Peripheral Ulcers Research Articles

Rituximab plus belimumab in non-infectious refractory cryoglobulinemia vasculitis: A pilot study

ObjectiveTo report the efficacy of rituximab plus belimumab in patients with refractory cryoglobulinemia vasculitis (CV). MethodsBelimumab was administered intravenously at a dose of 10 mg/kg on days 0, 14, 28 and then every month in association with rituximab in 4 patients with refractory CV. Demographic, clinical and laboratory characteristics, treatment modalities and outcomes were recorded. ResultsAll patients had type II IgM Kappa cryoglobulinemia, which was associated with primary Sjögren syndrome (n = 1), hepatitis C virus infection (n = 1), and essential (n = 2). Main manifestations of CV included purpura (n = 4), arthralgia and peripheral neuropathy (n = 3), and glomerulonephritis and skin ulcers (n = 1). In all cases, CV was refractory and/or relapse following rituximab. Intravenous belimumab infusion along with rituximab resulted in rapid clinical response in the four patients. Osteitis and recurrent urinary tract infections occurred in two patients. ConclusionBelimumab along with rituximab showed promising results in refractory patients with CV.

Association between sodium-glucose cotransporter 2 (SGLT2) inhibitors and lower extremity amputation: A systematic review and meta-analysis.

BackgroundThe association between sodium-glucose cotransporter 2 inhibitors (SGLT2i’s) and lower extremity amputation is unclear.PurposeTo systematically review randomized control trials (RCTs) and observational studies quantifying risk of lower extremity amputations associated with SGLT2i use.Data sources and study selectionWe searched PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials from January 2011 to February 2020 for RCTs and observational studies including lower extremity amputation outcomes for individuals with type 2 diabetes mellitus treated with SGLT2i’s vs. alternative treatments or placebo.Data extraction and synthesisTwo reviewers independently extracted data.Main outcomes and measuresOur primary outcome was risk of lower limb amputation. Secondary outcomes included peripheral arterial disease, peripheral vascular disease, venous ulcerations, and diabetic foot infections. We also evaluated the risk of bias. We conducted random and fixed effects relative risk meta-analysis of RCTs.ResultsAfter screening 2,006 studies, 12 RCTs and 18 observational studies were included, of which 7 RCTs and 18 observational studies had at least one event. The random effects meta-analysis of 7 RCTs suggested the absence of a statistically significant association between SGLT2i exposure with evidence of substantial statistical heterogeneity (n = 424/23,716 vs n = 267/18,737 in controls; RR 1.28, CI’s 0.93–1.76; I2 = 62.0%; p = 0.12) whereas fixed effects analysis showed an increased risk with statistical heterogeneity (RR 1.27, 1.09–1.48; I2 = 62%; p = 0.003). Subgroup analysis of canagliflozin vs placebo showed a statistically significantly increased risk in a fixed effects meta-analysis (n = 2 RCTs, RR 1.59, 1.26–2.01; I2 = 88%; p = 0.0001) whereas the meta-analysis of dapagliflozin or empagliflozin (n = 2 RCTs each) and a single RCT for ertugliflozin did not show a significantly increased risk. The findings from observational studies were too heterogeneous to be pooled in a meta-analysis and draw meaningful conclusions. Both randomized and observational studies were of generally good methodological quality.ConclusionsOverall, there was no consistent evidence of SGLT2i exposure and increased risk of amputation. The increased risk of amputation seen in the large, long-term Canagliflozin Cardiovascular Assessment Study (CANVAS) trial for canagliflozin, and select observational studies, merits continued exploration.

