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Objective: A new compound, Debrichem (DEBx Medical BV, the Netherlands), a topical desiccation agent (TDA), is an active gel that contains an acidic species with a potent hygroscopic action. When in contact with microorganisms and necrosis, rapid desiccation and carbonisation of the proteins in these microorganisms, as well as of the extracellular matrix of biofilms and necrosis, occurs. The resulting 'precipitate' rapidly dislodges from the wound bed, resulting in a clean wound which granulates, which is a prerequisite for healing by secondary intention. Method: In a retrospective study, a series of mostly large and hard-to-heal lesions of different aetiologies were treated with a one-time application of the TDA, followed by weekly dressing changes. Results: Of the total of 54 lesions included in this case series, 22 were diagnosed as venous leg ulcers (VLUs), 20 as diabetic foot ulcers (DFUs), nine as post-traumatic, hard-to-heal lesions, two as vascular ulcers and one as an ischaemic ulcer. All of the VLUs, 75% of the DFUs and all of the other lesions reached complete granulation. Conclusion: The use of a TDA may contribute to the consistent, fast and easy removal of both biofilms and necrosis, and hence to wound healing. [ABSTRACT FROM AUTHOR]

A study was conducted to investigate whether 2 diagnostic strategies are the same for management of symptomatic outpatients with suspected Deep vein thrombosis (DVT) of the lower extremities. Results indicated that 2 diagnostic strategies were equivalent for management of symptomatic outpatients with suspected DVT of lower extremities.

There may be an association between deep-vein thrombosis and the development of cancer, especially in patients who have recurrent episodes of unknown cause. Deep-vein thrombosis is the formation of a blood clot in a major vein. Among 250 patients with a first episode of deep-vein thrombosis who were followed over a two-year period, 145 were diagnosed with idiopathic venous thrombosis, or thrombosis of unknown cause, and 105 developed a venous thrombosis secondary to another disease. Eleven patients (7.6%) with idiopathic venous thrombosis developed symptomatic cancer during the follow-up period, compared with two patients (1.9%) with secondary venous thrombosis. Thirty-five patients with idiopathic venous thrombosis had recurring episodes of thrombosis. Six of these patients (17%) later developed cancer. Some patients with recurrent idiopathic venous thrombosis may be suffering from cancer, but have not developed symptoms yet.

Aim: An acid-based debriding gel (TDA*) works through a strong hygroscopic action. When applied onto biofilm and/or necrosis, rapid desiccation and denaturation of microorganisms and tissues occurs. Typically, quick sloughing follows. In a previous study, TDA was shown to assist in the rapid development of granulation tissue, a necessary step in healing by secondary intention. Negative pressure wound therapy (NPWT) also supports the development of granulation tissue. The aim of our study was to assess the combination of TDA and NPWT on efficacy of the development of granulation tissue. Method: TDA was applied for 60 seconds and rinsed off, after which NPWT (at -125 mmHg) was applied for up to one week. The percentage of granulation was assessed on a 3-daily basis. Results / Discussion: 12 ulcers (in 12 patients) of the lower leg participated. Ulcers were venous (N=5), arterial (N=2), and mixed venous/arterial (N=1). One lesion was post-trauma (etiology unknown: N=3). Average size was 308 cm2 and average wound-age was 13 months. Each patient had at least one serious comorbidity. Average time to complete granulation was 13,2 days (range: 7-21). There were no side effects to NPWT or TDA treatment. Conclusion: In this study, combining TDA therapy with NPWT was shown to assist in the rapid development of granulation tissue. This indicates that healing by secondary intention is supported by this treatment routine. The use of TDA was also shown to be cost-effective in a separate study. * Debrichem, DEBx, the Netherlands [ABSTRACT FROM AUTHOR]

