Lower-limb intramedullary nailing in patients with polyostotic fibrous dysplasia who had a previous unsuccessful treatment. A report of 48 cases

BACKGROUND

Intramedullary nailing (IN) seems to be the best primary surgical treatment for patients with either polyostotic fibrous dysplasia or McCune-Albright syndrome (PFD/MAS) when the femur and tibia are totally affected by fibrous dysplasia (FD) and pain, fracture and deformity are likely to occur. However, other management protocols have been applied in these cases, often leading to disabling sequelae. This study sought to evaluate if IN could also have been effective as a salvage procedure to provide patients with satisfactory results, regardless of the poor results due to the improper treatment previously performed.

MATERIALS AND METHODS

Twenty-four retrospectively registered PFD/MAS patients with 34 femurs and 14 tibias totally affected by fibrous dysplasia had received various treatments with unsatisfactory results in other institutions. Before the IN performed in our hospital, 3 patients were wheelchair bound; 4 were fractured; 17 limped; and many used an aid for walking. Salvage IN was performed in our hospital at a mean patient age of 23.66 ± 6.06 years (range, 15-37 years). The patients were evaluated before-except for the four fractured ones-and after IN using the validated Jung scoring system, and the data were statistically analyzed.

RESULTS

The mean length of follow-up after IN was 9.12 ± 3.68 years (range, 4-17 years). The patients' mean Jung score significantly improved from 2.52 ± 1.74 points before IN to 6.78 ± 2.23 at follow-up (p < 0.05). Ambulation was improved in ambulatory patients and restored in wheelchair users. The complication rate was 21%.

CONCLUSIONS

Regardless of the high rate of complications, IN may be considered a reliable surgical procedure to salvage a failed treatment in PFD/MAS, with long-lasting satisfactory results achieved in most patients. Trial registration statement: Not applicable.

LEVEL OF EVIDENCE

IV.

Temporal characteristics of an integrated diagnostics risk score before and after heart failure hospitalizations in a large real-world population of patients with implantable devices

Background

Diagnostic parameters measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) have been shown to change before and after heart failure (HF) events with fluid overload.

Purpose

We investigated the temporal characteristics of an integrated diagnostic risk score before and after HF events in a large real-world cohort of patients with ICD/CRTD devices.

Methods

We linked a de-identified database of aggregated electronic health record (EHR) data (2007–2017) to a manufacturer's device database with continuous diagnostic monitoring data. Patients with ICD/CRTD implants with intra-thoracic impedance diagnostic feature were included for this study. The previously defined integrated diagnostic risk score was derived by combining daily diagnostic data, including intra-thoracic impedance, night-time heart rate, activity, heart rate variability, and atrial fibrillation (AF) burden, ventricular rate during AF, CRT pacing, ventricular tachycardia episodes and shocks, in a Bayesian Belief Network framework. HF event was defined as an inpatient, emergency department, or observation unit stay in a hospital with primary diagnosis of HF and intravenous diuretic administration. Temporal average of daily risk score across all patients in the 60 days pre and post HF events were compared in HF events with and without readmission within 60 days and with no HF event during pre and post follow-up days.

Results

A total of 17,886 patients with 1.8±1.2 years of follow-up met inclusion criteria. The average age of patients was 66.6±12.3 years, with 72% being males, and 51% with ICD devices. The average integrated diagnostics risk score in HF events with and without readmission and with no events is shown in Figure. A total of 1174 patients had 1425 HF events with no readmission for HF within 60 days and 282 patients had 295 HF events which were followed by readmission for HF within 60 days. A total of 17,839 patients had no HF events over 86,858 follow-up months. The average daily risk score across all patients was higher on all 60 days pre and post HF event with readmission compared to HF events with no readmission (p&lt;0.001) and both were higher compared to follow-up period with no events (p&lt;0.001). The risk score recovers less often after HF events which are followed by readmission within 60 days compared to HF events with no readmission.

