ABC of arterial and venous disease

University of Nottingham, UK.
BMJ Clinical Research (Impact Factor: 14.09). 07/2000; 320(7249):1589-91. DOI: 10.1136/bmj.320.7249.1589
Source: PubMed


Ulceration of the lower limb affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and painful and greatly reduce patients' quality of life. Ulcer healing has been shown to restore quality of life. Lower limb ulceration tends to be recurrent, and the total annual cost of leg ulceration to the NHS has been estimated at £400m.

Causes of lower limb ulceration
Venous diseaseArterial diseaseMixed venous-arterial diseaseNeuropathyTraumaObesity or immobilityVasculitisMalignancyUnderlying osteomyelitisBlood dyscrasiasLymphoedemaNecrobiosis lipoidica diabetecorumPyoderma gangrenosumSelf inflicted

Venous disease, arterial disease, and neuropathy cause over 90% of lower limb ulcers. It is useful to divide leg ulcers into those occurring in the gaiter area and those occurring in the forefoot because the aetiologies in these two sites are different. At least two aetiological factors can be identified in one third of all lower limb ulcers.

Distribution of non-venous and venous ulcers of lower limb. The majority of venous ulcers are in the gaiter area and the majortiy of non-venous ulcers in foot

Venous ulcers most commonly occur above the medial or lateral malleoli. Arterial ulcers often affect the toes or shin or occur over pressure points. Neuropathic ulcers tend to occur on the sole of the foot or over pressure points. Apart from necrobiosis lipoidica, diabetes is not a primary cause of ulceration but often leads to ulceration through neuropathy or ischaemia, or both. The possibility of malignancy, particularly in ulcers that fail to start healing after adequate treatment, should always be borne in mind. The commonest malignancies are basal cell carcinoma, squamous cell carcinoma, and melanoma.

Common sites of venous, arterial, and neuropathic ulceration. Adapted from Tibbs et al

Patients with reduced mobility or obesity may develop ulceration in the gaiter area because of venous …