Recently, the sensitivity of impedance plethysmography (IPG) for the diagnosis of acute deep-vein thrombosis (DVT) in symptomatic outpatients has been questioned. In order to verify whether a change in the venographic pattern of DVT has occurred over years, accounting for the decreased sensitivity of IPG, the authors compared two series of consecutive venograms demonstrating proximal DVT, performed between 1984–1988 (166 patients) and 1990–1992 (140 patients). They evaluated both the extension and the occlusiveness of deep-vein thrombi in the two series. Moreover, changes in the referral characteristics of patients were investigated. In the second series of venograms a significant decrease in thrombi extension, expressed by a lower prevalence of iliac vein thrombosis (29% versus 43%; P = 0.0074) was observed; moreover, a significant increase in the prevalence of nonocclusive thrombi (22% versus 8%; P = 0.0004) was also recorded in the second series when compared with the first. During the study period, among the referral characteristics of patients, the authors observed both a significant decrease in the prevalence of proximal DVT (from 31% to 24%; P < 0.01) and a slight and not statistically significant decrease in the median time elapsed between onset of symptoms and referral for objective testing (from eight and a half to seven days). In conclusion, proximal deep-vein thrombi are currently less extensive and occlusive than observed in the past. These results might depend on earlier referral of less symptomatic patients and might explain the recently reported decrease in IPG sensitivity for proximal DVT. [ABSTRACT FROM AUTHOR]

Plasma thrombin-antithrombin III (T-AT) complexes are reputed to be an indirect manifestation of thrombin generation, and a role for their determination in the diagnosis of deep vein thrombosis (DVT) has been advocated. In order to evaluate the accuracy of T-AT complexes assay for DVT diagnosis, in 166 consecutive outpatients with clinical suspicion of the disease, plasma concentration of T-AT complexes was measured immediately before venography by means of an enzyme-linked immunosorbent assay kit. The result of the T-AT complexes assay was elevated in 29 of the 48 patients with DVT (sensitivity, 60%). The T-AT complexes levels were within the normal range in 104 of the 118 patients with normal venograms (specificity, 88%). The positive and the negative predictive value were 67% and 85%, respectively. The authors conclude that the T-AT complexes assay is of little value for the diagnosis of DVT in outpatients. [ABSTRACT FROM AUTHOR]

The prevalence of lupus anticoagulant (LA) and antiphospholipid antibodies (APA) in young patients (<45 years) with deep-vein thrombosis (DVT) is not clearly defined yet. We studied 93 consecutive patients (36 males, 57 females; aged 15 to 45) with objectively documented DVT. A control group consisting of 100 normal, sex- and age-matched individuals was also investigated. In all subjects, we evaluated prothrombin time (PT), partial thromboplastin time (PTT), AT III antigen and activity, protein C antigen and activity, free and total protein S antigen and protein S activity, fibrinogen, plas-minogen, heparin cofactor II, plasminogen activator inhibitor (PAI), lupus anticoagulant (LA), and APA. For the assessment of LA, we used the PTT-LA kit (Boehringer Mannheim, Milan, Italy) as a screening test, with mixing studies with the Staclot-PNP kit and the Staclot-LA kit (Boehringer Mannheim, Milan, Italy) as confirmatory procedures. For the detection of APA, we used a commercially available enzyme-linked immunoassay (ELISA) (Asserachrom APA, Boehringer Mannheim, Milan, Italy). History was elicited in all patients to determine if the thrombotic episode was idiopathic or the result of a well-identified risk factor. LA was found in 11 (11.8%) patients. APA were positive in 13 (14%) and borderline in 19 (20.4%) patients. In the control group, no patients were positive for LA or APA, but five exhibited borderline APA levels. LA was significantly more frequent (p = 0.05) in patients with idiopathic DVT than in patients with secondary DVT; no difference was found for APA (p > 0.5). An inherited coagulation defect was found in seven (7.5%) patients. Our data suggest that the presence of LA or APA is associated with an increased incidence of thrombotic manifestation in young patients. Moreover LA is more frequent in patients with idiopathic DVT. Because the incidence of recurrent thrombotic manifestations in patients with LA or APA is estimated to be ∼50%... [ABSTRACT FROM AUTHOR]

