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Encountering Chronic Wounds in Acute Care: Venous Ulcers. Adv Skin Wound Care 2022; 35:574-575. [PMID: 36125456 DOI: 10.1097/01.asw.0000873636.50249.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Boersema GC, Smart H, Giaquinto-Cilliers MGC, Mulder M, Weir GR, Bruwer FA, Idensohn PJ, Sander JE, Stavast A, Swart M, Thiart S, Van der Merwe Z. Management of Nonhealable and Maintenance Wounds: A Systematic Integrative Review and Referral Pathway. Adv Skin Wound Care 2021; 34:11-22. [PMID: 33323798 DOI: 10.1097/01.asw.0000722740.93179.9f] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
GENERAL PURPOSE To synthesize the evidence regarding nonhealable and maintenance wound management and propose an interprofessional referral pathway for wound management. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES After participating in this continuing professional development activity, the participant will apply knowledge gained to:1. Identify the ideas from the authors' systematic review that could prove useful in understanding nonhealable and maintenance wound management.2. Select evidence-based management strategies for nonhealable and maintenance wound management. ABSTRACT OBJECTIVEThis systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed. DATA SOURCES An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: ConsumerEdition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors. STUDY SELECTION Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected. DATA EXTRACTION Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention. DATA SYNTHESIS Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes. CONCLUSIONS Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.
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Weller CD, Team V, Ivory JD, Crawford K, Gethin G. ABPI reporting and compression recommendations in global clinical practice guidelines on venous leg ulcer management: A scoping review. Int Wound J 2019; 16:406-419. [PMID: 30485668 PMCID: PMC7949354 DOI: 10.1111/iwj.13048] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/28/2022] Open
Abstract
Clinical practice guidelines (CPGs) for venous leg ulcer (VLU) management recommend below-knee compression to improve healing outcomes after calculating the ankle-brachial pressure index (ABPI) to rule out significant arterial disease. This systematic scoping review aimed to complete a qualitative and quantitative content analysis of international CPGs for VLU management to determine if consensus existed in relation to recommendations for compression application based on an ABPI reading and clinical assessment. Our review shows that there is a lack of consensus across 13 VLU CPGs and a lack of clear guidance in relation to the specific ABPI range of compression therapy that can be safely applied. An area of uncertainty and disagreement exists in relation to an ABPI between 0.6 and 0.8, with some guidelines advocating that compression is contraindicated and others that there should be reduced compression. This has implications in clinical practice, including when it is safe to apply compression. In addition, the inconsistency in the levels of evidence and the grades of recommendation makes it difficult to compare across various guidelines.
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Affiliation(s)
| | - Victoria Team
- Monash Nursing and MidwiferyMonash UniversityClaytonVictoriaAustralia
| | - John D. Ivory
- School of Nursing & MidwiferyNational University of IrelandGalwayRepublic of Ireland
| | | | - Georgina Gethin
- School of Nursing & MidwiferyNational University of IrelandGalwayRepublic of Ireland
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Andriessen A, Apelqvist J, Mosti G, Partsch H, Gonska C, Abel M. Compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines. J Eur Acad Dermatol Venereol 2017; 31:1562-1568. [DOI: 10.1111/jdv.14390] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- A. Andriessen
- Radboud UMC; Nijmegen & Andriessen Consultants; Malden The Netherlands
- International Compression Club (ICC); Berndorf Austria
| | - J. Apelqvist
- Department of Endocrinology; University Hospital of Malmö; Malmö Sweden
| | - G. Mosti
- Department of Angiology; Clinica MD Barbantini; Lucca Italy
- International Compression Club (ICC); Berndorf Austria
| | - H. Partsch
- Medical University Vienna; Vienna Austria
- International Compression Club (ICC); Berndorf Austria
| | - C. Gonska
- Medical & Regulatory Affairs; Lohmann & Rauscher GmbH & Co KG; Rengsdorf Germany
| | - M. Abel