Conclusions

In a large real-world population of patients with ICD/CRTD devices, the average integrated diagnostics risk score was higher before and after HF events with readmission compared to HF events with no readmission. Re-admissions are more likely in patients with smaller risk score recovery after HF events.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic Plc

Infection rate of intramedullary nailing for treatment of lower limb polyostotic fibrous dysplasia

Polyostotic fibrous dysplasia (PFD) generally cause deformities and fractures of femur and tibia and surgery is often required. The current surgical treatment for deformities is based on single or multiple osteotomies followed by stabilization with intramedullary nails, which are commonly used also for fractures. One of the most common surgical complications of intramedullary nailing is represented by surgical site infection with possible extension to the whole skeletal segment. In the present study we evaluated the incidence of surgical site infections in 44 patients affected by PFD in which 91 femurs or tibiae underwent intramedullary nailing to treat deformities or fractures. We never observed any infection of the operated femurs or tibiae until the final follow-up. The only post surgical infection was present in a patient with monomelic involvement at the contralateral non affected limb, which was surgically treated for limb length inequality, by femur shortening osteotomy stabilized by an intramedullary nail. The most likely hypothesis to explain the complete absence of infections in these patients may be related to the high local concentration of prophylactic antibiotic in the highly vascularized fibrodysplastic bone.

Evaluation of Treatment of Diabetic Microangiopathy with Total Triterpenic Fraction of Centella asiatica: A Clinical Prospective Randomized Trial with a Microcirculatory Model

Fifty patients with diabetic microangiopathy were studied by laser Doppler flowmetry (measuring skin blood flow at rest) (RF) and the venoarteriolar response (VAR), by transcutaneous PO2 and PCO2 measurements, and by capillary permeability evaluation (rate of ankle swelling [RAS]). Thirty of these patients were treated for 6 months with total triterpenic fraction of Centella asiatica (TTFCA) (60 mg twice daily), a drug active on microcirculation and capillary permeability. A control group of ten patients was treated with placebo and another group of ten patients was left without treatment thus acting as a second control group. After six months there were no significant changes in the two control groups. There was a significant improvement of microcirculatory parameter in patients treated with TTFCA. RF (abnormally increased at the beginning of the treatment) decreased, and the VAR (impaired at the beginning of the study) improved. PO2 increased and PCO2 decreased the abnormally increased capillary permeability was also improved (decreased). According to these data, TTFCA is useful in diabetic microangiopathy by improving microcirculation and decreasing capillary permeability. Also TTFCA protects against the deterioration of microcirculation due to diabetic microangiopathy.

Microcirculatory Effects of Total Triterpenic Fraction of Centella asiatica in Chronic Venous Hypertension: Measurement by Laser Doppler, TcPo2-co2, and Leg Volumetry

The aim of this prospective, randomized study was to demonstrate whether an oral preparation of TTFCA was effective in improving the microcirculation and edema (leg volume) in venous microangiopathy. Forty patients with venous hypertension were included. Treatment was prescribed for 6 weeks (tablets, 60 mg twice daily). Patients were randomized into a treatment and a placebo group. There were 20 patients in each group. In the treatment group the mean age was 42 (SD 7; M:F = 10:10); in the placebo group, the mean age was 40 (SD 9; M:F = 10:10). Tolerability and compliance were very good; there were no dropouts. At inclusion there were no differences between placebo and treatment group. After treatment there was a decrease in resting flux (29%) and an improvement (increase) in venoarteriolar response (52%); PO2 was increased (7.2%) and PCO2 decreased (9.6%). There was an important decrease in leg volume (66 mL decrease; 1.3% volume variation). The difference in flux, O2-CO2 and volume parameters were significant and clinically important at 6 weeks in the treatment group. In conclusion, TTFCA improves microcirculation and leg volume in venous hypertension. The effects of TTFCA are observed even in a limited sample of patients.

Effects of the Total Triterpenic Fraction of Centella asiatica in Venous Hypertensive Microangiopathy: A Prospective, Placebo-Controlled, Randomized Trial

The aim of this study was to demonstrate whether total triterpenic fraction of Centella asiatica (TTFCA), was effective in improving the microcirculation in venous hypertension and microangiopathy. Forty patients with severe venous hypertension, ankle swelling, lipodermatosclerosis were included, After informed consent, patients were randomized into a treatment and a placebo group: those in the treatment group received TTFCA (tablets, 60 mg, twice daily for 8 weeks). The two groups of subjects were comparable for age and sex distribution. The mean age was 48 years (SD 9; M:F = 11:11) in the treatment group (22 patients) and 47.6 (SD 7; M:F = 10:8) in the placebo group (18 patients). There were no differences between placebo and treatment group at inclusion; there was no change between inclusion and measurements at 8 weeks in the placebo group. A decrease (p<0.05) in RF (flux at rest) and RAS (rate of ankle swelling) were observed in the treatment group. The decrease in capillary filtration was associated with improvement in signs and symptoms (p<0.05). The difference in flux, signs and symptoms, and filtration was clinically important at 8 weeks. No side effects were observed. In conclusion venous microangiopathy was improved by TTFCA treatment.

