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The COVID-19 pandemic has presented a great challenge for the healthcare systems and healthcare workers worldwide. The resources and the infrastructure of the healthcare systems are reorganized to provide care for abundant number of pandemic patients. All elective procedures and treatments have either cancelled or postponed. Treatment of lower extremity ulcers may be misclassified as non-essential during this pandemic; however, without regular best wound care, these ulcers are at a great risk of becoming quickly infected, which may lead to an increased rate of septicemia, amputations, and even deaths in this fragile patient population. In this review, we discuss the treatment strategies for lower leg ulcers and vascular pathologies during pandemic and provide an algorithm for triage which may be a useful guide for vascular surgeons. [Turk J Vasc Surg 2021; 30(2.000): 167-73]

Objective: The ulcers of lower extremities, both venous and diabetic, impose a massive burden on sufferers globally. This meta-analysis evaluates the efficacy of silver dressings in improving healing rate of these ulcers., Methods: We carried out comprehensive searches in PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Internet (CNKI) up to March 2024. Two reviewers independently screened the study and extracted data. While the primary outcome was wound healing rate, secondary outcomes included wound healing area and recurrence rate. Data were analyzed using Stata 16.0 software., Results: A total of 18 studies involving 1,825 participants were included. Silver dressings demonstrated statistically significant effects in improving healing rates for diabetic foot ulcers (DFUs) (OR 2.14, 95% CI: 1.52, 3.00, p = 0.00), whereas the effects were not statistically significant for venous leg ulcers (VLUs) (OR 1.32, 95% CI: 0.97, 1.78, p = 0.07). Silver dressings also reduced ulcer area by 27.44 cm2 (95% CI: 6.96-47.92) and recurrence rate by 45% (95% CI: 0.11-1.79). Subgroup analysis revealed that the Asia-Pacific region and treatments of 6 weeks or less exhibited higher healing rates than their respective counterparts, although there was no statistical significance., Conclusions: This study indicated a statistically significant benefit of the treatment for DFU. However, the effect on VLU, though positive, did not reach statistical significance. This distinction should be considered in clinical application and further research., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Objective: Lower extremity ulcers (LEUs) are associated with a decline in patients' quality of life (QoL). Better healthcare availability in remote regions, facilitated by telemedicine (TM), may improve patient wellbeing. The aim of this study was to compare the QoL of patients treated via synchronous video TM with that of patients treated with standard face-to-face (FTF) care. Method: The study was performed in a large health services provider in Israel (Maccabi Healthcare Services). TM was used in four remote locations; the FTF method was applied in two regional clinics. The treatment protocol was performed by a nurse and supervised by the regional physician in both treatment modes. A validated Wound-QoL questionnaire in Hebrew was used to assess patient outcomes. Results: A total of 83 patients were treated via TM and 94 patients were treated FTF. The mean QoL for patients treated via TM was 0.546±0.249 compared with 0.507±0.238 for the FTF group. A similarity relating to outcomes in both treatment methods was demonstrated by a difference of 0.039 (95% confidence interval –0.33–0.111) and p=0.291. The probability of the difference being within the limits of the interval in a replicated study was 83.4%. The equivalence/non-inferiority was established within the accepted Δ=0.12 range. Conclusion: The results indicated no reduced QoL for patients with LEUs treated with telemedicine versus with standard FTF care. Declaration of interest: The authors have no conflicts of interest. [ABSTRACT FROM AUTHOR]

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The COVID-19 pandemic has presented a great challenge for the healthcare systems and healthcare workers worldwide. The resources and the infrastructure of the healthcare systems are reorganized to provide care for abundant number of pandemic patients. All elective procedures and treatments have either cancelled or postponed. Treatment of lower extremity ulcers may be misclassified as non-essential during this pandemic; however, without regular best wound care, these ulcers are at a great risk of becoming quickly infected, which may lead to an increased rate of septicemia, amputations, and even deaths in this fragile patient population. In this review, we discuss the treatment strategies for lower leg ulcers and vascular pathologies during pandemic and provide an algorithm for triage which may be a useful guide for vascular surgeons. [ABSTRACT FROM AUTHOR]

