Platelet rich fibrin: A novel treatment for trophic ulcer in Hansen's disease.

Patients with Hansen's disease are liable to develop non-healing trophic ulcers. The aim of this study was to determine the efficacy of autologous platelet rich fibrin (PRF) applied at weekly intervals in the management of trophic ulcers. The mean age of the patients, duration and size of ulcer were 44.3 years, 7.4 months and 6.25cm2 respectively. After the third sessions of weekly dressing, there was a significant reduction in the ulcer area (p value = 0.015). All ulcers healed by a maximum of six weeks. No adverse events were noted. PRF thus seems a feasible, safe, simple and cost-effective treatment method.

PERCUTANEOUS TRANSLUMINAL ROTARY ATHERECTOMY IN PATIENTS WITH ATHEROSCLEROTIC LESIONS OF BELOW THE KNEE ARTERIES.

OBJECTIVE: The aim: To determine the effectiveness of the combination of the percutaneous transluminal rotational atherectomy (PTRA) techniques with plain old balloon angioplasty (POBA) and POBA monotherapy (POBA-mono) in endovascular treatment (ET) of patients with occlusive-stenotic lesions below the knee (BTK) arteries. PATIENTS AND METHODS: Materials and methods: We studied two groups, the main included patients (n=9) aged who underwent PTRA and POBA of BTK arteries, and the comparative group (POBA-mono) of patients (n=24) who underwent POBA monotherapy of BTK arteries. RESULTS: Results: Thrombosis of the reconstructed segments in the target arteries after 12 months was diagnosed in 95% of patients of the control and 1 - main groups (Ft, p=0.00001). Healing of trophic ulcers of the foot in the first month after ET was observed in 78% (n=7) of patients of the main group and in 13% (n=3) of the control group (χ2 (1, n=33) = 10.2961; p=0.0013), and after 3 months - in 100% (n=9) and 83% (n=20) of patients in the respective groups. CONCLUSION: Conclusions: The combination of PTRA with POBA reduces the probability of repeated violations of the patency of the target artery. In addition, it increases the healing efficiency of trophic ulcers of the LE compared to POBA monotherapy.

Development of local treatment approaches for trophic ulcers.

Trophic venous ulcers are a serious medical and economic issue. Despite a large number of proposed methods for treatment of trophic ulcers, it is not always possible to achieve their complete healing. All this dictates the expediency of further search for more efficient, costeffective and accessible means and methods of trophic ulcer treatment. AIM: The aim of the study was to develop approaches that increase the effectiveness of treatment of patients with trophic ulcers, by constructing a system of sanogenesis in a given pathology in the form of a scheme, analyzing this scheme and finding "weak links" in it, the strengthening of which will contribute to the achievement of the goal. MATERIALS AND METHODS: Modern foreign and domestic literature, Internet-resources and patent documentation were analyzed. The results of our earlier in vitro and in vivo experiments in which the role of neutrophils in wound healing had been studied, were taken into consideration. The deductive method was used in the development and the principle of the systematic approach to the phenomenon under study was implemented. RESULTS: We constructed a system of trophic ulcer sanogenesis in the form of a diagram. Guided by sanogenetic mechanisms, key strategic approaches to the local treatment of trophic ulcers were outlined. It is required to eliminate all factors supporting an inflammatory reaction, contributing to suppuration and create optimal conditions for the transformation and growth of regenerate cells. Certain treatments of the open wound surface at the first and second phases of the wound process were substantiated. It is proposed to moisten the surface of the ulcer with a liquid composition after cleansing the trophic ulcer from dead cells and microorganisms, applying a suspension of autoleukocytes obtained from the patient's venous blood to the wound surface.It contains components with high biocompatibility creating an optimal environment for tissue regeneration in the ulcer. The composition includes DMEM (Dulbecco's Modified Eagle's Medium) liquid medium + 10% of the patient's autosera + a combination of antibiotics active against both pathogenic and all nonpathogenic microorganisms vegetating in the patient's trophic ulcer, in the concentrations of 80-100 mcg/ml that do not interfere with the transformation of regenerate cells. The use of this liquid composition will accelerate the appearance of granulations, epithelialization, and the healing time of trophic ulcers. If a patient has an extensive wound surface, it can be prepared for autodermoplasty earlier. CONCLUSIONS: Based on the construction and analysis of the venous trophic ulcer sanogenesis system, approaches to the local treatment of trophic ulcers have been developed. It is required to eliminate all factors supporting an inflammatory reaction, contributing to suppuration and create optimal conditions for the transformation and growth of regenerate cells. Optimal conditions for the transformation and growth of cells in a trophic ulcer can be created by applying to the surface of the ulcer a liquid nutrient medium for cultivating DMEM cells with autoserum and antibiotics at concentrations that are not toxic to regenerated cells.

