[CHANGES OF PH AND CYTOLOGICAL PICTURE AT VARIOUS STAGES OF WOUND HEALING IN PATIENTS WITH VENOUS GENESIS TROPHIC ULCERS OF THE LOWER LIMBS]

The analysis of 82 patients medical records with venous trophic ulcers (VTU) of the lower limbs were presenting. pH in patients with VTU determined in three locations: the surface of ulcers, venous modified and unmodified skin and ulcers. Cytological examination of secretions from wounds conducted in 32 (39.1%) patients using smears. In 19 (23.2%) patients prevailed exudation stage, in 37 (45.1%) – granulation, in 26 (31.7%) - epithelialization. At all stages of wound healing at a distance from the ulcers observed values change skin pH to the acid side. Typical sings of first phase of wound healing were degenerative–inflammatory and inflammatory type of cytogram, and for the granulation phase – inflammatory–regenerative and regenerative one.

Chronic Venous Insufficiency and the Therapeutic Effects of Daflon 500 mg

Chronic venous insufficiency is linked to venous hypertension and forces of shear stress on the endothelium. Venous hypertension depends upon two forces: the weight of a column of blood from the right atrium transmitted through the valveless vena cava and iliac veins to the femoral vein, and pressure generated by contracting skeletal muscles of the leg transmitted through failed perforating veins. When valve failure occurs in superficial axial veins and perforating veins, the venous pressure in the veins and venules of the skin and subcutaneous tissue is raised. The skin changes in chronic venous insufficiency are directly related to the severity of the venous hypertension. Also, pathologic changes in the valves are linked to venous hypertension and leukocyte infiltration and activation. It is hypothesized that acute venous pressure elevations cause a shift in the venous hemodynamics with changes in wall shear stress. This initiates the inflammatory cascade. Daflon 500 mg ameliorates the effects of chronic inflammation. In randomized trials, 60 days of therapy with Daflon at a dosage of 500 mg 2 tablets daily was effective, in addition to elastic compression, in accelerating venous ulcer healing. Because venous insufficiency is linked to venous hypertension and an inflammatory reaction, it appears that Daflon 500 mg 2 tablets daily shows a great potential for accomplishing blockade of the inflammatory cascade.

Glycosaminoglycan sulodexide modulates inflammatory pathways in chronic venous disease

Inflammation represents an important epiphenomenon in the etiopathogenesis of chronic venous disease, a worldwide debilitating condition affecting millions of subjects. The pathophysiology of chronic venous disease (CVD) is based on the hemodynamic abnormalities in conjunction to alterations in cellular and extracellular matrix biocompounds. The endothelial dysfunction results from early perturbation in the endothelium linked to glycocalyx injury and promoted by inflammatory cells and mediators (such as matrix metalloproteinases and interleukins), which lead to progressive dilation of the vein resulting in chronic venous insufficiency. Activated leukocytes during the inflammatory process release enzymes, free radicals, chemokines and inflammatory cytokines in the vessel microenvironment, which are responsible for the changes of the venous wall and venous valve, reflux and venous hypertension, and the development/progression of tissue destruction and skin changes. Sulodexide, a highly purified mixture of glycosaminoglycans composed by 80% fast moving heparin and 20% of dermatan sulphate, exhibits anti-thrombotic and profibrinolytic properties, restoring also the essential endothelial glycocalyx. Glycosaminoglycan sulodexide has been also characterized to reduce the release of inflammatory cytokines/chemokines and to inhibit the matrix metalloproteinases-related proteolytic cascades, counteracting endothelial dysfunctions. The pleiotropic effects of sulodexide set the basis for a very promising agent in treating the spectrum of CVD.

[Trends in systemic inflammatory factors and aminoterminal brain natriuretic propeptide in the treatment of chronic heart failure]

AIM

To study trends in systemic inflammatory factors and aminoterminal brain natriuretic propeptide (NT-proBNP) in the blood of patients with stage IIA and IIB chronic heart failure (CHF) during therapy aimed at reducing venous congestion.

