Efficacy of autologous platelet-rich plasma gel in patients with hard-to-heal diabetic foot ulcers: a multicentre study in Japan.

OBJECTIVE: To evaluate the healing outcome of a platelet-rich plasma (PRP) gel prepared using TKKT01 (a wound care device to prepare the PRP gel) in patients with hard-to-heal diabetic foot ulcers (DFUs) and who showed an inadequate response to ≥4 weeks of standard of care (SoC). METHOD: This open-label, single-arm, multicentre study was conducted in 15 centres in Japan. Eligible patients received PRP gel treatment twice a week for eight weeks, followed by a final evaluation after the completion of week 8 (day 57). The primary endpoint was the percentage of patients who achieved ≥50% reduction in wound radius at the final evaluation (achievement criterion, ≥60% of patients). Secondary endpoints included: wound area and volume reduction rates; time to possible wound closure by secondary intention; time to possible wound closure using a relatively simple procedure (e.g., skin graft and suture); and safety at the final evaluation. RESULTS: A total of 54 patients were included in the full analysis set, with 47 patients included in the per protocol set; the primary endpoint was met in 38/47 (80.9%) (95% confidence interval: 66.7-90.9%) patients who achieved ≥50% wound radius reduction at the final evaluation. High rates of wound area (72.8%) and volume (92.7%) reduction were observed at the final evaluation. The median time to possible wound closure by secondary intention and by use of a relatively simple procedure was 57 and 43 days, respectively. Complete wound closure at the final evaluation was achieved in 27 (57.4%) patients. No safety concerns were raised. CONCLUSION: In this study, the efficacy and safety of PRP gel treatment with TKKT01 in patients with hard-to-heal DFUs in Japan were confirmed by our findings. DECLARATION OF INTEREST: This study was funded by Rohto Pharmaceutical Co., Ltd., Japan. NO has been paid a consulting fee by Rohto Pharmaceutical Co., Ltd. KH is the Chief Medical Officer of Rohto Pharmaceutical. Co., Ltd. The other authors have no conflict of interest to declare.

Association between Patients' Body Mass Index and the Effect of Monophasic Pulsed Microcurrent Stimulation on Pressure Injury Healing.

This secondary analysis study aimed to detect individual variables that influence the efficacy of monophasic pulsed microcurrent on pressure injury healing. Eleven patients with pressure injuries showing delayed healing underwent a microcurrent stimulation period and a placebo period. We analyzed the correlation between the individual variables and the following three outcomes using monophasic pulsed microcurrent: the wound reduction rate in the electrical stimulation period, the reduction rate in the placebo period, and the difference between these two reduction rates. Furthermore, the patients were divided into two groups, one with a wound reduction rate of more than 10% and the other with less than 10%, and the relationship between each variable was compared. As a result, the wound reduction rate in the electrical stimulation period and the difference in the reduction rate between the two periods showed significant positive correlations with patients' body mass index. In addition, a significant difference was observed in the body mass index between subjects with a reduction rate of 10% or higher and those with a reduction rate of less than 10%. This study found a correlation between the effect of monophasic pulsed microcurrent for pressure injury healing and the level of patients' body mass index.

Effect of Partial Foot Amputation Level on Gait Independence in Patients With Chronic Lower Extremity Wounds: A Retrospective Analysis of a Japanese Multicenter Database.

