A study of open, randomized, parallel-group design was performed to investigate the impact of a second freeze-thaw cycle on the cure rate, at 3 months, from cryotherapy of common warts on the hands and feet. Cryotherapy was performed at 3-week intervals, and subjects were randomized to receive either one or two freeze-thaw cycles. In addition, all subjects used keratolytic wart paints throughout the study, and plantar warts were pared prior to freezing. Three hundred subjects were recruited. At 3 months, 124 were cured, 83 were not cured, and 93 had defaulted. Among those who did not default the cure rate was 57% from the single freeze technique, and 62% from the double freeze technique, a difference of 5% (P = 0.53, 95% CI-8.1-18.6). Separate analyses for subjects with warts on the hands and on the feet demonstrated no effect of double freezing on hand warts. In contrast, for plantar warts, the cure rate was 41% from single freezing and 65% for double freezing, a difference of 24% (P = 0.04, 95% CI 2.9-44.4). The use of a double freeze-thaw cycle confers little or no advantage over a single freeze in the treatment of hand warts, but may be considerably more effective for plantar warts.
Several systems exist for classifying pressure ulcers, though none of them have been evaluated for interrater reliability. A new grading scale was compared with the commonly used Shea classification. This new scale was developed to provide a more complete description of pressure ulcer healing. The advantages of this scale include a classification of red areas as ulcers to help prevent further deterioration and classification of healed sores to note potential problems. The Yarkony-Kirk scale classifies a red area as a grade 1 ulcer, and involvement of the epidermis and dermis with no subcutaneous fat observed as a grade 2 ulcer. Grade 3 indicates exposed subcutaneous fat with no muscle observed. Exposed muscle without bone involvement is classified as a grade 4 ulcer, and grade 5 describes exposed bone with no joint space involvement. Grade 6 indicates joint space involvement. There is a classification of pressure sore healed to indicate a healed pressure ulcer. Interrater reliability was assessed by two nurses. In spite of an increased number of categories for the Yarkony-Kirk scale, there was no decline in reliability. Reliability was excellent with an interrater correlation of 0.90 for the Yarkony-Kirk scale and 0.86 for the Shea classification when measured for 72 patients. Eighty-five percent of the ratings for the Yarkony-Kirk scale were identical, whereas only 68% were identical for the Shea classification. Three percent of the ratings for the Shea classification were greater than +/- 1 category; 6% of the ratings for the Yarkony-Kirk scale were greater than +/- 1 category. This scale appears to possess good reliability and to describe pressure ulcers more completely. This scale may also be used to teach prevention activities as well as ulcer classification.
In Reply. \p=m-\We agree with the authors that when eschar is present d\l=e'\bridementis often necessary to determine the extent of the ulceration and that palpation may assist as well.Our classification of red areas' reflects our clinical practice of intervening if hyperemia persists for greater than 30 minutes.2 It is not necessary to wait for greater than 24 hours to institute therapeutic measures. Our approach is, in fact, more conservative than the authors outline. Of course, if their method has proven successful in their institutions, it can be used as long as there is sufficient interrater reliability. Muscle is frequently observed at the base of pressure ulcers. These ulcerations may occur in both common and uncommon areas and a classification including muscle is needed to classify all possible lesions. Patients who have had musculocutaneous flaps will certainly have muscle exposed if pressure ulcerations reoccur. We find grade IV to be useful and would not eliminate it from the classification. With Lipodermatosclerosis and Venous UlcerationTo the Editor.\p=m-\Iread with interest the article by Falanga et al1 on the potential association of protein S and protein C with venous ulceration and lipodermatosclerosis. Although I applaud the effort, I wish to caution interpretation of hypercoagulable evaluations analyzing isolated defects. Clot formation and dissolution is a very dynamic and complex process, and studies attempting to show a cause-and\x=req-\ effect relationship must exclude other potential factors. The authors state "One proposed hypothesis suggests that the sustained elevation of venous pressure (venous hypertension), resulting from inadequate functioning of the "calf muscle pump," lends to dermal pericapillary deposition of fibrin, which alters the interactions between vasculature and dermis." They further state: "Thus, an increased pro-pensity for deep vein thrombosis, as could occur in the setting of protein C or protein S deficiency, and perhaps in combination with a faulty fibrinolytic system, may lead to the development of venous occlusion and venous hypertension." Protein C and protein S are vitamin K-dependent natural anticoagulants produced by the liver, and activation is dependent on the presence of thrombin and an endothelial cell surface receptor (thrombomodulin).2 Know¬ ing that there is a poor association between depressed pro¬ tein C and protein S levels in the general population and thrombotic tendencies it is much more likely that an endo¬ thelial defect exists secondary to venous hypertension resulting in decreased protein C activation. If this is the case, then one should include tissue plasminogen activator (TPA) and tissue plasminogen activator inhibitor (TPAI-1) in the study since defects in this arm of anticoagulation may produce significant thrombosis. Both TPA and TPAI-1 are produced by endothelial cells.2 Up to 70% of individuals with idiopathic venous thrombosis have been shown to have ab¬ normal TPA results, suggesting that decreased TPA activ¬ ity may be a major com...
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