Livedoid vasculopathy (LV) can be a challenging diagnosis with an interesting pathophysiology. LV is an uncommon diagnosis that can be easily mistaken for more common skin conditions, especially in a person of color who may be underrepresented in pathology images used in medical education. LV has an average of five years from initial presentation to diagnosis, possibly due to providers not having it on their differential for lower extremity ulcerations. Prolonged time to diagnosis can potentially lead to life-changing complications. We present a case of a former professional sprinter who became debilitated by neuropathy secondary to complications from LV. He was seen multiple times and had an extensive work-up exploring a broad differential including autoimmune etiologies, hypercoagulable disorders, neuropathies, and other vascular disorders before reaching the diagnosis. This case emphasizes the importance of early diagnosis and treatment with a multidisciplinary team to help prevent the progression of these symptoms. We break down an extensive work-up that involves a multidisciplinary team including dermatology, hematology, neurology, rheumatology, and vascular surgery. This case will also highlight examples of LV in a patient with a dark skin complexion, which can be challenging to find in current literature. We additionally show images that demonstrate many of the classic pathologic findings associated with LV and how those can help lead to the diagnosis along with detailed descriptions of those findings. Classic physical exam findings including atrophic blanche and lower extremity ulcerations are highlighted. We also review LV's history, diagnosis, and treatment to help readers achieve a better understanding of the disease., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Del Valle et al.)

A randomised, controlled multicentre clinical trial was conducted at 14 wound care centres in the United States to confirm the efficacy of dehydrated human amnion/chorion membrane allograft (dHACM) for the treatment of chronic lower extremity ulcers in persons with diabetes. Patients with a lower extremity ulcer of at least 4 weeks duration were entered into a 2‐week study run‐in phase and treated with alginate wound dressings and appropriate offloading. Those with less than or equal to 25% wound closure after run‐in were randomly assigned to receive weekly dHACM application in addition to offloading or standard of care with alginate wound dressings, for 12 weeks. A total of 110 patients were included in the intent‐to‐treat (ITT) analysis, with n = 54 in the dHACM group and n = 56 in the no‐dHACM group. Of the participants, 98 completed the study per protocol, with 47 receiving dHACM and 51 not receiving dHACM. The primary study outcome was percentage of study ulcers completely healed in 12 weeks, with both ITT and per‐protocol participants receiving weekly dHACM significantly more likely to completely heal than those not receiving dHACM (ITT—70% versus 50%, P = 0.0338, per‐protocol—81% versus 55%, P = 0.0093). A Kaplan–Meier analysis was performed to compare the time‐to‐healing performance with/without dHACM, showing a significantly improved time to healing with the use of allograft, log‐rank P < 0.0187. Cox regression analysis showed that dHACM‐treated subjects were more than twice as likely to heal completely within 12 weeks than no‐dHACM subjects (HR: 2.15, 95% confidence interval 1.30–3.57, P = 0.003). At the final follow up at 16 weeks, 95% of dHACM‐healed ulcers and 86% of healed ulcers in the no‐dHACM group remained closed. These results confirm that dHACM is an efficacious treatment for lower extremity ulcers in a heterogeneous patient population. [ABSTRACT FROM AUTHOR]

Objective: Diabetic ulcers are a prevalent complication of diabetes mellitus and represent one of the most complex and severe complications that can occur in diabetic patients. Most existing studies have separately examined the neutrophil-to-lymphocyte ratio (NLR) prognostic value or the platelet-to-lymphocyte ratio (PLR). However, to our knowledge, no study has evaluated the relationship between the monocyte-to-lymphocyte ratio (MLR) and non-healing lower extremity ulcers (NHLU) in patients. This study explored the association between 3 hematological parameters (MLR, NLR, and PLR) and the risk of non-healing ulceration in patients with type 2 diabetes (T2D)., Methods: A cross-sectional study was performed using data from the National Health and Nutrition Examination Survey (NHANES) spanning 1999 to 2004. The primary outcome variable was NHLU status, determined by patients' self-reported responses to the question, "Have you had an ulcer or sore on your leg or foot that took more than four weeks to heal?" Logistic regression examined the relationships between MLR, NLR, PLR, and NHLU. Stratified analyses were also conducted based on age, gender, hemoglobin (HGB) level, and body mass index (BMI)., Results: In the multivariate regression models, after adjusting for age, sex, race/ethnicity, marital status, poverty income ratio (PIR), BMI, HGB, family history of diabetes, and low-density lipoprotein (model 3), the odds ratios (ORs) of MLR and NLR were 1.21 (1.09-1.33) and 1.02 (1.01-1.03), respectively. However, the association was no longer statistically significant for the NLR (OR = 1.0002, 95% CI: 0.99-1.0005, P  = .137). In the subgroup analysis, the effect sizes of MLR and NLR on the presence of NHLU were stable in all subgroups (all P  > .05)., Conclusions: After adjusting for confounding variables, MLR and NLR were significantly increased in T2D participants with NHLU. They may play a significant role in monitoring T2D patients during follow-up visits.