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Available from: Professor Richard Donnelly,
    • "The compression required to reverse venous hypertension is around 40 mmHg at the ankle (Ramstadius, 1997). Different levels of pressure, depending on the ulcer size, type and patient requirements may need to be applied (London and Donnelly, 2000), but, in general, higher compression has been shown to aid healing better than low compression (Fletcher et al., 1997). Patients that cannot (or will not) tolerate compression therapy in its standard short stretch (SS) form pose a clinical problem for medical staff (Bale and Harding, 2003). "
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    ABSTRACT: Venous Leg Ulceration (VLU) is a chronic condition for which healthcare systems worldwide face rising treatment costs. VLU can be due to sustained venous hypertension which causes the veins to become cuffed with fibrin, inhibiting the supply of nutrients to the wound site. For patients that cannot tolerate compression therapy with an inelastic short stretch (SS) bandage, the mainstay treatment, an elastic three layered (3L) bandage is an alternative. In this paper, a mathematical model is developed to investigate whether the healing of venous ulcers under SS and 3L bandages occurs at different rates and to postulate the reason for any difference. The two treatments were applied to a simplified wound geometry, under the assumption that the rate limiting step of healing is the supply of oxygen to the wounded tissue. Clinical data of wound size over time under the two treatments from Weller et al. (2012) was used to fit key, unknown, model parameters using a least squares approach. Numerical results are presented for the oxygen distribution within the wound space, using the fitted parameter values. The 3L bandage allows more oxygen flow into the wound than the SS bandage and, hence, the 3L bandage results in faster healing, however the difference is more significant for wounds of larger initial size. The model can be used as a predictive tool in a clinical setting to estimate the time to heal for a wound of a given initial size, treated with either a SS or 3L bandage. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Journal of Theoretical Biology 05/2015; 379. DOI:10.1016/j.jtbi.2015.04.028 · 2.12 Impact Factor
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    • "In Western societies, most chronic lower limb ulcers are due to vascular diseases, whereas in developing countries, trauma, infections, malignancies and poorly controlled diabetes remain the most common causes of chronic lower limb ulceration [2,9,10]. In the present study, traumatic ulcers secondary to road traffic accidents were the most common type of chronic lower limb ulcers accounting for more than sixty percent of cases, which is in keeping with other studies done in developing countries [9,10,20,21]. High incidence of traumatic ulcers secondary to road traffic accidents may be attributed to recklessness and negligence of the driver, poor maintenance of vehicles, driving under the influence of alcohol or drugs and complete disregard of traffic laws. "
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    ABSTRACT: Background Chronic lower limb ulcers constitute a major public health problem of great important all over the world and contribute significantly to high morbidity and long-term disabilities. There is paucity of information regarding chronic lower limb ulcers in our setting; therefore it was necessary to conduct this study to establish the patterns and outcome of chronic lower limb ulcers and to identify predictors of outcome in our local setting. Methods This was a descriptive prospective study of patients with chronic lower limb ulcers conducted at Bugando Medical Centre between November 2010 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was done using SPSS version 17.0 and STATA version 11.0. Results A total of 300 patients were studied. Their ages ranged from 3 months to 85 years (median 32 years). The male to female ratio was 2:1. The median duration of illness was 44 days. Traumatic ulcer was the most frequent type of ulcer accounting for 60.3% of patients. The median duration of illness was 44 days. The leg was commonly affected in 33.7% of cases and the right side (48.7%) was frequently involved. Out of 300 patients, 212 (70.7%) had positive aerobic bacterial growth within 48 hours of incubation. Pseudomonas aeruginosa (25.5%) was the most frequent gram negative bacteria isolated, whereas gram positive bacteria commonly isolated was Staphylococcus aureus (13.7%). Twenty (6.7%) patients were HIV positive with a median CD4+ count of 350 cells/μl. Mycological investigation was not performed. Bony involvement was radiologically reported in 83.0% of cases. Histopathological examination performed in 56 patients revealed malignancy in 20 (35.7%) patients, of which malignant melanoma (45.0%) was the most common histopathological type. The vast majority of patients, 270 (90.0%) were treated surgically, and surgical debridement was the most common surgical procedure performed in 24.1% of cases. Limb amputation rate was 8.7%. Postoperative complication rate was 58.3% of which surgical site infection (77.5%) was the most common post-operative complications. The median length of hospital stay was 23 days. Mortality rate was 4.3%. Out of the two hundred and eighty-seven (95.7%) survivors, 253 (91.6%) were treated successfully and discharged well (healed). After discharge, only 35.5% of cases were available for follow up at the end of study period. Conclusion Chronic lower limb ulcers remain a major public health problem in this part of Tanzania. The majority of patients in our environment present late when the disease is already in advanced stages. Early recognition and aggressive treatment of the acute phase of chronic lower limb ulcers at the peripheral hospitals and close follow-up are urgently needed to improve outcomes of these patients in our environment.
    BMC Dermatology 09/2012; 12(1):17. DOI:10.1186/1471-5945-12-17
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    • "Ulcers are generally divided into three main categories based on their etiological causes: vascular, pressure, and diabetic ulcers [2]. Ulcers are most commonly found on the lower extremity below the knee and affect around 1% of adult population and 3.6% of people older than 65 years [3]. Chronic ulcers introduce a major problem in dermatology and a huge economic dilemma especially in western countries. "
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    ABSTRACT: The ability to measure objectively wound healing is important for an effective wound management. Describing wound tissues in terms of percentages of each tissue colour is an approved clinical method of wound assessment. Wound healing is indicated by the growth of the red granulation tissue, which is rich in small blood capillaries that contain haemoglobin pigment reflecting the red colour of the tissue. A novel approach based on utilizing haemoglobin pigment content in chronic ulcers as an image marker to detect the growth of granulation tissue is investigated in this study. Independent Component Analysis is employed to convert colour images of chronic ulcers into images due to haemoglobin pigment only. K-means clustering is implemented to classify and segment regions of granulation tissue from the extracted haemoglobin images. Results obtained indicate an overall accuracy of 96.88% of the algorithm performance when compared to the manual segmentation.
    Visual Informatics: Sustaining Research and Innovations - Second International Visual Informatics Conference, IVIC 2011, Selangor, Malaysia, November 9-11, 2011, Proceedings, Part I; 01/2011
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