[Characteristics of chronic wounds in substance abuse: A retrospective study of 58 patients]. / Caractéristiques des plaies chroniques chez les toxicomanes : étude rétrospective de 58 patients.

BACKGROUND: Drug addiction causes chronic wounds (CW) responsible for severe complications. Very few studies are available on this topic. The aim of our study was to describe the demographic, clinical and etiological characteristics as well as the course of CW in drug addicts. PATIENTS AND METHODS: This was a retrospective and prospective multicenter study including all drug addicts with CW. RESULTS: We included 58 patients (17 prospectively), 84.5% of whom were male, of median age 43 years, presenting multiple CW as a result of intravenous (78.2%), inhaled (41.1%) and/or snorted (20%) drug abuse. Addiction to opioids (68.4%), cocaine (47.4%) and/or cannabis (40.4%) was ended and/or treated through substitution in 79.3% of patients. CW were fibrinous and necrotic (42.9 to 53.6%), recurrent (54.2%), and in some cases had been present for more than 1 year (61.5%). Intravenous drug addiction was associated with large, fibrinous, ulcers in a setting of venous and lymphatic insufficiency (74%). Only 23% of these wounds involved the upper limbs. Necrotic ulcers associated with clinical arteriopathy were described mainly with inhaled addiction. Abscesses (50%) and erysipelas (29.3%) were the most common cutaneous complications. After 3 months, 50% of CW were improved and 29.2% of patients were lost to follow-up. DISCUSSION: Drug abuse-related CW occurred preferentially in young men with history of intravenous abuse. For the most part, CW were seen on the legs and were associated with venous and lymphatic insufficiency, and the resulting major risk for cutaneous infection increased morbidity and mortality in this population in whom medical follow-up is inherently complicated.

Factors predictive of leg-ulcer healing in sickle cell disease: a multicentre, prospective cohort study.

BACKGROUND: Leg ulcers (LUs) are a chronic and severe complication of sickle cell disease (SCD). A prospective study in patients with SCD to identify factors associated with complete healing and recurrence of LUs is lacking. OBJECTIVES: To determine clinical and biological factors associated with SCD-LU complete healing and recurrence. METHODS: This prospective, observational cohort study was conducted at two adult SCD referral-centre sites (2009-2015) and included 98 consecutive patients with at least one LU lasting ≥ 2 weeks. The primary end points compared patients with healed vs. nonhealed LUs at week 24, and patients with vs. without recurrence during follow-up. RESULTS: The median (interquartile range) LU area, duration and follow-up were, respectively, 6·2 cm2 (3-12·8), 9 weeks (4-26) and 65·8 weeks (23·8-122·1). At week 24, LUs were healed in 47% of patients, while 49% of LUs recurred. Univariate analyses identified inclusion LU area < 8 cm2 (82% vs. 35%; P < 0·001), inclusion LU duration < 9 weeks (65% vs. 35%; P = 0·0013) and high median fetal haemoglobin level (P = 0·008) as being significantly associated with complete healing at week 24, and low lactate dehydrogenase level (P = 0·038) as being associated with recurrence. Multivariate analyses retained LU area < 8 cm2 (odds ratio 6·73, 95% confidence interval 2·35-19. 31; P < 0·001) and < 9 weeks' duration (OR 3·19, 95% confidence interval 1·16-8·76; P = 0·024) as being independently associated with healing at week 24. Factors independently associated with recurrence could not be identified. CONCLUSIONS: SCD-LU complete healing is independently associated with the clinical characteristics of LUs rather than the clinical or biological characteristics of SCD.

[Venous compression in venous insufficiency]. / La compression veineuse dans l'insuffisance veineuse.

Compression is a mandatory therapeutic measure in all stages of venous insufficiency. This treatment, recommended by the French Health Authority (HAS), is consistently included in the protocols of therapeutic studies involving venous ulcers. Given the great variety in materials available and in the approaches of individual doctors, it is essential to avoid a dogmatic approach and instead to adapt treatment to the therapeutic results based on the premise that well-controlled treatment should result in improvement in trophic disorders and in patient comfort, while poor treatment is badly tolerated, even potentially harmful, and rejected by patients. Manufacturers have made great progress in the design of compression hose and bandages; however, to assess this treatment using the evidence-based medical methods stipulated by learned societies, great rigour is demanded in clinical trials, and the active substances, mode of action and requisite "dosages" must be precisely defined.

Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers--a randomized controlled trial.