[Combined use of minimally invasive methods in treatment of varicose veins in an elderly woman]. / Sochetannoe primenenie maloinvazivnykh metodov v lechenii varikoznoi bolezni u pozhilogo patsienta.

The authors describe herein a clinical case report regarding a 70-year-old woman presenting with lower-limb varicosity in the system of the great and small saphenous veins, aneurysmal dilatation of the proximal portion of the great saphenous vein, and an open trophic ulcer of the crus with concomitant hypertension and coronary artery disease. Given these factors, she was subjected to endovenous laser coagulation of the great and small saphenous veins, microfoam echosclerotherapy of the distal portion of the trunk of the great saphenous vein and an incompetent perforating vein of the crus, followed by complete obliteration thereof. On POD 7, she developed positive dynamics in the process of healing of the trophic ulcer, and on POD 50 the ulcer healed completely. Thus, in elderly patients with lower limb varicose veins with incompetence of trunks of the great and small saphenous veins and pronounced trophic impairments of the crus, preference should be given to minimally invasive methods of treatment. Their combination ensures a good therapeutic effect without increasing the risk for local and systemic complications.

REPARATIVE PROCESSES FEATURES IN TROPHIC ULCERS CAUSED BY DIABETES MELLITUS WITH THE USE OF PLATELET-RICH PLASMA.

OBJECTIVE: The aim: Was following: the improvement of the treatment results of the lower limbs ulcers, caused by the diabetes mellitus by using our technique of the platelet-rich plasma application; the study of the features of the morphological and immunohistochemical changes, and the effect of the growth factors of the platelet-rich plasma on the regeneration and healing of the ulcers. PATIENTS AND METHODS: Materials and methods: 38 patients with the trophic ulcers of the lower limbs, caused by diabetes mellitus were involved in the study. To assess the morphological features of the reparative processes before and after the treatment with PRP, the histological and immunohystochemical studies of the biopsy specimen of ulcers were carried out. RESULTS: Results: The total epithelialization of the ulcers in the patients from the main group was achieved on 46.5 day, and in the comparison group - 81.7 day. The light and optical study of the specimen of the main group, using the autologous platelet-rich plasma revealed the elimination of the destructive changes and reduction of the mixed-cellular infiltration compared to the patients from the comparison group. The immunohystochemical study revealed the increase of the growth factors receptors. CONCLUSION: Conclusions: The usage of the autologous platelet-rich plasma in the treatment of the trophic ulcers results in the rapid regeneration by the decrease of the destructive and inflammatory changes as well as the improvement of the vascularization.

[Comprehensive treatment of indolent trophic ulcers of venous aetiology]. / Kompleksnoe lechenie dlitel'no nezazhivaiushchikh troficheskikh iazv venoznoi étiologii.

