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demonstrating that amniotic membrane significantly reduced ulcer size&#44; pain intensity&#44; and reepithelialization time through its capacity to promote growth&#44; adhesion&#44; and differentiation of epithelial cells and to prevent their apoptosis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Subsequently&#44; Pesteil et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13</span></a> confirmed these results&#46; The benefits obtained by these authors and those reported in the literature for other dermatological conditions<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;18</span></a> raised the possibility of using amniotic membrane to treat vascular ulcers refractory to standard treatment&#46; In conjunction with the tissue bank at our hospital&#44; which provided us with the amniotic membrane&#44; we set up a prospective&#44; uncontrolled&#44; observational pilot study based on a series of clinical cases in order to investigate the effectiveness of amniotic membrane transplantation in the treatment of refractory chronic leg ulcers&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The study was approved by the clinical research ethics committee at Hospital Cl&#237;nic de Barcelona&#46; Following the signing of informed consent&#44; amniotic membrane was grafted onto 4 refractory chronic vascular ulcers on the lower limbs of 3 patients&#46; The patients had venous and arterial lower limb ulcers that had appeared over 6 months earlier&#46; After treatment for 1 year with hydrocolloid and polyurethane foam dressings and even&#44; in 1 case&#44; with the failed application of an autograft&#44; the patients had acheived reepithelialization of less than 0&#46;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> per month and had negative serology for hepatitis B and C viruses and human immunodeficiency virus&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ulcers with bacterial infection or presence of fibrotic or necrotic tissue were excluded&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The amniotic membrane was obtained and processed at the tissue bank of the Transplant Services Foundation of Hospital Cl&#237;nic de Barcelona&#46; The criteria for selecting amniotic membrane donors were based on the standards of the Spanish Association of Tissue Banks&#46; Specific exclusion criteria were uncontrolled pregnancy&#44; an abnormal obstetric history&#44; symptoms of infection in the newborn&#44; delivery before 34 weeks&#8217; gestation&#44; and membrane rupture more than 12<span class="elsevierStyleHsp" style=""></span>hours before delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> The donors gave written informed consent for the donation and use of the amniotic membrane and were screened antepartum for hepatitis B and C viruses and human immunodeficiency virus&#46; The placentas were obtained from elective cesarean deliveries to avoid structural defects and contamination of the placenta by the vaginal flora&#44; chlamydia&#44; herpes&#44; or other infectious agents present in the birth canal&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">After donation the placenta was washed with physiological saline to remove traces of blood and kept at 4<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; A smear was taken immediately after collection of the placenta and placed for no longer than 24<span class="elsevierStyleHsp" style=""></span>hours in RPMI medium containing 50<span class="elsevierStyleHsp" style=""></span>mg&#47;mL amphotericin&#44; 50<span class="elsevierStyleHsp" style=""></span>mg&#47;mL penicillin&#44; and 50<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL streptomycin&#46; In the laboratory&#44; the amniotic membrane was identified and separated from the placenta by dissection in a laminar flow chamber&#59; fragments with no infiltrated blood&#44; tearing&#44; or other abnormalities were considered suitable&#46; The stromal side of the membrane was located&#44; placed on the filter paper used as a support&#44; and trimmed&#46; The fragments were placed in labeled containers and a sample of each was taken for microbiological tests&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Amniotic membrane transplantation was performed on an outpatient basis in the day hospital of the dermatology department of Hospital Cl&#237;nic de Barcelona&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The causes of the ulcers were treated where possible and ulcer size was measured using the Visitrak digital system&#46; Bacterial infection was ruled out according to the clinical appearance of the ulcer&#44; the surrounding skin&#44; and the exudate&#46; Pain was assessed using a visual analog scale&#44; where 0 represented no pain and 10 represented the worst pain imaginable&#46; Data were collected at weeks 0&#44; 4&#44; 8&#44; 12&#44; and 16&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The preparation of the ulcers included sponging with soap&#44; mechanical debridement of fibrinous debris or slough with a scalpel or curette when necessary&#44; and a compression bandage in cases without contraindications&#46; The membrane preservation solution was removed by washing with physiological saline and the membrane was applied directly onto the ulcer bed&#46; The graft was immediately covered with petrolatum-impregnated gauze and a secondary polyurethane foam dressing&#46; Patients were confined to bed for 2<span class="elsevierStyleHsp" style=""></span>hours and then allowed to do moderate activity for the next 5 days&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In all cases a single amniotic membrane transplantation was performed and 2 follow-up visits were held per week to assess progress and to perform standard wound