Modification of the Echogenicity of Femoral Plaques after Treatment with Total Triterpenic Fraction of Centella aslatica: A Prospective, Randomized, Placebo-Controlled Trial

The aim of this study was to evaluate whether TTFCA (total triterpenic fraction of Centella asiatica), was effective, by modulating collagen production, in a period of 12 months, increasing the echogenicity of echolucent plaques at the femoral bifurcation. Hypoechoic atherosclerotic plaques have been found to be associated with an increased evidence of cerebrovascular events. In this type of plaques stromal composition is limited as the collagen component is generally very low; the plaque composition is mainly due to lipid accumulation or thrombosis. The aim of this study was the evaluation of echogenicity of hyperechoic plaques and how it could be modified by a drug acting on the modulation of collagen synthesis. Antiplatelet agents were used in all patients; cholesterol-lowering agents were used in 34% of patients in the treatment group and in 36% in the placebo group. TTFCA was used at the dose of 60 mg thrice daily (oral tablets). Of the 60 included subjects 26 completed the study in the treatment group and 24 in the placebo group. At inclusion the average GSM in the treatment group was 14 (SD 3) and 14.3 (SD 3) in controls. At 12 months GSM was increased up to 22.8 (SD 4) in the treatment group and it was 15 (SD 3) in controls. Considering texture no significant changes were observed in controls while a qualitative increase in homogenicity was observed in the TTFCA group. Plaque size measured at the beginning and at the end of the study showed a median increase in size, in controls (23%; range 0%–44%); it was unchanged in the TTFCA group (variation 7%; 4%–26%). In conclusion in the treatment group plaques increased in echogenicity and in homogenicity; size and stenosis remained unchanged. Modulating the scarring process within echolucent plaques (low echogenicity, high echolucency, with a very low collagen/stromal component), possibly by collagen modulation, makes plaques more stable. This has been achieved and documented in the present study by an increase in the gray-scale median (plaques become more echogenic, more ‘white’). The variation in GSM is generally associated with a lower risk of wall thrombosis, rupture and embolization. These observations indicate a positive action of TTFCA on the stabilization of hypoechoic, low-density femoral plaques

Effectiveness of a novel boswellic acids delivery form (Casperome®) in the management of grade II ankle sprains due to sport trauma - a registry study

OBJECTIVE

In this study, we evaluated a novel delivery form of boswellic acids (Casperome®) in the management of signs and symptoms associated with ankle sprain grade II due to sport trauma.

PATIENTS AND METHODS

In this supplement registry study, 72 otherwise healthy subjects with grade II ankle sprain induced by sport activities were advised to either follow a standard management (SM, 37 subjects) for the condition or the SM with the additional daily intake of 1 tablet containing 250 mg Casperome® (35 subjects). Subjects were allowed to use rescue medications (ketoprofen tablets, 25 mg/tablet), and their intake was measured at the end of the management period of 7 days. Each individual was subjected to several non-invasive examinations (self-reported pain at rest and under moderate exercise, range of active and passive movement, presence of local hematomas by ultrasonography) at the following time periods: at inclusion, to evaluate the basal conditions of the subject before the beginning of the study, at day 3 and at the end of the week to evaluate the response differences between the two groups. Additionally, a blood sample from the Casperome® treated subjects (34 out of 35 subjects) was taken at day 7 and analyzed for the systemic concentration of boswellic acids.

RESULTS

The 72 individuals recruited in this study spontaneously decided which management to follow, either SM (n=37) or SM+Casperome® (n=35). Supplementation with Casperome® 250 mg/day showed beneficial effects in the reduction of signs and symptoms of ankle sprains evaluated at day 3 and day 7, and was shown to induce measurable plasma level of boswellic acids. Moreover, the supplementary use of Casperome® was well-tolerated and devoid of side effects.