AIM: The study was undertaken to evaluate efficacy of comprehensive treatment with the use of erbium laser radiation in patients suffering from venous trophic ulcers of lower limbs. PATIENTS AND METHODS: The study included a total of seventy-six 45-to-80-year-old patients. Of these, there were 43 (56.6%) women and 33 (43.4%) men. The duration of the disease averagely amounted to 10.8±4.8 years. In 38 patients, the bottom of the ulcerative defect was with pronounced periulcerative inflammation and various degree of purulent discharge. All patients were admitted to the surgical department and underwent meticulous examination. Erbium laser irradiation was carried out with consideration for the ulcer size. Laser irradiation was performed at a wavelength of 2940 nm, pulse duration - 0.3 ms, laser beam diameter - 7 mm with radiation power of 2.19 J/cm2. RESULTS: Efficacy of treatment was assessed in dynamics by the degree of pain syndrome, ulcer size upon completion of treatment, as well as the rate of trophic ulcer epithelialisation. In 15 (19.7%) patients with varicose disease the vertical and horizontal reflux was eliminated with performing phlebectomy and echosclerotherapy. The obtained findings demonstrated that 42 (91.3%) patients of the study group had decreased terms of the beginning of purification of the fundus of the ulcer. After 6 months of rehabilitation and follow up, complete ulcer healing was achieved in 18 (64.3%) patients of the control group and in 39 (86.7%) patients of the study group. CONCLUSION: The obtained findings showed that laser radiation proved to be an effective method of treatment in patients presenting with indolent trophic ulcers. Comprehensive treatment made it possible to effectively influence the microflora and the state of regional lymph drainage, to stimulate the processes of reparative regeneration.

Effectiveness and safety of autologous platelet-rich plasma therapy with total contact casting versus total contact casting alone in treatment of trophic ulcer in leprosy: An observer-blind, randomized controlled trial.

BACKGROUND: Trophic ulcers secondary to leprosy pose a great stigma to patients and remain a challenge to the treating dermatologists. Platelet-rich plasma (PRP) introduces growth factors directly into the wound and aids in rapid healing. The role of PRP in the treatment of trophic ulcers in leprosy patients has not yet been established by randomized controlled trials. AIMS: To study the effectiveness and safety of autologous PRP therapy with total contact casting versus total contact casting alone in the treatment of trophic ulcers in leprosy. METHODS: In an observer-blind, randomized (1:1) controlled study, 118 patients were enrolled. PRP was prepared by the manual double-spin method (1600 rpm for 10 min followed by 4000 rpm for 10 min). After wound bed preparation, activated PRP was injected intra- and perilesionally, and platelet-poor plasma gel was applied over the ulcer bed. Occlusive dressings and total contact casting were then applied in Group A, and only total contact casting was applied in Group B. The same procedure was repeated every 2 weeks for 8 weeks. RESULTS: In all, 56 patients were analyzable in Group A and 52 in Group B. The surface area of the ulcer decreased significantly from first follow-up onward in both the groups (P < 0.001 in both the groups). Intergroup comparison showed that the reduction in the surface area of the ulcer was significantly more in Group A than in Group B from the first follow-up onward (P = 0.038) and the difference was maintained till the fifth follow-up (P < 0.001). At the end of the study, 91.10 ± 9.65% ulcer surface area reduction had occurred in Group A, whereas it was 79.77 ± 17.91% in Group B (P < 0.001). Trophic ulcers healed completely more often in paucibacillary leprosy patients (P < 0.001) and in those with a lower initial surface area of the ulcer (P < 0.001). LIMITATION: Short duration of treatment (8 weeks). CONCLUSION: PRP combined with total contact casting accelerates the healing of trophic ulcers of leprosy and is more effective than total contact casting alone. Complete remission is more likely to occur when the duration and surface area of ulcer are less and in the paucibacillary spectrum.

Bacteriological Profile of Aerobic and Anaerobic Isolates of Trophic Ulcer in Leprosy: A Study from Eastern India.