425-P: Mechanisms Regulating VEGF Receptors in Diabetic Angiogenesis

Diabetes-related vascular complications underlie a number of life-threatening conditions including cardiovascular disease, stroke, and peripheral limb ulcerations, the latter of which can lead to severe infections and a multitude of serious medical issues. Our goal is to understand how chronic hyperglycemia impairs endothelial cell function to identify molecular targets that would form the basis for new therapies to treat the peripheral vascular complications associated with diabetes. Since VEGFRs are critical regulators of both angiogenesis and lymphangiogenesis, we and others have shown that VEGFRs 2 and 3 were significantly reduced in the endothelium of diabetic patients and animals. We demonstrated that loss of the endocytic adaptor proteins epsin 1 and 2 in lymphatic endothelial cells (LECs) prevents VEGFR3 endocytosis and degradation, leading to enhanced lymphangiogenesis in vivo and cell proliferation, migration, and tube formation in vitro. Mechanistically, reactive oxygen species produced in diabetes induced c-Src–dependent VEGFR3 phosphorylation and degradation, and upregulated epsins through the AP-1 transcription factor. Epsins bind to and promote the degradation of newly-synthesized VEGFR3 in the Golgi, resulting in reduced availability of VEGFR3 at the cell surface. Here, we show that diabetic conditions induce expression of the autophagosome-specific gene Ulk1, which promotes VEGFR2/3 degradation. Hence, Ulk1 deficiency inhibits autophagosome formation and enhances angiogenic responses under diabetic conditions through upregulation of multiple endothelial-specific pathways that support neovascularization. Loss of endothelial Ulk1 elevated VEGFR2/3 levels and enhanced in vitro angiogenesis as measured by endothelial proliferation, migration, and tube formation and augmented wound healing in diabetes. Collectively, our results show that inhibition of epsins and Ulk1 in diabetes can restore angiogenic and lymphangiogenic responses and provide therapeutic targets. Disclosure S. Bhattacharjee: None. H. Wu: None. J. Xu: None. H. Chen: None. Funding National Institutes of Health (R01HAO130845)

Severe Skin Ulcer on the Hand Caused by Hemodialysis Shunt-related Venous Hypertension That Required a Skin Graft.

Summary:In dialysis patients, peripheral venous hypertension–induced hand ulcers are rare. We report a case in which a severe hand ulcer was treated with skin grafting after shunt ligation. The patient was a 60-year-old woman who been undergoing dialysis for 13 years. Twelve years ago, a shunt was created in her right wrist via a side-to-side anastomosis. Swelling and congestion occurred in the right hand, and skin ulcers developed on the dorsal proximal portions of the index, middle, ring, and little fingers. No central vein obstruction was apparent. The right wrist shunt was explored, and the distal vein was ligated. A new shunt was created at the right elbow, but the proximal end of the vein that was used for the wrist shunt had to be used, resulting in complete cephalic vein occlusion from the wrist to the elbow. The swelling extended to the entire forearm. Four weeks after the wrist and elbow shunts were ligated, conservative treatment had resulted in granulation tissue formation in the ulcers. Debridement and full-thickness skin grafting from the abdomen were performed. Overall, skin graft survival was 75%. In conclusion, in this patient, side-to-end anastomosis of the proximal vein might be appropriate for shunt creation. When venous hypertension is suspected, ensuring an appropriate alternative shunt, promptly detecting the cause of the problem, and appropriate treatment are important. Venous hypertension must be completely resolved before surgery for ulcers.

Warfarin therapy in atrial fibrillation: assessment of patient knowledge of risks and benefits

