Lower-Extremity Vascular Ulcers: Assessment and Approaches to Management.

Healing of skin wounds of the lower extremities can be complicated by concomitant vascular disease. Dysfunction of the arterial, venous, and/or lymphatic systems can compromise the healing of skin ulcers of the legs, creating a burden for patients from painful, draining wounds and placing patients at risk for infection, amputation, and even death. Insights into vascular pathophysiology and an understanding of the processes of wound healing permit an evidence-based approach to patients with vascular leg ulcers. Clinical trials have demonstrated opportunities to improve the care of patients with vascular leg ulcers, thereby reducing morbidity and mortality and easing patients' burdens.

Bench-to-Bedside in Vascular Medicine: Optimizing the Translational Pipeline for Patients With Peripheral Artery Disease.

Peripheral arterial disease is a growing worldwide problem with a wide spectrum of clinical severity and is projected to consume >$21 billion per year in the United States alone. While vascular researchers have brought several therapies to the clinic in recent years, few of these approaches have leveraged advances in high-throughput discovery screens, novel translational models, or innovative trial designs. In the following review, we discuss recent advances in unbiased genomics and broader omics technology platforms, along with preclinical vascular models designed to enhance our understanding of disease pathobiology and prioritize targets for additional investigation. Furthermore, we summarize novel approaches to clinical studies in subjects with claudication and ischemic ulceration, with an emphasis on streamlining and accelerating bench-to-bedside translation. By providing a framework designed to enhance each aspect of future clinical development programs, we hope to enrich the pipeline of therapies that may prevent loss of life and limb for those with peripheral arterial disease.

Objective assessment of Platelet-Rich Plasma (PRP) potentiality in the treatment of Chronic leg Ulcer: RCT on 80 patients with Venous ulcer.

BACKGROUND: Chronic venous leg ulcer reduces the patients' activities and their overall quality of life. Platelet-rich plasma (PRP) was previously investigated as promising less invasive management for leg ulcers. THIS STUDY AIMS: To re-assess the efficacy and safety of PRP in the management of chronic leg ulcers due to venous factors. PATIENTS/METHODS: RCT enrolled 80 patients who clinically presented with chronic venous leg ulcers. Forty patients were allocated randomly for the treatment with autologous platelet-rich plasma (PRP). Intradermal and subdermal injection of PRP by 27guage syringe weekly, in all edges and in the granular floor of the ulcer for 4-6 sessions. Another 40 patients managed by conventional treatment by compression and dressing for the same period were allocated as Group B. Objective assessment achieved by the percentage of reduction of the size of the ulcer area, rate of healing, incidence of recurrence, and if side effects have been reported. RESULTS: PRP therapy showed better results and high p value significance when compared to conventional therapy. CONCLUSION: This study shows that PRP is effective and significant in promoting the wound healing process in chronic leg venous ulcers. PRP is simple, safe, and has a short learning curve technique.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners.

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Optimizing Technology Use for Chronic Lower-Extremity Wound Healing: A Consensus Document.

Innovations in technology are used in managing chronic wounds. Despite the wide range of technologies available, healing of chronic wounds remains variable. In this paper, the authors offer an evidence based approach to the use of technology for diagnosis and management based on the concept of standardised care.

Pyoderma Gangrenosum: A Report of 27 Patients.

The aim of this study was to document the profile of pyoderma gangrenosum (PG) patients who were treated in our clinic and to compare our patients' clinical and demographic characteristics with those described in the literature to help our understanding of the total burden of PG. A total of 27 (17 women, 10 men) patients with a mean age 48.6 years at diagnosis were included in the study. Seven (25.9%) of them had 3 or more ulcers. The lower extremity was the most common site of occurrence (92.5%). During the study period, 6 patients were admitted twice, and 7 were admitted 3 or more times (range 1 to >10), and the median length of stay was 27 days. A concomitant disease was present in PG patients especially in those between 20 and 40 years of age. Systemic therapy was used in 21 (91.3%) patients, 17 patients were treated with systemic corticosteroids, either alone in 7 patients or combination with other agents in 10 patients. Three of our patients died because of disease or treatment-related complications during the study period. Despite the high (70.3%) percentage of the PG patients with improving disease at the time of discharge, 1 year after hospital discharge, one third of our 27 patients still had PG requiring readmission. In conclusion, none of the current therapies provide satisfying results in all of the patients, and our data indicate a long-standing unmet need for effective therapy for the unexpected course of PG.

Assessment, Definition, and Classification of Lower Limb Ulcers in Systemic Sclerosis: A Challenge for the Rheumatologist.