INTRODUCTION: Trophic ulcer is a dreaded complication of leprosy. Secondary infection compounds the damage to the already neglected ulcer. AIMS: To find out the bacterial pathogens in the isolates from trophic ulcers of leprosy and to find the drug sensitivity of the aerobic isolates so as to start a suitable antibiotic therapy. METHODOLOGY: An institution-based, cross-sectional study done over a period of 2 years. Swab was taken from the deeper part of the ulcer. It was put on a suitable culture media. Bacteriological profile was determined and antibiogram was done subsequently. RESULTS: Sixty patients with trophic ulcer secondary to leprosy were screened, among which all were screened for aerobic isolates and 38 were screened for anaerobic isolates. Among the aerobic isolates, 88% of patients were culture-positive. The most common organism was Staphylococcus aureus (37.7%), followed by Pseudomonas aeruginosa (22.64%), Proteus mirabilis (15.09%), Escherischia coli (13.2%), Klebsiella (9.43%). Maximum overall sensitivity was seen with amikacin (93.1%) and linezolid (89.65%). Maximum overall resistance was noted with cotrimoxazole (58.62%) and coamoxiclav (51.72%). Among the 38 patients cultured for anaerobic isolates, 17 were culture-positive for anaerobic organisms. Isolates showing Peptococcus were 6 (15.7%), purely Peptostreptococcus were 4 (10.5%), purely bacteroides were 3 (7.8%), and mixed growths were 4 (10.5%). CONCLUSION: Secondary bacterial infection is quite common in leprosy trophic ulcers. The most common organism was Staphylococcus aureus. Isolates were mostly sensitive to amikacin and linezolid and resistant to cotrimoxazole and coamoxiclav. Anaerobic isolates were not uncommon, with Peptococcus being the most common among them.

[The application of combined low-intensity laser therapy for the treatment of the patients presenting with trophic ulcers associated with chronic venous insufficiency of the lower extremities]. / Kombinirovannaia lazernaia terapiia v lechenii patsientov s troficheskimi iazvami nizhnikh konechnostei.

AIM: The objective of the present study was the evaluation of the effectiveness of the combined treatment of the patients presenting with trophic ulcers associated with chronic venous insufficiency of the lower extremities of venous etiology with the application of low-intensity laser therapy (LILT) at different wavelengths. MATERIAL AND METHODS: The study included the patients presenting with chronic venous insufficiency (CVI) (class C6 in accordance with the CEAP clinical classification). The ultrasonic Doppler examination (USDG) of the lower extremities revealed valvular insufficiency in the saphenous veins in 98.8% of the examined patients, in the deep venous system in 58% of them, and in the perforating veins in 72% of the cases. The laser Doppler flowmetry technique was used to assess the state of the microcirculation. Group 1 was comprised of 34 (43.59%) patients undergoing the traditional conservative treatment that consisted of pharmacotherapy (including antibiotic therapy, depending on the sensitivity of microflora assessed by the culture technique), the local treatment in the form of dressing in compliance with the standard surgical treatment schemes depending on the phase of the wound healing process, and elastic compression of the lower extremities. The main group 2 consisted of 44 patients (56.41%) who were treated, in addition to the traditional conservative therapy, with the use of LILT according to the new technique that combines the external laser exposure of the trophic ulcer region using the 'LASMIK' laser device during a single 2 minute session per zone in the pulsed mode (light pulse duration of 100-130 ns, frequency 80 Hz), at a wavelength of 635 nm, by a matrix emitter (consisting of eight laser diodes with the surface area of 8 cm2), at a distance up to 7 cm, with pulsed power of 40 W, power density of 5 W/cm2, and the intravenous laser blood illumination (fiber output power 2 mW) with a wavelength of 365 nm (UV range) and 525 nm (green spectrum) alternately, every other day. Each patient underwent 12 daily procedures per course. RESULTS: Combined low-intensity laser therapy promoted the rapid recovery of the sympathetic regulation of the microvascular tone and normalization of arteriolar-venular relationships which contributed to the improvement of blood supply to the tissues, the reduction of inflammation, enhanced activation of the reparative processes, and acceleration of epithelialization of trophic ulcerous defects. CONCLUSION: The combined strategy makes it possible to carry out the more effective treatment of the patients presenting with trophic ulcers with the three-fold reduction of the ulcer healing time and the pronounced stimulation of the persistent adaptation of the physiological responses preventing the development of the relapses.