care&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Stat Crunch computer program was used to record ulcer size and pain intensity prior to amniotic membrane transplantation and 4&#44; 8&#44; 12&#44; and 16 weeks after treatment&#46; The data were analyzed descriptively using absolute and relative frequencies&#44; means &#40;SD&#41;&#44; and medians &#40;range&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">In 3 patients we performed a single amniotic membrane transplantation on a total of 4 ulcers located on the distal third of the lower limbs&#44; 2 on the left leg and 2 on the right leg&#46; The mean age of the patients was 71&#46;3 years&#46; The ulcers were venous in 3 cases &#40;ankle-arm index&#44;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#41; and arterial in 1 case &#40;ankle-arm index&#44;&#160;0&#46;48&#41;&#46; The mean ulcer size was 9&#46;15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;range&#44;&#160;4&#46;6-18&#46;8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#41; and the mean time since onset was 126 months with a maximum of 180 months &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The ulcer size decreased progressively after the amniotic membrane transplantation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the follow-up visit in week 8 complete reepithelialization of 1 of the ulcers was observed&#46; The mean reduction in ulcer size compared with baseline was 81&#46;93&#37; &#40;range&#44; 61&#46;70&#37;-100&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">One patient &#40;ulcer 3&#41; reported no pain at any time during the study&#46; Two patients reported the disappearance of pain perceived after the procedure&#46; However&#44; the patient with ulcer 2 reported an increase in pain in the follow-up visit at week 12 and this pain continued until the end of the study&#46; Taking into account all cases the pain intensity decreased by 86&#46;66&#37; compared with baseline &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Two of the patients had perilesional irritant dermatitis at week 4&#44; so the foam dressing was replaced with a carbon and colloidal silver dressing and betamethasone and gentamicin cream was applied to the damaged skin as needed&#44; with a follow-up visit after 7 days&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">No clinical infection or increase in size was observed in any of the ulcers&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The use of amniotic membrane for treating skin lesions can be traced back to the early 20th century&#46; Interest in their use in vascular ulcers of the lower limbs began to increase in the 1990s&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;11&#8211;13&#44;16</span></a> This interest stems from the fact that the membrane&#39;s antimicrobial&#44; antiinflammatory&#44; analgesic&#44; antiangiogenic&#44; and reepithelializing properties<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#44;9&#44;10&#44;12&#44;17&#8211;21</span></a>are considered ideal characteristics for a dressing&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Amniotic membrane is also easy to obtain and does not require invasive application techniques&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">This study is the first in Spain that has used amniotic membrane transplantation to foster or accelerate healing of refractory leg ulcers&#46; It was a pilot study designed to test the advantages reported in the literature and therefore included only 4 cases&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The ulcers treated were mainly venous&#46; The age of the patients&#44; the time since onset&#44; and the size of the ulcers were similar to those of other published cases&#46; Complete reepithelialization was achieved in 1 of the 4 cases in approximately 6 weeks&#59; a reduction in size of over 60&#37; was achieved in the remaining ulcers at the end of the study period&#46; These data are consistent with those obtained by other authors&#46; Mermet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> used amniotic membrane in 15 patients with mainly venous leg ulcers&#44; observing after 3 months a reduction of not less than 50&#37; in 12 patients &#40;80&#37;&#41;&#44; of whom 3 &#40;20&#37;&#41; achieved complete reepethelialization&#46; Pesteil et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13</span></a> used amniotic membrane in 8 patients with refractory arterial ulcers&#44; observing complete reepithelialization in 2 of the patients &#40;25&#37;&#41; after 26 weeks&#44; a reduction of not less than 50&#37; in a further 3 patients &#40;about 35&#37;&#41; after 32 weeks&#44; and no response in 3 patients&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In all cases amniotic membrane transplantation reduced pain significantly&#46; This beneficial effect is also reported in the literature<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;12&#44;13</span></a>&#59; its basis is unknown&#44; but it could result from the covering of the sensory nerve endings&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The increase in pain intensity in 1 patient in our series suggests that it might be advisable to repeat the procedure in those cases in which pain increases&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No clinical infection was detected in any of the cases treated&#46; This finding confirms that amniotic membrane can be safely grafted when it is harvested and handled following the strictest procedures&#46; Its well-known antibacterial activity<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;19</span></a>may be due to several factors&#58; presence of antibacterial substances in amniotic fluid&#44; expression of antimicrobial peptides of the innate immune system&#44; biological