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  • 1
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    The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment
    SAGE Publications ; 2022
    In:  Phlebology: The Journal of Venous Disease Vol. 37, No. 4 ( 2022-05), p. 252-266
    Details
    In: Phlebology: The Journal of Venous Disease, SAGE Publications, Vol. 37, No. 4 ( 2022-05), p. 252-266
    Abstract: Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts’ opinions on the available literature on lymphedema while following the Delphi methodology. Methods In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever 〉 70% agreement was achieved. Results The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3–C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. Conclusion This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.
    Type of Medium: Online Resource
    ISSN: 0268-3555 , 1758-1125
    URL: Article
    DOI: 10.1177/02683555211053532
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
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  • 2
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    Practice patterns of adjunctive therapy for venous leg ulcers
    SAGE Publications ; 2017
    In:  Phlebology: The Journal of Venous Disease Vol. 32, No. 1 ( 2017-02), p. 19-26
    Details
    In: Phlebology: The Journal of Venous Disease, SAGE Publications, Vol. 32, No. 1 ( 2017-02), p. 19-26
    Abstract: Venous leg ulcers (VLU) are the most severe clinical sequelae of venous reflux and post thrombotic syndrome. There is a consensus that ablation of refluxing vein segments and treatment of significant venous obstruction can heal VLUs. However, there is wide disparity in the use and choice of adjunctive therapies for VLUs. The purpose of this study was to assess these practice patterns among members of the American Venous Forum. Methods The AVF Research Committee conducted an online survey of its own members, which consisted of 16 questions designed to determine the specialty of physicians, location of treatment, treatment practices and reimbursement for treatment of VLUs Results The survey was distributed to 667 practitioners and a response rate of 18.6% was achieved. A majority of respondents (49.5%) were vascular specialists and the remaining were podiatrists, dermatologists, primary care doctors and others. It was found that 85.5% were from within the USA, while physicians from 14 other countries also responded. Most of the physicians (45%) provided adjunctive therapy at a private office setting and 58% treated less than 5 VLU patients per week. All respondents used some form of compression therapy as the primary mode of treatment for VLU. Multilayer compression therapy was the most common form of adjunctive therapy used (58.8%) and over 90% of physicians started additional modalities (biologics, negative pressure, hyperbaric oxygen and others) when VLUs failed compression therapy, with a majority (65%) waiting less than three months to start them. Medicare was the most common source of reimbursement (52.4%). Conclusions Physicians from multiple specialties treat VLU. While most physicians use compression therapy, there is wide variation in the selection and point of initiation for additional therapies once compression fails. There is a need for high-quality data to help establish guidelines for adjunctive treatment of VLUs and to disseminate them to physicians across multiple specialties to ensure standardized high-quality treatment of patients with VLUs.
    Type of Medium: Online Resource
    ISSN: 0268-3555 , 1758-1125
    URL: Article
    DOI: 10.1177/0268355515625526
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2017
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  • 3
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    Mitogen-Activated Protein Kinase Pathway Regulates Cell Proliferation in Venous Ulcer Fibroblasts
    SAGE Publications ; 2006
    In:  Vascular and Endovascular Surgery Vol. 40, No. 1 ( 2006-01), p. 59-66
    Details
    In: Vascular and Endovascular Surgery, SAGE Publications, Vol. 40, No. 1 ( 2006-01), p. 59-66
    Abstract: Venous ulcer fibroblasts have been demonstrated to have low growth rates in response to platelet-derived growth factor (PDGF). Mitogen-activated protein kinase (MAPK) is an important signal transduction mechanism that regulates growth, differentiation, and apoptosis in eukaryotic cells. PDGF binds PDGF receptors that activate a multitiered signaling cascade involving MAPK. We hypothesize that the growth regulation in venous ulcer fibroblasts is dependent on the MAPK extracellular signal-regulated kinase (ERK) pathway in the presence of PDGF. Fibroblasts (fb) were isolated from 8 patients with venous ulcers (w-fb) and the normal skin (n-fb) of the ipsilateral thigh via punch biopsies. Fb were plated at 1,500 cells/dish and treated with PDGF-AB (10 ng/mL) for 15 days. Growth rates were determined. Immunoblot analysis of MAPK ERK for n-fb and w-fb were analyzed. To determine if PDGF-stimulated w-fb and n-fb utilized the MAPK ERK pathway in a dependent manner, the upstream kinase MAPK kinase 1 (MEK 1) was inhibited by PD 98059. In addition, fb were treated with chronic venous ulcer wound fluid (WF) to study its effect on MAPK ERK. In the presence of PDGF, growth rates were substantially lower in w-fb than in n-fb, and MAPK was activated in 6/8 w-fb and in only 2/8 n-fb. Fibroblasts expressing MAPK had significantly reduced cell proliferation compared to fibroblasts not expressing MAPK (p = 0.023). PD 98059 significantly inhibited wfb and n-fb cell proliferation from basal level, which was reversible with addition of PDGF. In neonatal fibroblasts WF demonstrated inhibition of MAPK ERK over time and addition of PD98059 was not additive. This study suggests that the MAPK ERK pathway is important for cell proliferation in venous ulcer fibroblasts. In the presence of PDGF, fibroblasts with decreased growth rate express MAPK, and proliferation is further abrogated with addition of MEK 1 inhibitor, suggesting the importance of the MAPK ERK pathway regulating w-fb and nfb proliferation. Although the majority of w-fb activated the MAPK ERK pathway in the presence of PDGF, proliferation was significantly attenuated, indicating that other MAPK inhibitory pathways are competing. Venous ulcer wound fluid directly inhibits the MAPK ERK pathway, suggesting that the venous ulcer wound environment has negative trophic factors that effect fibroblasts proliferation and ulcer healing.
