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Mitschang C, Ehrchen J, Görge T. Differentialdiagnose Vaskulitis und Vaskulopathie aus
dermatologischer Sicht. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1876-2616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
ZusammenfassungVaskulopathien und Vaskulitiden stellen diagnostisch und therapeutisch eine
interdisziplinäre Herausforderung dar. Zugrunde liegen unterschiedliche
pathophysiologische Mechanismen, die zu vielfältigen klinischen
Krankheitsbildern führen können und therapeutisch
unterschiedliche Ansätze erlauben. Sowohl Vaskulitiden als auch
Vaskulopathien müssen nicht zwangsläufig mit einer
Systembeteiligung einhergehen, sondern können auch als rein kutane
Varianten auftreten. Aufgrund mangelnder pathognomonischer Laborparameter ist
die Diagnose häufig klinisch zu stellen. Dieser Artikel soll den
differentialdiagnostischen Blick, insbesondere auf die kutanen
Manifestationsformen bei Vaskulopathien und Vaskulitiden, schärfen.
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Affiliation(s)
- Carolin Mitschang
- Abteilung für Wundheilung/Phlebologie,
Universitätsklinikum Münster Klinik für Hautkrankheiten,
Münster, Germany
| | - Jan Ehrchen
- Abteilung für Autoimmun-Dermatologie,
Universitätsklinikum Münster Klinik für Hautkrankheiten,
Münster, Germany
| | - Tobias Görge
- Abteilung für Wundheilung/Phlebologie,
Universitätsklinikum Münster Klinik für Hautkrankheiten,
Münster, Germany
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Meulendijks AM, Franssen WMA, Schoonhoven L, Neumann HAM. A scoping review on Chronic Venous Disease and the development of a Venous Leg Ulcer: The role of obesity and mobility. J Tissue Viability 2019; 29:190-196. [PMID: 31668667 DOI: 10.1016/j.jtv.2019.10.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/02/2019] [Accepted: 10/07/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The risk factors obesity and reduced mobility are not well known in the development of a Venous Leg Ulcer (VLU). The aim of this scoping review is to explore the mechanisms by which obesity and reduced mobility contribute the development of a VLU in patients with Chronic Venous Disease (CVD). METHODS For this scoping review a search was performed in May 2019 in the Cochrane Library and Pubmed to identify studies on the working mechanisms of obesity and mobility in developing a VLU. Hand searches were performed to find additional studies explaining the working mechanisms (indirectly related to the VLU). Two reviewers independently reviewed the abstracts and full-text articles. RESULTS Twenty-eight studies met our eligibility criteria. Disturbed range of ankle motion and gait can lead to a reduced Calf Muscle Pump (CMP) function which leading to a venous outflow disorder. Increased abdominal pressure due to obesity can lead to a venous outflow obstruction and increased adipose tissue mass results in an increase in adipokine secretion. The venous outflow disorder, outflow obstruction and increased adipokine secretion can all lead to chronic systemic inflammation, increased endothelial permeability and hence microcirculatory dysfunction. This alone can result in a VLU. CONCLUSION Obesity and reduced mobility can lead to a reduction of the CMP function, an increase in abdominal pressure and an increase in adipose tissue mass. This can simultaneously lead to haemodynamic changes in the macro- and microcirculation of the lower extremities and eventually in a VLU. In patients with obesity and reduced mobility the microcirculation alone can lead to skin changes and eventually a VLU. Therefore, early recognition of CVD symptoms in patients with obesity and reduced mobility is crucial to diagnose and treat CVD to prevent a VLU.