closure of the wound&#44; or good adherence to the wound&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">One of the most valued features of amniotic membrane is its low immunogenicity<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#58; no adverse reactions have been reported after its use&#46; However&#44; in the first few weeks of the study 2 of our patients developed irritant dermatitis&#44; which responded to topical corticosteroids and a dressing change aimed at improving control of the exudate&#46; We therefore considered that the dermatitis was not caused by a reaction to the membrane but by excess exudate&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Amniotic membrane is more expensive than common dressings&#46; However&#44; in a previous study comparing the cost-effectiveness of amniotic membrane with that of autografts and allografts of biocompatible skin substitutes for the treatment of vascular ulcers on the lower limbs&#44; we concluded that amniotic membrane transplantation was the second most efficient option&#44; after autografts&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results suggest that amniotic membrane may be an effective and safe alternative for treating refractory leg ulcers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">Dr&#46; M&#46; Alsina is currently director of the skin bank of the Transplant Services Foundation of Hospital Cl&#237;nic de Barcelona but obtains no financial benefit from this post&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">S&#46; Pedregosa-Fauste reports no conflicts of interest&#46;</p></span></span>"
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            0 => "Resumen"
            1 => "Introducci&#243;n"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2011-07-06"
    "fechaAceptado" => "2012-01-01"
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            0 => "Amniotic membrane"
            1 => "Venous ulcer"
            2 => "Therapy"
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      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Membrana amni&#243;tica"
            1 => "&#218;lcera venosa"
            2 => "Terapia"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Approximately 1&#37; of the general population have venous or arterial lower limb ulcers&#46; These lesions can be treated with biological skin substitutes such as cadaver skin or tissue-engineered skin equivalents&#44; but treatment fails in 25&#37; of cases&#44; resulting in pain and loss of patient autonomy&#44; as well as increased morbidity and health care costs&#46; In the treatment of corneal ulcers&#44; amniotic membrane has been shown to have antimicrobial and bacteriostatic properties&#44; and to protect the wound without eliciting an immune response&#46; The same properties have been reported in the treatment of burns and postthrombotic ulcers&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness of amniotic membrane transplantation in the treatment of refractory chronic leg ulcers&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Amniotic membrane was grafted onto 4 refractory ulcers in 3 patients&#46; The mean time required for partial and complete reepithelialization was calculated by measuring the wound area at weeks 0&#44; 4&#44; 8&#44; 12&#44; and 16&#46; Pain intensity was assessed at the same intervals using a visual analog scale&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complete wound reepithelialization was achieved for 1 ulcer by week 8&#59; in the other 3 cases&#44; there was a 50&#37; reduction in size compared to baseline&#46; At week 16&#44; the mean reduction in wound size for the 4 ulcers was 81&#46;93&#37;&#46; The corresponding reduction in pain intensity was 86&#46;6&#37;&#46; No adverse effects were observed&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Amniotic membrane transplantation might be an effective alternative for the treatment of refractory chronic vascular ulcers on the lower limbs&#46;</p>"
      ]
      "es" => array:2 [
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las &#250;lceras vasculares &#40;venosas y arteriales&#41; de las extremidades inferiores afectan aproximadamente al 1&#37; de la poblaci&#243;n&#46; Para su tratamiento pueden utilizarse equivalentes cut&#225;neos vivos procedentes de donantes cadav&#233;ricos o desarrollados mediante bioingenier&#237;a tisular&#46; Un 25&#37; de las &#250;lceras no se resuelven&#44; lo que conlleva dolor y p&#233;rdida de autonom&#237;a para los pacientes&#44; adem&#225;s de un aumento de la morbilidad y de los costes sanitarios&#46; La membrana amni&#243;tica aplicada en &#250;lceras corneales ha demostrado poseer propiedades antimicrobianas y bacteriost&#225;ticas&#44; y ser capaz de proteger la herida sin inducir respuesta inmunol&#243;gica&#46; En &#250;lceras postromb&#243;ticas y quemaduras tambi&#233;n se han descrito estas mismas cualidades&#46;</p> <span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Valorar la eficacia de la aplicaci&#243;n del injerto de membrana amni&#243;tica en las &#250;lceras vasculares cr&#243;nicas refractarias de extremidades inferiores&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se aplic&#243; el injerto de membrana amni&#243;tica en cuatro &#250;lceras refractarias de tres pacientes&#46; Se calcul&#243; el tiempo medio de epitelizaci&#243;n total o parcial de la lesi&#243;n mediante el registro del &#225;rea y se valor&#243; el dolor mediante escala visual anal&#243;gica&#44; en las semanas 0&#44; 4&#44; 8&#44; 12 y 16&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En la semana 8 se observ&#243; la epitelizaci&#243;n completa de una &#250;lcera y la reducci&#243;n del 50&#37; de las otras tres&#46; En la semana 16 la reducci&#243;n del &#225;rea