MATERIAL AND METHODS

The study enrolled 52 patients with postinfarction cardiosclerosis (PICS). Clinical, echocardiographic and laboratory studies were conducted. The levels of TNF-alpha, IL-6, IL-10 and C-reactive protein (CRP) were measured by enzyme immunoassay. The concentration of endotoxin (ET) was estimated by the end-point chromogenic LAL test, that of NT-proBNP--by immunochromotographic assay.

RESULTS

In the patients with CHF, clinical signs of pulmonary venous congestion are associated with a statistically significant increase in the blood levels of TNF-alpha and CRP, those of systemic venous congestion are related to a further rise in TNF-alpha levels and elevation of blood concentrations of NT-proBNP, ET and IL-10. Treatment-related reduction in pulmonary venous congection is associated with a decrease in the levels of TNF-alpha, CRP and IL-6; that in systemic venous congestion--with lower concentrations of NT-proBNP, TNF-alpha and ET.

CONCLUSION

Specific changes in the levels of systemic inflammatory factors and NT-proBNP were found in patients with CHF in the presence of pulmonary and systemic venous congestion. Treatment aimed at elimination of the latter leads to reduction in the levels of systemic inflammatory factors and NT-proBNP.

[Remote results of using prostaglandins E1 and immunotherapy in combined modality treatment of various-aetiology trophic ulcers]

The purpose of this study was to assess short- and long-term efficacy of combined-modality therapy (comprising PGE1-group preparations and immunocorrection) used to treat indolent trophic ulcers in patients presenting with chronic venous insufficiency (CVI) and cutaneous angiitis. Examined herein were both immediate and remote therapeutic outcomes obtained in patients suffering from indolent trophic ulcers secondary to CVI (post-thrombophlebic disease [PTPD] and varicose disease [VD]), as well as ulcers resulting from vasculitis or vasculopathy. The conventional therapy was supplemented with infusion of PGE1-group preparations and immunocorrection. Also investigated were the indices of microcirculation and the immune status, the percentage of the trophic ulcers having healed, the trophic-ulcer recurrence rate in the remote period, feasibility offurther performing a radical surgical intervention, the patients' quality of life after the treatment, and the need for repeat therapeutic courses according to the regimen proposed. The use of PGE1-group preparations in a combination with immunocorrection confirmed high efficacy of the treatment for various-aetiology trophic ulcers (with the preserved arterial blood flow). The trophic ulcers were observed to epithelialize rapidly following the initiation of treatment, thus making it possible to appropriately prepare the patient suffering from varicose disease for further surgical management. The remote-period evidence clearly showed that the use of the proposed therapeutic regimen had eventually led to a considerable improvement in the patients' quality of life, dramatically decreasing the recurrence rate of trophic ulcers in patients with PTPD and vasculopathies, and thus may safely be recommended both for prevention of ulcer relapses and as part of maintaining therapeutic courses. The detected deviations in the immune status of the patients afflicted with vasculitis and those suffering from CVI confirmed the need for immunocorrection.

Immune function of erythrocytes in patients with chronic venous insufficiency of the lower extremities

BACKGROUND

The influence of inflammatory processes has been one of the hot topics in discussions of the etiology of chronic venous insufficiency (CVI). Erythrocytes are very important in controlling inflammatory immunity and innate immune reactions. The purpose of this study was to analyze the correlation between the development of CVI and the change of CD35, Fy6 on erythrocytes, and interleukin-8 (IL-8) levels.

METHODS

A group of 43 patients with CVI were studied in parallel with 8 healthy individuals serving as control subjects. Control subjects were those with normal findings on lower extremity duplex examinations. We used an erythrocyte flow cytometer to examine the expression of both CD35 and Fy6 on red blood cells, and an enzyme-linked immunosorbent assay analysis method to measure plasma IL-8 levels. We also analyzed the change of IL-8 levels under the influence of erythrocytes using a modified method of the hemaimmune reaction.

RESULTS

Compared with normal control subjects, CD35 expression increased significantly among patients with CVI classified as C4 without lipodermatosclerosis, but tended to decrease and reach the lowest level among patients classified as C5-C6. Fy6 expression increased significantly among patients in the early stages of CVI, but tended to decrease remarkably among patients classified as C5-C6. The inflammatory response intensified at the C5-C6 classification, where high levels of IL-8 coexisted with a low expression of Fy6. The increase in IL-8 in the CVI group was higher than in the control group in association with the complete blood cells, regardless of the presence of erythrocytes, when inactive tumour cells were added, whereas the level of IL-8 in the CVI group was significantly lower than in the control group.