- Medical & Regulatory Affairs; Lohmann & Rauscher GmbH & Co KG; Rengsdorf Germany
- Patient Outcome Group (POG); European Wound Management Association (EWMA); Frederiksberg Denmark
- International Compression Club (ICC); Berndorf Austria
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Bertanha M, Sobreira ML, Camargo PAB, Pimenta REF, Mariúba JVO, Moura R, Bagnato VS, Yoshida WB. Resultados preliminares do tratamento de insuficiência venosa grave com termoablação da veia safena magna por técnica endovascular com laser de diodo 980nm desenvolvido no Brasil, associado à escleroterapia com polidocanol. Rev Col Bras Cir 2017; 44:308-313. [DOI: 10.1590/0100-69912017003008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 03/09/2017] [Indexed: 11/22/2022] Open
Abstract
RESUMO A termoablação endovascular das veias safenas insuficientes com laser é descrita como uma técnica menos invasiva, com resultados semelhantes à cirurgia convencional, porém, com efeitos adversos menos frequentes. A técnica de escleroterapia com espuma de polidocanol ecoguiada vem sendo empregada com a mesma finalidade. A combinação de técnicas pode representar uma alternativa para pacientes mais graves, como os portadores de úlcera varicosa. Um equipamento de laser (denominado VELAS) foi desenvolvido no Centro de Pesquisas em Ótica e Fotônica da USP-São Carlos em convênio com a FMB-UNESP para termoablação endoluminal da veia safena insuficiente. Neste estudo apresentamos os resultados preliminares do uso do aparelho de laser VELAS (diodo MMO 980nm) na termoablação endovascular de veias safenas insuficientes, em portadores de úlcera venosa crônica, associado à complementação com espuma de polidocanol para o tratamento de varicosidades, após uma semana. Os desfechos analisados foram o tempo de cicatrização da úlcera venosa, oclusão das veias tratadas e eventos adversos relacionados aos tratamentos. Foram incluídos 12 pacientes portadores de insuficiência de veia safena e úlcera venosa crônica que aceitaram participar do projeto. Todos foram tratados em regime ambulatorial, com anestesia local e termoablação da veia safena insuficiente (VELAS). Após uma semana da cirurgia, as varicosidades foram esclerosadas com polidocanol espuma (técnica de Tessari). O equipamento laser VELAS nacional apresentou fácil manuseio, oclusão venosa total em 83,3% dos pacientes (em sete dias) e a associação das técnicas foi responsável por uma taxa de cicatrização de feridas de 83,3%, sem ocorrência de eventos adversos.
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Caimi G, Ferrara F, Montana M, Muratori I, Amato C, Canino B, Lo Presti R, Hopps E. Behaviour of the plasma concentration of gelatinases and their tissue inhibitors in subjects with venous leg ulcers. Clin Hemorheol Microcirc 2016; 60:309-16. [PMID: 25159491 DOI: 10.3233/ch-141863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Venous leg ulcers are common in subjects with chronic venous insufficiency. The increased intraluminal pressure causes alteration of the skin microcirculation, leukocyte activation and release of proteolytic enzymes leading to ulceration. An impaired expression and activity of matrix metalloproteases (MMPs) and their tissue inhibitors (TIMPs) might influence extracellular matrix degradation and deposition in chronic venous ulcers with the failure of the healing process. Our aim was to evaluate plasma concentration of gelatinases (MMP-2 and MMP-9) and their inhibitors (TIMP-1 and TIMP-2) in subjects with venous leg ulcers before and after the compression therapy. We enrolled 36 subjects (12 men and 24 women, mean age 67.38 ± 12.7 yrs) with non-infected venous leg ulcers (CEAP C6), which underwent a color Duplex scan examination of the veins and arteries of the inferior limbs and were treated with a multi-layer bandaging system. The ulcer healing was obtained in 23 subjects only (9 men and 14 women). We evaluated, on fasting venous blood, the plasma levels of MMP-2, MMP-9, TIMP-1 and TIMP-2 using ELISA kit, before and after the treatment. We observed a significant increase in plasma concentration of gelatinases and their inhibitors and in MMP-2/TIMP-2 ratio in subjects with leg ulcers in comparison with normal controls. In subjects with healed ulcers we found a decrease in MMP-9 and TIMP-1 levels and in MMP-2/TIMP-2 ratio compared to the baseline values, although higher levels of all the examined parameters in comparison with normal controls. In conclusion, plasma MMPs profile is impaired in subjects with venous leg ulcers and it improves after the healing, persisting anyway altered in respect to healthy controls.
