Low-grade elastic compression regimen for venous leg ulcers--an effective compromise for patients requiring daily dressing changes

One Molecule, Many Faces: Repositioning Cardiovascular Agents for Advanced Wound Healing

Chronic wound treatments pose a challenge for healthcare worldwide, particularly for the people in developed countries. Chronic wounds significantly impair quality of life, especially among the elderly. Current research is devoted to novel approaches to wound care by repositioning cardiovascular agents for topical wound treatment. The emerging field of medicinal products' repurposing, which involves redirecting existing pharmaceuticals to new therapeutic uses, is a promising strategy. Recent studies suggest that medicinal products such as sartans, beta-blockers, and statins have unexplored potential, exhibiting multifaceted pharmacological properties that extend beyond their primary indications. The purpose of this review is to analyze the current state of knowledge on the repositioning of cardiovascular agents' use and their molecular mechanisms in the context of wound healing.

Challenges and Prospects of Development of Herbal Biomaterial Based Ethical Wound Care Products-A Scoping Review

Total wound care is an unmet therapeutic need considering the morbidity and mortality associated with the rising prevalence of nonhealing/chronic wounds. Current wound management fails to address all aspects/types of wounds despite the availability of scores of traditional and modern, investigational products. Traditional medicine drugs of wound healing repute validated to target multiple biological pathways and key events in the mammalian wound healing cascade, reportedly affecting wound healing phases. Advances in the development of biocomposite matrices and their analytical characterization warrant a relook at consolidating time-tested wound healing properties of herbal bioactives for prospective development as ethical wound care products. Aside from the bottlenecks of their multiconstituent profiling and clinical trial data generation, regulatory hurdles also cloister any systematic attempts at their re-engineering into clinical deliverables. In the context of national policy changes to bring in totally indigenous solutions, countries with a huge knowledge/material resource on wound healing bioactives need to essentially facilitate the same.

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.

Elastic Bandage vs Hypertonic Albumin for Diuretic-Resistant Volume-Overloaded Patients in Intensive Care Unit: A Propensity-Match Study

OBJECTIVE

To compare elastic bandage (EB) vs hypertonic albumin solution administration to increase fluid removal by enhancing loop diuretic efficiency (DE) in patients with volume overload and diuretic resistance.

PATIENTS AND METHODS

In this historic cohort study with propensity matching, we included diuretic-resistant adult (≥18 years) patients with volume overload after fluid resuscitation admitted in the intensive care unit from January 1, 2006, through June 30, 2017. Regression models and propensity matching were used to assess the associations of these interventions with changes in DE and other clinical outcomes.

RESULTS

Of 1147 patients (median age, 66; interquartile range [IQR], 56-76 years; 51% [n=590] men), 384 (33%) received EB and 763 (67%) received hypertonic albumin solution. In adjusted models, EB was significantly associated with higher DE compared with hypertonic albumin solution (odds ratio, 1.37; 95% CI, 1.04 to 1.81; P=.004). After propensity matching of 345 pairs, DE remained significantly different between the 2 groups (median, 2111; IQR, 1092 to 4665 mL for EB vs median, 1829; IQR, 1032 to 3436 mL for hypertonic albumin solution; P=.02). EB, male sex, lower baseline serum urea nitrogen level, lower Charlson Comorbidity Index score, and higher baseline left ventricular ejection fraction were DE determinants. The lowest DE quartile (<1073 mL/40-mg furosemide equivalent) following adjustment for known predictors of mortality remained independently associated with higher 90-day death rate (odds ratio, 1.64; 95% CI, 1.13 to 2.36; P=.009).

CONCLUSION

EB use is associated with greater DE than hypertonic albumin solution during the deescalation phase of sepsis resuscitation. Prospective clinical trials would validate the findings of this hypothesis-generating study.

The Most Severe Stage of Chronic Venous Disease: An Update on the Management of Patients with Venous Leg Ulcers

Venous leg ulcers (VLUs) are the most severe manifestation of chronic venous disease (CVD). Due to their chronic nature, high recurrence rate and slow healing time, VLUs account for 80% of all leg ulcers seen in patients with CVD. VLUs impose a heavy burden on patients that reduces their quality of life; VLUs also represent a major socioeconomic impact due to the cost and duration of care. The primary medical approach to treating VLUs is local compression therapy in combination with venoactive drug (VAD) pharmacotherapy to promote the reduction of the inflammatory reaction initiated by venous hypertension. Micronized purified flavonoid fraction (MPFF; Daflon^®) is the most widely prescribed VAD. MPFF counteracts the pathophysiologic mechanisms of CVD and ulceration and has proven to be an effective adjunct to compression therapy in patients with large and chronic VLUs. Two other non-VAD drugs, pentoxifylline and sulodexide, have also been shown to improve VLU healing and are also recommended in addition to compression therapy. However, MPFF is the only VAD with the highest strength of recommendations in the 2018 guidelines for the healing of VLUs.