CONCLUSIONS

Abnormalities of erythrocyte innate immunity represents a fundamental derangement in CVI. These inadequate inflammatory responses may lead to local tissue and microvascular damage of the lower extremity.

The Impact of Gastrocnemius Muscle Cell Changes in Chronic Venous Insufficiency

OBJECTIVE

To investigate the pathological and metabolic changes in the gastrocnemius muscle in patients with chronic vein insufficiency (CVI).

METHOD

Thirty-six patients with varicose veins were investigated by ambulatory venous pressure (AVP) and duplex ultrasonography. Twelve age and height-matched controls were used for comparison. Patients and controls consented to participate in this study. Twenty-one patients with primary vein varicose (group AI) and 15 patients (group AII) with primary deep venous valve incompetence (DVI) underwent biopsies of the gastrocnemius muscle during operation. Adductor biopsies obtained from the same limbs served as a control group (group B) and specimens from controls subjects without venous disease served as the second control group (group C). All the specimens were investigated by superoxide dismutase (SOD), nitric oxide (NO), Na+-K+-ATPase, Ca2+-ATPase and lactic acid (LD) determinations. Samples were subjected to light and electron microscopy following H & E staining, special ATPase, cytochrome oxidase/succinate dehydrogenase (COX/SDH) stains.

RESULTS

Normal muscle architecture was seen following H & E, ATPase and COX/SDH staining and normal cell metabolism was observed in specimens of groups B and C. In group A, pathological changes were encountered in the gastrocnemius muscle including disseminated myofibril atrophy, cell denaturation and necrosis, inflammatory cell infiltration, proliferation and dilation of interfascicular veins. ATPase staining (pH 9.4) demonstrated grouping of atrophic fibres, especially type I myofibril grouping, accompanied by moderate to severe atrophy of type II muscle fibres. However, no patient had selective type I fibre atrophy. Enhanced enzymatic activity in single or multiple myofibrils was demonstrated by COX/SDH staining in approximately half of the specimens in group AII. In group AII, electron microscopy showed swelling, myelin figure denaturation of mitochondria, disruption of the myofibrils and increased lipid droplets in the gastrocnemius muscle. Increased concentration of LD was found in most specimens from group A patients. There were also reductions of SOD, NO, biochemical activity of Na+-K+-ATPase, Ca2+-ATPase with increasing concentration of LD in these patients, most prominently in group AII. We found correlation between AVP assessments and the biochemical measurements as well as morphological appearances of the gastrocnemius muscle.

CONCLUSION

Venous hypertension results in pathophysiological changes in the gastrocnemius muscles of patients with DVI, associated with decreased calf pump function.

Immunocytochemical characterisation of the inflammatory cell infiltrate of varicose veins

OBJECTIVES

To characterise the inflammatory cell infiltrate in varicose vein wall, and its relationship to the valve complex.

DESIGN

A comparative study of the distribution of inflammatory cells in normal and varicose vein.

MATERIALS

Specimens of proximal human long saphenous vein were obtained from patients with duplex Doppler confirmed long saphenous vein reflux (n=14). Control vein was obtained from patients undergoing coronary artery bypass without clinical evidence of venous insufficiency (n=6). Longitudinal 7 microm frozen sections of vein, displaying valve, were prepared.

METHODS

Using immunohistochemistry, T-lymphocytes (CD3), macrophage/monocytes (CD68), neutrophils (CD15s) and mast cells (anti-mast cell tryptase) were identified. The number of cells per unit length vein were counted using light microscopy.

RESULTS

There were significantly more mast cells and macrophage/monocytes in varicose vein as compared to control. There was a non-significant trend towards more T-lymphocytes in varicose vein. Few neutrophils were present in varicose or normal vein. The distribution of inflammatory cells with respect to the valve was not found to be significant.