[Efficacy and safety of collagen biomaterial local application in complex treatment of the diabetic foot syndrome (final results of the multicenter randomised study)]. / Éffektivnost' i bezopasnost' mestnogo primeneniia kollagenovogo biomateriala v kompleksnom lechenii sindroma diabeticheskoi stopy (itogi mnogotsentrovogo randomizirovannogo klinicheskogo issledovaniia).

AIM: To evaluate the efficacy and safety of collagen biomaterial application during the 4-week follow-up of patients with diabetic foot syndrome. MATERIAL AND METHODS: 75 patients with diabetic foot (Wagner II (69.3%) and III (30.7%)) aged 30-80 years were included in the multicenter study, among them were 50.7% with the wound unhealed for 1.5-6 months and 49.3% over 6-48 months. Patients were randomized into 2 groups: 1) standard therapy (n=37), 2) the additional use of the collagen material Collost (n=38). Observation period was at least 4 weeks for each patient. The size of ulcers, results of general and biochemical blood tests, oximetry, microbiological testing, ultrasound of lower extremities vessels as well as a detailed medical history, social and functional status, level of cardiovascular comorbidity and ongoing therapy were estimated. RESULTS: Additional use of a collagen biomaterial has led to a significant reduction ulcers of all sizes from 13.5 to 2.1 cm2 (in the comparison group - from 12.5 to 7 cm2). The best dynamics have been registered in Wagner II (4.4-fold average wound area regress in Collost group, from 8.8 to 2.0 cm2; average wound area regress by 1.8 times, from 10 to 5.6 cm2 in the comparison group) than in Wagner III group (in the main group from 55 to 21.3 cm2; in the control group from 36 to 32.4 cm2) and in ulcers existing less than 6 months. Treatment with biological material Collost within standard therapy after 4 weeks led to increase of complete epithelialization by 2.6% (21.1% as compared to 14.7%), while decreasing the frequency of ineffective treatment by 4.1 (7.9% in primary and 32.4% in the comparison group). CONCLUSION: We have proved the efficacy and safety of collagen biomaterial topical application in a diabetic foot syndrome treatment.

Autologous Platelet-rich Fibrin Matrix in Non-healing Trophic Ulcers in Patients with Hansen's Disease.

BACKGROUND: Non-healing trophic ulcers in Hansen's disease patients is one of the major causes for disability. It has been shown that autologous platelet-rich fibrin matrix (PRFM) is effective in healing chronic non-healing leg ulcers. AIM: The objective of this study is to demonstrate the efficacy of autologous platelet-rich fibrin matrix (PRFM) in non-healing trophic ulcers in patients treated for Hansen's disease. DESIGN: A prospective study. SETTING: An institution-based clinic. PARTICIPANTS: Seven treated patients with Hansen's disease, with a mean age of 38.33 years, with nine non-healing trophic ulcer of more than 6 weeks duration. MEASUREMENTS: Photographs were taken before treatment and at every subsequent sitting. Area and volume were calculated at baseline and every subsequent sitting till the closure was achieved. MATERIALS AND METHODS: The healthy ulcers were treated with PRFM at weekly intervals, repeated once a week for a maximum of five sittings as per requirement. RESULTS: The mean percentage improvement in the area was 93.52%, and volume was 97.74% at the end of the second sitting. All ulcers closed by a maximum of five sittings. No adverse events were noted. CONCLUSION: PRFM for the treatment of trophic ulcers in treated patients with Hansen's disease is a feasible, safe, simple and inexpensive method.

[The treatment of elderly and senile patients with venous trophic ulcers and type 2 diabetes mellitus.]

