Vasculitis

Published: April 1, 2024

Executive Summary

Substantial advancements in the diagnosis and treatment of the three major forms of vasculitis—antineutrophil cytoplasmic antibody-associated vasculitis, giant cell arteritis, and IgG4-related disease—have occurred over the past two decades. However, clinical management of patients with vasculitis remains challenging, and treatment options are limited. Glucocorticoids remain the mainstay of therapy, with two targeted therapies (tocilizumab and avacopan) now approved for specific types of vasculitis. Although treatment can lead to remission of disease, sustained remission without ongoing maintenance therapy is not viable. As the knowledge of these conditions has expanded, stark polarisations within each form of vasculitis have emerged.

This Series in The Lancet Rheumatology explores these pathophysiological polarisations with two complimentary reviews on each major vasculitide, exploring the two ends of each disease spectrum, with the aim of inspiring clinicians and scientists to gain a better understanding of, and to ultimately aid in developing better treatment options for patients across the spectre of these three diseases.

 

Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers

William Marston 1, Daniel Fish, Joshua Unger, Blair Keagy

PMID: 21215568

 

DOI: 10.1016/j.jvs.2010.10.120

Abstract
Methods: Patients with CEAP clinical class 5 and 6 venous insufficiency underwent evaluation with duplex ultrasound scan to identify the presence of venous reflux in the deep and superficial systems and either computed tomography (CT) or magnetic resonance (MR) venography to identify ICVO. The venograms were evaluated by two separate examiners to calculate the percentage of obstruction in the iliocaval outflow tract. Demographics and risk factors related to venous disease were collected and examined for their association with severe ICVO.

Results: A total of 78 CEAP clinical class 5 and 6 patients evaluated with either a CT or MR venogram were retrospectively reviewed. The average patient age was 59.3 years and 53.4% were men. The ulcer affected the left lower extremity in 46% of cases and 50% of patients reported a medical history of deep vein thrombosis (DVT). Overall, 37% of imaging studies demonstrated ICVO of at least 50% and 23% had obstruction of >80%. Risk factors that were found to be independently associated with a significantly higher incidence of >80% ICVO included female gender (P = .023), a medical history of DVT (P = .035), and reflux in the deep venous system (P = .035). No limb with superficial venous reflux (SVR) alone was found to have ICVO >80%.

Conclusions: ICVO is a frequent and underappreciated contributor to venous hypertension in patients with venous leg ulcers. Women and patients with a history of DVT or duplex scan-diagnosed deep venous reflux (DVR) have a higher incidence of outflow obstruction and should be routinely studied with CT or MR venography to allow correction in this high-risk group of patients.

Reference: Marston W, Fish D, Unger J, Keagy B. Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers. J Vasc Surg. 2011 May;53(5):1303-8. doi: 10.1016/j.jvs.2010.10.120. Epub 2011 Jan 7. PMID: 21215568.

Smart bandages - do they have future ?

 In May 2023, Gurtner and colleagues at Stanford University published a paper in Nature Biotechnology describing their smart bandage. It includes a microcontroller unit, a radio antenna, biosensors, and an electrical stimulator all affixed to a rubbery, skin-like polymer (or hydrogel) about the thickness of a single coat of latex paint.

The bandage senses changes in temperature and electrical conductivity as the wound heals. And it gives electrical stimulation to accelerate healing. Animals treated with the bandage healed 25% faster, with 50% less scarring. 

Electrical currents are already used for wound healing in clinical practice, Gurtner said. Because the stimulus is already approved and the cost to make the bandage could be low (as little as $10 to $50), he believes it could be ushered through the approval processes relatively quickly.

wound care is gaining momentum, lot of investment is going into the research wound care and dressing. It is estimated that at present 30 billion dollars are spent in USA for wound care. smart bandages can reduce the cost.

Diabetic foot attack - types

The "diabetic foot attack" is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. 

Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. 