CONCLUSIONS

Varicose veins display a greater inflammatory cell infiltrate than normal vein. The key role of macrophage/monocytes and mast cells in tissue damage and remodelling should stimulate further research into whether they play a significant role in the development of chronic venous insufficiency.

An animal model of venous hypertension: The role of inflammation in venous valve failure

BACKGROUND

Clinical observation suggests that chronic venous insufficiency is related to failure of venous valves. Duplex ultrasound studies of lower extremity superficial veins regularly show valve failure and venous reflux. Gross morphologic observation of venous valves in surgical specimens shows tearing, splitting, scarring, and disappearance of valves.

HYPOTHESIS

Venous valve damage is acquired, linked with venous hypertension, and affected by inflammation.

OBJECTIVE

The objective of this study was to investigate the inflammatory process in valve remodeling associated with acute and chronic venous hypertension.

METHODS

A femoral arteriovenous fistula was created in study animals (Wistar rats, n = 60), and animals without an arteriovenous fistula were studied as controls (n = 5). At 1, 7, 21, and 42 days animals with the femoral arteriovenous fistula were anesthetized, and systemic pressure, the pressure in the femoral vein distal to fistula, and the pressure of the femoral vein in the contralateral hind limb were measured. Timed collection of blood backflow after division of the femoral vein distal to the fistula and in the alive, anesthetized animal was collected, measured, and calculated per unit time to be used as an indicator of valve insufficiency. The femoral vein distal to the fistula was harvested; valvular structures were examined and measured. Specimens were processed, and longitudinal sections were made and challenged with immunostaining antibodies against matrix metalloprotease (MMP)-2 and MMP-9. Sections were examined, and expression of molecular markers was determined by light absorption measurements after image digitization.

RESULTS

One week after the procedure, all animals exhibited some degree of hind limb edema ipsilateral to the arteriovenous fistula. Pressure in the femoral vein distal to the fistula was markedly increased on average to 96 +/- 9 mm Hg. Reflux was increased in a time-dependent manner, with the 21-day and 42-day groups showing the highest values. Valves just distal to the fistula showed an increased diameter of the valvular annulus and a shortening of the annular height. Venous wall findings included fibrosis and fusion of the media and adventitia and scarring and disappearance of valves principally in the 21- and 42-day specimens. Immunolabeling for MMP-2 showed an increased level in the 21- and 42-day groups. MMP-9 showed an increased level at 1 day, followed by a more marked level in the 21- and 42-day groups.

CONCLUSIONS

In this animal model of venous hypertension the findings of limb edema, increasing valvular reflux, and morphologic changes of increased annulus diameter and valve height are seen. Histologic changes included massive fibrosis of media and fusion with adventitia. Inflammatory markers MMP-2 and MMP-9 are strongly represented, and valve disappearance occurs after these markers are present. The gross morphologic changes seen are quite similar to those observed in human surgical specimens removed in treatment of venous insufficiency.

CLINICAL RELEVANCE

When observed angioscopically at the time of vein stripping, saphenous vein valves show severe deformities including shortening, scarring, and tearing. The current model of induced venous hypertension demonstrates early venous valve changes that replicate those observed in humans. This observation provides a link from venous hypertension to an induced inflammatory reaction that stimulates the valve damage. Thus the model could be useful for defining the fundamental mechanisms that cause venous valve failure and varicose veins and in pharmacologic testing to prevent or treat venous insufficiency.

Venous Hypertension, Inflammation and Valve Remodeling

OBJECTIVES

To identify possible mechanisms for destruction of valves in chronic venous hypertension and the results of treatment with an anti-inflammatory micronized purified flavonoid fraction.

MATERIAL AND METHODS

The saphenous vein valves in a rat model of venous hypertension caused by a femoral arterial-venous fistula were studied. Studies included femoral venous pressure, valve morphology, femoral venous reflux and selected molecular inflammatory markers as examined by immunohistochemistry. The effects of treatment with the anti-inflammatory micronized purified flavonoid fraction (S 5628, Servier, 50 and 100 mg/kg/day) were investigated.

