Refractory Ulcers Research Articles

Skin grafting in the treatment of hard-to-heal leg ulcers

Some risk factors or comorbidities may make Chronic Leg Ulcers (CLU) very difficult to heal. These ulcers are usually defined refractory ulcers and may require an in-hospital intensive care to increase the healing rate. Aim of this retrospective study was to assess if our clinical routine in hospitalized patients, made up with surgical debridement followed by donor skin grafting (allografts), may favor the ulcer healing. The records of 120 patients (55 males and 65 females; mean age 73.9±11.3 years) with ulcers greater than 100 cm2 and lasting for more than 1 year were analyzed. The median ulcer size was 165 cm2 (IQR 130-250 cm2; range 100-1000 cm2). The median ulcer duration was 24 months (IQR 16-32 months; range 12-300 months). The ulcer pathophysiology was venous in 74 patients, arterial in 21, mixed in 12, vasculitis in 5 and post-traumatic in 8 patients. After debridement the patients were submitted to allograft procedures (single or multiple) up to the ulcer healing. When allograft was able to create an effective granulation tissue and reduce the ulcer size an autograft was performed to get the ulcer closure. 109 patients healed and 11 were lost at follow-up. 65 patients healed just with one allograft in 16 weeks (IQR 13-21 weeks). 42 patients healed with 2 procedures in 20 weeks (IQR 18-23 weeks). 31 of them received a final autograft while 11 healed with two allografts. 2 patients with an ulcer surface of 200 cm2, both affected by CLI, healed with 3 allografts procedures in 40 and 33 weeks, respectively. Pain and exudate amount were significantly decreased and even disappeared after the first allograft. Allografts alone or followed by an autograft are able to get the ulcer healing also in case of extensive and long lasting ulcers refractory to all previous treatments.

Accelerated Healing of a Diabetic Foot Ulcer Using Autologous Stromal Vascular Fraction Suspended in Platelet-Rich Plasma

We describe the case of a Type I diabetic patient with a refractory foot ulcer that remained unhealed for 2 years despite conventional therapy. Autologous adipose-derived stromal vascular fraction suspended in autologous platelet-rich plasma was applied to the wound, which completely healed within 1 month. The wound remained closed with no complications for a 2-year follow-up. Reporting of this and similar cases may lead to larger clinical trials that will prove the efficacy of this therapy that may offer accelerated healing and lessen the financial burden of more expensive therapeutic modalities.

Capillary Desertification and Refractory Digital Ulcers in Systemic Sclerosis

Capillary Desertification and Refractory Digital Ulcers in Systemic Sclerosis

Refractory gastric antral ulcers without Helicobacter pylori infection and non-steroidal anti-inflammatory drugs

Herein, we describe a rare case of refractory gastric antral ulcers. A woman in her 50s was admitted to Nagoya City University Hospital with epigastric pain after being diagnosed with gastric antral submucosal tumor at another hospital. Findings from esophagogastroduodenoscopy and endoscopic ultrasound examination revealed that the lesion was a gastric ulcer. The patient had no Helicobacter pylori infection and no recent history of using non-steroidal anti-inflammatory drugs. On the basis of these findings, we diagnosed this as a case of refractory gastric antral ulcer (RGAU). RGAU is considered a new disease concept and detailed analyses are expected in the future.

An Uncommon Cause of a Refractory Gastric Ulcer

A 29-year-old female with a history of bipolar disorder presented to the emergency department (ED) with worsening epigastric pain. Two years ago, esophagogastroduodenoscopy (EGD) showed a 1.5-cm benign-appearing superficial ulcer in the pylorus. She was presumed to have an NSAID-induced peptic ulcer and was treated with proton pump inhibitor therapy. She had multiple hospitalizations for abdominal pain and several subsequent EGDs showing refractory gastric ulcer.