More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of "time is tissue" and draw parallels with advances in acute myocardial infarction and stroke care. 

At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, some believe that it may help increase awareness of the urgent actions required in some situations.

Vitamin C Deficiency and wound healing

Vitamins are substances that your body needs to grow and develop normally. Vitamin C is an antioxidant. It is important for your skin, bones, and connective tissue. It promotes healing and helps the body absorb iron. Vitamin C comes from fruits and vegetables. Good sources include citrus, red and green peppers, tomatoes, broccoli, and greens. Some juices and cereals have added vitamin C. Some people may need extra vitamin C: Pregnant/breastfeeding women, Smokers, People recovering from surgery, Burn victims.

The recommended dose of vitamin C to promote healing was 500–1,000 mg per day. Altogether, it was hypothesized that dividing the total dose of 600 mg per day into 200 mg three times daily might be more effective in promoting wound healing based on the bioavailability of vitamin C.

How to measure the response to PGE-1 in non-reconstructable Peripheral arterial disease

In Non-reconstructable, leg peripheral arterial disease, the peripheral pulses at the ankle are generally not palpable and some times even doppler signals are not audible. Then it becomes a dilemma! in our minds about the assessment methods to measure of the response to treatment with Injections of PGE-1. We follow these patients based on the improvement of clinical symptoms such as pain, ulcer healing, 6 minute walking test, increase in the ankle pressures with portable doppler machine, intensity of the audible sound from the Dorsalis Pedis, Posterior tibial arteries. The ankle pressure may not improve immediately,  but slow and steady progress in the relief of symptoms is considered as positive response to the medication. The rest pain is relieved in majority of the patients. ulcers start healing in 6 weeks to 3 months. Mean while we should ask patients to refrain from smoking.

Prostaglandin E₁ (PGE1), also known as alprostadil, is a naturally occurring prostaglandin which is used as a medication.^[1] In infants with congenital heart defects, it is delivered by slow injection into a vein to open the ductus arteriosus until surgery can be carried out.^[2] By injection into the penis or placement in the urethra, it is used to treat erectile dysfunction.^[3] Common side effects when given to babies include decreased breathing, fever, and low blood pressure.^[1] When used for erectile dysfunction side effects may include penile pain, bleeding at the site of injection, and prolonged erection (priapism).^[1] Prostaglandin E₁ is in the vasodilator family of medications.^[1] It works by opening blood vessels and relaxing smooth muscle.^[1] Prostaglandin E₁ was isolated in 1957 and approved for medical use in the United States in 1981.^[1][4] It is on the World Health Organization's List of Essential Medicines.^[5]

1.  "Alprostadil". The American Society of Health-System Pharmacists. Archived from the original on 16 January 2017. Retrieved 8 January 2017.
2. ^ Northern Neonatal Network (208). Neonatal Formulary: Drug Use in Pregnancy and the First Year of Life (5 ed.). John Wiley & Sons. p. 2010. ISBN 9780470750353. Archived from the original on 13 January 2017.
3. ^ British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. p. 569. ISBN 9780857111562.
4. ^ Sneader, Walter (2005). Drug Discovery: A History. John Wiley & Sons. p. 185. ISBN 9780470015520. Archived from the original on 13 January 2017.
5. ^ World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.

FDA Warns People to Avoid Compounded Semaglutide Medicines!

Semaglutide ( GLP1ra) is promoted as antidiabetic and anti obesity drug. There is increasing demand for this drug in  America (USA) and many parts of the world. The trials found out the safety and efficacy of this drug.  It resulted in shortage of the drug Semaglutide. So, alternates molecules are made available, but this brings us to a situation where we are concerned about the safety and efficacy of such alternate molecules which are not tested for their safety and effectiveness. So, FDA expressed its concern and given a warning and asked people to avoid using these molecules. It is more important to know for people buying the medications on-line to be cautious and aware of such directive from the FDA.

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https://www.medscape.com/viewarticle/992632?icd=login_success_email_match_norm