The relevance of congenital thrombophilia in the pathogenesis of venous thromboembolism in young patients is still debated. In a case-control study, plasma antigen and activity of antithrombin, protein C, and plasminogen, as well as total and free protein S were measured in a series of 166 consecutive outpatients aged less than 50 years, who underwent contrast venography because of clinically suspected deep-vein thrombosis (DVT). The presence of major acquired risk factors for venous thrombosis was also recorded. The association between DVT and inherited thrombophilia or acquired risk factors was initially described using crude odds ratios (OR). Subsequently, a logistic regression model was used to test their independence. Of the 166 patients included, venography showed an acute DVT in 73 (cases), whereas it was normal in the remaining 93 (controls). Major acquired risk factors were identified in 51 cases and in 20 controls (crude OR: 8.5; 95% CI: 4.1-17.1). Inherited thrombophilia was detected in seven cases and in one control (crude OR: 9.8; 95% CI: 1.2-81.2). Inherited thrombophilia was equally distributed between patients with secondary and idiopathic DVT and was proved to be independent from acquired risk factors in the regression model. Inherited thrombophilia is an independent risk factor for DVT in young patients. However, its prevalence in unselected cases with the first episode of DVT is low. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate post-marketing efficacy and safety data for therapy with daptomycin (DAP) in Italy. Data from patients treated with DAP at 30 centres between January 2006 and July 2009 were analysed according to the protocol of the EU-CORE(SM). In 359 patients, DAP was most commonly prescribed for skin and skin-structure infections (55%), infective endocarditis (13%), and bacteraemia (12.5%). DAP was associated with rapid improvement, and clinical success rates ranging from 77 to 91%, despite almost half of the patient population being ≥65 years of age, 86% having significant underlying disease, and many being affected by drug-resistant pathogens. Staphylococcus aureus represented 35% of all pathogens isolated. Success rates for all staphylococcal and enterococcal infections were >80%, including methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA). Clinical outcomes were similar for DAP whether used as first- or second-line therapy. DAP was well tolerated even with prolonged treatment.

We report the case of a 41-year-old woman with severe mitral regurgitation due to infective endocarditis caused by a rare zoonotic microorganism (Capnocytophaga canimorsus). She had had a rheumatic mitral endocarditis successfully treated with antibiotics when she was 13 years old. She arrived to our attention for a fever of unknown origin. She had been bitten by her dog and medicated the wound herself. About 2 weeks later she developed a fever with values up to 39.5 degrees C. Blood cultures were initially negative but in view of her particular history (dog bite), the samples were sent to a specialized center where a Capnocytophaga canimorsus (a commensal bacterium contained in the saliva of dogs and cats) infection sensitive to ceftriaxone was detected. The antibiotic therapy was consequently modified and the patient's fever resolved. At echocardiography a mild mitral stenosis with severe regurgitation (3-4+/4+) was detected. We planned surgical mitral repair but the operative findings clearly showed the need for mitral replacement and a 29 mm size bileaflet mechanical prosthesis was implanted. The postoperative course was regular and the patient was discharged on the fifth day. We highlight the importance of a careful history and correct work-up for the diagnosis and treatment of false negative blood culture endocarditis.

Patients with diabetes have an impaired wound healing process that contributes to the pathophysiology that may lead to amputation. In this case study, an extensive (103.49 cm2) full-thickness cutaneous wound with exposure of a necrotic Achilles' tendon in a patient with diabetes, neuropathy, and infrapopliteal vascular disease of the lower limbs was healed using a two-stage autologous skin substitute technique. The scaffolds on which the autologous fibroblasts and keratinocytes were grown comprised an ester derivative of hyaluronic acid. Two applications of the cultured autologous fibroblasts and one of the cultured autologous keratinocytes were placed on the wound at 7-day intervals. The ulcer healed completely 60 days following the first fibroblast graft application. After 16 months of follow-up, no recurrence was noted and the patient can walk without ancillary support. This novel tissue engineering technique is a promising treatment for wound healing.