Autologous haematopoietic stem cell transplantation for Japanese patients with systemic sclerosis: Long-term follow-up on a phase II trial and treatment-related fatal cardiomyopathy

Objectives: The objective of this study is to elucidate the efficacy and safety of autologous haematopoietic stem cell transplantation (HSCT) for Japanese patients with systemic sclerosis (SSc).Methods: A phase II clinical trial included SSc patients diagnosed within the last three years having at least one of the following clinical features: diffuse skin sclerosis with modified Rodman total thickness skin score (mRSS) ≥ 15, refractory digital ulcer or interstitial lung disease (ILD). HSCT were performed after conditioning using cyclophosphamide.Results: Fourteen patients were enrolled and underwent HSCT. Median follow-up period was 137 months. Overall survival or event-free survival rate was 93% or 40% at 10 years, respectively. Eight patients (57%) achieved more than a 50% decrease in mRSS from baseline within six months after HSCT. Six patients (43%) required additional immunosuppressive treatments due to progression of diffuse skin sclerosis and/or ILD during follow-up period. Adverse events related to HSCT occurred in six patients (43%). Severe cardiomyopathy occurred in two patients, and one of them had a fatal course.Conclusion: HSCT is a feasible treatment bringing favourable results to more than half of our patients with SSc. Careful selection of the patients is essential for whom benefited from HSCT, considering the risk-benefit balance of the treatment.

Conjunctival flap cover surgery: 10-year review

Background: To evaluate the conjunctival flap cover surgery for the treatment of ocular surface disorders. Methods: Retrospective uncontrolled study was performed. A total of 253 eyes of 253 patients who had received conjunctival flap cover surgery during a 10-year period were included. The indications, symptoms and complications experienced by patients undergoing partial or total conjunctival flap cover surgery were reviewed. Results: In all of these cases, satisfactory anatomic and functional outcomes were achieved. The BCVA of 224 eyes out of 253 patients (88.5%) were no worse than that of preoperative and the BCVA of 29 eyes out of 253 patients (11.5%) decreased postoperatively. No eye pain, foreign body sensation and other discomforts presented in the last visit. The surgical indications was therapeutic for 138 out of 253 patients (54.5%), aesthetic for 63 eyes out of 253 patients (24.9%), tectonic for 45 eyes out of 253 patients (17.8%), and analgesic for 7 eyes out of 253 patients (2.8%). The primary diagnose of therapeutic indications is refractory corneal ulcer for 135 eyes out of 253 patients (53.4%). The main diagnose of aesthetic indications is atrophy of eyeball for 45 eyes out of 253 patients (17.8%) and corneal leukoma for 18 eyes out of 253 patients (7.1%). The principal diagnose of tectonic indications is corneal perforation for 43 eyes out of 253 patients (17%). The main intraoperative complications is buttonhole formation for 8 eyes out of 253 patients (3.2%), which can be handled by simple suture. The most severe complications postoperatively was conjunctival flaps dissolving and corneal perforation for 3 eyes out of 253 patients (1.2%), and corneal transplantation had to be performed to avoid enucleation. In addition, 4 eyes out of 253 patients (1.6%) presented cystic flap and two of them received surgical excision. Conclusions: Conjunctival flap cover surgery is an underused technique. Its primary indication is refractory corneal ulcer and corneal perforation, and its second indication is aesthetic with poor visual potential coexisting ocular surface diseases. It represents an interesting alternative to more mutilating surgeries.

Treatment of Cutaneous Ulcers with Multilayered Mixed Sheets of Autologous Fibroblasts and Peripheral Blood Mononuclear Cells