RESULTS

The femoral venous pressure was elevated close to arterial values for a period of 3 weeks. We then examined the morphology of the veins and selected molecular inflammatory markers were assessed. The results show that in this model venous reflux develops in response to venous hypertension. This can be inhibited by the administration of the anti-inflammatory micronized purified flavonoid fraction (S 5628, Servier, 50 and 100 mg/kg/day). The valve becomes incompetent by a combination of venous dilation and shortening of the valve leaflets. This is not inhibited by treatment with S 5628. The valve leaflets are infiltrated with granulocytes, monocytes and T-lymphocytes, and the endothelial cells express enhanced levels of P-selectin and ICAM-1. Cells in the valves are subject to extensive apoptosis although no enhancement of MMP 2,9 expression could be detected at the three-week time point examined in this study.

CONCLUSIONS

These results indicate that in this model chronic elevation of venous pressure is associated with an inflammatory reaction in venous valves, a process that may lead to their dysfunction, reflux, and upstream elevation of venous pressure. These effects are mitigated by the anti-inflammatory micronized purified flavonoid fraction in a dose dependent manner.

Symptoms of chronic venous disease and association with systemic inflammatory markers

PURPOSE

We recorded symptoms reported by patients with chronic venous disease (CVD) of the leg and correlated these with systemic inflammatory markers.

METHODS

This was an observational study in a cohort of 132 adult patients with CVD attending the vascular clinic of a teaching hospital. Patients were excluded in whom recent surgery, illness, or concomitant medication may have influenced measurements of systemic inflammatory mediators. Patients with CEAP clinical stages C(2) to C(5) only were considered for inclusion in the study. CEAP clinical stage was established for each patient, and duplex ultrasound scanning was used to assess extent of venous disease in the lower limbs. Blood was taken from a foot vein, and the following inflammatory mediators were measured with enzyme-linked immunosorbent assay: von Willebrand factor, intercellular adhesion molecule 1, vascular cell adhesion molecule 1, soluble (s)E-selectin, sP-selectin, L-selectin, VEGF, and cytokines interleukin (IL)-1 alpha, IL-1 beta, IL-6, and tumor necrosis factor-alpha. Symptoms were recorded by patients using a visual analog scale (VAS) for the symptoms of pain, cramps, heaviness, paresthesia, and feeling of swelling.

RESULTS

The greatest VAS symptom scores were observed in the less severe disease stages: C(2) median pain score, 2.8 units (interquartile range [IQR], 0.1-5); C(3), 4.5 (IQR, 3.4-5.5), C(4), 0.5 (IQR, 0-3.0); C(5), 0 (IQR, 0-4). Symptom scores were similar in patients with primary and recurrent venous disease after previous surgery and in patients with superficial venous reflux and deep venous reflux. No correlation was found between the measurements of inflammatory mediators and the symptoms assessed with the VAS.

CONCLUSION

We found no correlation between symptoms reported by patients and the internationally agreed clinical stages of venous disease of C(2) to C(5). Neither was there any correlation between levels of inflammatory mediators and patient symptoms. Symptoms reported by patients with CVD cannot be explained by anatomic distribution of venous disease in the lower limb veins or by the systemic inflammatory response in venous disease.

bFGF-induced alterations in cellular markers of senescence in growth-rescued fibroblasts from chronic venous ulcer and venous reflux patients

Fibroblasts cultured from the distal lower extremity of chronic venous insufficiency (CVI) patients exhibit characteristics of cellular senescence. Basic fibroblast growth factor (bFGF) has been shown to improve growth rates in these fibroblasts. In bFGF-treated fibroblasts, levels of fibronectin and matrix metaloproteinase-2 (MMP-2), known to be up-regulated in senescence, were examined to determine whether bFGF induces changes in these markers of senescence with rescue of cellular proliferation. Fibroblasts were isolated from the distal leg of patients with CVI with and without ulcers (fb-D). In all patients, a control was obtained from the proximal ipsilateral thigh (fb-P). Cells were plated at 3000 cells/plate and treated with bFGF (20 ng/mL) on days 1, 5, 8, and 11. Total cell number was obtained on days 5 and 12 using the Coulter particle counter, and concurrently cells were plated at 10,000 cells/plate and treated with bFGF on the same schedule; cell lysate was harvested on day 12 for immunoblot analysis for MMP-2 and fibronectin. In all patients (n = 7), fb-P grew faster than fb-D (p = 0.039). fb-D showed a mean 3.3-fold increase in growth in response to bFGF, and immunoblot analysis demonstrated an up-regulation of fibronectin and MMP-2 in response to bFGF. This represents the possibility that by stimulating growth, bFGF may drive cells toward senescence. This suggests clinical implication for the use of bFGF and other growth factors in general.

