New approaches in the medical management of venous ulceration

A randomized clinical trial to compare the efficacy of three treatment regimens along with footcare in the morbidity management of filarial lymphoedema

The progression of lymphoedema to elephantiasis associated with increased incidence of episodic adeno-lymphangitis (ADL) is of great concern, as it causes physical suffering, permanent disability and economic loss to lymphatic filariasis patients. This randomized clinical trial aimed to assess the efficacy in terms of reduction of oedema and ADL frequency of three treatment regimens among lymphoedema patients from Orissa, India. The regimens were: (I) oral penicillin--one tablet of 800 000 U penicillin G potassium twice daily for 12 days--repeated every 3 months for 1 year; (II) diethylcarbamazine--6 mg/kg bodyweight for 12 days-repeated every 3 months for 1 year; and (III) topical antiseptic, i.e. betadine ointment. Foot care was part of all regimens. All three drug regimens are efficacious in reducing oedema and frequency of ADL episodes. Although the efficacy was slightly higher in regimen I, the difference was not significant. About half of all patients had reduced oedema after the 90 days of treatment, with oedema reduction of 75-100% in 20%. A major proportion of the remaining patients had oedema reduced by less than 25%. The proportion of people whose oedema reduced was slightly but not significantly lower in regimen II. anova revealed that lymphoedema reduction varied according to grade; being greatest at grade 1 lymphoedema, followed by grade 2. All three regimens significantly reduced ADL frequency after 1 year of treatment. This may be because of foot care as well as use of antibiotics. The estimated costs of treatment per patient for a period of 3 months are US$2.4, 1.5 and 4.0 respectively for regimen I, II and III. Thus affordable treatments with simple antibiotics and foot care can give substantial relief to the patients and reverse early lymphoedema.

Some observations on the effect of Daflon (micronized purified flavonoid fraction of Rutaceae aurantiae) in bancroftian filarial lymphoedema

BACKGROUND: Morbidity management is a core component of the global programme for the elimination of lymphatic filariasis. In a double-blind clinical trial, the tolerability and efficacy of Daflon (500 mg) + DEC (25 mg) or DEC (25 mg) alone, twice daily for 90 days, was studied in 26 patients with bancroftian filarial lymphoedema. RESULTS: None of the patients in either drug group reported any adverse reaction throughout the treatment period (90 days). Haematological and biochemical parameters were within normal limits and there was no significant difference between the pre-treatment (day 0) and post-treatment (day 90) values. The group receiving Daflon showed significant reduction in oedema volume from day 90 (140.6 PlusMinus; 18.8 ml) to day 360 (71.8 PlusMinus; 20.7 ml) compared to the pre-treatment (day 0, 198.4 PlusMinus; 16.5 ml) value. This accounted for a 63.8% reduction in oedema volume by day 360 (considering the pre-treatment (day 0) as 100%). In the DEC group, the changes in oedema volume (between day 1 and day 360) were not significant when compared to the pre-treatment (day 0) value. The percentage reduction at day 360 was only 9%, which was not significant (P > 0.05). CONCLUSION: This study has shown that Daflon (500 mg, twice a day for 90 days) is both safe and efficacious in reducing oedema volume in bancroftian filarial lymphoedema. Further clinical trials are essential for strengthening the evidence base on the role of this drug in the morbidity management of lymphatic filariasis.

Animal models for the study of lower extremity chronic venous disease: lessons learned and future needs

The purpose of this review is to define animal models of chronic venous disease and to demonstrate how animal studies can impact our understanding and treatment of this disorder. To this end an extensive literature search was conducted highlighting potential animal models of chronic lower extremity venous disease. Scientific investigations using animals to study particular aspects of this disease are also reviewed. This review was conducted by members of the Committee on Research of the American Venous Forum to help provide direction for future venous research endeavors. Useful models of chronic venous occlusive disease involve controlled ligation of a major lower limb vein and multiple tributaries. Such a model can provide sustained venous hypertension and studies using this model have confirmed that an isodiametric graft can provide early hemodynamic relief. Models of primary, postphlebitic, and isolated chronic deep venous insufficiency are available for study. Valve repair or transplantation can positively impact the insufficiency observed in these models. Investigations into valve substitutes have generally been disappointing or are undergoing early evaluation. In conclusion, animal models for the study of some aspects of chronic venous disease do exist and have already affected our clinical approach to patients. The scientific study of basic pathophysiology, diagnostics, end-organ response, and long-term surgical treatments of this disorder in well-controlled animal experiments have not been conducted.

Pentoxifylline (oxpentifylline). A review of its therapeutic efficacy in the management of peripheral vascular and cerebrovascular disorders

Pentoxifylline (oxpentifylline) has been used widely in the treatment of intermittent claudication, a prevalent condition in the elderly population. The exact mechanism(s) of action of the drug are unclear, but may be related to identified effects on white blood cell function and haemorrheological parameters. Clinical trials which conform best with European and North American guidelines have shown that 6 months' oral therapy with pentoxifylline 1200 mg/day significantly improves walking distances in patients with intermittent claudication. Patients most likely to benefit from treatment are those with an ankle/arm blood pressure ratio < or = 0.8 and a history of disease > 1 year. However, it remains unclear whether pentoxifylline or any other conservative treatment approach (including physical training) offers long term benefit, as studies comparing the development of intermittent claudication after several years of treatment with the natural course of the disease are still lacking. In patients with more severe vascular disease, intravenous administration of pentoxifylline (1200 mg/day for 21 days) decreased rest pain in patients with critical limb ischaemia. Oral administration (1200 g/day for up to 6 months) increased the healing of venous ulcers of the leg when used as an adjunct to standard compression bandaging. However, further studies are required to confirm these initial findings. The efficacy of pentoxifylline in the treatment of cerebrovascular disease has been evaluated in controlled clinical trials. Most notably, long term therapy (1200 mg/day) may slow the progression of dementia in patients who meet the clinical diagnostic criteria for 'multi-infarct' dementia and who also have clinical and neuroradiological evidence of cerebrovascular disease. The drug is effective in decreasing the risk of transient ischaemic attacks, but there are insufficient data to determine its value in the prevention and treatment of stroke. Pentoxifylline is well tolerated, with gastrointestinal effects reported in fewer than 3% of treated patients. However, the incidence of adverse events may be higher in elderly patients and/or those receiving concomitant medications. In summary, pentoxifylline is the most established agent when drug therapy is deemed appropriate in patients with intermittent claudication. Moreover, a promising new development for the drug is in the management of cerebrovascular dementia, an area where few therapeutic options are currently available.