Las úlceras de la extremidad inferior presentan una elevada prevalencia que guarda una relación directa con la edad. El predominio de úlceras abiertas es del 0,1 a 0,3% y su incidencia de tres a cinco nuevos casos por 1.000 personas al año. Cuando estas se curan, ocurren recidivas del 33 al 42% de los casos, padeciendo una de cada tres úlceras una recidiva en un periodo de nueve meses y alrededor del 60% a los cinco años. Los ácidos grasos hiperoxigenados (AGHO) han demostrado ser eficaces en la prevención de las úlceras de la extremidad inferior gracias a su acción favorable sobre la piel, puesto que aumentan la microcirculación sanguínea, impulsan la renovación celular epidérmica y mejoran notablemente la hidratación cutánea. En el presente estudio, hemos querido evaluar una posible disminución de la incidencia de recidivas de lesiones vasculares con el uso continuado de los ácidos grasos hiperoxigenados (AGHO) en emulsión (Mepentol® Leche), en el mismo grupo de pacientes tratados con el producto en un estudio anterior, en el que se obtuvieron excelentes resultados que demostraron su efectividad en la prevención de la aparición de nuevas lesiones en la piel tratada con Mepentol® Leche, así como en la mejora de los diferentes síntomas que acompañan a este tipo de úlceras. Para ello, se ha realizado un seguimiento de dos años, desde 2006 a 2008, de estos mismos pacientes con úlceras de la extremidad inferior ya resueltas, con el fin de valorar la incidencia de recidivas en este grupo.Lower extremity ulcers have a high prevalence, which has a direct relationship with age, his prevalence is 0.1 to 0.3%, and its incidence is three to five new cases per thousand people per year. When these healed, relapses occur in 33 to 42% of cases, one in trhee suffer ulcer recurrence in a period of nine months, and about 60% at five years. Hyper-oxygenated fatty acids has proven to be effective in preventing lower extremity ulcers due to its favorable action on the skin, increasing blood microcirculation, promoting epidermal cell turnover and significantly improving skin hydration. In this study we wanted to evaluate a possible reduction in the incidence of recurrence of vascular lesions with continued use of hyper-oxygenated fatty acids (AGHO) emulsion, Mepentol® Leche, in the same group of patients treated with the product in a previous study, in which excellent results were obtained which showed its effectiveness in preventing appearance of new lesions in the skin treated with Mepentol® Leche, as well as the improvement of various symptoms that accompany this type of ulcers. To do this, it has been monitoring two years, from 2006 to 2008, these same patients with lower extremity ulcers healed in order to assess the incidence of recurrences in this group.

The motorized mobility scooter (MMS) provides considerable benefits to patients with mobility limitations. Nevertheless, safety concerns related to MMS use are an issue. With increased use because of increased life expectancy and chronic illness, there are a growing number of reports of MMS-related injuries, ranging from lacerations and contusions to fatalities. Comorbidities may also exacerbate wound care. Prevention of these injuries is greatly needed. The author presents 5 patients with lower-extremity ulceration caused by MMS injuries. To prevent these injuries, health care providers must carefully evaluate and monitor patients. Clinicians and MMS manufacturers also need to educate and train patients on the safe use of MMS devices, including the regular use of footwear. [ABSTRACT FROM AUTHOR]

Aetiological factors and their frequencies, causes, level and impact of immunosuppression on outcome of lower extremity ulcers were prospectively recorded. A total of 100 patients were evaluated. Consent for HIV testing was given by 68 patients and 31 (46%) of these were HIV infected. Thirty patients were diabetic. CD 4+ T-lymphocyte count was assessed in 41 patients. Eleven were HIV infected with a mean CD 4+ count of 229 ± 137 cells/µl. Six had non insulin-dependent diabetes mellitus (NIDDM) with a mean CD 4+ count 430 ± 308 cells/µl. Five had both HIV infection and NIDDM with a mean CD 4+ count of 299 ± 120 cells/µl. All three groups differed from the normal 707 ± 285 cells/µl found in 17 non HIV-infected non diabetic patients ( P < 0· 05). The main aetiologies were bacterial infection, arterial disease, trauma and neuropathy. Ulcer healing and limb salvage were noted in 71%. Mortality was 10%; seven in HIV-infected and three in non HIV-infected non diabetic patients ( P = 0· 06). Amputation rate was 9%. Persisting ulcers were noted in 8% and 2% were lost to follow-up. Our evaluation shows that wound aetiologies in Zimbabwe differ from those in the West. Immunosuppression because of HIV infection and NIDDM was noted in more than half of the patients. HIV infection may increase mortality in this group of patients. [ABSTRACT FROM AUTHOR]

