Chronic venous insufficiency and venous leg ulceration

Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis

Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.

Treatment of bacterially contaminated lower extremity ulcers with a fatty acid-containing wound matrix: a case series

OBJECTIVE

The aim was to evaluate the effectiveness of a marine omega fatty acid-containing multimodal wound matrix (MWM) in reducing bacterial contamination and supporting wound area reduction (WAR) in patients with hard-to-heal wounds of varying aetiologies.

METHOD

A prospective, single-site, pilot case series of patients with hard-to-heal wounds. All wounds were considered non-healing prior to inclusion as they had failed to achieve at least 50% WAR after at least four weeks of standard of care (SoC) treatments. Patients were seen once weekly for wound assessments, matrix application and dressing changes. Baseline and weekly fluorescence images, standard wound images and wound measurements were obtained.

RESULTS

A total of three patients, two with venous leg ulcers (VLUs) and one with a diabetic foot ulcer (DFU) were enrolled in this pilot study. The mean baseline wound age prior to study enrolment was 24 weeks, with a mean baseline wound size of 8.61cm2. The two VLUs went on to complete closure. The DFU displayed a total WAR of 53% by six weeks, when the patient was lost to follow-up due to a geographical relocation. The mean percentage area reduction of all wounds combined was 82% upon study completion.

CONCLUSION

The use of MWM proved to be effective and safe in this patient cohort. The wounds included in this case series failed to enter a healing trajectory with SoC wound therapies. The MWM supported wound closure and reduced bacterial loads in this patient cohort.

A systematic review of the impact of compression therapy on quality of life and pain among people with a venous leg ulcer

AIM

To gain a greater understanding of how compression therapy affects quality of life, this systematic review appraised existing published studies measuring the impact of compression therapy on health quality of life (HRQoL), and pain, among people with venous leg ulcers (VLU).

METHOD

Five databases were searched, and two authors extracted data and appraised the quality of selected papers using the RevMan risk of bias tool. Due to heterogeneity in the types of compression and instruments used to evaluate HRQoL, meta-analysis was not appropriate; thus, a narrative synthesis of findings was undertaken.

RESULTS

Ten studies were included, 9 RCTs and one before-after study. The studies employed nine different HRQoL tools to measure the impact of a variety of compression therapy systems, with or without an additional exercise programme, versus other compression systems or usual care, and the results are mixed. With the use of the Cardiff Cardiff Wound Impact Schedule, the SF-8 and the SF-12, study authors found no differences in QoL scores between the study groups. This is similar to one study using QUALYs (Iglesias et al., 2004). Conversely, for studies using EuroQol-5D, VEINES-QOL, SF-36 and CIVIQ-20 differences in QoL scores between the study groups were noted, in favour of the study intervention groups. Two further studies using QUALYs found results that favoured a two-layer cohesive compression bandage and the TLCCB group, respectively. Results for the five studies that assessed pain are also mixed, with one study finding no difference between study groups, one finding that pain increased over the study period and three studies finding that pain reduced in the intervention groups. All studies were assessed as being at risk of bias in one or more domains.

CONCLUSION

Results were varied, reflecting uncertainty in determining the impact of compression therapy on quality of life and pain among people with a venous leg ulcer. The heterogeneity of the compression systems and the measures used to evaluate HRQoL make it a challenge to interpret the overall evidence. Further studies should strive for homogeneity in design, interventions and comparators to enhance both internal and external validity.

Entwicklung eines Lokalisations-basierten Algorithmus zur Vorhersage der Ätiologie von Ulcera cruris

Hintergrund

Die diagnostische Abklärung des Ulcus cruris ist zeit‐ und kostenintensiv. Ziel dieser Studie war es, die Ulkuslokalisation als diagnostisches Kriterium zu bewerten und einen diagnostischen Algorithmus zur Unterstützung in der Diagnostik bereitzustellen.

Patienten und Methodik

Die Studie umfasste 277 Patienten mit Ulcera cruris. Es wurden die folgenden fünf Gruppen definiert: Ulcus cruris venosum, arterielle Ulzera, gemischte Ulzera, Arteriolosklerose und Vaskulitis. Mittels computergestütztem Oberflächenrendering wurden die Prädilektionsstellen der verschiedenen Ulkustypen bewertet. Die Ergebnisse wurden in ein multinomiales logistisches Regressionsmodell integriert, um die Wahrscheinlichkeit einer bestimmten Diagnose in Abhängigkeit von Lokalisation, Alter, bilateraler Beteiligung und Anzahl der Ulzera zu berechnen. Zusätzlich wurde eine neuronale Netzwerk‐Bildanalyse durchgeführt.

Ergebnisse

Die Mehrheit der venösen Ulzera fand sich in der medialen Malleolarregion. Arterielle Ulzera waren am häufigsten auf der dorsalen Seite des Vorfußes zu finden. Arteriolosklerotische Ulzera waren zumeist im mittleren Drittel des lateralen Unterschenkels lokalisiert. Vaskulitische Ulzera schienen zufällig verteilt zu sein und waren deutlich kleiner, häufiger multilokulär und bilateral. Das multinomiale logistische Regressionsmodell zeigte eine insgesamt zufriedenstellende Leistung mit einer geschätzten Genauigkeit von 0,68 bei ungesehenen Daten.

Schlussfolgerungen

Der vorgestellte Algorithmus auf Grundlage der Ulkuslokalisation kann als unterstützendes Instrument zur Eingrenzung potenzieller Differenzialdiagnosen und als Hilfestellung für die Einleitung diagnostischer Maßnahmen dienen.

Development of a localization-based algorithm for the prediction of leg ulcer etiology

BACKGROUND

Diagnostic work-up of leg ulcers is time- and cost-intensive. This study aimed at evaluating ulcer location as a diagnostic criterium and providing a diagnostic algorithm to facilitate differential diagnosis.

PATIENTS AND METHODS

The study consisted of 277 patients with lower leg ulcers. The following five groups were defined: Venous leg ulcer, arterial ulcers, mixed ulcer, arteriolosclerosis, and vasculitis. Using computational surface rendering, predilection sites of different ulcer types were evaluated. The results were integrated in a multinomial logistic regression model to calculate the likelihood of a specific diagnosis depending on location, age, bilateral involvement, and ulcer count. Additionally, neural network image analysis was performed.

RESULTS

The majority of venous ulcers extended to the medial malleolar region. Arterial ulcers were most frequently located on the dorsal aspect of the forefoot. Arteriolosclerotic ulcers were distinctly localized at the middle third of the lower leg. Vasculitic ulcers appeared to be randomly distributed and were markedly smaller, multilocular and bilateral. The multinomial logistic regression model showed an overall satisfactory performance with an estimated accuracy of 0.68 on unseen data.

CONCLUSIONS

The presented algorithm based on ulcer location may serve as a basic tool to narrow down potential diagnoses and guide further diagnostic work-up.

Topically-applied collagen-binding serum albumin-fused interleukin-4 modulates wound microenvironment in non-healing wounds

Non-healing wounds have a negative impact on quality of life and account for many cases of amputation and even early death among patients. Diabetic patients are the predominate population affected by these non-healing wounds. Despite the significant clinical demand, treatment with biologics has not broadly impacted clinical care. Interleukin-4 (IL-4) is a potent modulator of the immune system, capable of skewing macrophages towards a pro-regeneration phenotype (M2) and promoting angiogenesis, but can be toxic after frequent administration and is limited by its short half-life and low bioavailability. Here, we demonstrate the design and characterization of an engineered recombinant interleukin-4 construct. We utilize this collagen-binding, serum albumin-fused IL-4 variant (CBD-SA-IL-4) delivered in a hyaluronic acid (HA)-based gel for localized application of IL-4 to dermal wounds in a type 2 diabetic mouse model known for poor healing as proof-of-concept for improved tissue repair. Our studies indicate that CBD-SA-IL-4 is retained within the wound and can modulate the wound microenvironment through induction of M2 macrophages and angiogenesis. CBD-SA-IL-4 treatment significantly accelerated wound healing compared to native IL-4 and HA vehicle treatment without inducing systemic side effects. This CBD-SA-IL-4 construct can address the underlying immune dysfunction present in the non-healing wound, leading to more effective tissue healing in the clinic.