Biological properties of flavonoids pertaining to inflammation

Chronic venous insufficiency (CVI) is accompanied by a marked inflammatory response that is thought to contribute to the development and progression of the disorder. While compression therapy has long been considered the standard treatment for CVI, recent studies suggest that treatment with flavonoids may also be beneficial. The purpose of this review is to summarize how plant flavonoids attenuate inflammation and the immune response through their inhibition of important regulatory enzymes. Certain flavonoids are potent inhibitors of the production of prostaglandins, a group of powerful proinflammatory signaling molecules. Studies have shown that this effect is due to flavonoid inhibition of key enzymes involved in prostaglandin biosynthesis (i.e., lipoxygenase, phospholipase, and cyclooxygenase). Flavonoids also inhibit phosphodiesterases involved in cell activation. Much of this effect is upon the biosynthesis of protein cytokines that mediate adhesion of circulating leukocytes to sites of injury. The protein kinases are another class of regulatory enzymes affected by flavonoids. The inhibition of kinases is due to the competitive binding of flavonoids with ATP at catalytic sites on the enzymes. These modes of inhibition provide the mechanisms by which flavonoids inhibit the inflammation response and suggest that this class of molecules may be effective in the treatment of CVI.

Experimental models to investigate inflammatory processes in chronic venous insufficiency

Chronic venous insufficiency (CVI) is characterized by leukocyte adhesion and infiltration, venous hypertension and dilatation, and valvular dysfunction. The fact that activated white cells can direct a powerful cytotoxic arsenal at parenchymal cells following their extravasation into the tissues led to the original proposal that leukocytes may play a causative role in the pathogenesis of venous disease. A large body of subsequent work indicates that white blood cells are indeed activated in CVI. However, identification of the factors responsible for initiating leukosequestration and activation in such disorders and determination of whether these activated cells then contribute to the progression of venous disease have been hampered by the lack of appropriate animal models that accurately mimic the human condition. Tantalizing evidence suggesting that cyclical periods of ischemia and reperfusion (I/R) may occur in diseased regions of the skin is beginning to accumulate. As is the case with CVI, leukocyte infiltration is a prominent feature in I/R and activated neutrophils play a causative role in the reperfusion component of tissue injury via the targeted release of reactivate oxygen metabolites and hydrolytic enzymes. In light of these considerations, many investigators have suggested that examining the mechanisms of I/R injury in skin and skeletal muscle, where ischemia is produced by arterial occlusion, may provide a relevant model for studying the pathogenesis of CVI. Others have suggested that venous occlusion may represent a more appropriate model, as this approach also produces the venous hypertension that is characteristic of the disease. The purpose of this review is to summarize the evidence pointing to the involvement of I/R and venous hypertension as causative factors in CVI-induced leukocyte recruitment. In addition, we will describe the evidence in favor of the view that white blood cells contribute to the pathogenesis of CVI. Finally we will describe several different experimental models that have been used to examine the role of I/R-induced microvascular dysfunction as it may pertain to the development of CVI, together with a discussion of the relative advantages and limitations of the various models.

Circulating leucocyte adhesion molecules in chronic venous insufficiency

BACKGROUND

Enzyme-linked immunosorbent assay (ELISA) techniques have detected the existence of circulating forms of intercellular adhesion molecule-1 (ICAM-1), vascular endothelial adhesion molecule-1 (VCAM-1) and E-selectin, all of which mediate leucocyte-endothelial adhesion. This study determined whether circulating cell adhesion molecules were increased in patients with chronic venous insufficiency (CVI) which causes venous stasis.

PATIENTS AND METHODS

Before and after walking and upon recovery blood samples were drawn from the saphenous vein in 20 CVI patients: 10 with varicose veins (group 1), 10 with deep venous insufficiency (group 2). 10 healthy controls were enrolled. The total leucocyte count and the soluble levels of ICAM-1, VCAM-1 and E-selectin were determined.