OBJECTIVE: To evaluate pathogenesis and clinical features of lower limb ulcers in systemic sclerosis (SSc) and to propose a classification that could be used in clinical practice. METHODS: Charts of 60 patients with SSc who had lower limb cutaneous lesions were reviewed. All patients had videocapillaroscopy and arterial and venous lower limb color Doppler ultrasonography (US). Arteriography was performed if occlusive peripheral arterial disease was suspected. RESULTS: The 554 lesions were classified as hyperkeratosis, ulcers, and gangrenes. There were 341 (61.6%) hyperkeratoses, 208 (37.5%) ulcers, and 5 (0.9%) gangrenes. Ulcers were divided into pure ulcers, ulcers associated with hyperkeratosis, and ulcers secondary to calcinosis. Involvement of arterial and venous macrocirculation as determined by color Doppler US was observed in 17 (18.3%) and 18 (30%) patients, respectively. Seventeen out of 37 patients with pure ulcers (45.9%) presented neither venous insufficiency nor hemodynamically significant macrovascular arterial disease. In these patients, pure ulcers were most likely caused by isolated SSc-related microvascular involvement (pure microvascular ulcers). The only significant risk factor for development of pure microvascular ulcers in the multivariate analysis was the history of lower limb ulcers (OR 26.67, 95% CI 2.75-259.28; p < 0.001). CONCLUSION: Results of our study indicate that lower limb ulcers in SSc often have a multifactorial pathogenesis that may be difficult to manage. Further studies are needed to validate the proposed classification and to assess the most appropriate management of lower limb ulcers in SSc.

An introduction and guide to effective Doppler assessment.

Accurate and timely diagnosis of leg ulceration is an essential factor in making evidence-based, effective decisions regarding patient management with the aim of swift wound healing and/or referral to the appropriate specialty. Nurses are professionally responsible for ensuring that patients receive the appropriate assessment and evidence-based management. This article examines the most up-to-date guidance on Doppler ultrasound as a key element of this assessment. Approaches to assessment will be explored, with emphasis on the need to include a Doppler ultrasound as one key element of a larger, holistic assessment. An introduction to the ankle-brachial pressure index (ABPI) will be given, followed by a step-by-step guide to standard procedures for carrying out a full Doppler ultrasound. Alternative options for measuring ABPI are also provided.

Acute and critical limb ischemia: when time is limb.

Acute and critical limb ischemia post significant rates of morbidity and death, and need to be promptly recognized and treated to avoid amputation. Perfusion should be thoroughly assessed using multiple methods, and patients should be considered for revascularization (angioplasty or bypass surgery) to restore blood perfusion. Underlying conditions that need to be assessed and treated include cardiovascular disease, diabetes, and infection.

[Quality of life and burden of disease in peripheral arterial disease: a study among Hungarian patients]. / Magyarországi perifériás veroérbetegek életminoség és betegségteher vizsgálatának eredményei.

INTRODUCTION: Peripheral arterial disease may occur in about of 14% of patients with high blood pressure, of which 1-3% suffer from chronic critical limb ischemia. Literature data on the quality of life according to the Fontaine stages are very limited. AIM: The aim of this study was to assess the quality of life of Hungarian patients with peripheral arterial disease regarding Fontaine stages II, III and IV. METHODS: The study was based on a cross-sectional survey, which was carried out in four angiologic centres. One hundred and two respondents with peripheral arterial disease (43% woman) were evaluated. The average age of the patients was 70 years (SD-10). RESULTS: Based on the EQ-5D index, the results of the quality of life assessment with respect to Fontaine stages II, III and IV were 0.66, 0.35 and 0.18, respectively. In each stage the EQ-5D values were lower than the values of the age-matched average population. The results of the Pain Visual Analogue Scale (0-100 mm) were 38, 65 and 71 mm in Fontaine stages II, III and IV, respectively, and this showed a strong correlation with the EQ-5D (R = -0.68). In stage Fontaine IV the quality of life of the patients was significantly lower among those who had pain at rest and ALSO ulcer on the leg. CONCLUSIONS: Peripheral disease with clinical symptoms causes significant reduction in quality of life which can be measured with EQ-5D. It becomes worse as we move along the Fontaine stages. While measuring the health gain in stage Fontaine IV, the health gain from the reduction of pain in rest and partial recovery from ulcer should be taken into account.

Assessment and management of leg ulcers in the community and an outpatient clinic.

AIM: To compare the assessment and treatment of leg ulcers seen in the community and subsequently reviewed in an outpatient clinic, to the New Zealand Guidelines. METHODS: An observational study including consecutive patients presenting to vascular surgery outpatients with at least one leg ulcer. Outcomes included the clinical descriptions of ulcers, use of an Ankle Brachial Index (ABI) test and compression therapy for mixed and venous ulcers. RESULTS: The study included seventy-six patients. Every ulcer had an adequate clinical description. An ABI investigation was carried out in 9.1% and 66.7% of the patients in the community and outpatient clinic, respectively. Among 31 patients with venous or mixed ulcers in the community, 7 (22.6%) were initiated on compression therapy, and 1 (3.2%) on compression bandaging. Following outpatient clinic appointments, 29 (76.3%) of the 38 patients diagnosed with venous or mixed ulcers were on compression therapy with 20 (52.6%) on compression bandaging. CONCLUSION: There are low rates of ABI measurements and initiation of compression therapy for patients with leg ulcers in the Otago regional community. This may be due to low accessibility to expertise in ABI measurements delaying initiation of compression therapy. Innovations in facilitating ABI investigation in the community and promoting the use of compression therapy are indicated.