Skin aging from the perspective of dermal fibroblasts: the interplay between the adaptation to the extracellular matrix microenvironment and cell autonomous processes

This article summarizes important molecular mechanisms that drive aging in human skin from the perspective of dermal fibroblasts. The dermis comprises the bulk of the skin and is largely composed of a collagen-rich extracellular matrix (ECM). The dermal ECM provides mechanical strength, resiliency, and an environment that supports the functions of ibroblasts and other types of dermal cells. Fibroblasts produce the dermal ECM and maintain its homeostasis. Fibroblasts attach to the ECM and this attachment controls their morphology and function. During aging, the ECM undergoes gradual degradation that is nitiated by matrix metalloproteinases (MMPs). This degradation alters mechanical forces within the dermal ECM and disrupts he interactions between fibroblasts and the ECM thereby generating an aged fibroblast phenotype. This aged fibroblast phenotype is characterized by collapsed morphology, altered mechanosignaling, induction of CCN1, and activation of transcription factor AP-1, with consequent upregulation of target genes including MMPs and pro-inflammatory mediators. The TGF-beta pathway coordinately regulates ECM production and turnover. Altered mechanical forces, due to ECM fragmentation, down-regulate the type II TGF-beta receptor, thereby reducing ECM production and further increasing ECM breakdown. Thus, dermal aging involves a feed-forward process that reinforces the aged dermal fibroblast phenotype and promotes age-related dermal ECM deterioration. As discussed in the article, the expression of the aged dermal fibroblast phenotype involves both adaptive and cell-autonomous mechanisms.

Incidence and Significance of Deep Venous Reflux in Patients Treated with Saphenous Vein Ablation

BACKGROUND

Venous ablation (VA) of the saphenous vein is the most common procedure performed for venous insufficiency. The incidence of concomitant deep venous reflux (DVR) in patients undergoing VA is unknown. Our hypothesis is that patients undergoing saphenous VA with concomitant DVR exhibit a higher clinical, etiology, anatomy, and pathophysiology (CEAP) stage and less relief after VA compared to patients without DVR.

METHODS

Electronic medical records of patients treated with saphenous VA at a tertiary care center from March 2012 to June 2016 were reviewed. Patients were divided into 2 groups based on presence or absence of DVR on initial ultrasound (US) before saphenous VA. Patient characteristics and outcomes were compared. A telephone survey was conducted to assess long-term symptomatic relief, compliance with compression, and pain medication use. Subgroup analysis of patients with post-thrombotic versus primary DVR was performed.

RESULTS

362 patients underwent 497 ablations, and the incidence of DVR (>1 sec) was 20% (N = 71). Patients with DVR were significantly more likely to be male (46.4% vs. 32.1%, P = 0.021) and of Black race (21.2% vs. 5.5%, P = 0.0001) compared to patients without DVR. Patients with DVR were more likely to have a history of deep vein thrombosis (DVT) (15.1% vs. 7.9%, P = 0.045), but there was no difference in other comorbidities. There was no significant difference in presenting symptoms, CEAP stage, or symptom severity based on numeric rating scale (NRS) (0-10) for pain and swelling. Clinical success of saphenous VA was comparable between the 2 groups, but patients with DVR were more likely to develop endovenous heat-induced thrombosis (EHIT) II-IV (6% vs. 1%, P = 0.002). After a mean follow-up of 26 months, there was still no difference in pain or swelling scores, but patients with DVR were more likely to use compression stockings and used them more frequently. Only 11 of 71 patients with DVR had a history of DVT. Patients with post-thrombotic DVR were significantly older than patients with primary DVR (67.3 vs. 57.2, P = 0.038) and exhibited a trend toward more advanced venous disease (C4-C6: 45.4% vs. 33.3%, P = 0.439).

CONCLUSIONS

In this study, 20% of patients undergoing saphenous VA demonstrated DVR, which was more common in Black men. Presence of DVR is associated with increased risk of EHIT after saphenous VA but does not seem to impact disease severity or clinical relief after ablation. Larger studies are needed to understand outcome differences between post-thrombotic and primary DVR.

Gene expression changes in therapeutic ultrasound-treated venous leg ulcers

Introduction

Low-frequency, low-intensity ultrasound has been previously shown to promote healing of chronic wounds in humans, but mechanisms behind these effects are poorly understood. The purpose of this study was to evaluate gene expression differences in debrided human venous ulcer tissue from patients treated with low-frequency (20 kHz), low-intensity (100 mW/cm2) ultrasound compared to a sham treatment in an effort to better understand the potential biological mechanisms.

Methods

Debrided venous ulcer tissue was collected from 32 subjects one week after sham treatment or low-frequency, low-intensity ultrasound treatment. Of these samples, 7 samples (3 ultrasound treated and 4 sham treated) yielded sufficient quality total RNA for analysis by ultra-high multiplexed PCR (Ampliseq) and expression of more than 24,000 genes was analyzed. 477 genes were found to be significantly differentially expressed between the ultrasound and sham groups using cut-off values of p < 0.05 and fold change of 2.

Results and Discussion

The top differentially expressed genes included those involved in regulation of cell metabolism, proliferation, and immune cell signaling. Gene set enrichment analysis identified 20 significantly enriched gene sets from upregulated genes and 4 significantly enriched gene sets from downregulated genes. Most of the enriched gene sets from upregulated genes were related to cell-cell signaling pathways. The most significantly enriched gene set from downregulated genes was the inflammatory response gene set. These findings show that therapeutic ultrasound influences cellular behavior in chronic wounds as early as 1 week after application. Considering the well-known role of chronic inflammation in impairing wound healing in chronic wounds, these results suggest that a downregulation of inflammatory genes is a possible biological mechanism of ultrasound-mediated venous chronic wound healing. Such increased understanding may ultimately lead to the enhancement of ultrasound devices to accelerate chronic wound healing and increase patient quality of life.

Narrative Review of the Pathogenesis of Stasis Dermatitis: An Inflammatory Skin Manifestation of Venous Hypertension

INTRODUCTION

Stasis dermatitis (SD), also known as venous dermatitis, is a form of inflammatory dermatitis of the lower extremities that typically occurs in older individuals and represents a cutaneous manifestation of venous hypertension. Venous hypertension (also known as sustained ambulatory venous pressure) is most often due to retrograde blood flow, which occurs due to calf muscle pump failure. This failure is most commonly secondary to incompetent venous valves, valve destruction, or obstruction of the venous system. Many of the common symptoms associated with SD are caused by inflammatory processes.

METHODS

This review summarizes the pathogenesis and key role of inflammation in SD by reviewing inflammatory biomarkers associated with SD. The literature was selected though a high-level PubMed search focusing on keywords relating to inflammation associated with SD.

RESULTS

Venous reflux at the lower extremities causes venous hypertension, which leads to chronic venous insufficiency. High venous pressure due to venous hypertension promotes the local accumulation and extravasation of inflammatory cells across the vascular endothelium. Leukocyte trapping in the microcirculation and perivascular space is associated with trophic skin changes. Cell adhesion molecules are linked with the perpetuated influx of activated leukocytes into inflammatory sites. Here, inflammatory cells may influence the remodeling of the extracellular matrix by inducing the secretion of proteinases such as matrix metalloproteinases (MMPs). The increased expression of MMPs is associated with the formation of venous leg ulcers and lesions. Phosphodiesterase 4 activity has also been shown to be elevated in individuals with inflammatory dermatoses compared to healthy individuals.

DISCUSSION

Because inflammation is a key driver of the signs and symptoms of SD, several of the highlighted biomarkers of inflammation represent potential opportunities to target and interrupt molecular pathways of cutaneous inflammation and, therefore, remediate the signs and symptoms of SD.

CONCLUSION

Understanding the pathogenesis of SD may help clinicians identify drivers of inflammation to use as potential targets for the development of new treatment options.

Use of fetal bovine dermal repair scaffold in diabetic foot ulcers with recidivism: an open-label prospective clinical study

OBJECTIVE

This study aimed to establish the effectiveness of fetal bovine dermal scaffold (FBDS) application with multilayer offloading (standard of care) over that of traditional therapies in the treatment of diabetic foot ulcers (DFUs).

METHOD

Patients from a single centre in South Florida, US were recruited for this research. All patients underwent a run-in period of standardised care and vascular testing to determine and control the ability to heal. Patients were placed in multilayer offloading total contact cast (TCC) systems with application of FBDS every four weeks. Wound measurements and efficacy of offloading were monitored weekly.

RESULTS

In an older population with diabetes and above-normal body mass index (BMI), use of FBDS was successful in wound closure, with average time to closure of 7.85 weeks for the 20 patients in this study. It should be noted that surface wound area was reduced by approximately 40% by week 4 and by almost 83% by week 9. Follow-up at three and six months showed no residual or recurrent ulcerations in this study population for 19/20 patients.

CONCLUSION

Total wound closure of hard-to-heal DFUs in this patient series study was achieved with local surgical debridement, TCC offloading and application(s) of a FBDS in older patients with above-normal BMI and in wounds of >4 weeks non-progressive healing. Furthermore, at three and six months, 19/20 patients' wounds remained closed and did not re-ulcerate.

