Evaluation of hypochlorous acid washes in the treatment of chronic venous leg ulcers.

OBJECTIVE: Hypochlorous acid (HOCl) is a highly microbiocidal agent active against bacteria, viruses and fungi. Using quantitative microbiology, preliminary studies showed it achieved an appreciable reduction in the bacterial burden in chronic venous leg ulcers. The study aimed to determine whether it has a role as an additional treatment for chronic venous ulcers that have not healed with conventional treatment. METHOD: On the basis of previous reports we designed a study in which patients acted as their own controls, in that only patients who failed to achieve a 44% reduction in wound size with standard treatment (compression bandaging) received HOCl washes. RESULTS: Of 30 patients admitted to the study, 10 achieved a 44% ulcer reduction after three weeks of standard treatment. In addition to the standard compression treatment, the remaining 20 patients were given HOCl washes over 12 weeks. Of the 20 ulcers, nine (45%) healed and five (25%) reduced in size by over 60%. All patients became free of pain. CONCLUSION: These findings confirm the clinical efficacy of treating venous leg ulcers with hypochlorous washes. Use of HOCl washes as an adjunctive therapy for recalcitrant venous leg ulcers appreciably increases healing and rapidly relieves pain.

Comparison of two peri-wound skin protectants in venous leg ulcers: a randomised controlled trial.

OBJECTIVE: A randomised controlled trial was designed to determine whether or not early intervention with a suitable skin barrier preparation could prevent skin breakdown. This study was conducted to compare the efficacy and cost-effectivenss of two skin protectants, Cavilon No Sting Barrier Film (NSBF) (3M Health Care) and zinc paste compound, in the management of maceration and irritation of the peri-wound area of venous leg ulcers. METHOD: Thirty-five patients with venous leg ulcers and surrounding skin problems were randomised to receive either NSBF or zinc paste compound. The preparation was then applied at each dressing change for 12 weeks. All patients had been receiving compression bandaging before entering the study and continued wearing it throughout the 12-week study period. RESULTS: The decrease in wound area was 5.11+/-8.39cm2 in the NSBF group and 4.59+/-5.83cm2 in the zinc paste group. The healing rate was 0.046cm per week with NSBF and 0.039cm per week with zinc paste. There was a significant difference in the time required to remove and re-apply the skin protectants: an average of 0.19 (+/-0.17) minutes in the NSBF group and 5.53 (+/-2.10) minutes in the zinc paste group (p<0.0001). CONCLUSION: Both products were effective barrier preparations. However, NSBF was easy to apply and transparent. The zinc paste was messy to apply and difficult to remove, and thus took up considerably more nursing time than NSBF. DECLARATION OF INTEREST: This study was supported by 3M Health Care.

Using cycloidal vibration to heal venous leg ulcers: a cost-analysis based on retrospective data.

Using cycloidal vibration to stimulate the circulation to enhance healing can significantly reduce treatment costs. For the patient, the benefits include faster healing times, a better quality of life and a marked reduction in pain.

How echographic image analysis of venous oedema reveals the benefits of leg elevation.

OBJECTIVE: Venous insufficiency, leading to venous oedema, is a key pathogenic factor for the non-healing of venous leg ulcers. This study aimed to evaluate the effects of leg elevation on venous oedema. METHOD: Ten patients aged 44-89 years (median: 61) with leg oedema had high-frequency B-mode ultrasound scanning and digital image analysis before and after three to four hours of leg elevation. The echographic image analysis system was used, where oedema is represented by the hypoechogenic part of the image--that is, the total number or density of low echogenic pixels (LEPs) in a particular area. RESULTS: Compared with pre-elevation, the volume of the lower leg decreased by 2.9% +/- 0.6 (138 cm3 +/- 39) after three to four hours' elevation (p < 0.05). After elevation, the LEPs in the upper, middle and lower sites of the limb decreased by 8.8%, 15.6% and 17.3% respectively, reaching statistical significance (p < 0.05) in the lower site. The ratio of LEPs in the upper and lower dermis in the upper, middle and lower sites decreased by 30.3%, 45.8% and 22.5% respectively. This was significant in both the middle and lower sites (p < 0.01). After elevation dermal thickness increased by 0.047 mm, 0.194 mm and 0.232 mm respectively. This change was statistically significant in the middle (p < 0.05) and lower sites of the limb (p < 0.01). CONCLUSION: LEPs are a sensitive marker of dermal oedema and its effects. Leg elevation is extremely effective in reducing oedema, even if only for three to four hours.

Effect of glucose concentration on the growth of normal human dermal fibroblasts in vitro.