CONCLUSIONS

Our pilot registry study showed the effectiveness of Casperome® supplementation in improving recovery after ankle sprain of mild severity (grade II), suggesting a potentially beneficial role in relieving the trauma associated with sport activities and in decreasing the use of rescue drugs.

Histological, histochemical and ultrastructural study of slipped capital femoral epiphysis

PURPOSE

The purpose of our study was to investigate the histological, histochemical and ultrastructural aspects of the proximal femoral growth plate in slipped capital femoral epiphysis (SCFE).

METHODS

Eight core biopsies of the proximal femoral growth plate were performed during in situ epiphysiodesis in patients with SCFE that was at the pre-slipping stage in two cases and at the mild slipping stage (Southwick angle < 30°) in six cases. After fixation, the specimens were processed for either histological or histochemical or ultrastructural studies.

RESULTS

The proximal femoral growth plate was thicker than normal in the SCFE cases, and the 3:1 ratio between the thickness of the resting zone and the other zones of the plate was reversed. Chondrocytes of the proliferating, maturation, hypertrophic and degenerating zones were arranged in large clusters rather than in columns, which were separated by loose fibrillary septae that appeared moderately alcian blue positive and metachromatic. The collagen fibrils of the longitudinal septae were uniformly thin, measuring about 200 Å, whereas in the normal plate collagen fibrils were in the range of 300 to 1200 Å in thickness. Chondrocytes were elongated and smaller than normal, with a dark cytoplasm. In the degenerating zone, mineralisation of the longitudinal and transversal septae was scanty and enchondral ossification was impaired, with a few small osteoblasts forming thin bone trabeculae on the cartilage septae of the degenerating zone.

CONCLUSION

In SCFE, the proximal femoral growth plate undergoes several histological, histochemical and ultrastructural changes that precede slipping of the epiphysis since they are already present at a pre-slipping stage of the disease. The loss of solidity of the extracellular matrix and the disarrangement of the normal architecture of the physis very likely cause the consequent slipping of the proximal femoral epiphysis. SCFE aetiology remains unknown.

Microcirculatory Efficacy of Topical Treatment with Aescin + Essential Phospholipids Gel on Transcutaneous PO2 in Venous Insufficiency

A gel including aescin, essential phospholipids (EPL), and heparin (EG) has been used for many years for local treatment of venous, microcirculatory alterations (varicose veins, chronic venous insufficiency). Bruises, swelling, thrombophlebitis, and contusions are effectively treated with this compound. The aim of this study was the evaluation of the efficacy of the effects of an AEPL (aescin+EPL) gel on the microcirculation in subjects with chronic venous insufficiency, venous hypertension (CVH), and venous microangiopathy. Transcutaneous PO2 was measured at the perimalleolar region. After 2 weeks of treatment, all individual values (100%) were significantly increased (p<0.05). In all patients, PO2 increased, indicating a decrease in level of venous microangiopathy. Considering transcutaneous skin PO2, treatment with AEPL in areas of venous microangiopathy is beneficial in the prevention of ulceration and improves skin healing.

Variations in Plasma Free Radicals with Topical Aescin + Essential Phospholipids Gel in Venous Hypertension: New Clinical Data

The aim of this study was the evaluation of the effects of Aescin + essential phospholipids (AEPL) gel on plasma free radicals (PFRs). In this study, ten patients with venous hypertension, no ulcerations or infections, venous microangiopathy, and varicose veins were treated with topical AEPL applied in a standard protocol. AEPL was applied for 2 weeks, three times daily at the same skin region (perimalleolar internal region at defined distance from the medial malleolus and from the anterior edge of the tibia). In subjects with venous hypertension, PFR values were higher than 420 Carr units. After treatment, the values of PRF decreased to almost normal as an effect of the massage with AEPL gel. The decrease in value was observed in all treatment subjects. A ranking system indicates that the AEPL preparation is active in all subjects who have venous microangiopathy. The decrease in PFR value was greater than 30% in all treatment subjects (p<0.05). The decrease in PFR can be considered an important indication of an improvement in skin perfusion, which protects the skin from deterioration and eventually from venous ulcerations. The evaluation of PFR is an important new physiologic parameter that can be associated with other noninvasive tests to study the microcirculation and its evolution and improvement with systemic or topical medical treatment.