BACKGROUND: Stringent control of proteolytic activity represents a major therapeutic approach for wound-bed preparation. OBJECTIVES: We tested whether a protease-modulating polyacrylate- (PA-) containing hydrogel resulted in a more efficient wound-bed preparation of venous leg ulcers when compared to an amorphous hydrogel without known protease-modulating properties. METHODS: Patients were randomized to the polyacrylate-based hydrogel (n = 34) or to an amorphous hydrogel (n = 41). Wound beds were evaluated by three blinded experts using photographs taken on days 0, 7 and 14. RESULTS: After 14 days of treatment there was an absolute decrease in fibrin and necrotic tissue of 37.6 ± 29.9 percentage points in the PA-based hydrogel group and by 16.8 ± 23.0 percentage points in the amorphous hydrogel group. The absolute increase in the proportion of ulcer area covered by granulation tissue was 36.0 ± 27.4 percentage points in the PA-based hydrogel group and 14.5 ± 22.0 percentage points in the control group. The differences between the groups were significant (decrease in fibrin and necrotic tissue P = 0.004 and increase in granulation tissue P = 0.0005, respectively). CONCLUSION: In particular, long-standing wounds profited from the treatment with the PA-based hydrogel. These data suggest that PA-based hydrogel dressings can stimulate normalization of the wound environment, particularly in hard-to-heal ulcers.

Prognostic factors associated with healing of venous leg ulcers: a multicentre, prospective, cohort study.

BACKGROUND: Some prognostic markers of venous leg ulcer (VLU) healing have been evaluated, mostly in retrospective studies. OBJECTIVES: To identify which clinical characteristics, among those known as possible prognostic factors of VLU healing, and which VLU-associated sociodemographic and psychological factors, are associated with complete healing at week 24 (W24). METHODS: A prospective, multicentre, cohort study was conducted in 22 French dermatology departments between September 2003 and December 2007. The end point was comparison between healed and nonhealed VLUs at W24, for patient clinical and biological characteristics; psychological, cognitive and social assessments; affected leg inclusion characteristics; venous insufficiency treatment and percentage of initial wound area reduction during follow-up. RESULTS: In total, 104 VLUs in 104 patients were included; 94 were analysed. The mean VLU area and duration were 36.8 ± 55.5 cm2 and 24.8 ± 45.7 months, respectively. At W24, 41/94 VLUs were healed. Univariate analysis significantly associated complete healing with superficial venous surgery (P = 0.001), adherence to compression therapy at W4 (P = 0.03) and W24 (P = 0.01), ankle-joint ankylosis (P = 0.01) and mean percentage of VLU area reduction at W4 (P = 0.04). Multivariate analysis retained superficial venous surgery during follow-up [odds ratio (OR) 8.4, 95% confidence interval (CI) 1.9-48.2] and percentage reduction of the VLU area at W4 (OR 1.6, 95% CI 1.0-2.14) as being independently associated with healing. CONCLUSIONS: These results indicate that complete healing of long-standing, large VLUs is independently associated with ablation of the incompetent superficial vein and percentage of wound area reduction after the first 4 weeks of treatment.

[Hypertensive leg ulcers: epidemiological characteristics and prognostic factors for healing in a prospective cohort]. / Angiodermites nécrotiques : caractéristiques épidémiologiques et facteurs pronostiques de cicatrisation dans une cohorte prospective.

BACKGROUND: The data concerning changes in the characteristics of hypertensive leg ulcers (HLU) were taken from open studies in a small patient cohort. The aim of this study was to describe the epidemiological characteristics and to identify prognostic factors for healing in a prospective cohort of 59 patients presenting HLU. PATIENTS AND METHODS: The cohort comprised patients included in a randomized, double-blind, controlled study published elsewhere; the patients were receiving becaplermin gel (Regranex(®)) or Duoderm Hydrogel™ once daily for eight weeks for the most recent wound. Total follow-up was 12 weeks. RESULTS: The epidemiological analysis was performed for 59 consecutive patients randomized in 17 dermatology departments. Mean patient age was 74.5 ± 9 years and 61% were female. Mean wound duration was 11.1 ± 9 weeks and median wound area was 16 cm(2) (q1; q3: 8; 25.5). Among, 94.9% of patients had hypertension and 39.7% were diabetic. A homolateral peripheral pulse was present in 91.5% of patients. At the end of follow-up, complete wound healing was obtained in 30.5% of the patients. In univariate analysis, neither the foregoing criteria nor the treatment group were significantly associated with healing during the study. CONCLUSION: This study confirms female predominance, old age, prevalence of diabetes and delay in the diagnosis of HLU. The prognosis for healing does not appear to be dependent on wound duration, wound area or the presence of moderate peripheral arterial disease, doubtless because this condition progresses by episodes of flare-up and under specific conditions.