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Affiliation(s)
- A M Meulendijks
- University of Applied Sciences Utrecht, Research Group Healthy and Sustainable Living, Utrecht, the Netherlands; University Medical Centre Utrecht, Department Julius Centre for Health Sciences and Primary Care, Nursing Studies, Utrecht, the Netherlands.
| | - W M A Franssen
- University of Hasselt, REVAL, Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - L Schoonhoven
- University Medical Centre Utrecht, Department Julius Centre for Health Sciences and Primary Care, Nursing Studies, Utrecht, the Netherlands
| | - H A M Neumann
- Erasmus University Medical Centre Rotterdam, Department of Dermatology, Rotterdam, the Netherlands
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Barwell JR, Taylor M, Deacon J, Davies C, Whyman MR, Poskitt KR. Ankle Motility is a Risk Factor for Healing of Chronic Venous Leg Ulcers. Phlebology 2016. [DOI: 10.1177/026835550101600110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To investigate the effect of ankle motility on chronic venous leg ulcer healing, and to relate this to calf pump function and muscle bulk. Methods: This was a prospective cohort study undertaken in a leg ulcer clinic. Ankle motility, calf-ankle circumference ratio and calf pump power (derived from digital photoplethysmography) were assessed as to their effect on ulcer healing rate. Thirty consecutive patients undergoing multi-layer compression bandaging for open chronic venous ulcers were included. Results: Ankle motility was an independent risk factor for ulcer healing ( p = 0.001, hazard ratio 1.08, 95% CI 1.03–1.13). Ankle motility correlated with calf-ankle circumference ratio ( r = 0.48, p<0.01). No relationship was found between photoplethysmography-derived calf pump power, ankle motility or ulcer healing rate. Conclusions Ulcers in legs with poor ankle motility are slower to heal and this may be related to reduced calf muscle bulk. Ankle exercises or physiotherapy could be considered in such patients.
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Affiliation(s)
- J. R. Barwell
- Gloucestershire Vascular Group, Cheltenham General Hospital, Cheltenham, UK
| | - M. Taylor
- Gloucestershire Vascular Group, Cheltenham General Hospital, Cheltenham, UK
| | - J. Deacon
- Gloucestershire Vascular Group, Cheltenham General Hospital, Cheltenham, UK
| | - C. Davies
- Gloucestershire Vascular Group, Cheltenham General Hospital, Cheltenham, UK
| | - M. R. Whyman
- Gloucestershire Vascular Group, Cheltenham General Hospital, Cheltenham, UK
| | - K. R. Poskitt
- Gloucestershire Vascular Group, Cheltenham General Hospital, Cheltenham, UK
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Barwell JR, Ghauri ASK, Taylor M, Deacon J, Wakely C, Poskitt KR, Whyman MR. Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers. Phlebology 2016. [DOI: 10.1177/026835550001500202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To identify independent risk factors for delayed healing and increased recurrence of chronic venous leg ulcers. Design: Prospective study. Setting: Community-based leg ulcer service. Patients: Six hundred and thirty-three limbs in 587 consecutive patients with an ankle-brachial pressure index (ABPI) ≥0.85. Method: Potential risk factors were initially assessed in a one-stop clinic incorporating clinical evaluation, ABPI and venous duplex imaging. Limbs were treated within a defined protocol. Twenty-four-week healing and 3-year ulcer recurrence rates were determined. Results: Of 12 potential risk factors age ( p< 0.001), ulcer chronicity ( p< 0.001) and popliteal vein reflux ( p< 0.005) were independent risks for delayed healing. Of 13 potential risk factors rheumatoid arthritis ( p<0.005) and healing time ( p < 0.05) were independent risks for ulcer recurrence. Isolated superficial venous reflux treated by saphenous vein surgery predicted reduced ulcer recurrence ( p< 0.005). Conclusion: Targeting in primary care of ulcer patients with specific characteristics might encourage earlier referral and appropriate resource management. Leg ulcer patients with superficial venous reflux might benefit from surgical correction.