Management of Superficial Vein Thrombosis and Thrombophlebitis: Status and Expert Opinion Document

Superficial vein thrombosis is characterized by clotting of superficial veins (ie, following direct trauma) with minimal inflammatory components. Superficial thrombophlebitis is a minimally thrombotic process of superficial veins associated with inflammatory changes and/or infection. Treatments generally include analgesics, elastic compression, anti-inflammatory agents, exercise and ambulation, and, in some cases, local or systemic anticoagulants. It is better to avoid bed rest and reduced mobility. Topical analgesia with nonsteroidal, anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls symptoms. Hirudoid cream (heparinoid) shortens the duration of signs/symptoms. Locally acting anticoagulants/antithrombotics (Viatromb®, Lipohep ®, spray Na-heparin) have positive effects on pain and on the reduction in thrombus size. Intravenous catheters should be changed every 24 to 48 hours (depending on venous flow and clinical parameters) to prevent superficial vein thrombosis/superficial thrombophlebitis and removed in case of events. Low molecular weight heparin prophylaxis and nitroglycerin patches distal to peripheral lines may reduce the incidence of superficial vein thrombosis/superficial thrombophlebitis in patients with vein catheters. In case of superficial vein thrombosis/superficial thrombophlebitis, vein lines should be removed. In neoplastic diseases and hematological disorders, anticoagulants may be necessary. Exercise reduces pain and the possibility of deep vein thrombosis. Only in cases in which pain is very severe is bed rest necessary. Deep vein thrombosis prophylaxis should be established in patients with reduced mobility. Antibiotics usually do not have a place in superficial vein thrombosis/superficial thrombophlebitis unless there are documented infections. Prevention of superficial vein thrombosis should be considered on the basis of patient's history and clinical evaluation.

Ten years experience with breast reconstruction after salvage mastectomy in previously irradiated patients: analysis of outcomes, satisfaction and well-being

OBJECTIVE

Reconstruction following mastectomy offers women an opportunity to mollify some of the emotional and aesthetic effects of this devastating disease.

PATIENTS AND METHODS

The authors reviewed the files of 83 patients who underwent immediate postmastectomy reconstruction with tissue expander between January of 2003 and June of 2012 at our hospital. The patients were divided into two groups: Group A (study group) included 30 patients with previous quadrantectomy and radiotherapy who underwent salvage mastectomy after local recurrence; Group B (control group) included 53 patients submitted to primary radical mastectomy. We submitted Breast-Q reconstruction post-operative module to all of our patients.

RESULTS

The median follow-up time for the whole group was 36 months (range = 12-144 months). Between group A and group B, there were no significant differences. In the group A, the median time from RT to reconstruction was 24 months (range = 9-192 months). The overall rate of complications was not similar between the two groups (66.6% vs. 58.5%; p = NS). However, the  major complications occurred mostly in the irradiated group, showing a trend of statistical significance (53.3% vs. 32.0%; p = 0.07). In this group, the occurrence of major complications was not different according to time from RT to reconstruction (p = 0.313). In particularly, patients from the irradiated group (group A) had a significantly higher risk of grade III-IV capsular contracture (relative risk 3.75, p = 0.02) and autologous salvage reconstruction (relative risk 10.4, p = 0.02).

CONCLUSIONS

The results of this study prove that heterologous reconstruction is still possible following salvage mastectomy in previously irradiated patients.