RESULTS

After walking, the total leucocyte count decreased significantly (p < 0.01) only in group 2 and sICAM-1 and sVCAM-1 increased significantly (p < 0.01). Upon recovery, these significant differences remained in group 2. No significant modification was observed at any stage of the study in group 1 or in the control group.

CONCLUSIONS

These results suggest persistently high levels of circulating adhesion molecules may contribute to worsen microvascular perfusion, which leads to the onset of trophic damage in CVI.

Leukocyte activation in patients with venous insufficiency

PURPOSE

Cell activation may play an important role in the production of venous insufficiency, just as leukocytes participate in the cause of venous ulcer. If activated, monocytes observed on venous endothelium can migrate into the venous wall and produce toxic metabolites and free oxygen radicals that may participate in valve destruction and venous wall weakening. At present, it remains uncertain to what degree leukocytes are actually activated in patients. This study was designed to explore the level of activation and to examine whether patient plasma contains an activator that leads to leukocyte activation of unstimulated naive leukocytes from volunteers without venous insufficiency disease.

METHODS

Twenty-one patients (4 men, 17 women), who ranged in age from 34 to 69 years (mean age, 53.2 years), with chronic venous disease were compared with 16 healthy control volunteers (4 men, 12 women), who ranged in age from 18 to 65 years (mean age, 48.4 years). All the patients underwent evaluation with Doppler ultrasound scanning and were classified with the CEAP score.1 Nearly all the patients who smoked or were hypertensive were excluded. The blood types (ABO and Rh) of the controls were matched to the study group. Isolates of patient whole blood, plasma, or leukocytes were incubated with isolates of control whole blood, plasma, or leukocytes to separate actual activation from spontaneously observed activation. The granulocyte activation was measured with nitroblue tetrazolium (NBT) reduction and quantitation of granulocyte pseudopod formation. Hydrogen peroxide production in patient plasma was measured with a recently developed electrode method.

RESULTS

Leukocytes from healthy blood and patient plasma had significantly higher NBT-positive granulocyte counts than either patient blood, healthy blood, or patient blood incubated in healthy plasma. In a comparison of patient groups across the CEAP classes, the NBT-positive granulocyte counts were significantly greater in classes 4, 5, and 6 than in classes 2 and 3 (P <.001). Pseudopod formation was significantly greater in mixtures of granulocytes in healthy blood and patient plasma than in all other groups. There was no difference in the level of pseudopod formation in control leukocytes incubated with patient plasma in patients across the CEAP spectrum. The patient plasma produced significantly higher hydrogen peroxide values than did the controls.

CONCLUSION

These results suggest that patient plasma may contain an activating factor for granulocytes. The finding that activated neutrophils were fewer in number in patient whole blood than in healthy blood incubated in patient plasma could suggest that activated neutrophils in patients with chronic venous insufficiency might be trapped in the peripheral circulation. It is unknown what factors in the plasma might induce activation of naive neutrophils, but such activators could possibly be important in the pathogenesis of primary venous dysfunction and the development of chronic venous insufficiency.

Endothelial activation response to oral micronised flavonoid therapy in patients with chronic venous disease--a prospective study

BACKGROUND

Endothelial activation is important in the pathogenesis of skin changes due to chronic venous disease (CVD). Purified micronised flavonoid fraction has been used for symptomatic treatment of CVD for a considerable period of time. The exact mode of action of these compounds remains unknown.

AIM

To study the effects of micronised purified flavonoidic fraction (Daflon 500 mg, Servier, France) treatment on plasma markers of endothelial activation.

MATERIALS AND METHODS

Twenty patients with chronic venous disease were treated for 60 days with DAFLON 500 mg twice daily. Duplex ultrasonography and PPG was used to assess the venous disease. Blood was collected from a foot vein immediately before starting treatment and within 1 week of stopping treatment. Plasma markers of endothelial activation were measured using commercial ELISA kits.