Partial foot amputation (PFA) is generally planned to minimize the amputation level; nonetheless, the effect of PFA levels on gait independence in amputees remains unclear. This study aimed to investigate the impact of PFA levels of the forefoot on gait independence in patients with chronic lower extremity (LE) wounds. This multicenter retrospective cohort study included 232 hospitalized Japanese patients treated and rehabilitated for chronic LE wounds. A multivariate analysis based on PFA levels was conducted for gait independence at discharge, with age and comorbidities as independent variables. Patients with Lisfranc amputation had significantly less independent gait than patients with more distal amputation and those without amputation (<22% vs >40%; P = .027; Fisher's exact test). Logistic regression analysis revealed that Lisfranc amputation (odds ratio [OR]: 0.257, P = .047), age (OR: 0.559, P = .043), and chronic limb-threatening ischemia (OR: 0.450, P = .010) were independent factors associated with gait independence. Additionally, the regression model confirmed discrimination performance using the C index (0.691, P < .001) with receiver operating characteristic analysis. In patients with chronic LE wounds undergoing PFA, Lisfranc amputation was negatively associated with gait independence.

Influence of Peripheral Arterial Disease on Wound Healing in Heel Pressure Ulcers.

BACKGROUND: There are cases of heel pressure ulcer with peripheral arterial disease (PAD). The influence of ischemia on wound healing was investigated. METHODS: We retrospectively studied 253 patients with heel ulcers treated between January 2003 and March 2018. The patients were classified into PAD and non-PAD groups. The wound healing rate, wound healing time and the factors that influenced wound healing were examined. RESULTS: There were 186 patients with PAD (73.5%). There were 41 (22.0%) and 35 (52.2%) wound healing cases with PAD and non-PAD, respectively (P < 0.001). In the non-PAD group, the deeper the ulcer, the lower the wound healing rate. However, in the PAD group, the increase in blood flow owing to revascularization affected the wound healing rate. The wound healing rate in the endovascular therapy (EVT) and bypass groups were 26.7% and 65.0%, respectively (P = 0.003). The wound healing time was 128 (interquartile range [IQR] 88－196) and 79 (IQR 35.5－187) days, with PAD and non-PAD, respectively (P = 0.0268). The wound healing time in the PAD group was 128 (IQR 93－174.5) days with bypass and 155.5 (IQR 86－237.5) days with EVT (P = 0.459). CONCLUSIONS: Heel pressure ulcers with PAD are difficult to treat. The wound healing rate was lower in the PAD than in the non-PAD group and the wound healing time also tended to be long. Successful revascularization is important for wound healing and bypass surgery had a shorter wound healing time and a higher wound healing rate than EVT.

Tension-Free Management of Surgical Wound in Paramalleolar Bypass.

Objective: In paramalleolar bypass for critical limb-threatening ischemia (CLTI), excessive skin tension may occur for the closure of surgical wounds around the ankle. Furthermore, these surgical incisions are often proximal to infectious ischemic ulcers. Wound dehiscence caused by skin tension and surgical site infection carries a risk of graft exposure, anastomotic disruption, or graft insufficiency. Patients and Methods: Tension-free wound management was adopted in eight patients who underwent paramalleolar bypass for CLTI. Tension-free closure was adopted for surgical incisions for distal anastomotic site of the paramalleolar bypass, whereas the incisions for saphenous vein harvest were left open. A relief incision was made as needed. The opened incisions were covered with artificial dermis. Results: All surgical incisions and ischemic wounds healed successfully within 1.8 months after bypass. Two postoperative graft stenoses occurred, which were rescued by additional endovascular intervention. Secondary graft patency, wound healing, and limb salvage rates were 100% during an average follow-up period of 30 months. Conclusion: Tension-free wound closure using artificial dermis was effective in selected cases of paramalleolar bypass for CLTI.

Impact of infrapopliteal endovascular treatment on the outcome of subsequent ipsilateral distal bypass for critical limb ischemia.

