Lower Limb Ulcers Research Articles

Clinical significance of early venous enhancement on CT angiography of the ischemic lower limbs.

The authors observed good clinical courses in patients with lower limb ulcers and extensive skin inflammation who showed early venous enhancement at contrast-enhanced lower extremity computed tomographic angiography. The author hypothesized that these early venous enhancements tend to occur in conditions of healthier vascular status. A total of 145 patients who met the inclusion criteria were classified based on the degree of arterial occlusion and early venous enhancement according to lower extremity angiography. Early venous enhancement correlated with age over 65 (t-score = 0.001), absence of ulcer history (t-score = 0.003), absence of amputation history (t-score = 0.004), and low ankle-brachial index (P value = .001). We confirmed that the factors related with early venous enhancement differ from the factor inducing arterial occlusion. Prior to this study, early enhancement of veins in the lower limb was thought to be an artifact. However, in this study, veins that show early enhancement are suspected of being healthier and more responsive to inflammation than those that do not show early enhancement. These findings may help to predict the clinical course and to determine therapeutic planning without additional studies. Also, it can be easily reproduced in other facilities.

Lower limb ulcer and Raynaud's phenomenon

A 64-year -old patient sought medical advice for an ulcer of the lower extremities (Fig 1). He also presented with claudication, chronic dyspnea, skin thickening, and late-onset Raynaud's phenomenon (RP). There were no palpable dorsalis pedis or posterior tibial pulses. Skin examination showed reduction of forehead folds, facial and tongue telangiectasias, xerosis cutis, salt-and-pepper hyperpigmentation, sclerodactyly, digital ulcerations, and pitting scars (Fig 2). Chest auscultation revealed crackles on the lower lobes.

P11.14: The Use of Ex Vivo Normothermic Perfusion to ‘Pause’ Cold Ischaemic Time to Allow for Third Recipient to Be Selected And Undergo Kidney Transplant

Introduction: On arrival to the hospital on receipt of a transplant offer, recipients can be found to be unfit precluding transplantation. In this instance, the graft is offered back to NHS Blood and Transplant. Grafts often, however, remain locally to reduce cold ischaemic time inherent in further relocation. When another suitable recipient is not found, and cold ischaemic time (CIT) increases to undesirable levels, grafts can unfortunately be deemed unusable. Case Presentation: Herein we describe a case in which ex vivo normothermic perfusion (EVNP) facilitated the admittance of a third potential recipient for a 66yo DCDkidney. The first two allocated recipients who were deemed unfit: the first recipient was found to have an infected lower limb ulcer; the second patient was found to have raised inflammatory markers in the context of an aorto-bifemoral graft. At the time a third recipient (55yo, pre-dialysis) was selected the CIT on the graft was 19 hours. The patient was admitted to the ward and EVNP was used to ‘pause’/limit CIT in order for the patient to be prepared, assessed and consented for transplantation. Outcome: EVNP assessment score = 1 (one hour perfusion duration), with excellent perfusion demonstrated and good urine output (>100ml); total CIT was 23 hours at in situ reperfusion. The patient was successfully transplanted and the graft achieved primary function with a creatinine of 166µmol at time of discharge. At 5 months the creatinine is 151µmol and eGFR 32mls/min/m2. Discussion: Without EVNP this graft would have likely been discarded. Cold ischaemic time was effectively paused by the perfusion technology allowing the graft to be assessed and utilised, and ultimately prevented graft discard. EVNP offers a technique to improve organ utilisation.

Prevalence and risk factors of lower extremity disease in high risk groups in Malawi: a stratified cross-sectional study

ObjectiveLow/middle-income countries face a disproportionate burden of cardiovascular diseases. However, among cardiovascular diseases, burden of and associations with lower extremity disease (LED) (peripheral arterial disease and/or neuropathy) is neglected. We...

Changes in miroRNA-103 expression in wound margin tissue are related to wound healing of diabetes foot ulcers.