ABSTRACT Patients with atrial fibrillation are at an increased risk for stroke, and many benefits from anticoagulation. Despite the emergence of direct oral anticoagulants, many patients continue to rely on warfarin for their anticoagulation due to logistical, pharmacokinetic, clinical, or patient preference issues. Previous work has suggested that outcomes of warfarin therapy are related to patient education/knowledge. We assessed knowledge of indications, benefits, and complications of warfarin therapy in 99 randomly selected patients enrolled in the Warfarin Anticoagulation Clinic at the Mayo Clinic in Florida who were taking warfarin for non-valvular atrial fibrillation. Patients were labeled as ‘knowledgeable’ or ‘not knowledgeable’ regarding warfarin therapy according to the results of a cross-sectional questionnaire. The majority of patients in both the knowledgeable and not knowledgeable groups displayed understanding that they were taking warfarin for atrial fibrillation (valvular vs non-valvular atrial fibrillation was not an included answer choice). However, there was a clear lack of knowledge amongst patients with atrial fibrillation in both groups about their stroke risk while on and off warfarin, and their risk of major bleeding or adverse events related to their warfarin therapy. There was only a significant difference between the two groups regarding their knowledge of what increases or decreases the risk of bleeding while on warfarin. There was no major difference between the groups with regards to demographic and medical characteristics, except that ‘not knowledgeable’ patients tended to have more peripheral vascular disease, ulcer disease, and moderate-severe renal disease compared to ‘knowledgeable’ patients.

Study of AMG0001 to Improve Ulcer Healing and Perfusion in Subjects With Peripheral Ischemic Ulcers

Study of AMG0001 to Improve Ulcer Healing and Perfusion in Subjects With Peripheral Ischemic Ulcers

Risk of diabetic foot ulcer and its associated factors among Bangladeshi subjects: a multicentric cross-sectional study

ObjectiveTo assess the risk of diabetic foot ulcer (DFU) and find out its associated factors among subjects with type 2 diabetes (T2D) of Bangladesh.Design, setting and participantsThis cross-sectional study recruited...

Mooren's ulcer

The article reviews available data on Mooren's ulcer - a rare disease of, supposedly, autoimmune origin that manifests as peripheral ulceration of the cornea and poses a risk of its perforation. The variability of clinical presentation and course of the disease often leads to misdiagnosis and inadequate treatment. The present review focuses on specific signs characteristic of the disease and the most effective methods of its treatment.

Test-retest reliability, internal consistency, construct validity and factor structure of a falls risk perception questionnaire in older adults with type 2 diabetes mellitus: a prospective cohort study

BackgroundOlder adults with type 2 diabetes (DM2) are at increased risk of falling due to complications including: diabetic peripheral neuropathy, diabetic retinopathy, autonomic neuropathy and diabetic foot ulcers. The purpose of this study was to determine the test-retest reliability, internal consistency, construct validity and to perform factor analysis of a new falls Risk Perception Questionnaire (RPQ) in older community-dwelling adults with DM2.MethodsA prospective cohort of 30 community-dwelling older adults, ≥ 55 years, with DM2 was assembled. At baseline, perceived risk of falling, fear of falling and physical activity were measured. At time 2 (T2), at least 2 days later, perceived risk of falling was assessed again to determine the test-retest reliability of the RPQ. At time 3 (T3), approximately six weeks later, and time 4 (T4), at least 2 days after T3, perceived risk of falling was assessed by phone to determine the test-retest reliability of the RPQ when administered by phone.ResultsThe RPQ demonstrated excellent test-retest reliability when delivered in person (ICC = 0.78, 95% Confidence Interval, CI: 0.59–0.89) and by phone (ICC = 0.82, 95% CI: 0.65–0.91), good internal consistency (α = 0.78) and adequate construct validity (r = 0.52, 95% CI: 0.20–0.74, p = 0.003) in older adults with DM2.ConclusionGiven the good psychometric properties in this sample of persons with Diabetes, the RPQ has the potential to be used in clinical practice as a risk assessment and fall prevention tool. However, further testing needs to be done using a larger sample.

Intermittent pneumatic compression in patients with ESRD. A systematic review.