    Type of Medium: Online Resource
    ISSN: 1538-5744 , 1938-9116
    URL: Article
    DOI: 10.1177/153857440604000108
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2006
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  • 4
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    Mitogen-Activated Protein Kinase p38 Pathway in Venous Ulcer Fibroblasts
    SAGE Publications ; 2008
    In:  Vascular and Endovascular Surgery Vol. 42, No. 4 ( 2008-08), p. 367-374
    Details
    In: Vascular and Endovascular Surgery, SAGE Publications, Vol. 42, No. 4 ( 2008-08), p. 367-374
    Abstract: Objective: Venous ulcer fibroblasts (w-fb) have attenuated growth compared to normal fibroblasts (n-fb). The MAPKp38 pathway mediates stress-responses in various diseases. We hypothesize that p38 pathway is altered in w-fb. Methods: W-fb were isolated from venous ulcers and n-fb from the ipsilateral thigh. Fibroblasts were analyzed for phosphorylated p38 using immunoblot. The relation between p38 and w-fb proliferation was assessed with SB203580 (p38 inhibitor). Fibroblasts were treated with bFGF, TNF-a, and IL-1 and p38 expression analyzed. Results: Phosphorylated p38 expression was increased in w-fb (AU%=233.5±59.7, P=0.039) compared to n-fb (AU%=99.9±14.6). W-fb treated with SB203580 demonstrated increased growth compared to untreated w-fb. W-fb treated with bFGF demonstrated decreased p38. TNF-α and IL-1β significantly increase p38 expression. Conclusions: MAPK p38 is up-regulated in w-fb. Regulation of w-fb proliferation is influenced by p38. Altering the p38 pathway in vivo with growth factors or cytokine inhibition may improve fibroblast proliferation and venous ulcer healing.
    Type of Medium: Online Resource
    ISSN: 1538-5744 , 1938-9116
    URL: Article
    DOI: 10.1177/1538574408316140
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2008
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  • 5
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    Proliferative Capacity of Venous Ulcer Wound Fibroblasts in the Presence of Platelet-Derived Growth Factor
    SAGE Publications ; 2004
    In:  Vascular and Endovascular Surgery Vol. 38, No. 4 ( 2004-07), p. 355-360
    Details
    In: Vascular and Endovascular Surgery, SAGE Publications, Vol. 38, No. 4 ( 2004-07), p. 355-360
    Abstract: Growth factors have been demonstrated to increase the proliferation of wound fibroblasts. Platelet-derived growth factor (PDGF) is a potent cell mitogen. However, the role of PDGF in chronic venous ulcers is inconclusive. This study investigated whether PDGF stimulates venous ulcer fibroblasts to proliferate. Fibroblasts (fb) were isolated from 8 venous ulcers wounds (w-fb) and normal skin (n-fb) of the ipsilateral thigh via punch biopsies. Fibroblasts were plated at 1,500 cells/dish in Dulbecco's Modified Eagle Medium + 10% calf serum (CM) and treated with/without PDGF-ab (10 ng/mL) for 15 days. Growth rates were calculated. Western blotting and immunocytochemistry staining determined basal levels for PDGF-a and-b receptors, respectively. Growth rates were significantly lower in w-fb than in n-fb (1,579 ±546 vs 13,782 ±5,882 cells/day, p = 0.019). PDGF-ab treatment caused n-fb to increase their proliferative capacity relative to complete media (20,393 ±6,572 vs 13,782 ±5,882 cells/day, p= 0.005). However, PDGF-ab had no significant effect on w-fb proliferation over CM (1,030 ±264 and 1,579 ±546 cells/day, p=0.15). In the presence of PDGF-ab, w-fb had a significantly attenuated growth rate over n-fb (1,030 ±264 vs 20,393 ±6,572 cells/day, p=0.019). Western blot and immunocytochemistry analysis revealed diminished basal levels of PDGF-a and-b receptors, respectively, in ulcer fibroblasts. Venous ulcer fibroblasts had decreased proliferation. PDGF-ab had no effect on the growth rate of venous ulcer fibroblasts. In venous ulcers, decreased basal levels of fibroblast PDGF-a and-b receptors may explain reduced proliferation. Further clinical studies are needed to elucidate the role growth factors may play in venous ulcers.