To investigate the relationship between small noncoding microRNA-103 (miR-103) and wound healing of diabetic foot ulcers (DFU) and the underlying molecular mechanism, forty type 2 diabetes mellitus with DFU (DFU group), and 20 patients with a chronic skin ulcer of lower limbs and normal glucose tolerance (SUC group) were included. Quantitative real-time PCR method was used to determine miR-103 expression levels in the wound margin tissue of subjects, and to analyse the relationship between the expression of miR-103 and DFU wound healing. In vitro experiments were also performed to understand the effect of miR-103 on the high glucose-induced injury of normal human dermal fibroblasts (NHDFs) cells. The results showed that the miR-103 expression level in the DFU group was significantly higher than that in the SUC group [5.81 (2.25-9.36) vs 2.08 (1.15-5.72)] (P < 0.05). The expression level of miR-103 in the wound margin tissue of DFU was negatively correlated with the healing rate of foot ulcers after four weeks (P=0.037). In vitro experiments revealed that miR-103 could inhibit the proliferation and migration of NHDF cells and promote the apoptosis of NHDF cells by targeted regulation of regulator of calcineurin 1 (RCAN1) gene expression in a high glucose environment. Down-regulation of miR-103 could alleviate high glucose-induced NHDF cell injury by promoting RCAN1 expression. Therefore, the increased expression of miR-103 is involved in the functional damage of NHDF cells induced by high-glucose conditions, which is related to poor wound healing of DFU. These research findings will provide potential targets for the diagnosis and treatment of chronic skin wounds in diabetes.

Chronic wounds in the elderly: Decubitus, leg ulcers, and ulcers of rare aetiology

Abstract The ageing processes, primarily after the age of 60, bring about a number of important changes that affect the skin’s protective function. These changes directly and indirectly increase its vulnerability and impair its ability to heal. Hence, the incidence of chronic wounds increases in the elderly population. Dry skin, often accompanied by itching and consequent scratching, can lead to the development of wounds. The skin’s ability to regenerate itself is also impaired by the atrophy that affects all the three layers of the skin, the epidermis, dermis, and subcutis. The deterioration of vascularisation and innervation increases the chance of ulcer formation and impaired healing of existing wounds. Together these lead to the development of chronic lower limb ulcers in elderly patients or decubitus in older bedridden patients. Bedsores are more likely to develop in older patients with reduced body weight due to their decreased amount of adipose tissue capable of pressure-relieving. This latter negative tendency may be exacerbated by the presence of reduced mobility, impaired muscle strength, and frequent incontinence. In all respects, the propensity to heal is worse than in younger age, thus in many cases a chronic process is expected, and in some cases halting the progression may be a significant outcome. Ulcers of rare aetiology can occur at any age, so pyoderma gangrenosum, vasculitis, and other ulcers with rare aetiology in the elderly population should also be considered.

MicroRNA-301a-3p is a potential biomarker in venous ulcers vein and gets involved in endothelial cell dysfunction

ABSTRACT Venous ulcer is a common contributor to chronic venous insufficiency (CVI) of lower limbs, which seriously affects the life quality of patients. In this study, we researched the expression characteristics of microRNA-301a-3p (miR-301a-3p) in patients with CVI and investigated the impact of miR-301a-3p on the dysfunction of human umbilical vein endothelial cells (HUVECs). The plasma level of miR-301a-3p in normal controls, patients with varicose great saphenous vein, and patients with the venous ulcer of lower limbs were measured. We adopted Interleukin-1β (IL-1β), H2O2, and oxygen and glucose deprivation (OGD) to induce endothelial cell injury in vitro. In this way, we evaluated the influence of miR-301a-3p on HUVEC viability, apoptosis, inflammatory response, and oxidative stress. Our data showed that miR-301a-3p was substantially overexpressed in patients with lower limb venous ulcers. The viability of HUVECs decreased, and miR-301a-3p was up-regulated after IL-1β, H2O2, and OGD treatment. miR-301a-3p inhibition greatly ameliorated the dysfunction and cell damage of HUVECs, promoted IGF1/PI3K/Akt/PPARγ, and down-regulated NF-κB/MMPs. The phosphatidylinositol 3-kinase (PI3K) inhibitor (LY294002) or the peroxisome proliferator-activated receptor-γ (PPARγ) inhibitor (GW9661) reversed the anti-inflammatory, antioxidant, and anti-apoptotic effects mediated by miR-301a-3p down-regulation. The nuclear factor-κB (NF-κB) inhibitor lessened cell injury mediated by miR-301a-3p overexpression. In terms of the mechanism, miR-301a-3p targeted the 3ʹUTR of Insulin-like growth factor-1 (IGF1) and repressed the profile of IGF1. Thus, miR-301a-3p mediates venous endothelial cell damage by targeting IGF1 and regulating the IGF1/PI3K/Akt/PPARγ/NF-κB/MMPs pathway.

Application of alginate dressing in the healing of chronic ulcers of lower limbs.

Application of alginate dressing in the healing of chronic ulcers of lower limbs.

Randomized, double-blind clinical trial comparing the healing of stasis ulcers in lower limbs with standard hydrocolloid gel dressings and with dressings with Syzygium cumini extract.