Patients with end-stage renal disease (ESRD) experience frequent hemodialysis (HD) complications. Intradialytic hypotension (IDH) is a common complication presenting in approximately between 20 and 50% of HD sessions. Available interventions such as volume replacement or vasoactive medications are associated with significant side effects. Intermittent pneumatic compression (IPC) has been proposed as a feasible intervention for the prevention of IDH, treatment of peripheral arterial disease and venous ulcers. These devices apply intermittent pressure to the legs improving arterial blood flow, mobilization of pooled blood with an increase in venous return increasing the effective circulatory volume. Our goal was to identify the published clinical evidence on whether IPC has a circulatory benefit and is it well-tolerated among patients receiving HD. We conducted a systematic review to identify studies assessing the efficacy and safety of IPC in patients with ESRD. Our primary outcome was IDH. Secondary outcomes such as HD comfort, ultrafiltration volume, and physical activity were collected. No restrictions where used and we included all observational and interventional studies. Two reviewers performed screening and study quality assessment. We included seven studies. Out of the seven studies, five addressed IDH, and the rest were included for secondary outcomes such as physical capacity and HD comfort. In one randomized crossover trial comparing exercise against IPC, 21 patients were randomized to 3 different arms (no intervention, cycling, IPC) a decrease in the rates of IDH with IPC was described (43%, 38%, and 24% respectively P = 0.014). The smaller studies corroborated these results. All studies where at high risk of bias. IPC might offer significant benefits for patients undergoing HD not limited to prevention of IDH but also improvement of hemodialysis comfort and physical capacity. However, our results should be interpreted in the context of its limitations.

Mooren’s ulcer a rare cause of peripheral ulcerative keratitis

Authors report a rare cause of peripheral ulcerative keratitis. Mooren’s ulcer is a chronic, painful, relentless ulcerative peripheral keratitis that begins from periphery of cornea near limbus as narrow crescent corneal infiltrate which then progresses circumferentially and centrally. Mooren’s ulcer gets misdiagnosed as peripheral bacterial ulcer or another non-infective peripheral ulcerative keratitis.

2283-PUB: Association between Higher Health-Related Quality of Life Physical Component Score Measured by SF-8 and Lower All-Cause Mortality Risk among Japanese Patients with Type 2 Diabetes: A Prospective Cohort Study

Health-related quality of life (HRQoL) was reportedly associated with mortality; however, these studies used questionnaires with relatively large number of items ranging from 20 to 30. We thus evaluated the prospective association between HRQoL measured by Short-Form (SF)-8, a short version of SF-36, in Japanese individuals with type 2 diabetes. Longitudinal data of 3,269 individuals with diabetes were obtained from a large Japanese diabetes registry. To assess the independent correlation between the 10-point increment of SF-8 physical component summary score (PCS) or mental component summary score (MCS) and all-cause mortality, the Cox proportional hazards model was used with adjustment for age, sex, body mass index, HbA1c, types of diabetes therapy, urinary albumin-creatinine ratio, history of diabetic retinopathy, symptomatic diabetic neuropathy, and past medical history (acute myocardial infarction, chronic stable angina, peripheral artery disease, leg ulceration, ischemic stroke, and hemorrhagic stroke). The mean age, body mass index, and HbA1c level were 64.9 years (SD 11.2), 24.6 kg/m2 (SD 3.9), and 7.5% (SD 1.2) [or 58.6 mmol/mol (SD 12.7)], respectively. We recorded 248 deaths during the median follow-up of 6.1 years (incidence ratio = 14.0/1,000 person-years). We observed significant association of PSC score and all-cause mortality, and multivariable-adjusted hazard ratio (HR) was 0.775 [95% confidence interval (CI), 0.668-0.899; p = 0.001] per 10-point increment of PCS score. We did not observe significant association between MCS score and all-cause mortality [HR = 0.864 (95% CI, 727-1.027; p = 0.097)]. In conclusion, higher PCS of SF-8, not MCS, was associated with lower risk of all-cause mortality in Japanese individuals with type 2 diabetes. SF-8 could be useful for predicting mortality in individuals with diabetes. Disclosure Y. Hayashino: Speaker's Bureau; Self; Astellas Pharma Inc., Kowa Pharmaceuticals, Kyowa Hakko Kirin Co., Ltd., MSD K.K., Ono Pharmaceutical Co., Ltd. S. Okamura: None. H. Ishii: None. Funding Manpei Suzuki Diabetes Foundation; Japan Society for the Promotion of Science (25460641)

