# data[].attributes.headline
Therapeutics and Clinical Risk Management:

# data[].attributes.subject
Therapeutics and Clinical Risk Management:

# data[].attributes.body
"Combined therapy in the treatment of mixed etiology leg ulcer – case report"
- Jaroslaw Pasek
- Grzegorz Cieslar
- Aleksander Sieron
A summary by Michael Richard Rigali:
The above-mentioned article presents a case observing a 58-year-old patient diagnosed previously with CVD and ulcers to both shins, caused by chronic mixed venous-arterial insufficiency, and accompanied by acute pain. This patient did not suffer from any other comorbid diseases that affect the healing of type two diabetes. However, this patient was not benefiting from conservative means of treatment. As a result of a 9-week therapeutic cycle, healing of both shin ulcers was observed in addition to subsidence of pain and substantial reduction in the intensity of local inflammation around the ulcer. In conclusion, the application of physical procedures with the use of Laserobaria-S device is an effecting means of treatment as evidenced by this particular case.

# data[].attributes.headline
Most frequent causes of leg ulcer formation:

# data[].attributes.subject
Most frequent causes of leg ulcer formation:

# data[].attributes.body
As cited by the researchers of this article, the most frequent cause of leg ulcers include chronic venous disease (CVD). In addiction to CVD related mainly to venous hypertension, but more rarely, there is also peripheral artery disease (PAD) related to disseminated atheromatous lesions in the lower limbs.

An example of the primary cause (CVI) has been provided below:

# data[].attributes.headline
The minimum age in which CVD/leg ulcer formation generally affects:

# data[].attributes.subject
The minimum age in which CVD/leg ulcer formation generally affects:

# data[].attributes.body
According to the article, those aged >80 years are typically most affected. In addition, up to 2% of the population in this age category are affected.

# data[].attributes.body
As defined by the article, chronic venous insufficiency (CVI) is a condition resulting from the hemostasis (the stopping of blood flow) in veins.

The main cause of CVI is essentially injury to the veins, and their valves, transporting blood from lower extremities to the heart. The function of these valves is to help cope/prevent pooling with gravity without problems. However, disturbances cause venous reflux and thus remain in the valves, extending them, and also inhibiting their function to return blood to the heart.

# data[].attributes.body
According to the article, these include...
1) Older age
2) Family History
3) Female sex
4) Pregnancy
5) Obesity
6) Occupations performed while standing
7) High-impact physical activity
8) Habits of tobacco smoking/excessive alcohol consumption
9) Comorbid conditions such as the ones shown below...

# data[].attributes.body
Deep Vein Thrombosis (DVT)

# data[].attributes.body
Superficial thrombophlebitis

# data[].attributes.body
Obstructive sleep apnea

# data[].attributes.body
As described by the article, it is the most common symptom of PAD (less prevalent than CVD, but still affects the population). It is the pain in calf muscles with increasing intensity while walking and subsiding at rest/also causes difficulties in limb motion. Lastly, patients with intermittent claudication suffer from coldness of the limbs, muscle numbness and spasms, and also muscle hardening after physical activity.

# data[].attributes.headline
Percentage of leg ulcers caused by Mixed Venous-Arterial Ulcers:

# data[].attributes.subject
Percentage of leg ulcers caused by Mixed Venous-Arterial Ulcers:

# data[].attributes.body
An unusually high proportion of all leg ulcers are caused by CVD, upwards of 15% to 21% of patients, but a mixed venous-arterial etiology of ulcers can occur. In other words, the condition coexists with arterial insufficiency during the course of chronic ischemia (lack of blood flow) of the limbs. These ulcers in particular are more resistant to therapy as evidenced by the authors of this article. Typically, venous ulcers take 5.9 months to heal, while mixed etiology ulcers take 7.4 months to heal.

# data[].attributes.headline
Minimum Pressure (mmHg) to assist with venous ulcers at the ankle level:

# data[].attributes.subject
Minimum Pressure (mmHg) to assist with venous ulcers at the ankle level:

# data[].attributes.body
According to the article, for venous ulcers, high compression pressures of at least 40 mmHg at the ankle level should be used, but for mixed etiology ulcers, lower pressures are recommended. It should be noted that the mmHg applied should not exceed the patient's diastolic blood pressure.

# data[].attributes.headline
The Contemporary Management Model form of treatment used, in addition to forms of compression therapies:

# data[].attributes.subject
The Contemporary Management Model form of treatment used, in addition to forms of compression therapies:

# data[].attributes.body
The Contemporary Management Model form of treatment included the following:
1) Simultaneous action of hyperbaric oxygen (HBOT) - elicits systemic changes related to the functioning of the respiratory and circulatory systems, as well as topical/local action related to intensification of healing of chronic wounds
2) Extremely low-frequency (ELF) variable magnetic field - causes improvement of tissue matriculation, stimulation of angiogenesis and vasodilation, as well as stimulation of fibroblasts resulting in increased synthesis of collagen, as well as strong analgesic effect related to local inhibition of inflammation nearby ulceration.
3) Low-energy light radiation - Stimulation of collagen synthesis by activated fibroblasts, improvement of blood supply in tissues nearby ulceration due to vasodilation effect, and stimulation of lymphatic drainage, as well as strong anti-inflammatory and analgesic effects.

As defined by the article:
"As a result of a 9-week therapeutic cycle consisting of 30 daily procedures, a complete healing of ulcers in both shins with accompanying subsidence of pain and substantial reduction in the intensity of local inflammation around the ulcer was obtained. The patient reported no side effects, and no complications were observed during the therapy."
Ultimately, the article shows that conservative therapy, such as compression therapy, pharmacotherapy, wearing elastic stockings, leg elevation and massage, change of life-style, and regular physical exercise may not be enough to treat more resistant mixed venous-arterial etiology ulcers.

Below is a picture of the device;  Laserobaria-S, which was utilized for local combined physical therapy procedures.

# data[].attributes.headline
ABI (Ankle Brachial Index) for both extremities:

# data[].attributes.subject
ABI (Ankle Brachial Index) for both extremities:

# data[].attributes.body
According to the researchers of this article, the patient presented the following variables:
The value of the ankle-brachial index for the right leg was 0.8 and for the left leg was 0.7. This corroborates the notion that there was ischemia of both legs in the course of PAD and accepted as end point for high compression therapy. Because of these measurement, as well as the physical examination and Doppler ultrasound imaging findings, the shin ulcers were diagnosed as mixed venous-arterial ones.

# data[].attributes.headline
Personal Opinion--My belief about whether compression therapy should or should not be used:

# data[].attributes.subject
Personal Opinion--My belief about whether compression therapy should or should not be used:

# data[].attributes.body
I think that this article is a prime example of why traditional forms of therapy are not necessarily the most effective. For example, we are still taught whirlpool in class because it is on the board exam, but it can still embed infection further--the opposite result of what the treatment is supposed to do. I believe that contemporary/modern forms of treatment, such as the Laserobaria-S, should be utilized as much as possible because they are on the forefront of innovation. Ultimately, I do not think compression therapy should have been used because as the article has described, this patient's condition was resistant to older forms of therapy, and required a different/more adaptive approach.

# data[].attributes.headline
The overall healing time period, and the final pain scale, as a result of this treatment:

# data[].attributes.subject
The overall healing time period, and the final pain scale, as a result of this treatment:

# data[].attributes.body
In conclusion, the result of the therapeutic cycle (9 weeks in total), caused the ulcers to completely heal at the same time in both legs. In addition, the pain subsided altogether (subjective pain intensity in the VAS score was estimated by the patient as 0 points).