BACKGROUND: We retrospectively reviewed the outcomes of distal bypass for critical limb ischemia and investigated the impact on outcomes of prior unsuccessful ipsilateral infrapopliteal endovascular treatment (EVT). METHODS: Between January 2005 and December 2014, we performed 142 infrainguinal bypasses for critical limb ischemia with ischemic gangrene (Rutherford classes V or VI), including 80 distal bypasses in 74 patients (male 54, female 20, median age 68.4 years, range 51-81 years). All distal bypasses used an autologous saphenous vein graft. Surgical outcomes were compared between 37 distal bypasses without prior infrapopliteal EVT (NEVT group) and 43 distal bypasses after unsuccessful infrapopliteal EVT (PEVT group). Infrapopliteal EVT was performed with balloon dilatation without stenting in all cases. RESULTS: There were no significant differences in preoperative conditions or risk factors between the NEVT and PEVT groups, except for the era of bypass surgery and dependence on hemodialysis. The 3-year primary and secondary patencies were 69% and 72% in the NEVT group and 78% and 80% in the PEVT group (P=0.86, P=0.79). The 3-year limb salvage rates were 81% in the NEVT group and 82% in the PEVT group (P=0.52), and the 3-year amputation-free survival rates were 56% and 57% in the respective groups (P=0.32). Standard errors of the mean for all Kaplan-Meier curves were <10% within 3 years follow-up. CONCLUSIONS: The clinical outcomes of distal bypass without prior infrapopliteal EVT were not superior to those of distal bypass after unsuccessful ipsilateral infrapopliteal EVT. Therefore, unsuccessful infrapopliteal EVT does not have a negative impact on the outcome of subsequent ipsilateral distal bypass in patients with critical limb ischemia.

Retrograde Approach Using Surgical Cutdown Technique for Limb Salvage in a Case of Critical Limb Ischemia With Severely Calcified Tibial Occlusive Disease.

We here report a successful angioplasty for tibial artery occlusion using direct tibial puncture and subsequent retrograde approach under surgical cutdown technique. An 82-year-old man with ulcer/gangrene in first and second digits was referred to our hospital for endovascular therapy (EVT) of lower extremity ischemia. Diagnostic angiogram revealed anterior tibial artery (ATA) occlusion with severe calcification. Subintimal angioplasty was attempted using a 0.014-inch hydrophilic guidewire but was unsuccessful. A retrograde approach was subsequently attempted for ATA recanalization. However, because of severe calcification of dorsal pedis artery (DPA), percutaneous distal puncture was also unsuccessful. Direct puncture under surgical cutdown technique for DPA was subsequently performed and was successful. A 0.014-inch hydrophilic wire was advanced in retrograde fashion across the ATA occlusion and was used to access the microcatheter positioned at the proximal ATA via antegrade approach. Angioplasty of the ATA occlusion was performed using a 2.5-/3.0-mm tapered balloon. Completion angiogram revealed restoration of flow without dissection. Skin perfusion pressure was dramatically improved. Complete wound healing was achieved 5 months after EVT.

Traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery.

We describe a rare case of traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. The vein graft was disrupted at the level of ankle joint by blunt trauma and symptoms of acute foot ischemia were recognized. The injured vein graft was reconstructed with cephalic vein graft interposition. He has been free from any events of foot ischemia at 10 months follow-up with patent vein graft to the dorsalis pedis artery.

Is immobilization of the ankle and metatarsophalangeal joint effective in suppressing the spread of infection in diabetic foot ulcers?

Diabetics with foot-related problems might eventually need to undergo major or minor amputation because of infection or cellulites. It has been suggested that immobilization of the ankle and the metatarsophalangeal joint suppresses the spread of infection; however, there is no evidence to support this inference. Here, we demonstrate by histological analysis how the immobilization works. The tendon from the amputated toe is harvested, and a hematoxylin-eosin stained paraffin-embedded section is prepared and analyzed. Necrosis occurred in only a single fiber of the tendon, and intact and necrotic or infected tendon fibers were found intermingled. The reciprocal movements of the tendon and the joint (extension and flexion) may be the pathogenic cause of cellulites and infection, leading to the massage effect and the spread of bacteria along the tendon itself. We suggest that immobilizing the ankle and the metatarsophalangeal joint with a removable contacting cast would suppress the spread of infection in foot ulcers.