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Abstract
Venous leg ulcers are the most common cause of chronic leg wounds, accounting for up to 70 % of all chronic leg ulcers and carrying with them a significant morbidity, especially for elderly patients. Among people aged 65 years and older, the annual prevalence is 1.7 %. Billions of dollars per year are spent caring for patients with these often difficult-to-heal and sometimes recurrent chronic wounds. Chronic non-healing wounds of the lower extremities are susceptible to microbial invasion and can lead to serious complications, such as delayed healing, cellulitis, enlargement of wound size, debilitating pain, and deeper wound infections causing systemic illness. Recognition and treatment of the infected venous leg ulcer is an essential skill set for any physician caring for geriatric patients. Most physicians rely on subjective clinical signs and patient-reported symptoms in the evaluation of infected chronic wounds. The conventional bacterial culture is a widely available tool for the diagnosis of bacterial infection but can have limitations. Systemic antibiotics, as well as topical antiseptics and antibiotics, can be employed to treat and control infection and critical colonization. Better understanding of microbial biofilms in the wound environment have caused them to emerge as an important reason for non-healing and infection due to their increased resistance to antimicrobial, immunological, and chemical attack. A sound understanding of the microbial-host environment and its complexities, as well as the pathophysiology of venous hypertension, must be appreciated to understand the need for a multimodality approach to treating an infected venous leg ulcer. Other treatment measures are often required, in addition to systemic and topical antibiotics, such as the application of wound bandages, compression therapy, and wound debridement, which can hasten clearance of the infection and help to promote healing.
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Esquirol Caussa J, Herrero Vila E. Un enfoque para el tratamiento de las úlceras de origen vascular: revisión y papel del factor de crecimiento epidérmico. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Alavi A, Sibbald RG, Phillips TJ, Miller OF, Margolis DJ, Marston W, Woo K, Romanelli M, Kirsner RS. What's new: Management of venous leg ulcers. J Am Acad Dermatol 2016; 74:643-64; quiz 665-6. [DOI: 10.1016/j.jaad.2015.03.059] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/28/2015] [Accepted: 03/30/2015] [Indexed: 12/31/2022]
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Otero-Viñas M, Falanga V. Mesenchymal Stem Cells in Chronic Wounds: The Spectrum from Basic to Advanced Therapy. Adv Wound Care (New Rochelle) 2016; 5:149-163. [PMID: 27076993 PMCID: PMC4817558 DOI: 10.1089/wound.2015.0627] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/03/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Marta Otero-Viñas
- Dermatology Department, Boston University School of Medicine, Boston, Massachusetts
- The Tissue Repair and Regeneration Laboratory, Department of Systems Biology, Universitat de Vic—Universitat Central de Catalunya, Vic, Spain
| | - Vincent Falanga
- Dermatology Department, Boston University School of Medicine, Boston, Massachusetts
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Norman G, Westby MJ, Stubbs N, Dumville JC, Cullum N. A 'test and treat' strategy for elevated wound protease activity for healing in venous leg ulcers. Cochrane Database Syst Rev 2016; 2016:CD011753. [PMID: 26771894 PMCID: PMC8627254 DOI: 10.1002/14651858.cd011753.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Venous leg ulcers are a common and recurring type of complex wound. They can be painful, malodorous, prone to infection and slow to heal. Standard treatment includes compression therapy and a dressing. The use of protease-modulating treatments for venous leg ulcers is increasing. These treatments are based on some evidence that a proportion of slow to heal ulcers have elevated protease activity in the wound. Point-of-care tests which aim to detect elevated protease activity are now available. A 'test and treat' strategy involves testing for elevated proteases and then using protease-modulating treatments in ulcers which show elevated protease levels. OBJECTIVES To determine the effects on venous leg ulcer healing of a 'test and treat' strategy involving detection of high levels of wound protease activity and treatment with protease-modulating therapies, compared with alternative treatment strategies such as using the same treatment for all participants or using a different method of treatment selection. SEARCH METHODS We searched the following electronic databases to identify reports of relevant randomised clinical trials: The Cochrane Wounds Group Specialised Register (January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) Issue 12, 2015); Ovid MEDLINE (1946 to January 2016); Ovid MEDLINE (In-Process & Other Non-Indexed Citations January 2016); Ovid EMBASE (1974 to January 2016); EBSCO CINAHL (1937 to January 2016). We also searched three clinical trials registers, reference lists and the websites of regulatory agencies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA Published or unpublished RCTs which assessed a test and treat strategy for elevated protease activity in venous leg ulcers in adults compared with an alternative treatment strategy. The test and treat strategy needed to be the only systematic difference between the groups. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection; we planned that two authors would also assess risk of bias and extract data. MAIN RESULTS We did not identify any studies which met the inclusion criteria for this review. We identified one ongoing study; it was unclear whether this would be eligible for inclusion. AUTHORS' CONCLUSIONS Currently there is no randomised evidence on the impact of a test and treat policy for protease levels on outcomes in people with venous leg ulcers.