    Type of Medium: Online Resource
    ISSN: 1538-5744 , 1938-9116
    URL: Article
    DOI: 10.1177/153857440403800408
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2004
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  • 6
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    Case–control evaluation of the impact of below 20 mmHg elastic compression stockings on lower limb volume serial variations in standardized flights
    SAGE Publications ; 2020
    In:  Phlebology: The Journal of Venous Disease Vol. 35, No. 3 ( 2020-04), p. 199-206
    Details
    In: Phlebology: The Journal of Venous Disease, SAGE Publications, Vol. 35, No. 3 ( 2020-04), p. 199-206
    Abstract: Graduated compression stocking (GCS) use during flights demonstrated to positively impact leg oedema. Nevertheless, these data were collected in a single flight, mainly at the ankle, and using greater than 20 mmHg GCS. This investigation reports data from 16 flights in which the same passenger’s leg circumferences variation were assessed wearing non-graduated ankle-sock or a below-knee 15–20 mmHg GCS. Methods The limb was divided by the circumferences in eight sectors, every 4 cm, labelled from 1 to 8, starting from the ankle up. The assessment was done at the take-off and after a 4-h flight time, for a total of 16 flights. The subject used non-graduated ankle socks (elastic band at 4 cm from B-point) during the outgoing flight and below-knee GCS (15–20 mmHg) during the return flight. Interface pressure was assessed at the ankle point of minimum girth (B) and ascending proximally every 4 cm (B+cm) for the GCS, and at B and at the elastic band level (B + 4 cm) for the sock. Results GCS interface pressure was 13.3 ± 2.5 mmHg in B and 18.1 ± 2.4 mmHg in B + 4 cm. The sock interface pressure was 3.1 ± 0.7 mmHg in B and 8.1 ± 0.9 mmHg at the band level (B + 4 cm). Socks led to a significant total volume increase (117.3 ± 25.8 mL; 5.2% ±1.1%; P  〈  0.0001). GCS led to a non-significant total volume decrease (–3.1 ± 14.4 mL; –0.1 ± 0.6%; P = 0.3964) and did not allow for volume increase. The different sectors showed a heterogeneous volume variation, not following a precisely graduated or progressive compression profile. Conclusions Leg oedema following a 4-h flight is controlled by 〈 20 mmHg GCS. Leg fluids, with and without GCS, are mobilized in a non-graduated profile from the ankle to the knee after prolonged sitting on a plane.
    Type of Medium: Online Resource
    ISSN: 0268-3555 , 1758-1125
    URL: Article
    DOI: 10.1177/0268355519873527
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2020
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  • 7
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    Which dressings reduce inflammation and improve venous leg ulcer healing
    SAGE Publications ; 2014
    In:  Phlebology: The Journal of Venous Disease Vol. 29, No. 1_suppl ( 2014-05), p. 157-164
    Details
    In: Phlebology: The Journal of Venous Disease, SAGE Publications, Vol. 29, No. 1_suppl ( 2014-05), p. 157-164
    Abstract: Chronic venous leg ulcers (VLU) affect around 1% of the adult population in the Western world. The impact of VLU is both social and economic, with significant expenditures on active venous ulcers to provide medical treatment and eventual healing. At the core of VLU is venous hypertension which affects the venous macrocirculation. The changes incurred in venous hemodynamics leads to microcirculatory changes affecting the postcapillary venule and surrounding tissues. Inflammation by leukocytes affecting the venous endothelium, promotes a complex cascade and activation of adhesion molecules expression, chemokines and cytokines released, altered growth factor responses, and activation of protease (e.g. tPA) and proteinase (e.g. MMPs) activity that causes dysregulation and compromise of tissue integrity with eventual dermal damage and ulcer development. A critical component to treating VLU is correcting the abnormal venous hemodynamics and compression therapy. Unfortunately, VLU recurrence ranges between 30–70%, and other modalities in therapy along with compression are required. The goal for adjuvant products is to restore the balance from an inflammatory chronic wound to that of a reparative wound that will promote provisional matrix and epithelialization. There are many products on the market that can be used as adjuvant to compression therapy, but it must be recognized that there is a paucity of clinical trials that have evaluated the clinical effectiveness of specific products with clearly defined end points, and most importantly a healed VLU with a low recurrence rate. This review will discuss the fundamentals of VLU inflammation, and evaluate the available literature that may have benefit in reducing inflammation and lead to effective VLU healing.