Benefit of multidisciplinary wound care center on the volume and outcomes of a vascular surgery practice

ObjectiveMultidisciplinary care is recommended for the treatment of patients with ischemic and diabetic wounds. In addition to integrating care from multiple specialties, outpatient wound care centers provide an opportunity for continuity and organization of care after revascularization or hospitalization. The purpose of this study was to assess changes in the practice patterns and outcomes of patients treated by a tertiary care vascular surgery practice after the introduction of an affiliated outpatient wound care center. MethodsA prospective institutional database was used to identify patients who underwent lower-extremity revascularization, amputation, or surgical debridement during consecutive 3-year periods before (BWC; n = 735) and after (AWC; n = 1503) the opening of an affiliated wound care center. Patients were included if they underwent intervention for atherosclerotic peripheral arterial disease or diabetic foot ulcers (DFUs). Changes in case volume, surgical indication, and procedural characteristics were assessed. Clinical outcomes included freedom from lower-extremity amputations and mortality. ResultsWe identified a total of 1751 procedures performed in 1249 limbs that met inclusion criteria. After the opening of the wound clinic, procedures related to limb salvage represented a greater proportion of overall cases performed by the vascular service (19% vs 26%; P < .0001). The volume of lower-extremity interventions increased by 64%, from 662 procedures in the BWC period to 1085 procedures in the AWC period. There was no difference in type of revascularization performed between the two study periods, although surgical debridements (from 8.9% to 13%; P = .01) and infrapopliteal endovascular interventions (from 21% to 28%; P = .04) significantly increased. Compared with BWC patients, AWC patients more frequently presented with DFUs (7.3% vs 13%; P = .002) and chronic wounds (39% vs 45%; P = .05). At 1 year of follow-up, major amputation rates were significantly lower in the AWC group than in the BWC cohort (5.5% vs 8.8%; P = .04). Treatment during the AWC period was associated with a reduced risk of major amputation (adjusted hazard ratio, 0.41; 95% confidence interval, 0.27-0.62; P < .001), but no difference in all-cause mortality. ConclusionsThe opening of an outpatient wound center affiliated with a tertiary vascular surgical practice was associated with a higher volume of limb salvage patients and procedures. The risk of major amputation decreased following the opening of the wound care center. Integrating vascular surgeons into wound centers may result in a synergistic system that promotes more aggressive and effective limb salvage.

Serum vitamin D and diabetic foot complications.

ABSTRACTBackground: Foot complications such as ulceration and neuropathy are common complications of diabetes mellitus (DM). Previous reports have demonstrated a possible increased risk of these complications in diabetic patients with low levels of serum vitamin D.Objectctive: The purpose of this study is to compare serum vitamin D levels in diabetic patients with and without Charcot neuroarthropathy (CN), peripheral arterial disease (PAD), infection (DFI), ulceration (DFU), and peripheral neuropathy (DPN).Design: A retrospective chart review of all patients undergoing foot and ankle surgery with a history of DM over a 13 month period was performed. From this cohort, fifty subjects with CN were matched with 50 without CN and preoperative lab values were compared. A secondary evaluation was performed on the subjects’ other comorbidities including PAD, DFI, DFU, and DPN.Results: Seventy-eight percent of our patients had vitamin D deficiency or insufficiency. Preoperative serum vitamin D levels were not significantly different between diabetic patients with and without CN (p = 0.55). Diabetic patients with PAD (p = 0.03), DFI (p = 0.0006), and DFU (p = 0.04) were all found to have significantly lower serum vitamin D levels than diabetic patients without these complications. Lower levels of serum albumin and higher serum creatinine were also noted with subjects with PAD, DFI, DPN, and DFU. While seasonal serum vitamin D level fluctuation was noted, this difference did not reach statistical significance with the numbers available.Conclusion: We found various lower extremity complications to be associated with low serum vitamin D including PAD, DFI, and DFU. While other studies have questioned the role of vitamin D and CN, we were unable to identify any significant difference between diabetic patients with and without Charcot neuroarthropathy.Level of evidence: Level 2