OBJECTIVE: Glucose requirements increase in tissue repair as glucose is an energy source for cell proliferation and the formation of extracellular matrix components. Glucose concentrations in leg ulcer wound fluid are lower than in normal human serum, with a median of 0.7 mM (range: 0.3-1.2 mM). This study investigated the effect of such low concentrations on the growth of fibroblasts in vitro. METHOD: Fibroblasts from 50-year-old and 87-year-old subjects were used. Growth in medium with various concentrations of glucose was determined by a colorimetric assay and microphotography. RESULTS: Up to day 6, there were minimal differences in growth, but after day 6 a clear dose-dependent increase in growth was observed. In the lower dose range (up to 2.3 mM), growth was highly dose-dependent (r2 = 0.981), with an increase of 1.8 mM stimulating cell growth by day 10 up to 163% of the controls (p < 0.0001). Concentrations of 5.5-25.5 mM glucose stimulated cell growth by day 10 to about 210% of the controls (p < 0.0001), with little difference between these concentrations. CONCLUSION: These results suggest that glucose enhancement to cells involved in healing might serve as an adjunctive treatment for chronic wounds.

Sensory testing in patients with chronic venous leg ulcers using a 10 g Owen Mumford monofilament.

OBJECTIVE: Chronic venous insufficiency in the lower legs may directly contribute to tissue damage, and there is increasing evidence that neuronal damage may be involved. This study was carried out to determine the feasibility of using a simple neuropathy screening test in the community to diagnose sensory neuropathy in the feet of patients with chronic venous insufficiency. METHOD: We tested 15 randomly selected patients with documented chronic venous insufficiency with the 10 g Owen Mumford monofilament, in order to ascertain objectively sensory blunting. RESULTS: Forty-seven per cent of the patients had normal sensation in the foot of the ulcerated leg and 53% showed some degree of neuropathy. A recent study comparing the performance of commercially available 10 g monofilaments showed that the Owen Mumford filament was one of the most accurate, with 100% buckling within +/- 1 g of 10 g. CONCLUSION: This preliminary study indicates that the 10 g monofilament is an easy method of testing the sensory status of patients with chronic venous insufficiency in the community.

The cellular origins of the linear IgA disease target antigens: an indirect immunofluorescence study using cultured human keratinocytes and fibroblasts.

BACKGROUND: Linear IgA disease (LAD) is an IgA-mediated subepidermal immunobullous disease of adults and children, with heterogeneous immunopathology. Objectives To investigate to what extent the cellular origins of the target antigens account for the heterogeneity of the immune response in LAD. METHODS: Forty-nine adult and 33 childhood LAD sera were studied. Immunofluorescence was carried out to determine the expression of the LAD antigens by normal human keratinocytes, fibroblasts and mixed cultures of keratinocytes and fibroblasts. Immunoblotting was performed to determine the localization of the LAD target antigens in tissue extracts (48 adult and 31 childhood sera) and cell extracts (21 adult and 10 childhood sera). RESULTS: Thirty-one adult and 13 childhood LAD sera bound proteins expressed by human keratinocytes; of these sera, 15 adult and four childhood LAD sera also recognized proteins expressed by fibroblasts. A single adult serum was positive on fibroblasts alone. Seventeen adult and 20 childhood sera were negative on both cell types. There was a modest increase (9%) in the detection of the IgA autoantibodies on keratinocytes and fibroblasts grown together in mixed culture. Immunoblotting showed that the LAD target antigens could be detected in cell as well as in tissue extracts. CONCLUSIONS: Our results have shown that normal human keratinocytes and fibroblasts in culture express the LAD target antigens. LAD sera (with a single exception) bound antigens expressed by keratinocytes alone or by both keratinocytes and fibroblasts. The principal pattern of expression in keratinocytes was cytoplasmic, similar to that demonstrated by polyclonal antibodies to the 180-kDa bullous pemphigoid antigen (BP180). This reflects the pivotal role of BP180 in LAD. The finding that LAD antigens are expressed by both human keratinocytes and fibroblasts in culture may explain the heterogeneity of the target antigens, and may be a contributory factor in the immunopathology of the disease.

Effect of intermittent radiant warming on proliferation of human dermal endothelial cells in vitro.