The effectiveness of the inclusion of sulodexide in the pharmacotherapy of complex treatment of patients (n=52) elderly and senile with a combination of chronic diseases of the veins complicated by refractory trophic ulcers of the lower extremities, and type 2 diabetes mellitus was studied. Patients were randomly randomized in the 1st (n=26) and the 2nd (n=26) groups, the statistical differences between them in age (t1-2=0,2, p1-2=0,833), sex (χ21-2=0,008, p1-2=0,991), nosology (χ21-2=0,004, р1-2=0,993); the anamnesis of chronic diseases of veins (t1-2=0,14, p1-2=0,893); duration of trophic ulcers (t1-2=0,21, p1-2=0,827); planimetric parameters of trophic ulcers (t1-2=0,18, p1-2=0,865) were not recorded. Patients of the 1st group received treatment with sulodexide according to the standard schedule for 50 days. The primary outcome of the study is the complete closure of the trophic ulcer after 1 month. Secondary outcomes are epithelization after 2 months and dynamic planimetric indices within 12 months. The effectiveness of the use of sulodexide was assessed according to the VCSS scale, dynamic changes in the malleolar volume and changes in planimetric parameters. A statistically significant improvement in the overall VSCC score was observed in both the 1st (p=0,002) and the 2nd (p=0,0016) groups in all study outcomes. At the same time, a statistically significant improvement in the VSCC scores was more pronounced in the 1st group (p<0,05). After 2 and 6 months, a statistically significant decrease in the malleolar volume of the affected lower extremity was recorded both in the 1st (t=4,17, p=0,001) and in the 2nd (t=2,4, p=0,37) groups. Clinically and statistically significant decrease in malleolar volume was more pronounced in the 1st group (p<0,05). After 30 days, trophic ulcers were closed in 9 (34,6%) cases in the 1st group and in 5 (19,2%) patients in the 2nd group (p<0,05). On day 60 epithelization was achieved in 22 (84,6%) and 12 (46,1%) patients, respectively. The time of complete epithelization in patients of the 1st and the 2nd groups was 51,2±1,6 and 78,4±2,6 days (p<0,05). The conclusion is made that sulodexide is an effective and pathogenetically grounded pharmacological preparation for the treatment of patients of elderly and senile age with chronic clinical disease C6 of clinical class and type 2 diabetes mellitus.

Trophic ulcers-Practical management guidelines.

The management of patients with trophic ulcers and their consequences is difficult not only because it is a recurrent and recalcitrant problem but also because the pathogenesis of the ulcer maybe different in each case. Methodically and systematically evaluating and ruling out concomitant pathologies helps to address each patient's specific needs and hence bring down devastating complications like amputation. With incidence of diabetes being high in our country, and leprosy being endemic too the consequences of neuropathy and angiopathy are faced by most wound care specialists. This article presents a review of current English literature available on this subject. The search words were entered in PubMed central and appropriate abstracts reviewed. Relevant full text articles were retrieved and perused. Cross references from these articles were also reviewed. Based on these articles and the authors' experiences algorithms for management have been presented to facilitate easier understanding. It is hoped that the information presented in this article will help in management of this recalcitrant problem.

Angiocentric lesions of the head and neck.

Angiocentric lesions of the head and neck encompass a variety of benign and malignant lesions. Not unexpectedly the sequelae of an angiocentric process independent of its benign or malignant nature is one of tissue ischemia with a potential for either breakdown or reparative fibrosis. Therefore, the clinical presentations can be very similar despite a varied pathogenesis. Among the benign reactive infiltrates that will be considered are angiocentric eosinophilic fibrosis, Wegener's granulomatosis, microscopic polyangiitis and cocaine associated mid line facial destruction. We will discuss other conditions which enter into the differential diagnosis either clinically or histologically including Erdheim Chester disease and mid line facial undermining unrelated to an angiocentric event specifically in the context of trigeminal trophic ulcer and relapsing polychondritis. The two main neoplastic conditions exhibiting angiocentricity are in the context of lymphomatoid granulomatosis and NK/T cell lymphoma; hence these two particular hematologic dyscrasias will be discussed in some detail in this review.