Lower extremity chronic wounds affect 4.5 million Americans annually. Due to inadequate access to wound experts in underserved areas, many patients receive non-uniform, non-standard wound care, resulting in increased costs and lower quality of life. We explored machine learning classifiers to generate actionable wound care decisions about four chronic wound types (diabetic foot, pressure, venous, and arterial ulcers). These decisions (target classes) were: (1) Continue current treatment, (2) Request non-urgent change in treatment from a wound specialist, (3) Refer patient to a wound specialist. We compare classification methods (single classifiers, bagged & boosted ensembles, and a deep learning network) to investigate (1) whether visual wound features are sufficient for generating a decision and (2) whether adding unstructured text from wound experts increases classifier accuracy. Using 205 wound images, the Gradient Boosted Machine (XGBoost) outperformed other methods when using both visual and textual wound features, achieving 81% accuracy. Using only visual features decreased the accuracy to 76%, achieved by a Support Vector Machine classifier. We conclude that machine learning classifiers can generate accurate wound care decisions on lower extremity chronic wounds, an important step toward objective, standardized wound care. Higher decision-making accuracy was achieved by leveraging clinical comments from wound experts., Competing Interests: Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objective: Venous leg ulcers (VLUs) are one of the most common complications in lower extremity wounds. To date, clinicians employ visual inspection of the wound site during its healing process by monitoring surface granulation and reduction in wound size across weeks of treatment. In this study, a handheld near-infrared optical scanner (NIROS) has been developed at the Optical Imaging Laboratory to differentiate healing from nonhealing VLUs based on differences in blood flow to the wound and its surroundings. Approach: Noncontact near-infrared (NIR) area imaging of 12 VLUs have been carried out at two podiatric clinics. Diffuse reflectance images of the wounds were used to quantify optical contrasts between the wound and its surroundings. The variability in imaging conditions, analysis, and operator dependency were assessed to determine the robustness of the imaging approach. Results: Optical contrast obtained from diffuse reflectance images of VLUs were distinctly different for healing (positive contrast) and nonhealing (negative contrast) wounds, independent of the varying imaging and data analysis conditions. Innovation: NIR imaging of wounds to differentiate healing from nonhealing VLUs using a noncontact wide-area imager has been demonstrated for the first time. Conclusion: The application of a portable handheld imager to assess the healing or nonhealing nature of VLUs during weekly clinical treatment is significant since physiological changes, as observed using NIROS, manifest before visual reduction in wound size during the healing process.

Objective: Rising prevalence of obesity and uncontrolled diabetes mellitus has resulted in an increasing number of patients with multiple comorbidities who require treatment for chronic complex wounds. Because patients with diabetes and foot ulcers may have a higher risk for amputations, techniques that facilitate complex wound healing and prevent limb amputation are desirable. Here, we investigate a limb preservation strategy that includes application of a human acellular dermal wound matrix (HADWM)., Method: Medical history, physical examination and full wound assessment were completed for all patients. Systemic antibiotics and appropriate offloading were prescribed as needed. Wounds were debrided to create a bleeding bone and/or wound base for HADWM (Graftjacket regenerative tissue matrix, Wright Medical Technology, Inc., licensed by KCI, an Acelity company, San Antonio, TX). Healing progress was monitored over four weeks with weekly postoperative visits. 'Healed' was defined as full epithelialisation without drainage., Results: Lower extremity ulcers, 16 in 13 patients, were treated with HADWM between May 2004 and July 2013. The median patient age was 76 years (range: 38-90). The average number of comorbidities was three per patient, while 6 (46%) patients had ≥4 comorbidities. Diabetes mellitus (92%) and peripheral vascular disease (77%) were the two most common. All 16 (100%) wounds healed without complications. There were no recurrences in the 11 wounds of the nine patients available for follow-up. Of these patients two had previously advised to receive major leg amputations retained functional limbs., Conclusion: The results in this small study reflect our practice's 10-year experience using HADWM as part of a limb preservation strategy.