Inhibition of cell death and induction of G2 arrest accumulation in human ovarian clear cells by HNF-1ß transcription factor: chemosensitivity is regulated by checkpoint kinase CHK1.

OBJECTIVE: Appropriate cell cycle checkpoints are essential for the maintenance of normal cells and chemosensitivity of cancer cells. Clear cell adenocarcinoma (CCA) of the ovary is highly resistant to chemotherapy. Hepatocyte nuclear factor-1ß (HNF-1ß) is known to be overexpressed in CCA, but its role and clinical significance is unclear. We investigated the role of HNF-1ß in regulation of the cell cycle in CCA. METHODS: To clarify the effects of HNF-1ß on cell cycle checkpoints, we compared the cell cycle distribution and the expression of key proteins involved in CCA cells in which HNF-1ß had been stably knocked down and in vector-control cell lines after treatment with bleomycin. HNF-1ß (+) cells were arrested in G2 phase because of DNA damage. RESULTS: HNF-1ß (-) cells died because of a checkpoint mechanism. G2 arrest of HNF-1ß (+) cells resulted from sustained CHK1 activation, a protein that plays a major role in the checkpoint mechanism. HNF-1ß (+) cells were treated with a CHK1 inhibitor after bleomycin treatment. Flow cytometric analysis of the cell cycle demonstrated that DNA damage-induced G2-arrested cells were released from the checkpoint and killed by a CHK1 inhibitor. CONCLUSIONS: The chemoresistance of CCA may be due to aberrant retention of the G2 checkpoint through overexpression of HNF-1ß. This is the first study demonstrating cell cycle regulation and chemosensitization by a CHK1 inhibitor in CCA.

A modified transmetatarsal amputation.

The incidence of the diabetic foot is increasing worldwide. Because evidence has shown that transmetatarsal amputation is associated with fewer failures in amputations of the diabetic foot with or without peripheral arterial disease, improving its management and surgical technique is a mission for the surgeon. Conventional transmetatarsal amputation has held firm, however, for more than 150 years. With a new concept for the transmetatarsal amputation method aimed at a better outcome, we propose a modified procedure for preserving the soft tissue between the metatarsal bones (the vasculature complex with the muscles, periostea, and vessels) and applying it to the distal bone stumps. The purpose of this method is to secure a functional foot by preserving the longitudinal arch. The new method was applied to 11 patients with diabetes mellitus or peripheral arterial disease, or both. All wounds closed successfully. Of the 11 patients, 8 were still alive with no complications. Of these 8 patients, 6 were able to ambulate with a custom-made shoe and 2 used a wheelchair, just as preoperatively. Of the 3 patients who died, 1 died a natural death, 1 died of sepsis, and 1 of cerebral infarction. We believe that the modified transmetatarsal amputation that we have described in this report is a potential breakthrough in the care of patients with forefoot gangrene and may gain acceptance over time.

Total management of diabetic foot ulcerations--Kobe classification as a new classification of diabetic foot wounds.

Treatment must be conducted after proper assessment of diabetic foot wounds. This implies appropriate foot care and the use of proper footwear from the perspectives of prophylaxis and walking. Diabetic foot wounds have some wound impairment factors, including peripheral neuropathy (PN), peripheral arterial disease (PAD), and infection; such wounds comprise combinations of these lesions. An additional goal besides wound healing is gait salvage. Here, we propose a simple new four-level classification of diabetic foot ulcerations, which we have termed the Kobe classification, in order to assess the wounds more easily and treat them systematically; the classification is as follows: Type I, mainly PN; Type II, mainly PAD; Type III, mainly infection; Type IV, PN+PAD+infection.

Clinicopathologic features of ovarian cancer in patients with ovarian endometrioma.