OBJECTIVE: This study investigated the effect of Warm-Up therapy on the proliferation of human microvascular dermal endothelial cells. METHOD: Endothelial cells from an adult subject were seeded in six-well plates and placed in an incubator at 32.5 degrees C. The following day Warm-Up dressings were placed over the plates, with or without warming cards. Cards set at 38 degrees C or 42 degrees C raised the temperature in the medium to maxima of 34.5 degrees C and 37.5 degrees C respectively. Units were switched on daily for three one-hour periods. Cell numbers were counted by haemocytometer. RESULTS: Maximum stimulation of endothelial cell proliferation occurred under the 38 degrees C card, with cells numbering 135-158% of the controls (p < 0.05). the 42 degrees C card also stimulated cells (110-155%) but this did not reach statistical significance. CONCLUSION: The accelerated proliferation of microvascular dermal endothelial cells achieved by intermittent radiant warming may have contributed to the increase in granulation tissue reported previously in our clinic.

Healing venous ulcers with cycloidal multidirectional vibration therapy.

OBJECTIVE: This preliminary study combined compression bandaging with cycloidal vibration to determine whether this would enhance the rate of healing of venous leg ulceration. METHOD: Twenty-one patients with venous ulceration were enrolled into a 12-week trial. The vibration device was used three times daily for 30 minutes on each occasion, along with compression bandaging. RESULTS: Ulcers of 13 patients (62%) healed within 12 weeks. The remaining eight patients completed the 12-week study with a 31-90% reduction in ulcer size. A reduction in pain was observed in 17 out of 21 patients (81%). Ultrasound measurements showed reduced fluid content in the upper dermis in patients whose ulcers had healed and in others whose ulcers were improving. CONCLUSION: This preliminary study shows that gentle cycloid vibration, combined with standard compression bandaging, enhances the healing rate of venous ulcers and helps to relieve pain.

Venous leg ulcer recurrence: prevention and healing.

After a leg ulcer has healed, well-fitting compression stockings, patient education and regular check-ups are the basis for preventing recurrence. This article examines patterns in recurrence and subsequent healing among patients at an ulcer clinic.

Effect of a lipopolysaccharide from E. coli on the proliferation of fibroblasts and keratinocytes in vitro.

Studies previously conducted in our laboratory have shown that an extract from the leaves of Chromo-laena odorata is mitogenic for human skin fibroblasts and keratinocytes. However, lipopolysaccharides, sometimes present in plant extracts, can also play a role in cell growth and might have been responsible for or contributed to the mitogenic activity observed. The present study aimed to investigate whether a lipopolysaccharide would have any effect on the proliferation of human fibroblasts and keratinocytes. Cells were seeded in 96-well plates and concentrations from 0.0 to 5.0 microg/mL of lipopolysaccharide in basal or growth medium were added. Cell growth was determined over a period of 10 days using a colorimetric assay. Lipopolysaccharide at concentrations between 0.05 microg/mL and 0.5 microg/mL in the growth medium significantly stimulated fibroblast proliferation after incubation for more than 6 days. In basal medium, more than 8 days of incubation was needed for significant stimulation of growth. Lipopolysaccharide stimulation of keratinocytes was evident at 0.5 microg/mL by day 3 in basal medium and by day 5 in growth medium. Although the lipopolysaccharide did stimulate cell growth it did so only at higher concentrations than were present in our plant extracts and to a lesser degree.

Effects of an aqueous extract from the leaves of Chromolaena odorata (Eupolin) on the proliferation of human keratinocytes and on their migration in an in vitro model of reepithelialization.

Eupolin ointment, prepared from the leaves of Chromolaena odorata, has been shown to promote the healing of soft tissue wounds and burns in Vietnam. However, the mechanism by which this agent affects cells involved in the wound healing process is unknown. Cultured human keratinocytes were used in this study to investigate the effects of the Eupolin extract in vitro on processes involved in wound reepithelialization. Keratinocyte proliferation was monitored by a colorimetric assay and migration by the closure of a denuded area scratched in a confluent monolayer. Human keratinocyte proliferation was stimulated by low concentrations of the extract (from 0.1 to 5 microg/ml), cell differentiation by higher concentrations (50 to 300 microg/ml), and migration by intermediate concentrations (5 to 60 microg/ml). The increased proliferation and migration of human keratinocytes observed in vitro might explain, in part, the beneficial effects that have been observed in the clinic.

Mandibular metastasis from renal cell carcinoma. A case report.

Renal cell carcinoma (RCC) metastasizing to the mandible and subsequently spreading to oropharynx in a 62 year old man is reported. The patient presented with solitary mandibular lesion with hematuria, which on further investigation was diagnosed to be RCC with no other systemic involvement. Clinical manifestation of the mandibular metastasis from RCC is rarely seen. A case is reported and literature regarding extracranial head and neck metastasis by RCC is reviewed.