[Preventing high-risk diabetic foot ulceration by a new method of custom-made shoes in high-risk patients. Prospective study]. / Prévention des plaies du pied chez les diabétiques à haut risque par une méthode innovante d'appareillage par podo-orthèses sur mesure. Etude prospective.

BACKGROUND: The efficacy of custom-made shoes to prevent diabetic foot ulcerations is still unsatisfactory and specific conception is lacking. METHOD AND PATIENTS: We conducted a prospective study on 32 consecutive patients with diabetic mellitus, sensitive neuropathy and healed minor amputation of the foot. They were following a prevention program (education, medical consultation every month). They were treated by custom-made shoes in order to obtain a tested and effective load-off area (after trying and modifying a temporary footwear according to a simple qualitative test of the plantar pressure). RESULTS: At 1 year, 9% of patients presented a new foot ulceration and 3% new minor amputations of the foot. The custom-made shoes had very thick multiple layer total-contact soles (mean thickness 25 mm for a forefoot deformity and 40 mm for a mid-foot deformity). CONCLUSION: This new concept of custom-made shoes might be effective in enhancing the prevention of neuropathic ulcerations for high-risk patients. A randomized controlled trial would be needed to establish sound evidence supporting this new approach for therapeutic footwear.

[Radiation arteritis- and radiodermitis-induced leg ulcer: surgical revascularization]. / Un ulcère de jambe par artérite radique et radio-dermite. Revascularisation chirurgicale.

A forty-four-year old man was hospitalized for diagnosis and treatment of a left leg ulcer which did not heal despite good compliance with a three-month medical regimen. Twenty years before he had undergone surgical curettage and radiotherapy (81 gy) for an osteosarcoma of the upper third of the left tibia. He was considered completely cured with regular findings. On examination he had a 5 X 7 cm deep ulcer with raised margins and no signs of infection, localized on the radiodermatitis on the medial aspect of his left leg. Arterial examination confirmed the left arteriopathy with absence of distal pulses; the Ankle Brachial Pressure Index was 0.69 and the foot TcPO2 27 mmHg. Arteriography confirmed the localized left lesions with three distal popliteal and proximal arterial occlusions, all other arteries being strictly normal. Arterial and dermatological radiation leg ulcer was retained as the etiological diagnosis. As the ulcer was very painful, extensive and limited walking distance, surgical revascularisation was undertaken because endoluminal revascularization was impossible. A femoroperoneal saphenous bypass was performed with surgical incisions beyond the radiodermatitis area. Two months after a split skin graft, the ulcer was considered healed and the patency of the by-pass confirmed on duplex examination. This is the first case report of a successful distal by-pass performed for radiation arteritis and ulcer healing. Long-term follow up should be reported.

[Compression therapy: Choosing the right option for leg ulcers in 2016]. / Quelle compression veineuse utiliser en 2016 pour un ulcère de jambe ?

Compression therapy is a mandatory treatment of leg ulcers whether the goal is cure (stage C6 in the international classification for chronic venous disease) or prevention of recurrence (stage C5). Different indications for compression therapy were proposed by the French Superior Health Authority (HAS) in 2010, but new studies have modified attitudes since that time. Considering the very large number of options available, the many co-morbid conditions observed in these patients, as well as patient age and available assistance, it is important to adapt to the variable clinical and social situations encountered. One must keep in mind that a well-controlled treatment should improve trophic disorders and patient comfort. A poorly-adapted treatment with little or even deleterious effect will be abandoned by the patient.

Methicillin-resistant Staphylococcus aureus. Nosocomial acquisition and carrier state in a wound care center.

OBJECTIVE: To assess methicillin-resistant Staphylococcus aureus (MRSA) nosocomial acquisition and carrier state in a wound care center. DESIGN AND SETTING: The results of an intervention to control MRSA were compared with those of historical controls at the wound care center of university-based Hôpital Broussais, Paris, France. PATIENTS: Patients admitted for specific care of chronic ulcers and surgical wounds. MAIN OUTCOME MEASURES: Incidence rates of MRSA carriers and acquisition in wounds. RESULTS: Of 88 patients admitted during a 3-month preintervention period in 1993, 18 (21%) were MRSA carriers. Of 334 patients admitted in 1994 and 395 in 1996, 65 (19.5%) and 81 (20.5%) were MRSA carriers, respectively (P=.80). In 1993, 6 (9%) of 70 patients without MRSA acquired MRSA wound infections; the corresponding numbers were 6 (2.2%) of 269 in 1994 and 3 (0.9%) of 314 in 1996. Despite that the number of MRSA carriers remained stable at admission to the wound care center, the rate of MRSA infections in wounds per 100 noncarriers decreased significantly between the preintervention period and subsequent years: 1994 (P=.02) and 1996 (P=.002). CONCLUSIONS: Although our results are limited by the use of historical controls, they showed that simple infection control measures, such as the use of soap and water and barrier precautions associated with staff education, seemed to significantly reduce MRSA infection rates in patients with chronic skin breaks.