Rational Design of Intelligent and Multifunctional Dressing to Promote Acute/Chronic Wound Healing

Currently, the clinic's treatment of acute/chronic wounds is still unsatisfactory due to the lack of functional and appropriate wound dressings. Intelligent and multifunctional dressings are considered the most advanced wound treatment modalities. It is essential to design and develop wound dressings with required functions according to the wound microenvironment in the clinical treatment. This work summarizes microenvironment characteristics of various common wounds, such as acute wound, diabetic wound, burns wound, scalded wound, mucosal wound, and ulcers wound. Furthermore, the factors of transformation from acute wounds to chronic wounds were analyzed. Then we focused on summarizing how researchers fully and thoroughly combined the complex microenvironment with modern advanced technology to ensure the usability and value of the dressing, such as photothermal-sensitive dressings, microenvironment dressing (pH-sensitive dressings, ROS-sensitive dressings, and osmotic pressure dressings), hemostatic dressing, guiding tissue regeneration dressing, microneedle dressings, and 3D/4D printing dressings. Finally, the revolutionary development of wound dressings and how to transform the existing advanced functional dressings into clinical needs as soon as possible have carried out a reasonable and meaningful outlook.

Hydrogel dressings for venous leg ulcers

BACKGROUND

Venous leg ulcers are a chronic health problem that cause considerable economic impact and affect quality of life for those who have them. Primary wound contact dressings are usually applied to ulcers beneath compression therapy to aid healing, promote comfort and control exudate. There are numerous dressing products available for venous leg ulcers and hydrogel is often prescribed for this condition; however, the evidence base to guide dressing choice is sparse.

OBJECTIVES

To assess the effects of hydrogel wound dressings on the healing of venous leg ulcers in any care setting.

SEARCH METHODS

In May 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE, 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, reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), either published or unpublished, that compared the effects of hydrogel dressing with other dressings on the healing of venous leg ulcers. We excluded trials evaluating hydrogel dressings impregnated with antimicrobial, antiseptic or analgesic agents as these interventions are evaluated in other Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included four RCTs (10 articles) in a qualitative analysis. Overall, 272 participants were randomised, in sample sizes ranging from 20 to 156 participants. The mean age of the included population in the trials ranged from 55 to 68 years, 37% were women based on studies that reported the sex of participants. The studies compared hydrogel dressings with the following: gauze and saline, alginate dressing, manuka honey and hydrocolloid. Two studies were multicentre and the others were single-centre trials. Length of treatment using hydrogel dressing was four weeks in three studies and two weeks in one study. The follow-up period was the same as the duration of treatment in three studies and in one study the follow-up for wound healing was at 12 weeks after four weeks of treatment. Overall risk of bias was high for all trials because at least one of the three key criteria (selection bias, detection bias and attrition bias) was at high risk. Hydrogel compared with gauze and saline It is uncertain whether there is a difference in complete wound healing (risk ratio (RR) 5.33, 95% confidence interval (CI) 1.73 to 16.42; 1 trial, 60 participants) or change in ulcer size (mean difference (MD) -1.50, 95% CI -1.86 to -1.14; 1 trial, 60 participants) between interventions because the certainty of the evidence is very low. Data reported from one trial were incomplete for time-to-ulcer healing. Hydrogel compared with alginate dressing It is uncertain whether there is a difference in change in ulcer size between hydrogel and alginate gel because the certainty of the evidence is very low (MD -41.80, 95% CI -63.95 to -19.65; 1 trial, 20 participants). Hydrogel compared with manuka honey It is uncertain whether there is a difference in complete wound healing (RR 0.75, 95% CI 0.46 to 1.21; 1 trial, 108 participants) or incidence of wound infection (RR 2.00, 95% CI 0.81 to 4.94; 1 trial, 108 participants) between interventions because the certainty of the evidence is very low. Hydrogel compared with hydrocolloid One study (84 participants) reported on change in ulcer size between hydrogel and hydrocolloid; however, further analysis was not possible because authors did not report standard errors or any other measurement of variance of a set of data from the means. Therefore, it is also uncertain whether there is a difference in change in ulcer size between hydrogel and hydrocolloid because the certainty of the evidence is very low. No studies provided evidence for the outcomes: recurrence of ulcer, health-related quality of life, pain and costs. Overall, independent of the comparison, the certainty of evidence is very low and downgraded twice due to risk of bias and once or twice due to imprecision for all comparisons and outcomes.

AUTHORS' CONCLUSIONS

There is inconclusive evidence to determine the effectiveness of hydrogel dressings compared with gauze and saline, alginate dressing, manuka honey or hydrocolloid on venous leg ulcer healing. Practitioners may, therefore, consider other characteristics such as costs and symptom management when choosing between dressings. Any future studies assessing the effects of hydrogel on venous wound healing should consider using all the steps from CONSORT, and consider key points such as appropriate sample size with the power to detect expected differences, appropriate outcomes (such as time-to-event analysis) and adverse effects. If time-to-event analysis is not used, at least a longer follow-up (e.g. 12 weeks and above) should be adopted. Future studies should also address important outcomes that the studies we included did not investigate, such as health-related quality of life, pain and wound recurrence.

A meta-review of the impact of compression therapy on venous leg ulcer healing

This meta-review aimed to appraise and synthesise findings from existing systematic reviews that measured the impact of compression therapy on venous leg ulcers healing. We searched five databases to identify potential papers; three authors extracted data, and a fourth author adjudicated the findings. The AMSTAR-2 tool was used for quality appraisal and the certainty of the evidence was appraised using GRADEpro. Data analysis was undertaken using RevMan. We identified 12 systematic reviews published between 1997 and 2021. AMSTAR-2 assessment identified three as high quality, five as moderate quality, and four as low quality. Seven comparisons were reported, with a meta-analysis undertaken for five of these comparisons: compression vs no compression (risk ratio [RR]: 1.55; 95% confidence interval [CI] 1.34-1.78; P < .00001; moderate-certainty evidence); elastic compression vs inelastic compression (RR: 1.02; 95% CI: 0.96-1.08; P < .61 moderate-certainty evidence); four layer vs <four-layer bandage systems (RR: 1.07; 95% CI: 0.82-1.40; P < .63; moderate-certainty evidence); comparison between different four-layer bandage systems (RR: 1.08; 95% CI: 0.93-1.25; P = .34; moderate-certainty evidence); compression bandage vs compression stocking (RR 0.95; 95% CI 0.87-1.03; P = .18; moderate-certainty evidence). The main conclusion from this review is that there is a statistically significant difference in healing rates when compression is used compared with no compression, with moderate-certainty evidence. Otherwise, there is no statistically different difference in healing rates using elastic compression vs inelastic compression, four layer vs <four-layer bandage systems, different four-layer bandage systems, or compression bandages vs compression stockings.

Safety and efficacy of acellular human amniotic fluid and membrane in the treatment of non-healing wounds in a patient with chronic venous insufficiency

Chronic, non-healing venous ulcers of the lower extremity are often limb-threatening conditions. Their management is characterized by a prolonged and frequently frustrating clinical course that represents an economic burden to both the patient and healthcare system. During the last two decades, thermal ablation of underlying incompetent venous systems has been extensively utilized to treat chronic venous insufficiency. Despite successful correction of venous hypertension, a substantial subgroup of patients remain affected by non-healing venous ulcers, thus posing a significant clinical challenge. In this case report, we detail quantitative and qualitative wound treatment course in a patient refractory to standard interventions, by treatment with a combination of cell-free amniotic fluid and dehydrated amniotic membrane following successful thermal ablation of refluxing veins.

The effects of gravity and compression on interstitial fluid transport in the lower limb

Edema in the limbs can arise from pathologies such as elevated capillary pressures due to failure of venous valves, elevated capillary permeability from local inflammation, and insufficient fluid clearance by the lymphatic system. The most common treatments include elevation of the limb, compression wraps and manual lymphatic drainage therapy. To better understand these clinical situations, we have developed a comprehensive model of the solid and fluid mechanics of a lower limb that includes the effects of gravity. The local fluid balance in the interstitial space includes a source from the capillaries, a sink due to lymphatic clearance, and movement through the interstitial space due to both gravity and gradients in interstitial fluid pressure (IFP). From dimensional analysis and numerical solutions of the governing equations we have identified several parameter groups that determine the essential length and time scales involved. We find that gravity can have dramatic effects on the fluid balance in the limb with the possibility that a positive feedback loop can develop that facilitates chronic edema. This process involves localized tissue swelling which increases the hydraulic conductivity, thus allowing the movement of interstitial fluid vertically throughout the limb due to gravity and causing further swelling. The presence of a compression wrap can interrupt this feedback loop. We find that only by modeling the complex interplay between the solid and fluid mechanics can we adequately investigate edema development and treatment in a gravity dependent limb.