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Affiliation(s)
- Gill Norman
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Nikki Stubbs
- Leeds Community Healthcare NHS Trust, St Mary's HospitalWound Prevention and Management Service3 Greenhill RoadLeedsUKLS12 3QE
| | - Jo C Dumville
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Nicky Cullum
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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McDaniel JC, Kemmner KG, Rusnak S. Nutritional profile of older adults with chronic venous leg ulcers: a pilot study. Geriatr Nurs 2015; 36:381-6. [PMID: 26141998 DOI: 10.1016/j.gerinurse.2015.05.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/15/2015] [Accepted: 05/26/2015] [Indexed: 11/25/2022]
Abstract
The purpose of this cross-sectional descriptive pilot study was to describe daily intake of select nutrients important for efficient wound healing and general health in a sample of older adults (64.25 ± 9.49 years of age) with chronic venous leg ulcers (CVLUs; N = 12), compared to recommended dietary allowances (RDA). Anthropometric data were also collected. Compared to RDA, participants on average consumed lower vitamin C (60.03 ± 49.73 mg/d) and higher sodium (3197.07 ± 1455.04 mg/d), sugar (181.21 ± 115.45 g/d), and saturated fat (33.75 ± 1.06 g/d). They also demonstrated a relatively high plasma n-6/n-3 polyunsaturated fatty acid ratio, a biomarker of inflammation (11.25 ± 1.99). The mean body mass index indicated extreme obesity (41.48 ± 11.47). A multidisciplinary treatment approach that includes routine dietary assessments followed by tailored dietary interventions may improve wound healing and long-term health outcomes in this population.
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Affiliation(s)
- Jodi C McDaniel
- The Ohio State University, College of Nursing, 372 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA.
| | - Kaitlyn G Kemmner
- The Ohio State University, College of Nursing, 372 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA
| | - Sarah Rusnak
- The Ohio State University Clinical Research Center, Center for Clinical and Translational Science, Columbus, OH, USA
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White-Chu EF. Prognostication and Management of Non-Healable Wounds and Wounds at the End of Life. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0129-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.
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Affiliation(s)
- Yung-Wei Chi
- Department of Internal Medicine, Section of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Joseph D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA
- Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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The effectiveness of extracorporeal shock wave therapy for the treatment of lower limb ulceration: a systematic review. J Foot Ankle Res 2015; 8:3. [PMID: 25722746 PMCID: PMC4342213 DOI: 10.1186/s13047-014-0059-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 12/22/2014] [Indexed: 11/29/2022] Open
Abstract
Extracorporeal shock wave therapy has been reported as an effective treatment for lower limb ulceration. The aim of this systematic review was to investigate the effectiveness of extracorporeal shock wave therapy for the treatment of lower limb ulceration. Five electronic databases (Ovid MEDLINE, CINAHL, Web of Knowledge, Scopus and Ovid AMED) and reference lists from relevant studies were searched in December 2013. All study designs, with the exception of case-reports, were eligible for inclusion in this review. Assessment of each study’s methodological quality was performed using the Quality Index tool. The effectiveness of studies was measured by calculating effect sizes (Cohen’s d) from means and standard deviations. Five studies, including; three randomised controlled trials, one quasi-experimental study and one case-series design met our inclusion criteria and were reviewed. Quality assessment scores ranged from 38 to 63% (mean 53%). Improvements in wound healing were identified in these studies following extracorporeal shock wave therapy. The majority of wounds assessed were associated with diabetes and the effectiveness of ESWT as an addition to standard care has only been assessed in one randomised controlled trial. Considering the limited evidence identified, further research is needed to support the use of extracorporeal shock wave therapy in the treatment of lower limb ulceration.