    Type of Medium: Online Resource
    ISSN: 0268-3555 , 1758-1125
    URL: Article
    DOI: 10.1177/0268355514529225
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2014
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  • 8
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    Unilateral Male Breast Masses: Cancer Risk and Their Evaluation and Management
    SAGE Publications ; 1999
    In:  The American Surgeon Vol. 65, No. 3 ( 1999-03), p. 250-253
    Details
    In: The American Surgeon, SAGE Publications, Vol. 65, No. 3 ( 1999-03), p. 250-253
    Abstract: Breast cancer is an uncommon cause of breast enlargement in the adult male. Overall, it accounts for 〈 1 per cent of all male cancers. Although most male breast carcinomas are clinically apparent, distinguishing early breast cancer from gynecomastia, the most common cause of male breast enlargement, is considered a difficult task. To overcome this difficulty, many surgeons proceed directly to surgery as their initial diagnostic test. Although appropriate in some cases, the infrequent occurrence of male breast cancer and the diagnostic accuracy of mammography and fine-needle aspiration cytology suggest a modification of our present management. The aim of this study was to assess the incidence of breast cancer in men with unilateral breast masses and to propose a treatment algorithm for unilateral male breast masses. The medical records of 36 male patients who underwent subcutaneous mastectomy for a unilateral breast mass at the Buffalo Veterans Administration Medical Center between 1989 and 1996 were retrospectively reviewed. Data was collected on a standard data form. The median age was 63-years-old (range, 22–82). Gynecomastia was diagnosed in 30 patients (83%), lipoma in 4 patients (11%), invasive breast cancer in 1 patient (3%), and melanoma in situ in 1 patient (3%). Of the 30 patients with gynecomastia, 60% (18 patients) gave a history of a medical condition or use of medications known to cause gynecomastia, compared with 16 per cent (1 of 6) of the patients without gynecomastia (P = 0.08). Half of the patients with gynecomastia presented with an asymptomatic mass compared with 67 per cent of the patients without gynecomastia (P = not significant). The median duration of symptoms for patients with gynecomastia was 3 months. Men with unilateral breast masses have a low incidence of breast cancer. A male patient with a palpable unilateral breast mass consistent with gynecomastia on the basis of historical, physical and mammographic findings does not require surgical biopsy unless other clinical indications prevail. Lack of symptoms (pain) related to the mass is probably not helpful in deciphering gynecomastia from breast cancer.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313489906500314
    Language: English
    Publisher: SAGE Publications
    Publication Date: 1999
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  • 9
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    Asymptomatic portal vein aneurysms: To treat, or not to treat?
    SAGE Publications ; 2018
    In:  Phlebology: The Journal of Venous Disease Vol. 33, No. 8 ( 2018-09), p. 513-516
    Details
    In: Phlebology: The Journal of Venous Disease, SAGE Publications, Vol. 33, No. 8 ( 2018-09), p. 513-516
    Abstract: Portal vein aneurysms are rare dilations in the portal venous system, for which the etiology and pathophysiological consequences are poorly understood. Method We reviewed the existing literature as well as present a unique anecdotal case of a patient presenting with a very large portal vein aneurysm that was successfully managed conservatively and non-operatively without anticoagulation, with close follow-up and routine surveillance. Result The rising prevalence of abdominal imaging in clinical practice has increased rates of portal vein aneurysm detection. While asymptomatic aneurysms less than 3 cm can be clinically observed, surgical intervention may be necessary in large asymptomatic aneurysms ( 〉 3 cm) with or without thrombus, or small aneurysms with evidence of evolving mural thrombus formation on imaging. Conclusion Portal vein aneurysms present a diagnostic challenge for any surgeon, and the goal for surgical therapy is based on repairing the portal vein aneurysm, and if portal hypertension is present decompressing via surgically constructed shunts.
    Type of Medium: Online Resource
    ISSN: 0268-3555 , 1758-1125
    URL: Article
    DOI: 10.1177/0268355517733375
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2018
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  • 10
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    Venous leg ulceration pathophysiology and evidence based treatment
    SAGE Publications ; 2015
    In:  Vascular Medicine Vol. 20, No. 2 ( 2015-04), p. 168-181
    Details
    In: Vascular Medicine, SAGE Publications, Vol. 20, No. 2 ( 2015-04), p. 168-181
    Abstract: Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.
    Type of Medium: Online Resource
    ISSN: 1358-863X , 1477-0377
    URL: Article
    DOI: 10.1177/1358863X14568677
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2027562-6
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