RESULTS

Reduction in the level of ICAM-1, 32% (141 ng/ml: 73 ng/ml) and VCAM 29% (1292 ng/ml: 717 ng/ml) was seen. Reduction in plasma lactoferrin (36% decrease, 760 ng/ml: 560 ng/ml) and VW factor occurred in the C4 group only.

CONCLUSIONS

Micronised purified flavonoidic fraction treatment for 60 days seems to decrease the levels of some plasma markers of endothelial activation. This could ameliorate the dermatological effects of (CVD). This could also explain some of the pharmacological actions of these compounds. Our study demonstrates the feasibility of using soluble endothelial adhesion molecules as markers for treatment.

Pathogenesis of venous thrombosis: a new insight

Venous thrombosis and thrombophlebitis have long been observed to result in painful inflammation around the affected veins. The full extent of the synergistic interaction between thrombosis and the inflammatory response and how this leads to the later sequelae of chronic venous insufficiency is only now beginning to be understood. Venous thrombosis is known directly to elicit an inflammatory response in the thrombus and vein wall. Leukocytes including neutrophils and monocytes roll, adhere, activate and extravasate into the vein wall based on a vein wall cytokine/chemokine gradient producing an inflammatory response. Such a response leads to amplification of thrombus formation through mechanisms such as the elaboration of tissue factor on the surface of monocytes and the release of cathespin G from activated neutrophils (distrupting the endothelial cell barrier), exposing the thrombogenic subendothelial vein wall collagen. Selectins such as P-selectin and the proinflammatory cytokine tumor necrosis factor appear important in this vein wall response. Inhibition of inflammation before the initiation of the thrombotic event may decrease the detrimental vein wall changes that contribute to vein wall and vein valve damage and thrombus formation.

[The balneotherapy importance of the silicon compounds in siliciferous waters when used externally]

Bath therapy was assigned to 300 patients with primary hypothyroidism, chronic venous insufficiency of the legs, neurologic symptoms of lumbar osteochondrosis. Fresh, siliceous, siliceous carbon-dioxide and carbon-dioxide waters were tested comparatively. It is reported that siliceous baths with threshold silicon compounds concentration 50 mg/l had the effect similar to that of fresh-water baths. Indications have been specified for introduction of carbon dioxide and siliceous carbon dioxide baths in the diseases studied.

Circulating activated T lymphocytes in autoeczematization

BACKGROUND AND DESIGN

Autoeczematization, the symmetric diffuse spread of a previously localized dermatitis, has an unclear etiology although some investigators have postulated that activated T lymphocytes play a role. Two estimates of activation of peripheral T lymphocytes are the cell surface expression of the HLA-DR antigen and the interleukin 2 receptor (IL-2R). We measured the percentage of circulating activated T lymphocytes in nine patients with autoeczematization compared with normal controls (n = 10), patients with stasis dermatitis (n = 6), and patients with severe (n = 10) or mild (n = 8) psoriasis. The percentage of activated T lymphocytes was determined by fluorescent, activated cell sorter analysis of peripheral leukocytes doubly stained with antibodies to T lymphocytes and HLA-DR antigen or IL-2R.

RESULTS

Statistically significant elevations of HLA-DR- and IL-2R--positive T lymphocytes were seen in autoeczematization patients (P less than .004 and P less than .04, respectively) and those with severe psoriasis (P less than .004 for HLA-DR antigen and IL-2R). Percentages of HLA-DR- and IL-2R--positive T lymphocytes in patients with mild psoriasis were not significantly elevated. Two patients with autoeczematization had a reduction of their previously elevated levels of HLA-DR- and IL-2R--positive T lymphocytes after treatment.

CONCLUSIONS

These data suggest a possible role for circulating activated T lymphocytes in the pathogenesis of autoeczematization and possibly in severe psoriasis.

Contact sensitivity in stasis dermatitis

A large group of contactants was found to yield positive patch tests much more often in stasis dermatitis than in other forms of dermatitis. Most of these substances were topically applied medicaments and aromatic amines. Positive tests for the other contactants (including potassium dichromate, nickel sulphate, cobalt chloride, mercaptobenzothiazole, tetramethylthiuram disulphide and formaldehyde) were not significantly more frequent in stasis dermatitis than in other forms of dermatitis.