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The effect of a connexin43-based Peptide on the healing of chronic venous leg ulcers: a multicenter, randomized trial. J Invest Dermatol 2014; 135:289-298. [PMID: 25072595 PMCID: PMC4269806 DOI: 10.1038/jid.2014.318] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 06/30/2014] [Accepted: 07/14/2014] [Indexed: 12/29/2022]
Abstract
The gap junction protein, connexin43 (Cx43), has critical roles in the inflammatory, edematous, and fibrotic processes following dermal injury and during wound healing, and is abnormally upregulated at the epidermal wound margins of venous leg ulcers (VLUs). Targeting Cx43 with ACT1, a peptide mimetic of the carboxyl-terminus of Cx43, accelerates fibroblast migration and proliferation, and wound reepithelialization. In a prospective, multicenter clinical trial conducted in India, adults with chronic VLUs were randomized to treatment with an ACT1 gel formulation plus conventional standard-of-care (SOC) protocols, involving maintaining wound moisture and four-layer compression bandage therapy, or SOC protocols alone. The primary end point was mean percent ulcer reepithelialization from baseline to 12 weeks. A significantly greater reduction in mean percent ulcer area from baseline to 12 weeks was associated with the incorporation of ACT1 therapy (79% (SD 50.4)) as compared with compression bandage therapy alone (36% (SD 179.8); P=0.02). Evaluation of secondary efficacy end points indicated a reduced median time to 50 and 100% ulcer reepithelialization for ACT1-treated ulcers. Incorporation of ACT1 in SOC protocols may represent a well-tolerated, highly effective therapeutic strategy that expedites chronic venous ulcer healing by treating the underlying ulcer pathophysiology through Cx43-mediated pathways.
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White-Chu EF, Conner-Kerr TA. Overview of guidelines for the prevention and treatment of venous leg ulcers: a US perspective. J Multidiscip Healthc 2014; 7:111-7. [PMID: 24596466 PMCID: PMC3930479 DOI: 10.2147/jmdh.s38616] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Comprehensive care of chronic venous insufficiency and associated ulcers requires a multipronged and interprofessional approach to care. A comprehensive treatment approach includes exercise, nutritional assessment, compression therapy, vascular reconstruction, and advanced treatment modalities. National guidelines, meta-analyses, and original research studies provide evidence for the inclusion of these approaches in the patient plan of care. The purpose of this paper is to review present guidelines for prevention and treatment of venous leg ulcers as followed in the US. The paper further explores evidence-based yet pragmatic tools for the interprofessional team to use in the management of this complex disorder.
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Affiliation(s)
- E Foy White-Chu
- Oregon Health and Science University, Portland VA Medical Center, Portland, OR
| | - Teresa A Conner-Kerr
- Winston-Salem State University, Department of Physical Therapy, Winston Salem, NC, USA
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Ribeiro CTD, Fregonezi GAF, Resqueti VR, Dornelas de Andrade A, Dias FAL. Hydrocolloid dressings for healing venous leg ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd010918] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Cibele TD Ribeiro
- Federal University of Rio Grande do Norte; Graduate Program in Physiotherapy; Avenida Senador Salgado Filho, 3000 Bairro Lagoa Nova Natal Rio Grande do Norte Brazil 59078-970
| | - Guilherme AF Fregonezi
- Federal University of Rio Grande do Norte; PhD Program in Physical Therapy; Avenida Senador Salgado Filho, 3000 Bairro Lagoa Nova Natal Rio Grande do Norte Brazil 59078-970
| | - Vanessa R Resqueti
- Federal University of Pernambuco; Master Degree Program, Department of Physical Therapy; Av. Prof. Moraes Rego, 1235 Cidade Universitária Recife Pernambuco Brazil 50670-901
| | - Armele Dornelas de Andrade
- Master Degree Program in Physical Therapy, Federal University of Pernambuco, Recife, Brazil; Physical Therapy; Av Prof Moraes Rego, 1235 Cidade Universitaria Recife Pernambuco Brazil 50670-901
| | - Fernando AL Dias
- Federal University of Paraná; Department of Physiology; Centro Politécnico, Jardim das Américas Caixa Postal 19031 Curitiba Paraná Brazil 81531-980
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Ribeiro CTD, Dias FAL, Fregonezi GAF. Hydrogel dressings for venous leg ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010738] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Cibele TD Ribeiro