Effects of Shock Waves on Microcirculation, Perfusion, and Pain Management in Critical Limb Ischemia

Shock waves (SW) are used to control pain in different clinical conditions (eg, painful knee, elbow, and shoulder, etc). The effects of SWs may be due to cellular “stunning” (particularly nervous components). It may also be the consequence of unknown metabolic actions on tissues, which may include changes in cellular permeability, the liberation of proteins and mediators locally acting on pain and nerve endings. The aim of this study was to evaluate the reduction in pain and the improvement in microcirculation induced by SW treatment in a 2-week study in patients with chronic limb ischemia (CLI). Of the 32 patients with CLI, 30 (20 with rest pain only, 10 with necrosis) completed the study. The treatment was well tolerated. Foot radiographs performed before and after treatment indicate no bone damage after treatment. Foot (tibial arteries) blood pressure was unchanged after 2 weeks. The increase in laser Doppler flux was significant (p<0.05) after treatment. The ORACLE score at 2 weeks was decreased (p<0.05). The same trend was observed with the analogue scale line for pain (p<0.05). Partial pressure of oxygen (PO2) increased (p<0.05) and partial pressure of carbon dioxide (PCO2) decreased (p<0.05). In all patients an increase in pain-free walking distance was observed (the distance increased on average 2.4 times). Flux improvement was still present after 1 month. The outcome at 3 months in these patients indicates that the improvement (concerning the survival of the limbs) was persistent. In conclusion SWs treatment in CLI produced changes both on the microcirculation and pain. These results are very interesting, confirming previous observations, and opening new treatment options in CLI. The skin flow improvement did not relate to an increase in pressure.

HR, 0-(Beta-Hydroxyethyl)-Rutosides; (Venoruton®): Rapid Relief of Signs/Symptoms in Chronic Venous Insufficiency and Microangiopathy: A Prospective, Controlled Study

The aim of this independent study was to demonstrate the rapidity of the clinical action of HR 0-(beta-hydroxyethyl)-rutosides, Venoruton® (Novartis Consumer Health) in patients with chronic venous insufficiency (CVI). Two groups of patients with venous hypertension and microangiopathy were treated with HR (1 or 2 g/day, for 8 weeks). Twelve patients (age 56.4; range 44-66; M:F = 6:6) were included in group 1 (1 g/day) (moderate CVI and microangiopathy); 10 patients (age 57.4; range 42-67; M:F = 5:5) in group 2 (2 g/day) with more severe CVI and microangiopathy. Average ambulatory venous pressure (AVP) was 58.6 (range 50-65) with a refilling time (RT) shorter than 10 seconds. There were no significant differences in AVP and RT between the 2 groups, but the duration of the disease was longer in group 2: 3.5 years (SD 2.0) in group 1 and 6.4 years (SD 3.3) in group 2. All included subjects completed the study and no dropouts were observed. In both dose groups there was a progressive decrease in laser Doppler resting flux (RF), indicating improvement in microangiopathy and a significant decrease in capillary filtration (RAS) associated with a significant improvement in analogue scale line score (ASLS) and edema. Although the effect in the 2 g dose group was more rapid on the microcirculatory parameters with a significant effect on RF and RAS after 4 days (effect of 1 g per day after 8 days and 6 days, respectively), there was no difference in the time to onset of a significant clinical improvement (ie, the ASLS and the edema score): 4 days in both groups. Venous microangiopathy and edema were improved by the treatment with HR within a few days. The effects were visible with both dosages, in both severity groups.

HR, 0-(Beta-Hydroxyethyl)-Rutosides, in Comparison with Diosmin+Hesperidin in Chronic Venous Insufficiency and Venous Microangiopathy: An Independent, Prospective, Comparative Registry Study