Patients’ clinical charecteristics and predictors for diabetic foot amputation

IntroductionMedical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients. MethodsIn this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed. ResultsOf the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p<0,05). Amputees also exhibited significantly longer smoking histories (p<0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p=0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision. ConclusionThe following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4–5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.

Outcome of patients undergoing amputation for diabetic foot ulcer

Background: Foot ulcers are the principal cause of severe complications and hospitalization among patients with diabetes, substantially increasing the costs with this disease. Peripheral neuropathy, ulceration, infection, and peripheral vascular disease are the principal factors for ulcer complications and loss of a lower limb in diabetic patients. The aim of the present endeavor was to study the patients undergoing amputation for the diabetic foot ulcer.Methods: Total 150 patients with diabetic foot ulcer were included in this study. The variables investigated were related to diabetes, infection, and surgical treatment. In our series amputation were done at different levels anatomical levels ranging from toe level ranging from toe level to above knee amputation.Results: Pus culture and sensitivity done for diabetic foot ulcers reveal E. coil as the most common organism (40%). Skin biopsy done in these patients reveal neuropathic changes in 102 patients. 40% of patients had vaso-occlusive disease. Nine out of 150 patients showed osteomyelitis changes emphasizing those diabetic ulcer patients are prone for osteomyelitis of the underlying bone. 46% of patients with diabetic foot ulcer needed either minor or major amputation, which correlates with the standard study.Conclusions: Lack of awareness about diabetes mellitus and its lower limb complications, poor compliance to the treatment, poorly controlled blood sugar levels, delay in diagnosis, and late presentation to the tertiary care center are all factors which led to the occurrence of diabetic foot ulcer.

Peripheral arterial disease and neuroischemic ulcers in diabetic Charcot foot: a criminal conspiracy?

Peripheral arterial disease and neuroischemic ulcers in diabetic Charcot foot: a criminal conspiracy?

Extraordinary Rapid Wound Healing Time in Diabetic patients treated with Microburst Insulin Infusion

Importance: Non-healing diabetic ulcerations of the foot lead to amputations and premature mortality. Microburst Insulin Infusion has demonstrated an ability to accelerate healing in otherwise non-healing wounds. Objective: To demonstrate the benefit of adding Microburst Insulin Infusion to conventional diabetic wound care to significantly decrease wound healing time. Methods: A case series of five patients received Microburst Insulin Infusion therapy for significant peripheral diabetic ulcerations after failing conventional wound care. These five cases were treated from 4 independent Microburst Insulin Infusion clinics. Four of the wounds exceeded 6 cm². Patient charts were reviewed and relevant data was collected. All individuals in this manuscript have given written informed consent to publish these case details. Setting: Multicenter referral clinics providing Microburst Insulin Infusion Therapy Exposure: Microburst Insulin Infusion is an adjunctive treatment to conventional diabetic therapy performed in an outpatient clinic setting. A weight based oral glucose dose is administered while pulsatile intravenous insulin is delivered by the Bionica Microdose pump. The treatment is comprised of three 1 hour sessions and occurs up to five times a week, when the patient presents with un-healing wounds. Main Outcomes and Measures: Time to wound healing. A secondary outcome was failure of wound healing. Hypothesis for this study was formulated post treatment. Results: A significant decrease in wound healing time was observed when utilizing Microburst Insulin Infusion. The mean time to complete healing was 84.2 days compared to 133 days in published literature(1). The patient with a foot wound measuring an amazing 228.6 cm² healed in 102 days and amputation was not necessary. There were no treatment failures in this small series. As a result of decreased healing time, there was an absence of infection and no amputations were required for these wounds. Conclusion and Relevance: The addition of Microburst Insulin Infusion therapy resulted in a shortening of the time to healing by 49 days (7 weeks) for patients with poor response to conventional wound care. This is a 37% reduction in the time to heal thus reducing risk of infection and additional healthcare costs. The mechanism of action of Microburst Insulin Infusion in healing diabetic wounds is still unclear, but may involve an improved cellular metabolism, decreased inflammation and increased levels of Nitric oxide that enhance peripheral vascular supply and tissue healing.