Background/Aims: We have developed a mixed-cell sheet consisting of autologous fibroblasts and peripheral blood mononuclear cells with a high potency for angiogenesis and wound healing against refractory cutaneous ulcers in mouse and rabbit models. To increase the effectiveness of the mixed sheet, we developed a multilayered mixed sheet. Methods: We assessed the therapeutic effects of multilayered sheets on cutaneous ulcers in mice. Growth factors and chemokines were assessed by enzyme-linked immunosorbent assay. Angiogenesis and fibroblast migration were measured by using tube formation and migration assays. Wound healing rate of cutaneous ulcers was evaluated in mice with diabetes mellitus. Results: The concentration of secreted vascular endothelial growth factor, hepatocyte growth factor, transforming growth factor, C-X-C motif chemokine ligand (CXCL)-1, and CXCL-2 in multilayered sheets was much higher than that in single-layered mixed-cell sheets (single-layered sheets) and multilayered sheets of fibroblasts alone (fibroblast sheets). The supernatant in multilayered sheets enhanced angiogenic potency and fibroblast migration compared with single-layered and fibroblast sheets in an in vitro experiment. The wound healing rate in the multilayered sheet-treated group was higher compared with the no-treatment group (control) at the early stage of healing. Moreover, both vessel lumen area and microvessel density in tissues treated with multilayered sheets were significantly increased compared with tissues in the control group. Conclusion: Multilayered sheets promoted wound healing and microvascular angiogenesis in the skin by supplying growth factors and cytokines. Accordingly, our data suggest that multilayered sheets may be a promising therapeutic material for refractory cutaneous ulcers.

Pharmacognostical Studies on the leaves of Jatropha tanjorensis

Species of Jatropha belonging to the family of Euphorbiaceae are found distributed in the tropical, Subtropical region. Most of them are generally grown as hedge species and contain sticky, opalescent, acrid and astringent latex, which promote healing of wounds, refractory ulcer, Septic gums and as styptic in cuts and bruises. Jatropha tanjorensis is one of the 9 species in Tamil Nadu. This paper deals with the micro morphological studies carried out on in the leaves of Jatropha tanjorenesis one of the WHO Accepted Parameters for identification of medicinal plants; Taxonomy, Distribution and Medicinal Uses of Jatropha L. Pharmacognosy, Physico-chemical standards, Determination of Total Ash; Water-Soluble Ash, Acid-Insoluble Ash, Alcohol-Soluble Extractive, Water-Soluble Extractive, Leaf Constant, Vein Islet Number and Vein Termination Number, Stomatal Index and Stomatal Number, Microscopical Evaluation of Leaf and Powder, Collection of Plant Specimens, Sectioning and Photomicrographs.

An inflammatory memory and angiogenic self-assembling nanofiber hydrogel scaffold seeded with Akkermansia muciniphila to accelerate the healing of diabetic ischemic ulcers.

Refractory ulcers are a major challenge in the treatment of a diabetic foot, because of the immunodeficient, ischemic and high-glucose microenvironment. Inflammatory memory peptides, which were extracted from the immune mediator absent in melanoma 2 (AIM2), could effectively improve the immunodeficient microenvironment and special angiogenic peptides could effectively promote angiogenesis. Moreover, the gut flora Akkermansia muciniphila (A. muciniphila) participates in diabetic metabolism and could decrease high-glucose levels. In this research, a polypeptide skeleton (PPS) was synthesized based on 3,4-dihydroxyphenylalanine (DOPA) and peptides, forming the hydrophilic and hydrophobic parts. Inflammatory memory peptides and angiogenic peptides were synthesized and conjugated with the PPS, which then formed an anisotropic hydrogel through the self-assembling of β-sheet peptides based on hydrophobicity and DOPA oxidation. A. muciniphila was seeded into the hydrogel and transported into diabetic ischemic ulcers through subcutaneous injection, and the healing of diabetic ischemic ulcers was promoted. The inflammatory memory peptides were released based on the A. muciniphila enzyme response, and they firstly improved the immunity of the local surroundings. Then, the angiogenic peptides were also released through irradiation and they promoted angiogenesis. Additionally, the transported A. muciniphila could decrease the local glucose levels and spontaneously regress once the diabetic ischemic ulcers had healed. A. muciniphila combined with a functional polypeptide hydrogel may be a novel strategy for diabetic ischemic ulcer treatment.