Quality of life evaluation in wounds: validation of the Freiburg Life Quality Assessment-wound module, a disease-specific instrument.

Many patients with chronic wounds suffer not only directly from their wounds but also from high financial, social and psychological impairments, significantly reducing their quality of life. In order to provide an instrument both applicable to different patient populations and sensitive to areas of impact specific to certain skin diseases, the modular instrument 'Freiburg Life Quality Assessment' has been developed. Each disease-specific version of the instrument consists of a core module of generic items and items specific for a distinct skin disease. Objective of the study was to assess reliability, sensitivity to change, and validity of the module for chronic ulcers. The instrument was implemented in a longitudinal observational study on vacuum-seal therapy (n = 175), in a cross-sectional observational study involving patients with chronic leg ulcers (n = 384) and in a randomised clinical trial on keratinocyte transplantation (n = 198). The instrument showed good internal consistency (Cronbach's alpha ≥0·85). There were minor floor effects ≤4·3%, but no ceiling effects. Retest-reliability and convergent validity with the EuroQol quality of life questionnaire (EQ-5D) (visual analogue scale) were satisfactory. Change scores correlated with change in other quality-of-life instruments (r = 0·59-0·61), but not with change in wound status.

The prevalence, management and outcome for patients with lower limb ulceration identified in a wound care survey within one English health care district.

482 people with leg ulcers were identified among those receiving health care in Bradford, UK. Of these wounds 195 (40.4%) were venous leg ulcers. Typically the people who experienced these wounds were elderly Caucasian females however a sub-group of younger males of Asian descent were seen to experience ulcers involving neuropathy. The leg ulcers were typically small in size although 33 people had wounds over 25 cm2 in surface area. The leg ulcers tended to persist with many present for at least 1 year with 4 wounds active for over 5 years. 205 people had experienced previous episodes of leg ulcer occurrence. Of the leg ulcers encountered 18.0% (n = 87) were infected and where wounds were swabbed for their microbial burden MRSA was identified in 8.5% of cases. Use of Doppler ultrasound to assess the aetiology of the wound had been performed in 66.4% of cases and where wounds remained undiagnosed (n = 69) only 8 had been Doppler assessed. While 75% of all venous leg ulcers received compression 48 people with venous leg ulcers did not have compression applied to their wound.

Telemedicine in wound care.

Telemedical wound care is one of the applications of teledermatology. We present our experience using telemedicine in the successful assessment and treatment of three patients with hard-to-heal ulcers. Three patients were seen at the PEMEX General Hospital in Veracruz, Mexico. The first patient was a 53-year-old man with hypertension, morbid obesity, chronic venous insufficiency, recurrent erysipelas, leg ulcers and lymphoedema. There was one ulcer on his left lower leg (20 x 10 cm) and one on his right leg (9 x 7 cm). The second patient was a 73-year-old woman with class III obesity and ulcers in her right leg, secondary to surgical debridement of bullous erysipelas. The third patient was a 51-year-old female with rheumatoid arthritis with one ulcer on each leg and chronic lymphostasis. Photographs with a digital camera were taken and sent weekly via email to a wound care specialist in Mexico City. The photographs allowed the expert to diagnose and evaluate the chronic wounds periodically. In the present cases, telemedicine allowed us to have a rapid evaluation, diagnosis and treatment. The images were of enough quality to be useful and small enough to be sent via regular email to the remote physician who immediately gave his feedback. The expert was confident to give therapeutic recommendations in this way, and we considered this method to be very cost-effective, saving the patient and the health care system, especially in transportation.

Efficacy of TNP on lower limb wounds: a meta-analysis.

This meta-analysis of the three RCTs that have compared topical negative pressure with conventional treatment in patients with lower limb ulcers found that it significantly reduced healing times and increased the number of healed wounds.

What lies beneath? Assessment of leg ulcers during acute hospital admission.

Chronic leg ulceration is a common condition often noted in patients during an acute hospital admission. We present the case of a patient in whom thorough examination and investigation of an incidentally noted ulcer revealed a serious, previously unexpected diagnosis of disseminated Merkel cell carcinoma. This article illustrates how important it is that medical staff are aware of the different patterns of an ulcer disease and are alert to atypical appearances. Acute admission, regardless of cause, represents an opportunity for full examination of all ulcers with a view to further investigation or specialist referral if needed. Such assessment can support the often overburdened community services and ensure appropriate investigation and treatment, particularly in the context of detecting malignancy.