Urolithin A Promotes Angiogenesis and Tissue Regeneration in a Full-Thickness Cutaneous Wound Model

The treatment of chronic wound is an important topic of current clinical issue. Neovascularization plays a crucial role in skin wound healing by delivering fresh nutrients and oxygen to the wound area. The aim of this study was to investigate the mechanisms of urolithin A (UA) in angiogenesis during wound healing. The results of in vitro experiments showed that treatment with UA (5–20 μM) promoted the proliferation, migration, and angiogenic capacity of HUVECs. Furthermore, we investigated the effect of UA in vivo using a full-thickness skin wound model. Subsequently, we found that UA promoted the regeneration of new blood vessels, which is consistent with the results of accelerated angiogenesis in vitro experiments. After UA treatment, the blood vessels in the wound are rapidly formed, and the deposition and remodeling process of the collagen matrix is also accelerated, which ultimately promotes the effective wound healing. Mechanistic studies have shown that UA promotes angiogenesis by inhibiting the PI3K/AKT pathway. Our study provides evidence that UA can promote angiogenesis and skin regeneration in chronic wounds, especially ischemic wounds.

Topically administered purified clinoptilolite-tuff for the treatment of cutaneous wounds: a prospective, randomized phase I clinical trial

In an ageing society, chronic ulcers pose an increasingly relevant healthcare issue associated with significant morbidity and an increasing financial burden. Hence, there is an unmet medical need for novel, cost‐effective therapies that improve healing of chronic cutaneous wounds. This prospective, randomised, open‐label, phase I trial investigated the safety and tolerability of topically administered purified clinoptilolite‐tuff (PCT), mainly consisting of the naturally occurring zeolite‐mineral clinoptilolite, in artificial wounds in healthy male volunteers compared to the standard of care (SoC). We found that topically administered PCT was safe for therapeutic application in acute wounds in healthy male volunteers. No significant differences in wound healing or wound conditions were observed compared to SoC‐treated wounds. However, we found a significantly higher proportion of CD68‐positive cells and a significantly lower proportion of α‐smooth muscle actin‐positive cells in PCT‐treated wounds. Scanning electron microscopy revealed PCT particles in the restored dermis in some cases. However, these did not impede wound healing or clinical symptoms. Hence, purified PCT could represent an attractive, cost‐effective wound treatment promoting the process of healing.

Melittin and diclofenac synergistically promote wound healing in a pathway involving TGF-β1

A dysregulation of the wound healing process can lead to the development of various intractable ulcers or excessive scar formation. Therefore it is essential to identify novel pharmacological strategies to promote wound healing and restore the mechanical integrity of injured tissue. The goal of the present study was to formulate a nano-complex containing melittin (MEL) and diclofenac (DCL) with the aim to evaluate their synergism and preclinical efficacy in an in vivo model of acute wound. After its preparation and characterization, the therapeutic potential of the combined nano-complexes was evaluated. MEL-DCL nano-complexes exhibited better regenerated epithelium, keratinization, epidermal proliferation, and granulation tissue formation, which in turn showed better wound healing activity compared to MEL, DCL, or positive control. The nano-complexes also showed significantly enhanced antioxidant activity. Treatment of wounded skin with MEL-DCL nano-complexes showed significant reduction of interleukin-6 (IL-6), IL-1β, and tumor necrosis factor-α (TNF-α) pro-inflammatory markers that was paralleled by a substantial increase in mRNA expression levels of collagen, type I, alpha 1 (Col1A1) and collagen, type IV, alpha 1 (Col4A1), and hydroxyproline content as compared to individual drugs. Additionally, MEL-DCL nano-complexes were able to significantly increase hypoxia-inducible factor 1-alpha (HIF-1α) and transforming growth factor beta 1 (TGF-β1) proteins expression compared to single drugs or negative control group. SB431542, a selective inhibitor of type-1 TGF-β receptor, significantly prevented in our in vitro assay the wound healing process induced by the MEL-DCL nano-complexes, suggesting a key role of TGF-β1 in the wound closure. In conclusion, the nano-complex of MEL-DCL represents a novel pharmacological tool that can be topically applied to improve wound healing.

Long-Term Outcomes of Endovenous Laser Ablation, n-Butyl Cyanoacrylate and Radiofrequency Ablation in the Treatment of Chronic Venous Insufficiency

INTRODUCTION

This study aims to evaluate the long-term results regarding the effectiveness and reliability of endovenous laser ablation (EVLA), endovenous n-butyl cyanoacrylate (NBCA) application and radiofrequency ablation (RFA) methods in the management of Chronic venous insufficiency (CVI).

METHODS

Charts of patients treated with EVLA, NBCA and RFA methods for CVI between January 1^st, 2014 and January 1^st, 2017, were reviewed. Records were made of personal information including sex, age, body mass index (BMI), American Society of Anesthesiologists score (ASA) and admission symptoms. Great saphenous vein (GSV) diameter, score of CEAP (Clinical, Etiology, Anatomy and Pathophysiology) classification, and Venous Clinical Severity Score (VCSS) were also noted. All patients were followed up with physical examination and CDUS at the first week, and 6^th and 12^th months after the procedures. After 12^th month, follow-ups were annual.

RESULTS

Enrolled in the study were a total of 232 patients who underwent lower limb CVI procedures (77 patients with EVLA, 73 patients with NBCA and 82 patients with RFA). The mean follow-up time was 67.5±4.7 months. Time of procedure was significantly shorter in patients treated with NBCA (13.5 minutes) in comparison of patients treated with EVLA (31.7 minutes) and RFA (27.9 minutes) (p= 0.001). Pain score was highest in EVLA group (p= 0.001). Significantly higher complication rates and longer time to return daily activity was recorded in those undergoing EVLA procedure (p= 0.001). Post hoc analysis revealed comparable occlusion success among groups on post-operative first day, and at 6^th month, first year and second year. However, significantly better success of occlusion rates were found for RFA in comparison of EVLA in third and fifth-years follow-ups (p= 0.024 and p= 0.011). The success of NBCA and RFA was similar in third and fifth-years follow-ups (p= 0.123 vs p= 0.330) CONCLUSION: Outcomes showed similar levels of early postoperative occlusion success among all three CVI treatment techniques, but RFA has a significantly higher success rate over EVLA in the third and fifth-year follow-ups. Additionally, NBCA and RFA procedures achieved comparable long-term success. EVLA was associated with significantly higher complication rates and pain scores, and longer time to return daily activities, while NBCA procedure had a significantly shorter operation time than the other procedures.

Management of hard-to-heal leg ulcers with an acid-oxidising solution versus standard of care: the MACAN study

OBJECTIVE

The efficacy of available wound dressings in the treatment of hard-to-heal wounds is limited. A new therapeutic approach using an acid-oxidising solution (AOS) was developed. Its effect on healing progress, tolerability and safety properties were investigated in a clinical study, and compared with standard of care (SOC) wound dressings. The study aimed to demonstrate the non-inferiority of AOS to SOC in terms of wound healing progress.

METHOD

This open-label, randomised controlled trial was conducted at two study centres in Austria with patients with either infected or non-infected hard-to-heal leg ulcers of different aetiology. Patients were treated for six weeks either with AOS or SOC wound dressings. Outcome assessments included the percentage of granulation and re-epithelialisation tissue, wound size reduction, changes in wound pH, infection control and wound pain, local tolerability and adverse events (AEs). Healing time and rate were also assessed.

RESULTS

A total of 50 patients took part. In the AOS group, wounds exhibited higher amounts of granulation and re-epithelialisation tissue, and a faster and more pronounced wound size reduction compared with wounds in the SOC group. In the AOS-treated versus SOC-treated patients, a greater percentage of complete healing of hard-to-heal ulcers was achieved by the end of the study period (32% versus 8%, respectively). Furthermore, the wound pH decreased significantly faster in these wounds (p<0.0001). In all patients with infected leg ulcers, local infection was overcome more rapidly under AOS treatment. In the AOS group, one AE and no serious adverse events (SAEs) were detected versus 24 AEs and two SAEs in the SOC group.

CONCLUSION

In this study, AOS proved to be a highly effective treatment to support wound healing in infected or non-infected hard-to-heal leg ulcers of different aetiology. Efficacy was found to be not only non-inferior but superior to SOC wound dressings. Furthermore, tolerability and safety profiles were favourable for AOS.