To evaluate the healing of venous ulcers in the lower limbs (VLU) using dressings with hydrocolloid gel associated with Syzygium cumini extract (SHG) compared to standard hydrocolloid gel dressings (HG). This prospective, double-blind, randomized trial recruited 90 patients with VLU divided into: dressings with SHG (n = 44) and dressings with HG (n = 46). Primary endpoint was healing in the 14th visit. Secondary endpoints were healing rate, complete healing during follow-up, and improvement in the pain scale and in quality of life. There were no significant between-group differences in healing (p = 0.15). The wound area made healing difficult (p = 0.008). Age, body mass index, and wound time demonstrated a tendency to worsen the healing. Positive culture for Pseudomonas aeruginosa resulted in 88% reduction in the healing risk (p < 0.0001). There was no difference between the dressings evaluated. The presence of Pseudomonas aeruginosa significantly impaired wound healing.

High Versus Low Frequency Transcutaneous Electric Nerve Stimulation On Chronic Venous Lower Limb Ulceration Randomized Controlled Trial.

The major objective of the current paper is to trace and investigate which method is more effective whether the high or the low Transcutaneous electric Nerve Stimulations (TENS) on venous ulcers. A single-blinded, randomized, and controlled trial was done successfully. Sixty venous ulcer patients were divided randomly into three groups; Group (A): control group, Group(B): High-TENS group, and Group(C): Low-TENS group. Group (A), contains twenty participants who received routine medical care and dressing. As for group (B), includes twenty participants who obtained high-frequency TENS; Frequency (80-120) HZ, Intensity (15 - 30 amp), Pulse duration 250 Micro sec, 60 min per session with routine medical care and dressing. The third group (c) L-TENS, encompasses twenty participants who received low-frequency TENS (1-5) HZ; Intensity (30 -80 amp), Pulse duration 250 Micro sec, 60 min per session with routine medical care and dressing. All the participants were examined before and after two months of intervention; four weeks (post1), then after eight weeks (post2). Participants were examined by using (image j) to measure the ulcer area. Saline was used for measuring the ulcer volume, and a visual analog scale was adopted to evaluate pain. After drawing a comparison among the three groups after four weeks and after eight weeks of treatment, a statistically significant decrease (P <0.05) in wound surface area, wound volume, and pain in favor of L-TENS was noticed. It has been found that L- TENS is more effective than H -TENS and is highly recommended in the treatment protocol for such debilitating conditions.

Current and emerging treatments for people living with lower limb ulcers: Session summary

Lower limb ulcers (LLUs) are common, with a prevalence of 0.8 to 2.2 patients per 1000 population, doubling in incidence in people aged over 65. Lower limb ulcers significantly impact an affected individual’s quality of life and are costly to treat. Diagnosing the cause of the ulcer is critical to successful management. Many affected individuals have ulcers with mixed etiology, which makes diagnosis and therapy challenging. (Session summary from Wounds Canada 2021 National Conference.)

Lower Limb Assessment Related to Vascularity: A Simple Bedside Enabler.

The lower limb is a vulnerable area of the body and often subjected to minor or major trauma. In the presence of underlying systemic disease, especially with comorbidities related to arterial blood supply and simple venous backflow compromise, traumatic injury may trigger an acute lower limb skin injury to become a chronic ulcer.1 Regardless of the cause of skin breakdown, the majority of chronic lower limb wounds often have an underlying venous etiology2 that can be managed successfully with compression therapy.3 However, not all leg wounds present in the same way nor should they be treated equally. The subtle presence of arterial compromise in a predominantly venous etiology may change the appearance of the wound, the pain experience of the patient, and patient adherence to the treatment protocol (mixed venous-arterial etiology).4 Equally challenging may be lower limb edema in the limb of a person with arterial insufficiency who is not eligible for full compression therapy (mixed arterial-venous etiology).5 These mixed clinical presentations often have subtle differences and, if those are missed, clinical outcomes may not be achieved. The importance of interprofessional team involvement in managing challenging wounds that do not heal at the expected rate cannot be emphasized enough.6 Accordingly, the aim of this bedside enabler is to help clinicians recognize different clinical presentations of lower limb ulcers and assessment markers (Table 1). Recognizing these nuances in day-to-day clinical practice will promote correct initiation of adapted intervention protocols, leading to improved patient outcomes. The Table in this Practice Points column includes markers associated with blood flow etiologies of venous, arterial, mixed arterial-venous, mixed venous-arterial, and the combined neuroischemic diabetic foot.Table 1: FACTORS ASSOCIATED WITH DIFFERENT UNDERLYING ETIOLOGIES IN LOWER LIMB WOUNDSBy empowering clinicians to use multiple markers associated with lower leg and ischemic-related foot ulcers, early detection of complex lower limb ulcers with potential healing difficulties can be established from the outset. Clinicians should prioritize the correction of underlying etiologies and form an interprofessional team centered around the patient. Appropriate interventions should be initiated as needed, such as correction of arterial blood supply, smoking cessation, edema control, and weight loss, as well as metabolic control of blood glucose in persons with diabetes. Astute clinical assessment promotes timely wound treatment, lowering cost while improving patient quality of life.