Tumeur évoluée du tronc d’origine lymphomateuse

Malignant lymphomas are a group of cancers that arise in the lymphoid tissue, in the lymph nodes or in extranodal sites due to neoplastic lymphocytic cell transformation. Within this group, malignant non-Hodgkin lymphomas are distinctive. We report a case of diffuse advanced and extremely aggressive malignant cutaneous non-Hodgkin lymphoma. The study involved a 30-year old patient, driver, married and father of one child, followed-up in the Department of Hematology and Oncology for 2 years due to malignant non-Hodgkin lymphoma diagnosed on the basis of axillary and inguinal polyadenopathies. The patient underwent 13 chemotherapy sessions. He was admitted to the Department of Plastic, Cosmetic and Burn Surgery at the University Hospital Mohammed VI in Marrakech with skin involvement of his lymphoma manifesting as an advanced left latero-thoracic tumor rapidly increasing in size. On clinical examination, his general condition was quite good. It showed voluminous left latero-thoracic mass adherent to its deeper structure with ipsilateral axillary shield. Partial biopsy was performed. Anatomo-pathological examination confirmed the diagnosis of diffuse malignant large B-cells non-Hodgkin's lymphoma. Immunohistochemical and genetic study was not performed. Serology tests were negative. Serial Computed Tomography (CT) scan showed voluminous left antero-lateral predominantly axillary and thoracic ganglionic mass made of confluent lymph nodes, with persistence of peripheral lymph nodes, skin ulcers and necrotic areas measuring 30cm in diameter. In our Hospital, the patient underwent wide tumor resection, then coverage with a split-thickness skin, thus reducing tumor volume and ensuring better patient's comfort. When the patient started healing, he was referred to the Department of Hematology and Oncology for complementary treatment.

Is intermittent pneumatic compression (IPC) an appropriate method for increasing 99m Tc-MDP uptake in bone scan?

Background: Currently, intermittent pneumatic compression (IPC) is a standard method of lymphedema treatment. Recently, the effect of this modality in patients with limb arterial insufficiency has been researched. It has been suggested that the arterial inflow to the long bones is also increased by IPC. The purpose of this paper is to assess the effect of lower limb IPC on the blood flow as well as delayed bone uptake. Methods: In this prospective study, we evaluated 30 patients who were referred for whole body bone scan to our Nuclear Medicine Department. All the patients had been examined by a vascular surgeon for ruling out any peripheral neuropathy, vasculopathy or ulcer in the lower limbs. Also, all the patients were questioned about hypertension, diabetes mellitus, and other chronic diseases with peripheral complications. Following 925MBq of 99mTc-methylenediphosphonate (MDP) injection, perfusion and blood pool images of both legs as well as static delayed images were done after the completion of IPC. Results: Thirty patients (10 male) with the age range of 30–84 years (mean = 53.4) were included. Radiotracer uptake in flow and blood pool images in the compressed limb was significantly more than the contralateral limb, however, on delayed images, no significant difference was noted between two limbs. Conclusion: Although IPC can significantly increase blood flow of the compressed limb, MDP uptake on the delayed images was not increased. According to this study, IPC may not be useful as a technique to increase releasing chemotherapy drugs or other substances to the bone and promoting bone growth.