Point-of-Care Ultrasound as a Tool to Assess Wound Size and Tissue Regeneration after Skin Grafting

Chronic wounds can be difficult to heal and are often accompanied by pain and discomfort. Multiple skin substitutes or cellularized/tissue-based skin products have been used in an attempt to facilitate closure of complex wounds. Allografts from cadaveric sources have been a viable option in achieving such closure. However, early assessment of graft incorporation has been difficult clinically, often with delayed evidence of failure. Visual cues to assess graft integrity have been limited and remain largely superficial at the skin surface. Furthermore, currently used optical imaging techniques can penetrate only a few millimeters deep into tissue. Ultrasound (US) imaging offers a potential solution to address this limitation. This work evaluates the use of US to monitor wound healing and allograft integration. We used a commercially available dual-mode (US and photoacoustic) scanner operating only in US mode. We compared the reported wound size from the clinic with the size measured using US in 45 patients. Two patients from this cohort received an allogenic skin graft and underwent multiple US scans over a 110-d period. All data were processed by two independent analysts; one of them was blinded to the study. We measured change in US intensity and wound contraction as a function of time. Our results revealed a strong correlation (R² = 0.81, p < 0.0001) between clinically and US-measured wound sizes. Wound contraction >91% was seen in both patients after skin grafting. An inverse relationship between wound size and US intensity (R² = 0.77, p < 0 .0001) indicated that the echogenicity of the wound bed increases as healthy cells infiltrate the allograft matrix, regenerating and leading to healthy tissue and re-epithelization. This work indicates that US can be used to measure wound size and visualize tissue regeneration during the healing process.

Combining Biocompatible and Biodegradable Scaffolds and Cold Atmospheric Plasma for Chronic Wound Regeneration

Skin regeneration is a quite complex process. Epidermal differentiation alone takes about 30 days and is highly regulated. Wounds, especially chronic wounds, affect 2% to 3% of the elderly population and comprise a heterogeneous group of diseases. The prevailing reasons to develop skin wounds include venous and/or arterial circulatory disorders, diabetes, or constant pressure to the skin (decubitus). The hallmarks of modern wound treatment include debridement of dead tissue, disinfection, wound dressings that keep the wound moist but still allow air exchange, and compression bandages. Despite all these efforts there is still a huge treatment resistance and wounds will not heal. This calls for new and more efficient treatment options in combination with novel biocompatible skin scaffolds. Cold atmospheric pressure plasma (CAP) is such an innovative addition to the treatment armamentarium. In one CAP application, antimicrobial effects, wound acidification, enhanced microcirculations and cell stimulation can be achieved. It is evident that CAP treatment, in combination with novel bioengineered, biocompatible and biodegradable electrospun scaffolds, has the potential of fostering wound healing by promoting remodeling and epithelialization along such temporarily applied skin replacement scaffolds.

The economic impact of infection requiring hospitalization on venous leg ulcers

OBJECTIVE

To determine the impact of infection (INF) on medical resource utilization (MRU) and cost of care in patients with venous leg ulcers (VLU).

METHODS

We performed a retrospective case-control study of 78 patients followed for a minimum of 12 months with C₆ VLUs treated by vascular surgeons, at our wound center. To eliminate minor episodes of INF or incorrectly diagnosed episodes, only patients who had an inpatient admission specifically for INF comprised the INF group, whereas all other admissions were excluded for this group. MRU was defined as the number of clinic visits, Visiting Nurse Association (VNA) visits, and inpatient admissions. The actual cost for treatment was determined using financial data provided by both the hospital and physician organization billing units. The total cost over the 1-year follow-up period comprised individual cost centers: inpatient and outpatient facility fees, physician fees, and visiting nurse services. Mean MRU and cost data were compared using the two-sample t-test between INF and NON-INF.

RESULTS

Of the 78 patients with C₆ VLU, 9 (11.5%) had at least one inpatient admission for INF related to their VLU in the 1-year treatment period, with an additional five recurrent admissions for a total of 14 admissions, whereas 69 NON-INF had three NON-INF-related admissions. There was no difference between INF and NON-INF for usual risk factors, but INF had a greater proportion of congestive heart failure (44%; 13%, P < .02). Regarding MRU, both the number of outpatient wound center visits (INF 16.89 ± 6.41; NON-INF 9.46 ± 7.7, P = .008) and VNA blocks (INF 3.89 ± 2.93; NON-INF 1.94 ± 2.24, P < .02) were greater for INF. Total costs for INF ($27,408 ± $10,859) were threefold higher than those for NON-INF ($11,088 ± $9343, P < .0001) and subsequent VNA costs were doubled for INF ($9956 ± $4657) vs NON-INF ($4657 ± $5486, P = .01).

CONCLUSIONS

INFs in patients with VLU led to an overall increase in MRU and cost of care, with the INF cohort requiring more inpatient admissions, outpatient visits, and VNA services than NON-INF. Given the major impact INF has on cost and MRU, better treatment modalities that prevent INF as well as identifying risk factors for INF in patients with VLU are needed.

Early period results of radiofrequency ablation and cyanoacrylate embolization for great saphenous vein insufficiency

OBJECTIVE

To evaluate the 6 months efficacy and safety of cyanoacrylate closure for the treatment of incompetent great saphenous veins (GSVs) in comparison with radiofrequency ablation (RFA).

METHODS

In this multicenter, retrospective, clinical trial, 398 symptomatic subjects with incompetent GSVs were assigned to either cyanoacrylate closure or RFA. The primary endpoint, complete closure of the target GSV, was determined using duplex ultrasound examination starting from one-, three-, and six-month visits.

RESULTS

All patients were followed for 6 months and there was no difference between the groups in terms of mean follow-up time. Hospital stay and return to work/activity were shorter in the cyanoacrylate ablation (CAA) group, and these differences between the groups were statistically significant. Ecchymosis was observed higher in the RFA group and was statistically significant.

CONCLUSIONS

In this study, in which we examined the CAA and RFA methods, we found that both methods were effective and reliable; however, we found that patients in the CAA group had a more comfortable postoperative period and returned to work earlier.

Lymphatico-venous anastomosis in chronic ulcer with venous insufficiency: A case report

Patients presenting with chronic wounds in venous insufficiency often represent a challenge, like other conditions, like lymphatic impairment, may complicate the wound healing process. The purpose of this report is to highlight how the treatment of lymphatic impairment may be beneficial in patients affected by chronic ulcers with concomitant venous insufficiency. We present the case of a 78-year-old woman affected by chronic venous insufficiency (CVI) with long-lasting ulcers secondary to sclerosing agents treatment for varicose veins. The patient's condition was refractory to both conservative and surgical treatment. Since the patient also presented with severe lymphorrhea, with a significant amount of daily secretion, ICG-lymphography was performed subcutaneously, to visualize the pathway of lymphatic drainage and leakage. It also allowed marking on the skin the exact location of lymphatic vessels distally to the wound area. Hence, two lymphatico-venous anastomoses were performed between the two major collecting lymphatic vessels and two subcutaneous veins of adequate size. The postoperative course was uneventful and the procedure allowed for immediate resolution of lymphatic leakage and complete wound healing within 2 weeks with no recurrence in the follow-up time of 1.5 years. Based on the outcomes of this case, it is possible to consider the use of CVI treatment and lymphedema surgery as a combined approach to complicated cases of long-standing venous ulcers with lymphorrhea.

Use of a bacterial fluorescence imaging system to target wound debridement and accelerate healing: a pilot study

OBJECTIVE

Optimal wound-bed preparation consists of regular debridement to remove devitalised tissues, reduce bacterial load, and to establish an environment that promotes healing. However, lack of diagnostic information at point-of-care limits effectiveness of debridement.

METHOD

This observational case series investigated use of point-of-care fluorescence imaging to detect bacteria (loads >10⁴CFU/g) and guide wound bed preparation. Lower extremity hard-to-heal wounds were imaged over a 12-week period for bacterial fluorescence and wound area.

RESULTS

A total of 11 wounds were included in the study. Bacterial fluorescence was present in 10 wounds and persisted, on average, for 3.7 weeks over the course of the study. The presence of red or cyan fluorescent signatures from bacteria correlated with an average increase in wound area of 6.5% per week, indicating stalled or delayed wound healing. Fluorescence imaging information assisted in determining the location and extent of wound debridement, and the selection of dressings and/or antimicrobials. Elimination of bacterial fluorescence signature with targeted debridement and other treatments correlated with an average reduction in wound area of 27.7% per week (p<0.05), indicative of a healing trajectory.

CONCLUSION

These results demonstrate that use of fluorescence imaging as part of routine wound care enhances assessment and treatment selection, thus facilitating improved wound healing.

Objective assessment of Platelet-Rich Plasma (PRP) potentiality in the treatment of Chronic leg Ulcer: RCT on 80 patients with Venous ulcer

BACKGROUND

Chronic venous leg ulcer reduces the patients' activities and their overall quality of life. Platelet-rich plasma (PRP) was previously investigated as promising less invasive management for leg ulcers.

THIS STUDY AIMS

To re-assess the efficacy and safety of PRP in the management of chronic leg ulcers due to venous factors.

PATIENTS/METHODS

RCT enrolled 80 patients who clinically presented with chronic venous leg ulcers. Forty patients were allocated randomly for the treatment with autologous platelet-rich plasma (PRP). Intradermal and subdermal injection of PRP by 27guage syringe weekly, in all edges and in the granular floor of the ulcer for 4-6 sessions. Another 40 patients managed by conventional treatment by compression and dressing for the same period were allocated as Group B. Objective assessment achieved by the percentage of reduction of the size of the ulcer area, rate of healing, incidence of recurrence, and if side effects have been reported.