OBJECTIVE: The purpose of this study was to describe the clinicopathologic features of malignant transformation in patients with ovarian endometrioma, their treatment and outcome in the Kinki region, Japan. PATIENTS AND METHODS: Patients meeting Sampson and Scott's criteria for cancer associated with endometriosis were identified by chart review and pathology reports. This retrospective survey describes 18 women with a history of ovarian endometrioma. These cases were followed as benign ovarian endometrioma before malignant transformation on the basis of imaging findings by gynecologic oncologists or radiologists. RESULTS: Mean age at presentation of malignant transformation was 45.2 years (range, 36-66 years), and 78% (n=14) were premenopausal women. The pattern of spread was local in 16 (89%), regional in 2 (11%) and distant in 0 (0%). There was a common left-sided predominance. Characteristic histologic findings were 61% clear cell carcinoma. Endometriosis-associated malignancies have a favorable prognosis. The patients showed long latency intervals before developing ovarian cancer (mean, 4.5 years; range, 1-16 years). Among them, subjects (n=10) whose ages are more than 45 years old had shorter latency intervals (mean, 1 year; range, 1-3 years), compared with those (n=8) aged less than 45 years old (mean, 8.4 years; range, 3-16 years). CONCLUSION: Ovarian endometrioma could be viewed as a neoplastic process, particularly in perimenopausal women.

Two cases of pregnant women with ovarian endometrioma mimicking a malignant ovarian tumor.

The detection of an ovarian mass during pregnancy is often a diagnostic challenge. We describe 2 cases of ovarian endometrioma during pregnancy with marked mural nodules on the cyst wall. The sonographic and MR imaging findings mimicked ovarian cancer. Surgical intervention may still be inevitable to exclude the possibility of malignancy.

Molecular structure and function analysis of bikunin on down-regulation of tumor necrosis factor-alpha expression in activated neutrophils.

OBJECTIVE: We performed a detailed molecular analysis of bikunin-mediated anti-inflammation (suppressive effect of cytokine release, MAP kinase activation, and nuclear translocation of NF-kB) using a truncated form of bikunin. MATERIALS AND METHODS: We obtained bikunin derivatives that contained O-glycoside-linked N-terminal glycopeptide (Bik-m1), N-glycoside-linked C-terminal tandem Kunitz domains (Bik-m2), bikunin lacking O-glycoside (Bik-c), asialo bikunin (Bik-a), bikunin lacking N-glycoside (Bik-n), and purified C-terminal Kunitz domain II (kII) of bikunin (HI-8). Enzyme-linked immunosorbent assay and Western blot were carried out to measure secreted TNF-alpha and MAP kinase activation. RESULTS: We examined the TNF-alpha secretion in control and lipopolysaccharide (LPS)-treated neutrophils and did not see any changes of its protein levels in the cells pretreated with Bik-m1, Bik-m2, Bik-c, or HI-8. In all of the derivatives tested, only the derivatives that lacked N-glycoside side chain showed a significant suppression of TNF-alpha secretion by LPS. Only a small (21 amino acids) deletion of the N-terminal portion of bikunin (which corresponds to Bik-m2) abolished its suppressing activity of TNF-alpha secretion, thus suggesting that the N-terminal 21 amino acids play a critical role in anti-inflammation. Bik-m1 alone failed to show anti-inflammatory response. Bikunin failed to inhibit ionomycin-induced phosphorylation of MAP kinases. CONCLUSION: These data allow us to conclude that the cytokine expression was inhibited only by the O-glycoside-linked core protein without the N-glycoside side chain. Our results also suggest a possible role of bikunin for receptor-dependent MAP kinase activation.

Giant abdominal tumor of the ovary.

A giant abdominal tumor can exert a mass effect on surrounding structures. We report here a 34-year-old single female who presented with an increased abdominal girth and was subsequently found to have a giant abdominal mass. Large volume aspiration (85 L) at a slow rate (1 L/min) was initially performed before surgical resection to prevent the development of severe clinical hypotension after large volume aspiration. The patient underwent left salpingo-oophorectomy. Histology revealed a serous cystadenoma of the ovary. Systemic hemodynamics were sequentially measured during the perioperative period. The patient is now well.