A case of foot reconstruction with a scapular flap performed for a refractory forefoot ulcer secondary to congenital insensitivity to pain

A case of foot reconstruction with a scapular flap performed for a refractory forefoot ulcer secondary to congenital insensitivity to pain

A Case of a Plantar Arteriovenous Fistula of the Refractory Venous Stasis Ulcer Treated with Coil Embolization and Vacuum-assisted Closure (VAC) Therapy

A Case of a Plantar Arteriovenous Fistula of the Refractory Venous Stasis Ulcer Treated with Coil Embolization and Vacuum-assisted Closure (VAC) Therapy

Pengaruh Senam Kaki Terhadap Penurunan Resiko Neuropati Perifer Dengan Skor Diabetic Neuropathy Examination Pada Pasien Diabetes Melitus Tipe 2 Di Puskesmas Sibela Kota Surakarta

Abstract : Foot Gymnastics, Diabetic Neuropathy Examination Score. Peripheral neuropathy is one of chronic complications frequently found in diabetes mellitus case. The risks of the diabetic patient with peripheral neuropathy face included repeated infection, refractory ulcer and finger and foot amputation. This condition requires an easy and cheaper primary treatment, foot gymnastic. This research aimed to find out the effect of foot gymnastic on the decreased peripheral neuropathy with diabetic neuropathy examination score in patients with type 2 diabetes mellitus in Puskesmas (Public Health Center) Sibela in Surakarta City. The Research Methods could be used design using quasy experiment design with one group method pre test – post test. The samples are 30 participant of foot gymnastics at Puskesmas Sibela in February until April 2015. This research use paired t test in order to know risk decrease of peripheral neuropathy by diabetic neuropathy examination score. The results could from 30 respondents is obtained a mean diabetic examination neuropathy score before foot gymnastics was 7,67 with a standard deviation of 2,63 and after foot gymnastics was 5,37 with a standard deviation of 2,632. From the paired t test analysis was obtained p = 0,001 (p<0,05). Conclusion existence of influence foot gymnastic againts a decreased risk of peripheral neuropathy based on diabetic neuropathy examination scores. Suggestion for the next research measurement diabetic neuropathy examination scores for 3 to 6 months to obtain optimal result.

Tuberculosis of the Oral Cavity Misdiagnosed as Precancerous Lesion.

IntroductionThe aim of this case report was to discuss an extremely rare oral lesion as a result of primary pulmonary tuberculosis.Case reportIn this case report, the patient with refractory painless ulceration at ventral surface of the tongue was described. Detailed medical history was taken followed by clinical examination of the oral mucosa and palpation of regional lymph nodes. Clinical examination revealed ulceration on the patient’s ventro-lateral surface of the tongue, approximately two centimeters in diameter. Palpation of regional lymph nodes has not revealed enlargement. The toluidine blue test of the suspected lesion was performed at each control examination. Biopsy samples for histopathologic diagnosis were taken three times. The analysis of the first biopsy sample for histopathology revealed a non-specific inflammation, the second biopsy revealed a caseous necrosis without positive Ziehl-Neelsen staining and the third biopsy revealed a granulomatous inflammation which was highly suspicious of sarcoidosis. During hospitalization, the patient underwent a complete physical examination, and laboratory and radiological diagnostics. Physical chest examination revealed bilaterally coarse crepitations and laboratory findings of his complete blood count revealed normocytic anemia of chronic disease. Radiographic examination of lungs showed multiple small nodules bilaterally and positive direct sputum smear.ConclusionAlthough oral tuberculosis is a rare condition, it must be taken into account in differential diagnosis of refractory painless oral ulcers.

