques are infrequently performed. The newer minimally invasive techniques lack evidence. Randomized controlled trials for the endovenous procedures used today for treating CVUs are needed.
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Affiliation(s)
- Mahmoud B Malas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Umair Qazi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Gerald Lazarus
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - M Fran Valle
- School of Nursing, University of Maryland, Baltimore, Md
| | - Lisa M Wilson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Elisabeth B Haberl
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Eric B Bass
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jonathan Zenilman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Md
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Abstract
Venous ulcers are the most common ulcers of the lower limb. It has a high morbidity and results in economic strain both at a personal and at a state level. Chronic venous hypertension either due to primary or secondary venous disease with perforator paucity, destruction or incompetence resulting in reflux is the underlying pathology, but inflammatory reactions mediated through leucocytes, platelet adhesion, formation of pericapillary fibrin cuff, growth factors and macromolecules trapped in tissue result in tissue hypoxia, cell death and ulceration. Duplex scan with colour flow is the most useful investigation for venous disease supplying information about patency, reflux, effects of proximal and distal compression, Valsalva maneuver and effects of muscle contraction. Most venous disease can be managed conservatively by leg elevation and compression bandaging. Drugs of proven benefit in venous disease are pentoxifylline and aspirin, but they work best in conjunction with compression therapy. Once ulceration is chronic or the patient does not respond to or cannot maintain conservative regime, surgical intervention treating the underlying venous hypertension and cover for the ulcer is necessary. The different modalities like sclerotherapy, ligation and stripping of superficial varicose veins, endoscopic subfascial perforator ligation, endovenous laser or radiofrequency ablation have similar long-term results, although short-term recovery is best with radiofrequency and foam sclerotherapy. For deep venous reflux, surgical modalities include repair of incompetent venous valves or transplant or transposition of a competent vein segment with normal valves to replace a post-thrombotic destroyed portion of the deep vein.
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Affiliation(s)
- Sasanka S. Chatterjee
- Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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14
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Lymphatic regeneration in meshed skin grafts. Burns 2012; 38:461-3; author reply 463. [DOI: 10.1016/j.burns.2011.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/11/2011] [Indexed: 11/22/2022]
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Egemen O, Ozkaya O, Ozturk MB, Aksan T, Orman Ç, Akan M. Effective use of negative pressure wound therapy provides quick wound-bed preparation and complete graft take in the management of chronic venous ulcers. Int Wound J 2012; 9:199-205. [PMID: 21992173 PMCID: PMC7950862 DOI: 10.1111/j.1742-481x.2011.00876.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Venous ulcers are characterised by longstanding and recurrent loss of skin integrity. Once occurred, healing is slow and recurrence is high because of inappropriate conditions of the wound bed. This study involves 20 patients with chronic venous ulcers at least 6 weeks of duration treated with negative pressure wound therapy (NPWT). Patients underwent a radical debridement of all devitalised tissues in the first operation. After adequate haemostasis, silver-impregnated polyurethane foam was applied. Once the wounds were determined to be clean and adequate granulation tissue formation was achieved, split-thickness skin grafts were applied. Black polyurethane foam was applied over them. All wounds completely healed without the need for further debridement or regrafting. The mean number of silver-impregnated foam dressing changes prior to grafting was 2·9 (one to eight changes). The mean number of NPWT foam changes was 2·6 after skin grafting (two to five changes). Two patients who did not use conservative treatments for chronic venous insufficiency (CVI) after discharge from the hospital had recurrence of venous ulcers in the follow-up period. Application of NPWT provides quick wound-bed preparation and complete graft take in venous ulcer treatment.
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Affiliation(s)
- Onur Egemen
- Okmeydani Education and Research Hospital Plastic and Reconstructive Surgery Clinic, Istanbul, Turkey.
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Abstract
INTRODUCTION Venous ulcers of lower limbs are often chronic and non-healing, many a time neglected by patients and their treating physicians as these ulcers mostly do not lead to amputation as in gangrenous arterial ulcer and also cost much to complete the course of treatment and prevention of recurrence. MATERIALS AND METHODS One hundred and twenty two lower limb venous ulcers came up for treatment between May 2006 and April 2009. Only twenty nine cases completed the treatment. The main tool of investigation was the non invasive Duplex scan venography. Biopsy of the ulcer was done for staging the disease. Patients' choice of treatment was always conservative and as out-patient instead of hospitalisation and surgery, which required a lot of motivation by the treating unit. RESULTS Out of twenty nine cases, ten cases were treated conservatively and seven (24.13%) healed well. Remaining nineteen cases were given surgical modality in which fifteen cases (51.74%) were successful. Only seven cases (24.13%) failed to heal. Compression stockings were advised to control oedema, varices and pain. Foot care, regular exercises and follow-up were stressed effectively.
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Affiliation(s)
- V Alamelu
- Department of Plastic, Reconstructive and Faciomaxillary Surgery, Madras Medical College and Govt General Hospital, Chennai - 600 003; Sri Jayam Hospital, West Tambaram, Chennai - 600 045; K.J. Hospital and Research Foundation, Poonamallee High Road, Chennai - 600 084, India
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