- Federal University of Rio Grande do Norte; Graduate Program in Physiotherapy; Avenida Senador Salgado Filho, 3000 Bairro Lagoa Nova Natal Rio Grande do Norte Brazil 59078-970
| | - Fernando AL Dias
- Federal University of Paraná; Department of Physiology; Centro Politécnico, Jardim das Américas Caixa Postal 19031 Curitiba Paraná Brazil 81531-980
| | - Guilherme AF Fregonezi
- Federal University of Rio Grande do Norte; Department of Physical Therapy; Avenida Senador Salgado Filho, 3000, Lagoa Nova Natal Rio Grande do Norte Brazil 59078-470
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Dabiri G, Heiner D, Falanga V. The emerging use of bone marrow-derived mesenchymal stem cells in the treatment of human chronic wounds. Expert Opin Emerg Drugs 2013; 18:405-19. [PMID: 24004161 DOI: 10.1517/14728214.2013.833184] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Close to 5 million people in the USA are affected by chronic wounds, and billions of dollars are spent annually for their treatment. Despite advances in chronic wound management over the past decades, many patients afflicted with chronic wounds fail to heal or their ulcers recur. There is emerging evidence that the use of bone marrow-derived mesenchymal stem cells (BM-MSCs) can offset this situation of impaired healing. AREAS COVERED This article provides a review of the use of BM-MSC for the treatment of chronic wounds, the current development of stem cell delivery to chronic wounds and related challenges are also described in this manuscript. EXPERT OPINION Numerous animal studies and a few pilot studies in human wounds have shown that BM-MSC can augment wound closure. Still, the primary contribution of mesenchymal stem cells (MSCs) to cutaneous regeneration and the long-term systemic effects of MSCs are yet to be established. In addition, we need to determine whether other types of stem/progenitor cells will be more effective. Therefore, more randomized controlled clinical trials need to be undertaken. It is of importance to remember that even with the most advanced and sophisticated therapeutic approaches, proper wound care and adherence to basic principles remain critical.
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Affiliation(s)
- Ganary Dabiri
- Roger Williams Medical Center, Department of Dermatology and Skin Cancer , 50 Maude Street, Providence, RI 02908 , USA
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Kirsner RS, Marston WA, Snyder RJ, Lee TD, Cargill DI, Zhang Y, Dickerson JE, Slade HB. Durability of healing from spray-applied cell therapy with human allogeneic fibroblasts and keratinocytes for the treatment of chronic venous leg ulcers: a 6-month follow-up. Wound Repair Regen 2013; 21:682-7. [PMID: 23927847 DOI: 10.1111/wrr.12076] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 06/19/2013] [Indexed: 11/29/2022]
Abstract
Patients who participated in a Phase 2 trial of HP802-247 for venous leg ulcers were invited to participate in this 24-week follow-up study to assess the durability of healing, document additional ulcer closures, and evaluate posttreatment safety. Consent was given by 90% (206/228), with 80% (183/228) completing all visits. Blinding was retained from the previous trial in which subjects had been randomized to vehicle or one of four cell therapy regimens. Visits were every 8 weeks. Among the 183 subjects, 43% (21/49) previously treated with cells and entering follow-up with an open wound achieved closure, compared with 35% (7/20) previously treated with vehicle, while 10% (11/106) and 17% (3/18), respectively, experienced reopening of a previously closed wound. Subjects previously treated with cells closed more open wounds than those previously treated with vehicle (OR 1.39, 95% CI 0.47-4.10; p = 0.739), and less subjects with a previously closed wound reopened (OR 0.65, CI 0.16-2.60; p = 0.821); however, these findings were not statistically significant. At the final visit, the difference in proportion of subjects with wounds closed continued to favor the best dose from the prior trial (83% closed vs. 58%, delta 25%). Follow-up beyond 12 weeks is necessary to evaluate the full benefit of this therapy, as treatment with cells may provide stimulus toward healing that persists for up to several weeks following the last application. The results show that the greater proportional benefit achieved by HP802-247 relative to standard care after 12 weeks of treatment persists over a meaningful timeframe.
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Affiliation(s)
- Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida
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