Ethanol Embolotherapy for the Management of Refractory Chronic Skin Ulcers Caused by Arteriovenous Malformations

PurposeTo describe the clinical features and treatment outcomes of ethanol embolotherapy in refractory chronic skin ulcers caused by arteriovenous malformations (AVMs). Materials and MethodsFrom October 2011 to October 2015, 12 patients (5 male; mean age, 26.2 y) with refractory chronic skin ulcers caused by AVMs were treated at a single institution. Ethanol embolotherapy was performed by direct puncture techniques. Needles were directly inserted toward the nidus of the lesion based on imaging analysis. When fast blood reflux was noted, angiography was performed to ensure only the nidus and draining vein were opacified. Symptoms before and after treatment, previous treatment of AVMs and ulcers, embolotherapy sessions, follow-up time, complications, and degree of devascularization were recorded. Treatment outcomes were established by evaluating symptom outcomes and the degree of devascularization on follow-up angiography. ResultsFifty embolotherapy procedures were performed in 12 patients: 6 underwent procedures on the head and neck, 4 on the feet, and 2 on the hands. Four patients (33.3%) experienced complete resolution of abnormal angioarchitecture according to follow-up angiography. Complete control of ulcers was achieved in all 12 patients. Two procedures (4%) in 2 patients (16.7%) caused superficial skin necrosis that healed spontaneously within 4 weeks. Thirteen procedures (26%) in 9 patients (75%) caused blistering immediately after treatment. There were no major complications. ConclusionsIn a limited series, ethanol embolotherapy was effective and safe in the treatment of refractory chronic skin ulcers caused by AVMs.

Novel autoantibody against the β2‐glycoprotein I/human leucocyte antigen– DR complex in patients with refractory cutaneous ulcers

Novel autoantibody against the β2‐glycoprotein I/human leucocyte antigen– <scp>DR</scp> complex in patients with refractory cutaneous ulcers

A5207 - Emergent Reversal of Gastric Bypass: A Case Series from an Accredited Surgical Weight Loss Program

Despite the safety and efficacy of Roux-en-Y gastric bypass (RYGB), a subset of patients (<1%) requires RYGB reversal. This reestablishes continuity between the pouch and bypassed stomach after resecting the gastrojejunostomy. Whether the alimentary limb is reconnected or discarded depends on clinical findings. The most common indications for reversal include excessive weight loss, neuroglycopenia and refractory marginal ulceration. In rare cases, RYGB reversal is required in the emergent setting. We present 3 cases of emergent RYGB reversal for ischemic complications of internal hernia and need for safe and rapid assurance of GI continuity.

Commercial Acetic Acid: A Potential Regenerative Agent for Chronic Cutaneous Wounds? A Quasi-Experimental Study

BACKGROUND: The acetic acid in the form of vinegar has been used for medicinal purposes since ancient times. Acetic acid is reported to be used for medicinal uses at 1-5% concentration. The mechanism behind the regenerative potential of commercial acetic acid has not been fully explored.MATERIALS &amp; METHODS: Twelve Iraqi patients with chronic skin ulceration were admitted and managed at a Dermatology clinic. Patients included men (7) and women (5) of diverse age groups (23-81 years). The aetiology behind the skin ulceration included; diabetic ulcer, decubitus ulcer, and others induced by trauma, bone fracture, insect bites and substance abuse. All patients were strictly treated with commercial acetic acid (at 4-6% concertation) and followed-up in time until the complete resolution of their cutaneous ulcerations.RESULTS &amp; DISCUSSION: This study is quasi-experimental; two cases are discussed thoroughly; the first case belongs to a Caucasian male aged 26 years with schizophrenia and addiction towards psychoactive substances; he developed a refractory ulcer in left cubital fossa following an intravenous injection. The second case belongs to a middle age male patient, hypertensive otherwise healthy; he had a displaced intra-articular fracture affecting the distal end of the left radius; it was surgically treated with an internal fixation which was incriminated for the development of an ulcer over the volar aspect of left forearm overlying the internal fixation site. Local disinfection with commercial apple vinegar was very effective in restoring the skin integrity with minimal scarring.CONCLUSION: The regenerative potential of acetic acid has been marginally covered in the literature. The presented cases indicate a regenerative potential or at least an accelerant role in the process of cutaneous wound healing and repair.