Pyoderma gangrenosum mimicking a Buruli’s ulcer in an HIV-positive patient from Ivory Coast

A lower limb ulcer is a disabling disease with significant functional impact and difficulties to manage. Ulcers, due to infectious agents, an inflammatory etiology, or microvascular occlusion are particularly challenging in terms of diagnosis and treatment. The management of such ulcers requires proper clinical examination as well as oriented biological and histological assessments. Herein, we report the case of a 39-year-old female from Ivory Coast with an extensive bilateral lower limb ulcer evoking a Buruli’s ulcer. Investigations, however, revealed a severe case of pyoderma gangrenosum in an HIV-positive patient. Our case report demonstrates the difficulties in the diagnosis of leg ulcers, especially in immunosuppressed patients. Confusing pyoderma gangrenosum with a Buruli’s ulcer may lead to extensive surgery or the use of long-term steroids with multiple iatrogenic complications, hence the importance of a skin biopsy and biological assessments in establishing a correct diagnosis.

Observation of effect of pulse debridement combined with prp in the healing of chronic ulcers of lower limbs.

Observation of effect of pulse debridement combined with prp in the healing of chronic ulcers of lower limbs.

Deep Venous Thrombosis and Ulcers of Lower Limbs: Ultrasound Findings in 156 Patients.

Venous ulcers (VUs) of lower limbs affect 1% of Western population. In most cases, ultrasounds show only superficial venous insufficiency (SVI), but a deep venous insufficiency (DVI) may also be present without a history of deep vein thrombosis (DVT). To assess SVI and DVI in DVT-positive and DVT-negative patients with VU, a retrospective cohort of 123 patients entered the study (50 male and 73 female, minimum age 29 years and maximum age 90 years, and mean 70.6 years). In 56 patients (45.5%), ulcer was on the right leg, in 52 (42.3%) on the left leg, and in 15 patients (12.2%), ulcer was bilateral, resulting in a total number of 138 limbs in the study. Sixty-six patients suffered DVT, while in 72 anamnesis was negative. Color duplex ultrasound was performed on both limbs, which revealed insufficiencies of superficial and/or deep veins in 18 limbs which had not been affected by an ulcer or a previous DVT. So the study was on 156 limbs. SVI were substantially overlapping in two groups ( p -value = 0.593), while combined SVI and DVI was 72.5% in DVT positive limbs ( p -value = 0.001). In 70% of cases with a femoral vein insufficiency ( p -value = 0.036) or popliteal vein insufficiency (PVI) ( p -value 0,003), a DVT history was present. Of 18 limbs, although not affected by ulcer or previous DVT, eight were positive for DVI (two femoral veins and six popliteal veins). In the patient with VU, the history of DVT is a strong predictor of DVI insufficiency. In DVT-positive patients with ulcer, the number of "combined superficial and deep insufficiencies" appears to be particularly significant and surgical treatment must take this into account. A previous DVT has a low impact on great and small saphenous insufficiencies in ulcer patients; these were substantially overlapping in DVT-positive and DVT-negative patients. The 18 limbs with DVI and SVI without ulcer and DVT history were unexpected result. We think these patients must have a close follow-up to avoid the onset of a VU.

Predictive Value of Contrast-Enhanced Ultrasound in Chemical Lumbar Sympathectomy for End-Stage Arteriosclerosis Obliterans of the Lower Extremities.