The aim of this independent study was to investigate differences in efficacy between HR, (0-[beta-hydroxyethyl]-rutosides) and D+H (500 mg, diosmin+hesperidin) in patients with chronic venous insufficiency (CVI). A first group of 90 patients with severe venous hypertension (CVI, ankle swelling) were randomized into an HR or a D+H group. The HR group received oral HR (2 g/day, 8 weeks); the D+H group received a 500 mg tablet 3 times daily for 8 weeks. A second group of comparable patients was included in a registry following the same study format. Patients were openly included; the 2 treatments were administered with the same methods and procedures. Clinical conditions were comparable to those described in the randomized study. Patients treated for at least 8 weeks were included in the registry. A number of physicians (specialists or general practitioners) included patients when they considered that clinical conditions were compatible with using 1 of the 2 treatments on the basis of their personal evaluation and experience. When cases were compatible with the registry, the prescribing physician communicated the case. Patients were evaluated without interfering with the treatment. Main targets of evaluation were skin flux at rest (RF), strain-gauge-derived rate of ankle swelling (RAS), and analogue symptoms score (ASLS). Ninety subjects completed the study in the first group; 122 in the second, registry group (total of 212 patients). The first and second (registry) groups and the 2 treatment groups were comparable for age and sex distribution. The pooled mean age was 42 years (SD ±5.5) in the HR group (46+62 patients) and 41.5 (SD ±6) in the D+H group (44+60 patients). Considering pooled data there were no differences in microcirculatory parameters between the pooled treatment groups at inclusion. A significant decrease (p<0.05) in RF and RAS was observed in the HR group at 8 weeks. The decrease in resting skin flux and in capillary filtration was associated with a significant improvement in signs/symptoms (analogue scale line) from an average of 9.4 (range 3-10) to 3.3 (4-6) (p<0.05). Significantly smaller variations were observed in the D+H group. The decrease in RF was 47.6% in the HR group vs 15.7% in the D+H group. The decrease in RAS was 40.9% in the HR group vs 12.8% in the D+H group. The decrease in ASLS was 64.8% in the HR group vs 12.9% in the comparative group. In conclusion venous microangiopathy and edema were improved by the treatment with HR both in the randomized study and in the pooled analysis. The comparison with D+H indicates that HR is comparatively more effective both on microcirculatory parameters and on signs/symptoms of CVI.

Prevention of Edema and Flight Microangiopathy with Venoruton ® (HR), (0-[Beta-Hydroxyethyl]Rutosides) in Patients with Varicose Veins

The aim of this open study was the evaluation of the effects of HR (Venoruton®) at a dose of 1 g/day on the prevention and control of flight microangiopathy and edema in subjects with varicose veins and moderate chronic venous insufficiency flying for more than 11 hours. Patients with varicose veins, edema, but without initial skin alterations or complications, were included. Measurements of skin laser Doppler (LDF) resting flux (RF) venoarteriolar response (VAR), ankle swelling (RAS), and edema were made within 12 hours before and within 3 hours after the flights. The resulting edema after the flights was evaluated with a composite edema score (analogue scale line). A group of 20 subjects was treated with HR (1 g/day, starting 2 days before the flight and 1 g for every 12 hours on day of travel). Another group of 18 subjects formed the control group. The length of the flights was between 11 and 13 hours; all seats were in coach class. Fifty patients were enrolled and 38 patients were evaluable at the end of the trial. The 2 groups (treatment and control) were comparable for age and sex distribution. The decrease in RF was significant in both groups with a higher flux at the end of the flight in the HR group (p<0.05). The venoarteriolar response was decreased at the end of the flights; the decrease was lower in the HR group (p<0.05). The increase in RAS and the edema score were significantly lower in the HR group. In conclusion HR is useful for reducing the level of microangiopathy and the increased capillary filtration and in controlling edema in patients with venous disease in long flights. The higher level of flux and VAR and the reduction in edema indicate a positive effect of HR on the microcirculation. This study confirms that HR prophylaxis is effective to control flight microangiopathy associated with edema.

Prevention of Edema in Long Flights with Pycnogenol®

The aim of this study was to evaluate the prevention of edema during long-haul flights with an oral, anti-edema and antithrombotic agent (Pycnogenol®, Horphag, Research Management SA, Geneva, Switzerland) in asymptomatic subjects. The assessment of edema was performed by evaluating an analogue scale, the rate of ankle swelling by strain-gauge derived rate of ankle swelling (RAS), and by assessing the ankle circumference variation. The study included 211 subjects; 169 completed the study (88 in the control group and 81 in the Pycnogenol® group). There were no important differences between the two groups (comparable for age, gender, weight, body mass index, and pattern distribution). The edema score, the RAS, and the circumference at inclusion were also comparable. After the flight in those treated with Pycnogenol®, the edema score was increased only by 17.9% (vs. an increase of 58.3% in the control group) (p<0.05). The RAS, evaluated in 22 subjects in the Pycnogenol® group (age 44.5; SD 8) and in 23 in the control group (age 45; SD 9) was increased on average by 91% in the control group and 36% in the Pycnogenol® group (p<0.05). The variation on circumference at the ankle was 6% in the Pycnogenol® group (11% in the control group; p<0.05). These results indicate a positive effect of Pycnogenol® on edema during long flights when considering subjective and objective data. No unwanted effects were observed.