Leucocyte- and platelet-rich fibrin (L-PRF) as a regenerative medicine strategy for the treatment of refractory leg ulcers: a prospective cohort study

Chronic wounds (VLU: venous leg ulcer, DFU: diabetic foot ulcer, PU: pressure ulcer, or complex wounds) affect a significant proportion of the population. Despite appropriate standard wound care, such ulcers unfortunately may remain open for months or even years. The use of leukocyte- and platelet-rich fibrin (L-PRF) to cure skin ulcers is a simple and inexpensive method, widely used in some countries but unknown or neglected in most others. This auto-controlled prospective cohort study explored and quantified accurately for the first time the adjunctive benefits of topical applications of L-PRF in the management of such refractory ulcers in a diverse group of patients. Forty-four consecutive patients with VLUs (n = 28, 32 wounds: 17 ≤ 10 cm2 and 15 > 10 cm2), DPUs (n = 9, 10 wounds), PUs (n = 5), or complex wounds (n = 2), all refractory to standard treatment for ≥3 months, received a weekly application of L-PRF membranes. L-PRF was prepared following the original L-PRF method developed more than 15 years ago (400g, 12 minutes) using the Intra-Spin L-PRF centrifuge/system and the XPression box kit (Intra-Lock, Boca Raton, FL, USA; the only CE/FDA cleared system for the preparation of L-PRF). Changes in wound area were recorded longitudinally via digital planimetry. Adverse events and pain levels were also registered. All wounds showed significant improvements after the L-PRF therapy. All VLUs ≤ 10 cm2, all DFUs, as well as the two complex wounds showed full closure within a 3-month period. All wounds of patients with VLUs > 10 cm2 who continued therapy (10 wounds) could be closed, whereas in the five patients who discontinued therapy improvement of wound size was observed. Two out of the five PUs were closed, with improvement in the remaining three patients who again interrupted therapy (surface evolution from 7.35 ± 4.31 cm2 to 5.78 ± 3.81 cm2). No adverse events were observed. A topical application of L-PRF on chronic ulcers, recalcitrant to standard wound care, promotes healing and wound closure in all patients following the treatment. This new therapy is simple, safe and inexpensive, and should be considered a relevant therapeutic option for all refractory skin ulcers.

Histologically proved cytomegalovirus as a terrible and neglect disease: a 13-year report of gastrointestinal and hepatobiliary manifestations from single referral center

The aim of the present study was to evaluate the gastrointestinal and hepatobiliary manifestation of cytomegalovirus. In a retrospective study, demographic and clinical information of patients with gastrointestinal or hepatobiliary manifestations and histologically confirmed cytomegalovirus infection was investigated among pathological records. The association between serum cytomegalovirus pp65 and blood positivity of cytomegalovirus polymerase chain reaction with histological findings was also evaluated. Of the 74 included patients, 27 cases (36.5%) were female. The most common symptoms were diarrhea (24.3%). Unusual presentations of cytomegalovirus diseases were gastrointestinal obstruction, refractory peptic ulcer, and corticosteroid-refractory inflammatory bowel disease. In total, 54 cases (75.0%) were transplanted, with the most frequency of kidney transplantation in 32 patients (59.2%). These patients had also more mortality rate. The most prescribed medicine in transplanted patients was CellCept and cyclosporine (40.6%). Mortality rate was more in blood polymerase chain reaction-negative patients. Cytomegalovirus diseases in transplanted patients were more primary infection compared with reactivation infection. No significant difference in mortality rate was seen between ganciclovir and non-ganciclovir recipients. The majority of the patients were negative for antigen or polymerase chain reaction. Early detection of cytomegalovirus could be lifesaving, and negative results of antigen and polymerase chain reaction cannot rule out cytomegalovirus diseases. Early endoscopic evaluation for unusual presentations of cytomegalovirus disease and also liver donor evaluation should be done more carefully. Ganciclovir has no significant effect on mortality of the patients, and then, it should be started at appropriate time.