RESULTS

PRP therapy showed better results and high p value significance when compared to conventional therapy.

CONCLUSION

This study shows that PRP is effective and significant in promoting the wound healing process in chronic leg venous ulcers. PRP is simple, safe, and has a short learning curve technique.

Preclinical assessment of stem of Nicotiana tabacum on excision wound model

Agro-waste material derived from N. tabacum has shown enormous potential antioxidant and antimicrobial activity. Hence in the present study, we investigated the wound healing efficacy of ethanolic extract of stem of Nicotiana tabacum on wistar rat model. Ethanolic extract prepared from defatted stem was to check various phytochemicals using spectrophotometric and chromatographic technique. The antioxidant potential was determined by FRAP and Reducing Power assay in extract. Cytotoxicity of extracts was determined using mouse fibroblast L929 cell lines by MTT assay. In vivo angiogenic activity was observed on chick chorioallantoic membrane (CAM) model by observing blood vessels formation and its branching. In vivo wound healing activity was observed on excision wounds in rat model by quantifying percentage of wound contraction, antioxidant activity and histopathology studies. From the present study, polyphenols, tannins and alkaloids were found to be determined in the ethanolic extract by means of spectrophotometric and chromatographic analysis against standards. Antioxidant assay revealed maximum antioxidant potential in ethanolic extract. Cytotoxic effect of extract has not been shown on L929 cell line. From CAM model, extract has shown growth of blood vessels formation at concentration of 480 µg/ml. Topical application of extracts on excision wounds, revealed wound healing activity i.e. 98.7% ± 0.002 on 14th day as well as enzymatic activity (SOD, CAT, GST) and non enzyme content (GSH and Lipid peroxidation) has been found to be high in granulated tissue. Hisopathological studies confirmed the re-epithelization in skin wounds. It can be concluded that stem of N. tabacum can be used as herbal remedy in wound healing process as a topical application.

Use of Sponge-Foam Inserts in Compression Bandaging of Non-Healing Venous Leg Ulcers

Objective: Venous leg ulcers (VLUs) caused by chronic venous insufficiency are difficult to treat. Outcomes after compression therapy and the current standard of care often used in conjunction with other options vary widely. We examined the effects of foam inserts on sub-bandage pressures in patients with VLUs and compared use of foam inserts in elastic and inelastic compression bandaging. Methods: Six patients (≥20 years old) with VLUs and skin perfusion pressure >40 mmHg were included. Each patient underwent weekly treatment regimens of debridement, dressing changes, and dual sponge-insert application followed by elastic (n=3) or inelastic (n=3) compression bandaging. The median resting sub-bandage pressures of the ulcer beds, wound sizes, and healing percentages were recorded. Wound beds were biopsied before and after treatment for histological assessment. Nine healthy volunteers served as controls during preliminary testing. Results: With proper sub-bandage pressures (>35 mmHg), the average healing time was 88.0±66 days, which was shorter than anticipated (i.e., ≥6 months). Combining large and local sponge-foam inserts increased sub-bandage pressures regardless of the compression bandage selected, with marked improvements seen in deeper wounds. Conclusion: Layering one or two sponge-foam inserts beneath compression bandages facilitates uniform and optimal wound-bed pressure, which accelerates the healing of VLUs.

Distribution and Antibiotic Resistance Patterns of Pathogenic Bacteria in Patients With Chronic Cutaneous Wounds in China

Background: To determine the distribution and antimicrobial susceptibility pattern of pathogenic bacteria in patients with chronic cutaneous wounds on a national scale. Methods: A retrospective study was conducted using the data recorded between January 1, 2018 and January1, 2020 in 195 hospitals across China. After screening the data, 815 patients with chronic wounds were finally analyzed. The data collected included information about the patients' general condition and local cutaneous wound assessments, especially microbial culture and antibiotic susceptibility tests. The analyses were performed using SPSS Version 26. Results: The study included 815 patients (290 [35.6%] females; 63 [50-74] years). The most common causes of chronic cutaneous wounds were diabetes (183, 22.5%), infection (178, 21.8%), and pressure (140, 17.2%). Among these, 521(63.9%) samples tested yielded microbial growth, including 70 (13.4%) polymicrobial infection and 451 (86.6%) monomicrobial infection. The positive rate of microbial culture was highest in wound tissue of ulcers caused by infection (87.6%), followed by pressure (77.1%), diabetes (68.3%), and venous diseases (67.7%). Bates-Jensen wound assessment tool (BWAT) scores >25 and wounds that lasted for more than 3 months had a higher positive rate of microbial culture. BWAT scores >25 and wounds in the rump, perineum, and feet were more likely to exhibit polymicrobial infection. A total of 600 strains were isolated, of which 46.2% (277 strains) were Gram-positive bacteria, 51.3% (308 strains) were Gram-negative bacteria, and 2.5% (15 strains) were fungi. The most common bacterial isolates were Staphylococcus aureus (29.2%), Escherichia coli (11.5%), Pseudomonas aeruginosa (11.0%), Proteus mirabilis (8.0%), and Klebsiella pneumoniae (5.8%). The susceptibility tests showed that 116 cultured bacteria were Multidrug resistant (MDR) strains. The resistance rates of S. aureus were 92.0% (161/175) to penicillin, 58.3% (102/175) to erythromycin, and 50.9% (89/175) to clindamycin. Vancomycin was the most effective antibiotic (0% resistance rate) against all Gram-positive bacteria. Besides, the resistance rates of E. coli were 68.1% (47/69) to ampicillin, 68.1% (47/69) to ciprofloxacin, 60.9% (42/69) to levofloxacin. However, all the isolated Gram-negative bacteria showed low resistance rates to tigecycline (3.9%) and amikacin (3.6%). Conclusions: The distribution of bacteria isolated from chronic cutaneous wounds varies with the BWAT scores, causes, duration, and the location of wounds. Multidrug resistance is a serious health issue, and therefore antibiotics used in chronic wounds must be under strict regulation. Our findings may help clinicians in making informed decisions regarding antibiotic therapy.

Systematic review and meta-analysis of the efficacy of Unna boot in the treatment of venous leg ulcers

This systematic review determined the effectiveness of the Unna boot in the treatment of venous leg ulcers (VLUs) by assessing the quality of the available evidence. A systematic search of studies published between August 2019 and February 2020 was conducted using the PubMed, PubMed/PMC, BVS/BIREME, CINAHL, Web of Science, MEDLINE, Embase, Cochrane, ProQuest, BDTD, CAPES Thesis and Dissertation, OPEN THESIS, Centre for Reviews and Dissemination and SciELO databases. Studies were eligible if they reported primary studies, controlled clinical trials, quasi-experimental studies or observational studies (cross-sectional studies or cohort studies). We identified 302 articles. After screening and critical appraisal, eight articles were included in this review, while six articles were included in the meta-analysis. Four studies were included in the outcome of complete ulcer healing rate with a weighted estimate of the odds ratio of 0.43 (95% CI = 0.188-1.01). No evidence of the presence of considerable heterogeneity was observed (p = 0.35, I² = 32%). Two studies were assigned to the outcome time to complete ulcer healing (days) with a weighted estimated mean difference of 41.3 days (95% CI = 21.62-61.04). Evidence of the presence of considerable heterogeneity was observed (p = 0.01, I² = 85%). The results showed a moderate degree of evidence that there is no difference in the healing rates of VLUs with the use of the Unna boot. For the time to complete ulcer healing, the low number of studies and low classification impaired the reporting at any level of evidence.

Therapeutic potential of flavonoids in the treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) is a common disorder associated with a variety of symptoms in later disease stages; despite the high prevalence of this pathology, suitable pharmaceutical therapies have not been explored to date. In this context, it was recently reported that a chronic increase in venous wall stress or biomechanical stretch is sufficient to cause development of varicose veins. Recent evidence demonstrate that flavonoids are natural substances that convey the circulatory system functionality, playing a key role in blood flow. Particularly, troxerutin, diosmin and horse chestnut extract, appear protective for the management of vascular diseases. The aim of the present study was to evaluate the effect of a flavonoid compound, containing troxerutin, diosmin and horse chestnut extract on in vitro model on HUVECs cells, due to its production of vasculoregulatory and vasculotropic molecules, on an ex-vivo model on mesenteric vessel contraction, to regularize mesenteric microcirculation and on in vivo model of CVI-induced by saphene vein ligation. Furthermore, the flavonoid compound capacity of extensibility and compatibility with peripheral veins was investigated through a tissue block culture study. The degree of absorption, the contractile venous activity, the histological analysis, the immunoistochemical and immunofluorescence evaluation for VEGF and CD34 were performed, together with inflammatory mediators dosage. For the first time, this research revealed the therapeutic potential of a compound, enriched with flavonoids, to be a supportive treatment, suitable to reduce varicose vein pathophysiology and to regularize venous tone.

