No More Venous Ulcers-What More Can We Do?

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

Inequalities in the patterns of dermoscopy use and training across Europe: conclusions of the Eurodermoscopy pan-European survey.

BACKGROUND: Dermoscopy is a widely used technique, recommended in clinical practice guidelines worldwide for the early diagnosis of skin cancers. Intra-European disparities are reported for early detection and prognosis of skin cancers, however, no information exists about regional variation in patterns of dermoscopy use across Europe. OBJECTIVE: To evaluate the regional differences in patterns of dermoscopy use and training among European dermatologists. MATERIALS & METHODS: An online survey of European-registered dermatologists regarding dermoscopy training, practice and attitudes was established. Answers from Eastern (EE) versus Western European (WE) countries were compared and their correlation with their respective countries' gross domestic product/capita (GDPc) and total and government health expenditure/capita (THEc and GHEc) was analysed. RESULTS: We received 4,049 responses from 14 WE countries and 3,431 from 18 EE countries. A higher proportion of WE respondents reported dermoscopy use (98% vs. 77%, p<0.001) and training during residency (43% vs. 32%) or anytime (96.5% vs. 87.6%) (p<0.001) compared to EE respondents. The main obstacles in dermoscopy use were poor access to dermoscopy equipment in EE and a lack of confidence in one's skills in WE. GDPc, THEc and GHEc correlated with rate of dermoscopy use and dermoscopy training during residency (Spearman rho: 0.5-0.7, p<0.05), and inversely with availability of dermoscopy equipment. CONCLUSION: The rates and patterns of dermoscopy use vary significantly between Western and Eastern Europe, on a background of economic inequality. Regionally adapted interventions to increase access to dermoscopy equipment and training might enhance the use of this technique towards improving the early detection of skin cancers.

A Novel Mutation in the FOXC2 Gene: A Heterozygous Insertion of Adenosine (c.867insA) in a Family with Lymphoedema of Lower Limbs without Distichiasis.

BACKGROUND: Primary lymphoedema is a rare genetic disorder characterized by swelling of different parts of the body and highly heterogenic clinical presentation. Mutations in several causative genes characterize specific forms of the disease. FOXC2 mutations are associated with lymphoedema of lower extremities, usually distichiasis and late onset. PATIENTS AND METHODS: Subjects from three generations of a family with lymphoedema of lower limbs without distichiasis were searched for mutations in the FOXC2 gene. RESULTS: All affected family members with lymphoedema of lower limbs without distichiasis, and still asymptomatic six years old girl from the same family, carried the same previously unreported insertion of adenosine (c.867insA) in FOXC2. CONCLUSIONS: Identification of a novel mutation in the FOXC2 gene in affected family members of three generations with lymphoedema of lower limbs without distichiasis, highlights the high phenotypic variability caused by FOXC2 mutations.

Lymphedema after breast and gynecological cancer - a frequent, chronic, disabling condition in cancer survivors.

The goal of our study was to determine clinical characteristics of women cancer survivors treated for secondary lymphedema, the time from cancer treatment to the development of lymphedema, and the effect of therapy on reduction of lymphedema and occurrence of erysipelas. We performed a retrospective study of women with secondary lymphedema after breast cancer (BR) and gynecological (cervical, uterine, ovarian, vulvar) cancers (GYN) treated at our Department from 2004 to 2010. The average time from cancer treatment to the development of lymphedema in our patients was 2.2 and 4.75 years in the BR and GYN groups, respectively, ranging from within days after the procedure to as long as 31 years. The duration of lymphedema in our patients before they first received appropriate therapy was on average 4.1 and 2.65 years in the BR and GYN groups, respectively. In our series, untreated lymphedema was a strong predisposing risk factor for erysipelas, whereas no cases of erysipelas were noticed after the establishment of therapy. Compression therapy was shown to be an effective measure to reduce lymphedema. The duration of required initial decongesting therapy with short-stretch elastic bandages was longer in patients with more long-standing edema. Lymphedema may first appear several years after the cancer procedure. Our findings emphasize the need for awareness of lymphedema as a possible long-term iatrogenic complication in cancer survivors to avoid a delay in diagnosis and therapy. Physicians in care of cancer survivors should actively look for lymphedema. Untreated lymphedema is a strong predisposing risk factor for erysipelas.

[Setting of compression therapy]. / Postavljanje kompresijske terapije.

Compression therapy is the basic therapy in phlebology and lymphology. The pressure under the bandages has to exceed the intravenous pressure especially in standing position. Different compression materials such as short stretch systems, long stretch bandages and compression garments work differently on ambulatory venous hypertension, speed of reducing edema and arterial flow. Compression with high stiffness, inelastic materials is more effective than compression with low stiffness, elastic materials. These materials have to be placed correctly. Inelastic systems should be applied with high initial pressure because the pressure will loose at some time after walking. Even after one week of wearing, inelastic bandages keep higher resting and working pressure during walking than elastic bandages. However, more important is that they have lower resting pressure than elastic materials. Long stretch bandages and compression garments with great extensibility ensure low working pressure and higher resting pressure than short stretch systems.

[Modern wound dressings]. / Suvremena pokrivala za rane.

Chronic wounds are, due to the slow healing, a major clinical problem. In addition to classic materials, a great number of supportive wound dressings for chronic wound treatment, developed on the basis of new knowledge about the pathophysiological events in non-healing wounds, are available on the market. Today we know that modern wound dressings provide the best local environment for optimal healing (moisture, warmth, appropriate pH). Wound dressings control the amount of exudate from the wound and bacterial load, thus protecting local skin from the wound exudate and the wound from secondary infections from the environment. Using supportive wound dressings makes sense only when the wound has been properly assessed, the etiologic factors have been clarified and the obstacles making the wound chronic identified. The choice of dressing is correlated with the characteristics of the wound, the knowledge and experience of the medical staff, and the patient's needs. We believe that the main advantage of modern wound dressing versus conventional dressing is more effective wound cleaning, simple dressing application, painless bandaging owing to reduced adhesion to the wound, and increased absorption of the wound exudate. Faster wound granulation shortens the length of patient hospitalization, and eventually facilitates the work of medical staff. The overall cost of treatment is a minor issue due to faster wound healing despite the fact that modern supportive wound dressings are more expensive than conventional bandaging. The article describes different types of modern supportive wound dressings, as well as their characteristics and indications for use.

[Compression therapy for lymphedema: our experience]. / Nasa iskustva s kompresijskom terapijom limfedema.

The term lymphedema refers to a chronic, progressive edema, usually of a limb, due to insufficient lymphatic flow. It may appear as a primary disturbance or secondary to other causes, e.g., after infections or surgery. The most common cause of lymphedema in the Western world is cancer surgery and/or radiotherapy. The authors summarize the etiology, pathophysiology and clinical staging of lymphedema. The diagnosis of lymphedema is usually based on history and clinical appearance. However, lymphoscintigraphy is the gold standard of imaging in doubtful cases. Adequate and early compression therapy and good patient compliance are the cornerstones of management of lymphedema. The authors present their experience with compression therapy for lymphedema. While no differences were found in the efficiency of compression therapy between oncologic and non-oncologic patients, compression stockings of class III seemed to be efficient in the majority of secondary lower limb lymphedemas but not as maintenance therapy for primary lower limb lymphedema.