Effects of Buddleja globosa leaf and its constituents relevant to wound healing.

An aqueous extract of Buddleja globosa leaves, used traditionally in Chile for wound healing, was tested for the ability to stimulate growth of fibroblasts in vitro and for antioxidant activity in the same fibroblast cell system challenged with hydrogen peroxide. Low concentrations of the extract gave an increase in fibroblast growth which was not statistically significant but cytotoxicity was observed at concentrations greater than 50 microg/ml. The extract showed strong antioxidant effect and fractionation led to the isolation of three flavonoids and two caffeic acid derivatives, each of which was shown to contribute to the antioxidant effect at concentrations below 10 microg/ml. These activities would accelerate the healing of wounds.

Sleep-disordered breathing in stable methadone programme patients: a pilot study.

AIMS: To explore the possibility that stable MMP patients have sleep-disordered breathing (SDB) and abnormal sleep architecture defined by nocturnal sleep stages and sleep efficiency. DESIGN: Observational. SETTING: Regional Methadone Service and sleep disorders laboratory in a university affiliated hospital. Participants and measurements. Ten stable MMP patients and nine normal subjects were assessed clinically and with overnight polysomnography. FINDINGS: There were no differences in age, sex and body mass index between the groups. The methadone dose ranged between 50 and 120 mg/day. Six patients had central apnoea index (CAI) greater than 5, four had a CAI greater than 10 and three of these exhibited periodic breathing. No normal subject had central sleep apnoea. The patients had lower sleep efficiency (p < 0.05), less slow wave sleep (p < 0.01), less rapid eye movement sleep (p < 0.05) and more Stage 2 sleep (p < 0.05) than controls. CONCLUSIONS: Stable MMP patients have more sleep architecture abnormalities than controls and a higher prevalence of central sleep apnoea. Further studies are needed to confirm these findings, to delineate the mechanisms for the abnormalities and to assess whether the SDB is related to sudden death in stable MMP patients. We recommend that MMP patients have awake and sleep respiration assessed to identify those potentially at risk.

Guidelines in practice: the effect on healing of venous ulcers.

OBJECTIVE: To determine the effect of guidelines on vascular assessment, compression usage, dressing selection, and healing rates of patients with a venous ulcer. DESIGN: Prospective descriptive intervention evaluation. SETTING: Oxfordshire Community National Health Service (NHS) Trust, United Kingdom. PATIENTS: 40 consecutive prospective patients seen by Oxfordshire district nurses, either at home or at a wound clinic coordinated by district nurses located in a surgery office. INTERVENTION: The Guideline for Diagnosis and Treatment of Venous Leg Ulcers (University of Pennsylvania) and the Oxfordshire Leg Ulcer Guideline. MAIN OUTCOME MEASURES: Time to healing, compliance with vascular assessment, compression usage, and nursing costs. MAIN RESULTS: 91% of patients had a vascular assessment; all patients were treated with compression. Mean time to healing was 8 weeks and was not related to dressing selection or type of compression (short- versus long-stretch bandage). Nursing costs were slightly higher for wounds that healed after 12 weeks and were treated with a long-stretch bandage (Pound Sterling 170.00 [$250.00] vs Pound Sterling 272.00 [$395.00]). CONCLUSION: Use of compression was influenced by guidelines that emphasize a vascular assessment. Choice of dressing or type of compression was not a significant factor in healing rates.

Upregulation of adhesion complex proteins and fibronectin by human keratinocytes treated with an aqueous extract from the leaves of Chromolaena odorata (Eupolin).

The fresh leaves and extract of the plant Chromolaena odorata are a traditional herbal treatment in developing countries for burns, soft tissue wounds and skin infections. We have previously shown that the extract had an effect on the growth and proliferation of keratinocytes and fibroblasts in culture. This study has demonstrated that Eupolin extract increased expression of several components of the adhesion complex and fibronectin by human keratinocytes. Using indirect immunofluorescence we found increased expression (dose-dependent) of laminin 5, laminin 1, collagen IV, and fibronectin. The expression of the b1 and b4 integrins was upregulated by the extract at low concentrations (0.1 and 1 microg/ml), but the expression was decreased at higher doses of Eupolin (10 microg-150 microg/ml). A number of clinical studies carried out by Vietnamese and international medical investigators have demonstrated the efficacy of this extract on the wound healing process. In this study we have shown that Eupolin stimulated the expression of many proteins of the adhesion complex and fibronectin by human keratinocytes. The adhesion complex proteins are essential to stabilise epithelium and this effect could contribute to the clinical efficacy of Eupolin in healing.