Neuromuscular stimulation of the common peroneal nerve increases arterial and venous velocity in patients with venous leg ulcers

Activation of the venous muscle pumps by neuromuscular stimulation of the common peroneal nerve has been previously shown to increase venous and arterial flow in the legs of healthy subjects. The aim of this study is to determine whether a similar effect is observed in patients with chronic venous leg ulcers. 1 Hz intermittent electrostimulation of the common peroneal nerve was applied to 14 patients with ulcers between 1 and 10 cm in diameter, eliciting a small, painless, regular, muscular twitch of the leg. Flow was measured using Duplex ultrasound in the popliteal vein and the popliteal artery. Peak arterial velocity increased from 57 to 78 cm/s (P = .001) in sitting position, and from 79 to 98 cm/s in recumbent position (P = .001). Peak venous velocity increased from 10 to 33 cm/s (P = .001) sitting, and from 14 to 47 cm/s (P = .001) recumbent. Significant increases were observed in both venous and arterial blood flow in the lower limb. This suggestsed that activation of the venous muscle pump and improvement of arterial flow assisted oxygen delivery at the wound site. Moreover this may be a worthwhile intervention to assist in the healing of venous leg ulcers, and may provide a mechanistic explanation for the increased healing rates previously reported with neuromuscular stimulation of the common peroneal nerve.

Thin-Film Flexible Wireless Pressure Sensor for Continuous Pressure Monitoring in Medical Applications

Physiological pressure measurement is one of the most common applications of sensors in healthcare. Particularly, continuous pressure monitoring provides key information for early diagnosis, patient-specific treatment, and preventive healthcare. This paper presents a thin-film flexible wireless pressure sensor for continuous pressure measurement in a wide range of medical applications but mainly focused on interface pressure monitoring during compression therapy to treat venous insufficiency. The sensor is based on a pressure-dependent capacitor (C) and printed inductive coil (L) that form an inductor-capacitor (LC) resonant circuit. A matched reader coil provides an excellent coupling at the fundamental resonance frequency of the sensor. Considering varying requirements of venous ulceration, two versions of the sensor, with different sizes, were finalized after design parameter optimization and fabricated using a cost-effective and simple etching method. A test setup consisting of a glass pressure chamber and a vacuum pump was developed to test and characterize the response of the sensors. Both sensors were tested for a narrow range (0–100 mmHg) and a wide range (0–300 mmHg) to cover most of the physiological pressure measurement applications. Both sensors showed good linearity with high sensitivity in the lower pressure range <100 mmHg, providing a wireless monitoring platform for compression therapy in venous ulceration.

Treatment of venous leg ulcers using bilayered living cellular construct

Background: Venous leg ulcers (VLUs) present a significant economic burden on the US healthcare system and payers (US$14.9 billion). Aim: To evaluate the quality of life (QoL) of patients with VLUs; to analyze the limitations of standard of care (SOC) for VLUs; and to explain how using bilayered living cellular construct (BLCC) with SOC for treatment of VLUs can help heal more VLUs faster (than using SOC alone) as well as help improve QoL and help reduce the burden on the US healthcare system and payers. Materials & methods: This is a review study. The search was conducted in February 2020 by way of electronic databases to find relevant articles that provided information related to QoL of patients with VLUs, limitations of SOC for VLUs and economic analyses of using BLCC for treatment of VLUs. Results: VLUs impact patients' physical, functional and psychological status and reduce QoL. A total 75% of VLU patients who used SOC alone failed to achieve healing in a timely fashion, which led to increased healthcare costs and healthcare resource utilization. Although the upfront cost is high, the greater effectiveness of BLCC offsets the added cost of the product during the time period of the studies. Therefore, BLCC helps to improve the QoL of VLU patients. As an example, for every 100 VLU patients in a healthcare plan, the use of BLCC can create cost savings of US$1,349,829.51. Conclusion: Payers' coverage of BLCC results in reduction of the overall medical cost for treating VLU patients.

Prevention, Diagnosis, and Management of Chronic Wounds in Older Adults

Chronic wounds are common, disproportionately affect older adults, and are likely to be encountered by providers across all specialties and care settings. All providers should be familiar with basic wound prevention, identification, classification, and treatment approach, all of which are outlined in this article.

Animal models of ischemic limb ulcers: a systematic review and meta-analysis

The aims of this systematic review were to assess the clinical relevance and quality of previously published animal models of ischemic ulceration and examine the available evidence for interventions improving ulcer healing in these models. Publicly available databases were searched for original studies investigating the effect of limb ischemia on wound healing in animal models. The quality of studies was assessed using two tools based on the Animal research: Reporting of In Vivo Experiments (ARRIVE) guidelines and the clinical relevance of the models. A total of 640 wounds (ischemic=314; non-ischemic=326) were assessed in 252 animals (92 mice, 140 rats, 20 rabbits) from 7 studies. Meta-analyses showed that wound healing was consistently delayed by ischemia at all time-points examined (day-7 standard median difference (SMD) 5.36, 95% CI 3.67 to 7.05; day-14 SMD 4.50, 95% CI 2.90 to 6.10 and day-21 SMD 2.53, 95% CI 1.25 to 3.80). No significant difference in wound healing was observed between 32 diabetic and 32 non-diabetic animals with ischemic wounds. Many studies lacked methods to reduce bias, such as outcome assessors blinded to group allocation and sample size calculations and clinically relevant model characteristics, such as use of older animals and a peripheral location of the wound. Five different interventions were reported to improve wound healing in these models. The impaired wound healing associated with limb ischemia can be modeled in a variety of different animals. Improvements in study design could increase clinical relevance, reduce bias and aid the discovery of translatable therapies.

Paeoniflorin promotes angiogenesis and tissue regeneration in a full-thickness cutaneous wound model through the PI3K/AKT pathway

The treatment of wounds remains a clinical challenge because of poor angiogenesis under the wound bed, and increasingly, the patients' need for functional and aesthetically pleasing scars. For the wound healing process, new blood vessels which can deliver nutrients and oxygen to the wound area are necessary. In this study, we investigated the pro-angiogenesis ability and mechanism in wound healing of paeoniflorin (PF), which is a traditional Chinese medicine. In our in vitro results, the ability for proliferation, migration and in vitro angiogenesis in human umbilical vein endothelial cells was promoted by coculturing with PF (1.25-5 μM). Meanwhile, molecular docking studies revealed that PF has excellent binding abilities to phosphatidylinositol-3-kinase (PI3K) and protein kinase B (AKT), and consistent with our western blot results, that PF suppressed PI3K and AKT phosphorylation. Furthermore, to investigate the healing effect of PF in vivo, we constructed a full-thickness cutaneous wound model in rats. PF stimulated the cellular proliferation status, collagen matrix deposition and remodeling processes in vitro and new blood vessel formation at the wound bed resulting in efficient wound healing after intragastric administration of 10 mg·kg^-1 ·day^-1 in vivo. Overall, PF performed the pro-angiogenetic effect in vitro and accelerating wound healing in vivo. In summary, the capacity for angiogenesis in endothelial cells could be enhanced by PF treatment via the PI3K/AKT pathway in vitro and could accelerate the wound healing process in vivo through collagen deposition and angiogenesis in regenerated tissue. This study provides evidence that application of PF represents a novel therapeutic approach for the treatment of cutaneous wounds.

Sesamin promotes angiogenesis and accelerates wound healing in rats via alleviates TBHP-induced apoptosis in human umbilical vein endothelial cells

Acute stress induces tissue damage through excessive cellular apoptosis. In our study, the effects of sesamin on apoptosis and wound healing were investigated. The angiogenesis effect of sesamin was evaluated by the abilities of adherence, migration and tube formation in human umbilical vein endothelial cells (HUVECs). Our data demonstrated that treatment with sesamin dose-dependently promoted the proliferation, adherence, migration and enhanced their angiogenic ability in vitro. Moreover, the increased apoptosis in HUVECs, which stimulated by tert-butyl hydroperoxide (TBHP) was significantly attenuated by the sesamin treatment. Furthermore, we revealed that neogenesis of granulation tissue and deposition and remodeling of the collagen matrix were accelerated by the administration of sesamin in our in vivo study. These results confirm that sesamin accelerates wound healing at least partly through its antiapoptotic effects on endothelial cells at the injury site. Thus, sesamin represents a potential therapeutic medicine for vessel injury-related wounds.