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Affiliation(s)
- J. R. Barwell
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - A. S. K. Ghauri
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - M. Taylor
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - J. Deacon
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - C. Wakely
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - K. R. Poskitt
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
| | - M. R. Whyman
- Cheltenham General Hospital and Gloucestershire Vascular Group, Cheltenham, UK
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Brown A. Life-style advice and self-care strategies for venous leg ulcer patients: what is the evidence? J Wound Care 2012; 21:342-4, 346, 348-50. [DOI: 10.12968/jowc.2012.21.7.342] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A. Brown
- East of England Strategic Health Authority, UK
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Shanmugam VK, DeMaria DM, Attinger CE. Lower extremity ulcers in rheumatoid arthritis: features and response to immunosuppression. Clin Rheumatol 2011; 30:849-53. [PMID: 21340497 DOI: 10.1007/s10067-011-1710-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/12/2011] [Accepted: 02/01/2011] [Indexed: 11/26/2022]
Abstract
Lower extremity ulcers are a recognized complication of rheumatoid arthritis (RA). Their prevalence has not been assessed since the advent of more aggressive disease modifying antirheumatic therapies. The purpose of this study was to establish the period prevalence of lower extremity ulcers in a modern-day unselected cohort of patients with RA, and to report the features associated with ulcer development and response to therapy. Between June 2007 and June 2010, 366 RA patients were evaluated at the Georgetown Division of Rheumatology. Data were collected and analyzed retrospectively on demographics, antibody and prothrombotic profile, comorbidities, disease activity, and outcomes. The period prevalence of ulcers in this cohort of 366 patients with RA followed over 3 years was 4.37%. Patients with ulcers were predominantly female (81.25%) and more commonly African American (56.2%). The mean disease duration at ulcer development was 25.9 years. All patients with ulcers had erosive disease and 63% were seropositive. Only five patients (31.25%) healed over a mean follow-up of 22.8 months. However, in this small sample, treatment with anti-tumor necrosis factor-α (anti-TNFα) therapy was associated with significantly higher likelihood of healing (p = 0.039). In this modern-day cohort of patients with RA, we found a prevalence of lower extremity ulcers of 4.37% over 3 years. Only 31.25% of patients healed after a mean 22.8 months of follow-up. However, treatment with a biologic agent was associated with a significant increased likelihood of healing (RR 3.27, 95% CI 0.59-18.29, p = 0.039).
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, NW Washington, DC 20007, USA.
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Kelechi TJ, McNeil RB. A pilot study of venous photoplethysmography screening of patients with chronic venous disorders. Appl Nurs Res 2010; 23:178-83. [PMID: 20643329 DOI: 10.1016/j.apnr.2008.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 06/24/2008] [Accepted: 06/30/2008] [Indexed: 11/24/2022]
Abstract
In office and clinical practice settings, standard methods do not exist to objectively quantify lower extremity venous dysfunction. This pilot feasibility study examined venous refill time, an objective measure of skin microcirculation reflux, using photoplethysmography in 13 patients with known chronic venous disorders. The test was found to be feasible and easy to administer and provided objective data to corroborate clinical signs. Further research is needed to evaluate and validate the relationships among clinical signs, comorbid conditions, and objective findings with the severity of venous dysfunction in patients with suspected or known chronic venous disorders.
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Affiliation(s)
- Teresa J Kelechi
- College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas Street, MSC 160, USA.