Massive ovarian edema in pregnancy after ovulation induction using clomiphene citrate.

BACKGROUND: Massive ovarian edema is a benign enlargement of the ovary caused by accumulation of fluid occurring mainly in young women. Most cases are thought to result from venous and lymphatic obstruction. CASE REPORT: We treated a 40-year-old multiparous pregnant woman with massive ovarian edema who had been received clomiphene citrate. She was admitted at 13th week of pregnancy for acute pelvic pain. Left oophorectomy was performed, and pathologic examination disclosed massive ovarian edema. Our report is the first case of massive ovarian edema with pregnancy after ovulation induction using clomiphene citrate.

Hepatocyte growth factor induces anoikis resistance by up-regulation of cyclooxygenase-2 expression in uterine endometrial cancer cells.

Cyclooxygenase-2 (COX-2) has been implicated in the promotion of carcinogenesis. Although the role of COX-2 in endometrial cancer remains unclear, recent experiments suggest that COX-2 antagonizes cell apoptosis, increases the invasiveness of malignant cells, and promotes angiogenesis. Hepatocyte growth factor (HGF) is a mesenchymal-derived cytokine and the interaction between HGF and its tyrosine kinase receptor, c-Met proto-oncogene, is associated with tumor progression and metastasis. To investigate the molecular mechanism of HGF-induced anoikis resistance, we analyzed the signal transduction and COX-2 expression in endometrial cancer cells. Here, we show i) the expression of COX-2 protein significantly increased in a dose-dependent manner after HGF stimulation in endometrial cancer cell lines (HEC-IB and RL95-2), reaching 200-270% stimulation at the highest doses of HGF tested (40 ng/ml); ii) flow cytometry and TUNEL analyses revealed that HGF significantly inhibited anoikis of RL95-2 cells; iii) phosphatidylinositol 3-kinase (PI3K) inhibitor (LY294002), but not mitogen-activated protein kinase/ERK kinase (MEK) inhibitor (PD98059), specifically blocked HGF-mediated anoikis resistance in RL95-2 cells; and iv) COX-2 inhibitor, Meloxicam, abrogated HGF-mediated anoikis resistance. Our data suggest that HGF induces anoikis resistance in endometrial cancer cells possibly through PI3K/Akt pathway-dependent up-regulation of COX-2 expression.

Prevalence of ovarian cancer among women with a CA125 level of 35 U/ml or less.

BACKGROUND: The optimal upper limit of the normal range for CA125 in ovarian cancer screening is unknown. We investigated the prevalence of ovarian cancer among women in the Shizuoka Cohort Study on Ovarian Cancer Screening (SCSOCS) trial who had an abnormal ultrasound (US) and a CA125 level of 35 U/ml or less. METHODS: Of 48,027 women enrolled in the SCSOCS trial, 40,801 women never had a CA125 level of more than 35 U/ml, and underwent transvaginal US. RESULTS: Among the 40,801 women (age range 45-85 years), 4,859 women had an abnormal transvaginal US examination (category 1 [simple morphology], 4,741 women, and category 2 [complex morphology], 118 women). Of the 4,859 women, 981 (912 with the category 1 and 69 with the category 2) had a surgery. Of the 981 women, ovarian cancer was diagnosed in 8 (0.815%), and 5 of these 8 cancers (63%) were in stage I. The prevalence of ovarian cancer with abnormal US was 0.207% among women with a CA125 level of up to 15 U/ml, 0.488% among those with values of 15-20 U/ml, 0.685% among those with values of 20-25 U/ml, 2.04% among those with values of 25-30 U/ml, and 6.12% among those with values of 30-35 U/ml. CONCLUSIONS: Surgery-detected ovarian cancer is not rare among women with CA125 levels of 35 U/ml or less - levels generally thought to be in the normal range.