Autologous platelet-rich plasma injection enhances healing of chronic venous leg ulcer: A prospective randomised study

Our aim was to compare the efficacy and safety of platelet-rich plasma (PRP) application versus PRP injection for chronic venous leg ulcer (VLU) healing compared with compression therapy as a control. From July 2018 to December 2019, 90 chronic VLU patients were randomly assigned to PRP dressings (n = 30), local PRP injections (n = 30), and compression therapy alone (n = 30). Standard compression accompanied both PRP groups. The main endpoints were ulcer healing and area reduction within 3, 6, and 12 months. Complications and ulcer recurrence were also recorded. The study included 72 (80.0%) males and 18 (20.0%) females aged 22 to 66 years, having VLUs for 1 to 11 years. PRP injection promoted healing (24/30, 80%) more than PRP application (20/30, 66.7%) and compression (14/30, 46.7%), P = .007. Healing time was significantly shorter after PRP injection compared with the other two groups. A greater area reduction was observed after PRP injection compared with compression at all follow-up visits, P = .013, .002, and < .001, and compared with PRP application only at 3 months post-treatment, P = .016. Recurrence and complications were comparable among the groups. PRP injection enhances the healing of chronic venous ulcers more than each of PRP application and compression therapy. All had comparable recurrence and safety.

Unna boot therapy impact on wellbeing, hope and spirituality in venous leg ulcer patients: a prospective clinical trial

Objective:

To assess the impact of Unna boot therapy on subjective wellbeing, hope and spirituality in patients with venous leg ulcers (VLU).

Method:

This was a prospective, descriptive, analytical, multicentre clinical trial conducted in a nursing care and education centre, an outpatient wound care clinic and a primary health care unit in Brazil. Adult patients with VLUs took part in the study. Patients with diabetic foot ulcers and mixed ulcers were excluded. A questionnaire assessing sociodemographic and religious characteristics of patients, the Subjective Wellbeing Scale, the Spirituality Self-Rating Scale (SSRS), and the Herth Hope Index (HHI) were administered to all patients.

Results:

A total of 60 patients (63.3% female; 86.7% aged ≥60 years) participated. Before Unna boot therapy, 65%, 66.7% and 65% of patients reported a score of one on positive affect, negative affect and life satisfaction, respectively, indicating poor subjective wellbeing. After one month of compression therapy, 66.7%, 50.0%, and 80.0% of patients reported a score of three for each element positive affect, negative affect and life satisfaction, respectively, showing a significant improvement in subjective wellbeing (p=0.029). A significant increase in total SSRS scores (p=0.017) was found between baseline (mean: 9.77) and one month of treatment (mean: 25.47), indicating a significant increase in a sense of spirituality. There was also a significant increase in total HHI values (p=0.009) between baseline (mean: 15.68) and one month of compression therapy (mean: 39.38), suggesting a significant increase in hope among patients.

Conclusion:

Patients with VLUs treated with Unna boot therapy in this study showed significant improvement in subjective wellbeing, spirituality and hope for cure.

Dancing: More than a therapy for patients with venous insufficiency

Objective

This study aims to figure out the effects of dance therapy on patients with chronic venous insufficiency disease.

Methods

Forty subjects with chronic venous insufficiency were recruited to either the control group or the dance therapy group. As the severity of chronic venous insufficiency was defined with the Venous Clinical Severity Scores (VCSS), patients in control group received only medical treatment. Twenty patients with chronic venous insufficiency in dance therapy group received three times a week, for five weeks, totally 15 sessions of dance therapy in addition to medical treatment.

Results

There was no significant difference in pre- and post-treatment results of Rivermead Index, VCSS parameters constipation complaint, assistive breath muscle activity, lower limb circumference, strength and range of motion between groups ( p > 0.05). The remarkable result of this study was obtaining that the post-treatment quality of life scale’s bodily pain score was significantly higher in the dance therapy group than the control group ( p < 0.05).

Conclusions

It was concluded that dance therapy has positive effects on quality of life. There were no barriers to chronic venous insufficiency patients in this form of gentle exercise, showing that it is to meliorate the cardiovascular, physical and psychological benefits of an activity that is enhancing of the self-esteem in addition to the quality of life. Treatment of chronic venous insufficiency should consist of methods that support the patient mentally, physically and psychologically, in addition to the medical treatment. Dance therapy might be a potential exercise intervention for improvements in chronic venous insufficiency patients, so clinicians focusing on them could recommend this form of gentle exercise in addition to the medical treatment.

Aspirin versus placebo for the treatment of venous leg ulcers-a phase II, pilot, randomised trial (AVURT)

BACKGROUND

Venous leg ulcers (VLUs) can take many months to heal and 25% fail to heal. The main treatment for venous leg ulcers is compression therapy and few additional therapies exist. Two previous trials indicated that low-dose aspirin may improve healing time, but these trials were insufficiently robust.

METHODS

A multi-centred, pilot, phase II, randomised, double blind, parallel-group, placebo-controlled, efficacy trial (RCT) was conducted to determine: if aspirin improves VLU healing time; the safety of aspirin in this population; treatment compliance; and the feasibility of recruitment to a phase III trial. We recruited patients from secondary care who were aged ≥ 18 years, had a chronic VLU and not regularly taking aspirin. Participants were randomly assigned (1:1) to receive 300 mg of daily aspirin or placebo in addition to standard care, which consisted of multi component compression therapy aiming to deliver 40 mmHg at the ankle where possible. The randomisation list was stratified by ulcer size (≤ 5 cm2 or > 5 cm2). The primary endpoint was time to ulcer healing, which was defined as 'complete epithelial healing in the absence of scab (eschar) with no dressing required'. Safety outcomes were assessed in all participants who received at least one dose of the study drug.

RESULTS

Twenty-seven patients were recruited from eight sites (target 100 patients). A short time-frame to recruit and a large number of patients failing to meet the eligibility criteria were the main barriers to recruitment. There was no evidence of a difference in time to healing of the reference ulcer following adjustment for log ulcer area and duration (hazard ratio 0.58, 95% confidence interval 0.18 to 1.85; p = 0.357). One expected serious adverse event related to aspirin was recorded. A number of options to improve recruitment were explored.

CONCLUSIONS

There was no evidence that aspirin was effective in expediting the healing of chronic VLUs. However, the analysis was underpowered due to the low number of participants recruited. The trial design would require substantial amendment in order to progress to a phase III (effectiveness) trial.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02333123. Registered on 5 November 2014.

Skin substitutes are more potent than dermal or epidermal substitutes in stimulating endothelial cell sprouting

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.

Influences of sodium and glycosaminoglycans on skin oedema and the potential for ulceration: a finite-element approach

Venous ulcers are chronic transcutaneous wounds common in the lower legs. They are resistant to healing and have a 78% chance of recurrence within 2 years. It is commonly accepted that venous ulcers are caused by the insufficiency of the calf muscle pump, leading to blood pooling in the lower legs, resulting in inflammation, skin oedema, tissue necrosis and eventually skin ulceration. However, the detailed physiological events by which inflammation contributes to wound formation are poorly understood. We therefore sought to develop a model that simulated the inflammation, using it to determine the internal stresses and pressure on the skin that contribute to venous ulcer formation. A three-layer finite-element skin model (epidermis, dermis and hypodermis) was developed to explore the roles in wound formation of two inflammation identifiers: glycosaminoglycans (GAG) and sodium. A series of parametric studies showed that increased GAG and sodium content led to oedema and increased tissue stresses of 1.5 MPa, which was within the reported range of skin tissue ultimate tensile stress (0.1-40 MPa). These results suggested that both the oedema and increased fluid pressure could reach a threshold for tissue damage and eventual ulcer formation. The models presented here provide insights to the pathological events associated with venous insufficiency, including inflammation, oedema and skin ulceration.

Comparison of cyanoacrylate closure and radiofrequency ablation for the treatment of incompetent great saphenous veins: 36-Month outcomes of the VeClose randomized controlled trial

Objective

To evaluate the 36-month efficacy and safety of cyanoacrylate closure for the treatment of incompetent great saphenous veins in comparison with radiofrequency ablation.

Methods

In this multicenter, prospective, randomized controlled trial, 222 symptomatic subjects with incompetent great saphenous veins were assigned to either cyanoacrylate closure or radiofrequency ablation. The primary endpoint, complete closure of the target great saphenous vein, was determined using duplex ultrasound examination starting from three-month visit.

Results

At month 36, the great saphenous vein closure rates were 94.4% for the cyanoacrylate closure group and 91.9% for the radiofrequency ablation group. Stable improvement in symptoms and quality of life was observed in both groups. Adverse event rates between the 24- and 36-month visits were similar between the groups as were serious adverse events which were infrequent and judged unrelated to either the device or the procedure in both groups.

Conclusions

This trial continues to demonstrate the safety and efficacy of cyanoacrylate closure for the treatment of great saphenous vein incompetence with great saphenous vein closure rate at 36 months similar to that of radiofrequency ablation, indicating non-inferiority of cyanoacrylate closure to radiofrequency ablation. The improvement in quality of life outcomes were also sustained and similar between the two treatment groups.