Assessment of the use of Unna boot in the treatment of chronic venous leg ulcers in adults: systematic review protocol

INTRODUCTION

Chronic venous insufficiency (CVI) is an anomaly of the normal functioning of the venous system caused by valvular incompetence with or without the obstruction of venous flow. This condition can affect either or both of the superficial and the deep venous systems. Venous dysfunction can even result in congenital or acquired disorders, and its complications include venous leg ulcers (VLUs). The objective of this systematic review is to determine the effectiveness of Unna boot in the treatment of wound healing of VLU by assessing the quality of the available evidence.

METHODS AND ANALYSIS

A literature search in PubMed, CINAHL, Scopus, Web of Science, Cochrane Library, BVS/BIREME, Embase, ProQuest, BDTD, Thesis and Dissertation Catalog, Sao Paulo Research Foundation/Thesis and dissertation, OPEN THESIS, A service of the US National Institute of Health, Center for Reviews and Dissemination-University of New York and SciElo published in the last 10 years, the period from January 1999 to March 2019. The review will include primary studies (original), and Controlled Trials or Observational studies (cross-sectional, case-control or longitudinal studies) with VLU. The exclusion will include leg ulceration due to different causes, such as pressure, arterial, diabetic or mixed-aetiology leg ulcers. Data synthesis will be performed using a narrative summary and quantitative analysis.

ETHICS AND DISSEMINATION

This systematic review does not require approval by the ethics committee, as individual patient data will not be collected. Dissemination of findings will be through publications in peer-reviewed journals and/or via conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019127947.

[Evaluation of compression bandage application technique in patients with venous leg ulcers: A mixed methods observational study]

Introduction: Treating venous leg ulcers involves replacing dressings and applying compression bandages (CB). The technique for applying these bandages set out in the best practice guidelines shows nurses how to achieve the required level of pressure. Considerable differences have been observed between these guidelines and the actual application of CB. Methodology: An observational study combining a quantitative and a qualitative component was conducted to analyze CB application and explore the elements taken into account by nurses when they perform this procedure. Results: For the 261 patients included in the study, 27% of CB were applied as described in the guidelines. The main difference was that the heel was not included in the bandage in 48% of patients. The freelance nurses interviewed reported taking patient views into account in order to encourage adherence. Discussion: The nursing knowledge identified from the nurse interviews was compared to Carper’s “Patterns of Knowing” classification. It would seem that Carper’s empirical knowledge is not the only “pattern of knowing” taken into consideration. Patient involvement in the choice of CB application technique, which could be likened to Carper’s “esthetic knowledge,” helps guide nursing practice.

Compression therapy: Unna boot applied to venous injuries: an integrative review of the literature

OBJECTIVE

To analyze the literature related to the types of therapies for venous injuries with emphasis on use of the Unna boot, and to investigate and discuss the main aspects related to its use compared to other techniques.

METHOD

Integrative review of the literature of the last five years through searches in the following databases: VHL, LILACS, BDENF, SciELO, MEDLINE/PubMed.

RESULTS

Twenty-two publications were identified, with 15,931 cases among adult or elderly individuals, whose mean age was 60 (35-78) years or greater with no sex differences. The Unna boot presented a shorter healing time than the single and two-layer elastic bandage.

CONCLUSION

Although other compression techniques may prove to be more efficient than the Unna boot by adding more technology, the boot stands out as a traditional low-cost dressing. Multilayer bandage is a gold standard technique. This review demonstrated the best option may not be the Unna boot, because it requires a higher healing time compared to the multilayer bandage, but it meets the expectation with a high rate of treatment efficiency, also when compared to simple dressing, single or two-layer bandage.

Recommendations for the medical management of chronic venous disease: The role of Micronized Purified Flavanoid Fraction (MPFF)

Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index < .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.

Mesenchymal Stem Cells in Chronic Wounds: The Spectrum from Basic to Advanced Therapy

Significance: Almost 7 million Americans have chronic cutaneous wounds and billions of dollars are spent on their treatment. The number of patients with nonhealing wounds keeps increasing worldwide due to an ever-aging population, increasing number of obese and diabetic patients, and cardiovascular disease. Recent Advances: Advanced treatments for difficult wounds are needed. Therapy with mesenchymal stem cells (MSCs) is attractive due to their differentiating potential, their immunomodulating properties, and their paracrine effects. Critical Issues: New technologies (including growth factors and skin substitutes) are now widely used for stimulating wound healing. However, in spite of these advances, the percentage of complete wound closure in most clinical situations is around 50-60%. Moreover, there is a high rate of wound recurrence. Future Directions: Recently, it has been demonstrated that MSCs speed up wound healing by decreasing inflammation, by promoting angiogenesis, and by decreasing scarring. However, there are some potential limitations to successful MSC therapy. These limitations include the need to improve cell delivery methods, cell viability, heterogeneity in MSC preparations, and suboptimal wound bed preparation. Further large, controlled clinical trials are needed to establish the safety of MSCs before widespread clinical application.