IntroductionThe therapeutic effect of chemical lumbar sympathectomy (CLS) on ischemic diseases of the lower limbs varies greatly among individuals. The time to peak (TTP) response in contrast-enhanced ultrasound (CEUS) can reflect the perfusion disorder of the calf skeletal muscle and the collateral circulation. In this study we evaluated the predictive value of CEUS in patients treated with CLS for end-stage atherosclerotic occlusive disease of the lower extremity (ASO-LE).MethodsThis was a prospective study that included patients with end-stage ASO-LE and moderate to severe pain who had undergone a CEUS examination and CLS procedure and who were observed for 12 months after surgery. The patients’ characteristics and prognostic factors, including lower limb pain score, skin temperature, walking distance, and ulcer and gangrene healing, were recorded.ResultsFifty-eight patients with a mean age of 66.24 (range 58–78) years were included in the study, of whom 42 (71.41%) were men. Following the CLS procedure, the numerical rating scale (NRS)-measured pain decreased significantly, and the skin temperature of the affected limb increased significantly (P < 0.05). The satisfaction rate of lower limb pain relief 1 year after operation was 53.45%. Correlation analysis showed that preoperative TTP response was correlated with the NRS score and skin temperature of the affected limb at 6 months and 12 months post surgery (P < 0.05). The binary logistic regression analysis indicated that a longer preoperative TTP response was associated with a higher risk of poor pain relief after CLS (odds ratio 1.126, 95% confidence interval 1.058–1.205). The receiver operating characteristic curve showed that preoperative TTP response had a certain predictive value on CLS treatment effect, with a sensitivity and specificity of 81.5% and 83.9%, respectively. When the preoperative TTP response was > 77.5, the risk of poor response after CLS increased.ConclusionsPreoperative TTP response was able to predict the therapeutic effect of CLS to a certain extent, and thus may aid physicians in determining the choice of CLS treatment for patients with ASO-LE.Trial RegistrationChinese Clinical Trial Registry: ChicTR1900028424 (principal investigator: Yue Wu; date of registration: 21 December 2019).Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-021-00347-9.

The presence of anemia in patients with leg ulcer: laboratory test.

To evaluate the presence of anemia in patients with chronic lower limb ulcers based on profile and hematometric indices. This is a cross-sectional study carried out in a university hospital in Rio de Janeiro. The sample was composed of 64 participants with lower limb ulcers and evolution time greater than 12 weeks. Data was collected between May/2016 and December/2017 from hematological analyses, records from medical records, and wound assessment form. 36 (56.2%) were male; 38 (59.4%) between 60 and 80 years old; 56 (87.5%) with chronic diseases and 52 (81.2%) with venous ulcers. 6 years mean of active ulceration. Anemia was detected in 36 (56.2%), 27 (75%) of which were normochromic and normocytic; 14 (38.8%) had deficiency anemia recorded in their medical chart. The low hemoglobin concentration is recurrent among the participants characterizing an anemia condition, whose profile reveals congruence to the anemia of chronic disease.

Complex treatment of lower limb ulcers in patients with diabetes mellitus type 2

To estimate the efficiency of stimulation of reparative processes in patients with diabetes mellitus type 2 and trophic ulcers of the lower limbs. There were 94 patients with diabetes mellitus type 2 complicated by trophic ulcers of the lower limbs. Mean age of patients was 67.8±8.6 years. The main group consisted of 50 (53.2%) patients who underwent stimulation of reparative processes, control group - 44 (46.8%) patients with standard treatment and hydrocolloid dressings. Efficiency of treatment was analyzed every 5 days considering wound healing and cytological data. We found significant reduction of neurotrophic ulcer volume by 29.9% after 10 days. Positive macroscopic data were accompanied by reduction of white blood cells count up to 40-50% and increase in the number of histiocytes and endothelial cells. Among patients with ischemic ulcers, we obtained significant reduction of ulcerative defect only after 15-20 days in 3 (60%) cases. Overall efficiency of original management way 96%, mean duration of treatment - 37.1±5.9 days. In the control group, overall efficiency of treatment was 70.5%, duration of treatment - 45.9±6.1 days. The original method was valuable to improve the outcomes in patients with diabetes mellitus type 2 and trophic ulcers of the lower limbs. The best results were obtained for neurotrophic ulcers. In case of ischemic ulcers, these technologies should be combined with measures on improvement of pulsatile blood flow and microcirculation. This method does not require hospitalization and reduces treatment cost.

Calcinose distrófica cutânea na doença venosa crônica de membros inferiores

Lower limb ulcers secondary to chronic venous disease (CVD) are a significant public health problem in Brazil and account for about 70% of these ulcers. Despite recent technological advances and the various therapeutic options for treatment of these chronic injuries, several factors may be involved in resistance to treatment. Dystrophic calcinosis cutis (DCC) is a rare and often underdiagnosed condition that, when in conjunction with CVD, may be associated with a refractory healing process. In this article, we report a case of DCC in a patient with CVD and discuss its etiology, pathophysiology and possible treatment options.

Recommendations for Lower Limb Ulcers

Recommendations for Lower Limb Ulcers