Leg ulcers and hydroxyurea: forty-one cases.

BACKGROUND: Hydroxyurea is an antitumor agent used to treat chronic myeloproliferative disorders. Leg ulcerations have been reported in patients undergoing long-term hydroxyurea therapy for myeloproliferative diseases. To better define this dermatological adverse effect of hydroxyurea therapy and to try to understand the pathophysiological process of this disease, we collected medical information for such patients in a multicenter retrospective study. OBSERVATIONS: Forty-one patients (mean age, 67 years) developed leg ulcerations while undergoing hydroxyurea therapy (mean therapy duration, 5 years). The sex ratio was 1, and there was no underlying vascular disease. Hematologic abnormalities were identified. Complete recovery from the ulcerations occurred quickly after withdrawal of treatment in 33 (80%) of the cases. CONCLUSIONS: This longest-reported series of patients confirms the role of hydroxyurea therapy in the onset of leg ulcerations. Healing or improvement requires cessation of treatment. Cutaneous atrophy and impaired wound healing may explain the relationship between hydroxyurea and leg ulcers. In addition, the megaloblastic erythrocytes resulting from the presence of hydroxyurea may circulate poorly through the capillary network. A prospective study in hematologic centers would be valuable.

Fine structural capillary changes and basal lamina thickening in scleroderma (progressive systemic sclerosis) and Raynaud's disease.

Capillary abnormalities were found by electron microscopy in labial salivary gland biopsies obtained from 20 patients with progressive systemic sclerosis (PSS). They consisted of marked thickening and multilayering of basal lamina, degenerative and adaptative endothelial cell changes, alterations of pericytes and perivascular mononuclear cell infiltration. There was no correlationship between the intensity of the capillary abnormalities and the duration of the disease. In 12 patients with Raynaud's disease (RD) such changes were not found. Thus capillaries displayed normal-looking ultrastructural appearances. Mean capillary basal lamina width was consistently thicker in the PSS group than in the RD group (p less than 0.001). These observations are consistent with the hypothesis that the primary event in PSS occurs in the microvessels. It is suggested that labial salivary gland biopsy may be helpful for early recognition of PSS among subjects with Raynaud's syndrome.

Efficacy of Daflon 500 mg in venous leg ulcer healing: a double-blind, randomized, controlled versus placebo trial in 107 patients.

The objective of this study was to evaluate the efficacy of Daflon 500 mg (Dios)* in venous ulcers. A multicenter, double-blind, randomized, controlled versus placebo (Plac) trial was conducted, with stratification according to the size of ulcer (< or = 10 cm and > 10 cm). The protocol called for a two-month treatment with Dios (one tablet = 450 mg micronized purified Diosmin) or a placebo, two tablets/day, in addition to compression therapy. Evaluations were performed every fifteen days, from D0 to D60. The primary endpoint, in accordance with Alexander House group requirements were: percentage of patients with complete ulcer healing, ie, comparison between Dios and Plac group at D60, and comparison of survival curves in each group between D0 and D60 (log rank test). Secondary endpoints included ulcer surface area assessed by computerized planimetric measurements, qualitative evaluation of ulcers, and symptoms. The patients were 105 men and women ranging in age from eighteen to eighty-five years, with standard compression stocking, who were undergoing standardized local care of ulcer and had no significant arterial disease (ankle/arm systolic pressure index > 0.8). Fifty-three patients received Dios, and 52 received Plac. The 2 groups were well matched for age (m +/- 1 SD = seventy-one +/- eleven years), gender, ulcer size, and associated disorders. Among patients with ulcer size < or = 10 cm (Dios = 44, Plac = 47) a significantly larger number of patients had a complete ulcer healing at two months in the Dios group (n = 14) in comparison with the Plac group (n = 6) (32% vs 13%, P = 0.028) with a significantly shorter time duration of healing (P = 0.037). No difference was shown for the secondary criteria, except for sensation of heavy legs (P = 0.039) and a less atonic aspect of ulcer (P = 0.030) in favor of Dios. Among the 14 patients with ulcer size > 10 cm (Dios = 9, Plac = 5), subjected to a descriptive analysis only, no ulcer healed. This study showed that a two-month course of Daflon 500 mg at a daily dose of two tablets, in addition to conventional treatment, is of benefit in patients with venous ulcer < or = 10 cm by accelerating complete healing.