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Kelechi TJ, Bonham PA. Measuring venous insufficiency objectively in the clinical setting. JOURNAL OF VASCULAR NURSING 2008; 26:67-73. [DOI: 10.1016/j.jvn.2008.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 05/11/2008] [Accepted: 05/13/2008] [Indexed: 10/21/2022]
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Abadi S, Nelson EA, Dehghani A. Venous ulceration and the measurement of movement: a review. J Wound Care 2007; 16:396-402. [DOI: 10.12968/jowc.2007.16.9.27860] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S Abadi
- School of Mechanical Engineering, University of Leeds, UK
| | - E. A Nelson
- School of Healthcare, University of Leeds, UK
| | - A. Dehghani
- School of Mechanical Engineering, University of Leeds, UK
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Nelson EA, Prescott RJ, Harper DR, Gibson B, Brown D, Ruckley CV. A factorial, randomized trial of pentoxifylline or placebo, four-layer or single-layer compression, and knitted viscose or hydrocolloid dressings for venous ulcers. J Vasc Surg 2007; 45:134-41. [PMID: 17210398 DOI: 10.1016/j.jvs.2006.09.043] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 09/14/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We evaluated the effectiveness of pentoxifylline, knitted viscose or hydrocolloid dressings, and single-layer or four-layer bandaging for venous ulceration. METHOD A factorial randomized controlled trial with 24-week follow-up was conducted in leg ulcer clinics in Scotland with blinded allocation to pentoxifylline (1200 mg) or placebo, knitted viscose or hydrocolloid dressings, and single-layer or four-layer bandages. The study enrolled 245 adults with venous ulcers. The main outcome measure was time to complete healing. Secondary outcomes included proportions healed, withdrawals, and adverse events. Analysis was by intention to treat. RESULTS There was no evidence of interaction between the drug, bandages, and dressings. Pentoxifylline was associated with nonsignificant increased ulcer healing (62% vs 53%; P = .21). Four-layer bandages were associated with significantly higher healing rates (67% vs 49%; P = .009). There was no difference in healing between knitted viscose and hydrocolloid dressings (58% and 57%; P = .88). Cox regression models increased the significance of the pentoxifylline effect (relative risk of healing, 1.4; 95% confidence interval, 1.0 to 2.0). CONCLUSIONS Pentoxifylline increased the proportion healing compared with placebo to the same extent as shown in recent systematic reviews, although this finding was only statistically significant when a secondary adjusted analysis was conducted. Four-layer bandaging produced higher healing rates than single-layer bandaging. There was no difference in time to healing between knitted viscose and hydrocolloid dressings.
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Firth J. Tissue viability in rheumatoid arthritis. J Tissue Viability 2005; 15:12-8. [PMID: 16104470 DOI: 10.1016/s0965-206x(05)53003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Acupuncture was used to treat a 69-year-old man for bilateral ankle pain related to his rheumatoid arthritis. This led to a dramatic improvement in one of his chronic venous leg ulcers. There is very little recent literature on such cases, where acupuncture may be a useful additional treatment.
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Oien RF, Håkansson A, Hansen BU. Leg ulcers in patients with rheumatoid arthritis--a prospective study of aetiology, wound healing and pain reduction after pinch grafting. Rheumatology (Oxford) 2001; 40:816-20. [PMID: 11477288 DOI: 10.1093/rheumatology/40.7.816] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To study the aetiology of leg ulcers in patients with rheumatoid arthritis (RA) and to study healing and pain relief after pinch grafting. METHODS Twenty patients with RA and leg ulcers were studied. Diagnosis of the ulcers was founded on the clinical picture and measurements of the ankle-brachial pressure index. To detect vasculitis, skin biopsies were taken for immunohistochemistry and histopathology. Pain severity was assessed pre- and post-operatively using a visual analogue scale. RESULTS Ten of the 20 patients had ulcers with multifactorial aetiology. Fifteen had signs of venous insufficiency, 11 had histopathological evidence of vasculitis, four had reduced arterial circulation and two patients had diabetes. Healing after pinch grafting was found in eight patients, all of whom had an ulcer area less than 15 cm(2). Eleven out of 18 patients had pain reduction after pinch grafting. CONCLUSION The causation of leg ulcers in patients with RA was found to be multifactorial, with vasculitis and venous insufficiency as the main determinants. Pinch grafting seems to be a good alternative to conservative treatment for minor leg ulcers for these patients, regarding both wound healing and pain relief.
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Affiliation(s)
- R F Oien
- Lyckeby Health Centre, S-371 62 Lyckeby, and Department of Community Medicine, Malmö University Hospital, S-205 02 Malmö, Sweden
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McRorie E. Regarding "management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: the importance of concomitant arterial and venous disease". J Vasc Surg 2001; 33:664-5. [PMID: 11241156 DOI: 10.1067/mva.2001.113304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Patients with rheumatoid arthritis appear to be at increased risk of developing chronic leg ulcers. This review identifies the factors that predispose these patients to leg ulceration and highlights how this problem can be managed and the risk of recurrence reduced.
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Affiliation(s)
- E R McRorie
- Rheumatic Diseases Unit, Western General Hospital, Edinburgh, UK
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