[Multiple arterial lesions in von Recklinghausen's disease. A case]. / Lésions artérielles multiples au cours de la maladie de von Recklinghausen. Une observation.

Arterial lesions are thought to be rare in neurofibromatosis. In the case reported here full vascular exploration demonstrated diffuse lesions of the aorta, splenic artery, renal arteries, left internal carotid artery, right common iliac artery and arteries of the legs. This underlines the usefulness of thorough angiographic exploration when arterioplasty is envisaged in a patient with neurofibromatosis. Microscopic examination of an arterial biopsy specimen showed fibrodysplasia of the media associated with hyperplasia of the periarterial nerves, thus confirming that the lesions involved tissues of both mesodermal and neuroectodermal origins.

[Nutritional status assessment of patients with leg ulcers]. / Evaluation du statut nutritionnel des malades atteints d'ulcères de jambe.

INTRODUCTION: Nutritional deficiencies may delay the wound healing process. The aim of this study was to evaluate the prevalence of protein malnutrition in patients presenting with a leg ulcers and to determine which clinical data can predict malnutrition on population. PATIENTS AND METHODS: This prospective survey included community patients, hospitalized in rehabilitation care unit for treatment of a leg ulcer unhealed for at least 3 months. Clinical, anthropometric and biological data were collected on admission. RESULTS: Sixty-six patients, mean age 72.9 +/- 16.3 years, were included. Fifty-three p. 100 presented wound surfaces over 30 cm(2); 59 p. 100 of the ulcers had lasted for more than one year; 62 p. 100 of the ulcers were venous. 48.5 p. 100 of the patients exhibited protein malnutrition defined by biological criteria, associated with an inflammatory syndrome in 66 p. 100. Anemia and an inflammatory syndrome were present in respectively 59 and 58 p. 100 of the patients. Neither anthropometric measurements nor nutritional intake or wound characteristics significantly differenced between patients with malnutrition or not. Hypoalbuminemia was significantly more frequent and severe in patients aged over 70. DISCUSSION: Protein malnutrition prevalence is very high in patients with leg ulcers, particularly in the elderly. Since nutritional interview or clinical data failed to predict protein malnutrition, systematic biological assessment is justified in all patients with leg ulcers.

[Diagnostic pitfalls of cutaneous complications of chronic venous insufficiency]. / Pièges diagnostiques des complications cutanées de l'insuffisance veineuse chronique.

Cutaneous lesions of the lower limbs are not always of venous origin. Only careful examination of the skin and of the leg can detect other causes. Such examination is important not only for understanding the pathophysiological origin but especially for treatment decision. Certain possible causes should be routinely sought such as arterial abnormalities and cutaneous vasculitis. Some ulcerations from the onset have an atypical appearance, such as necrotic angiodermatitis and pyoderma gangrenosum. Rarer causes (tumoural, haematologic, infectious or congenital) should be considered in case of resistance to usual treatments for severe venous insufficiency.

[Risk factors of serious bleeding among ambulatory patients taking antivitamin K aged 75 and over]. / Les déterminants d'hémorragies graves des sujets ambulatoires âgés de 75ans et plus sous antivitamine K.

The benefits of anti-vitamin K (AVK) drugs have been acknowledged in several indications. Such indications increasing with increasing age, AVK prescriptions also increases with age. At the same time, conditions involving significant bleeding are common in this elderly population. It is thus essential to recognize the determining factors. This study included all patients taking AVK drugs aged 75 years and older who sought emergency care at the Cochin Hospital from January to December 2011 for significant bleeding. These patients were compared with a cohort of patients aged 75 years or older who were taking AVK drugs and who were admitted to the same unit during the same time period for other reasons. The case-control comparison included demographic data, comorbidity factors, multiple medications, emergency measured INR, and CHA2DS2VASC level. The hemorrhagic risk was evaluated by HEMORR2HAGES and HAS-BLED. A total of 34 patients were studied and compared with 70 case-controls. The Charlson comorbidity index was higher in patients than case-controls (P<0.05), with a much higher hemorrhagic risk for scores ≥ 9 (OR=2.5; P<0.05). Multiple medication was also more predominant in patients (P<0.05). The risk of serious hemorrhage was also higher when the hemorrhagic scores were high, especially for HEMORR2HAGES (P<0.0001) and HAS-BLED (P<0.001). The risk of serious hemorrhage in elderly outpatients taking AVK drugs is related to their higher comorbidity and hemorrhagic levels which need to be evaluated before starting or stopping AVK treatment.