fue de media un 81&#44;93&#37; en los cuatro casos&#46; La intensidad del dolor percibido se redujo un 86&#44;6&#37;&#46; No se detectaron efectos adversos&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La membrana amni&#243;tica puede ser una alternativa eficaz en el tratamiento de las &#250;lceras vasculares cr&#243;nicas refractarias de extremidades inferiores&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Alsina-Gibert M&#44; Pedregosa-Fauste S&#46; Aplicaci&#243;n de membrane amni&#243;tica en el tratamiento de las &#250;lceras cr&#243;nicas de extremidades inferiores&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;608&#8211;613&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Ulcer size&#46; A&#44; week 0&#46; B&#44; week 16&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Changes in the size of the 4 ulcers following amniotic membrane transplantation&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Changes in the pain intensity reported by patients following amniotic membrane transplantation&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; VAS&#44; visual analog scale &#40;0 being no pain and 10 the worst pain imaginable&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Age of patient&#44; y&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Venous insufficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arterial vasculopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Time since onset&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">156</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower right leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower left leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower left leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower right leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ankle-arm index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial size&#44; cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial VAS pain score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab182304.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Demographic and Clinical Data of Patients and Description of Ulcers&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Tratamiento de las &#250;lceras cr&#243;nicas de extremidades inferiores con injertos cut&#225;neos alog&#233;nicos&#46; Fondo de Investigaci&#243;n Sanitaria &#40;FIS&#41;&#44; IP- 010189&#44; 2004-2007&#46; Investigador principal&#58; Alsina MM&#46;"
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efectividad de los Ap&#243;sitos Especiales en el Tratamiento de las &#218;lceras por Presi&#243;n y Vasculares"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Agencia de Evaluaci&#243;n de Tecnolog&#237;as Sanitarias &#40;AETS&#41;&#46; Instituto de Salud Carlos III - Ministerio de Sanidad y Consumo"
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                        ]
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                        "editorial" => "AETS - Instituto de Salud Carlos III"
                        "editorialLocalizacion" => "Madrid"
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            2 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tratamiento de &#250;lceras vasculares cr&#243;nicas con equivalentes cut&#225;neos obtenidos mediante ingenier&#237;a tisular"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Camblor"
                            1 => "A&#46; Meana"
                            2 => "J&#46;M&#46; Llaneza"
                            3 => "F&#46; Vaquero"
                            4 => "S&#46; G&#243;mez"
                            5 => "D&#46; L&#243;pez"
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                      ]
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                  "host" => array:1 [
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                        "fecha" => "2003"
                        "volumen" => "55"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Estudio coste-beneficio del trasplante de membrana amni&#243;tica para &#250;lceras venosas de extremidades inferiores refractarias a tratamiento convencional"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "S&#46; Guti&#233;rrez-Moreno"
                            1 => "M&#46; Alsina-Gibert"
                            2 => "L&#46; Sampietro-Colom"
                            3 => "S&#46; Pedregosa-Fauste"
                            4 => "P&#46; Ayala-Blanco"
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                    0 => array:2 [
                      "doi" => "10.1016/j.ad.2011.01.003"
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                        "tituloSerie" => "Actas Dermosifiliogr"
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                        "paginaFinal" => "288"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Aplicaciones de la membrana amni&#243;tica en patolog&#237;a ocular"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Z&#46; Del Campo"
                            1 => "O&#46; Gris"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Annals d&#8217;Oftalmologia"
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                        "volumen" => "10"
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                      "titulo" => "The role of Allogenic Amni&#243;tic Membrane in Burn Treatment"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;R&#46; Kesting"
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                            2 => "B&#46; Hohlweg-Majert"
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                    0 => array:2 [
                      "doi" => "10.1097/BCR.0b013e31818b9e40"
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                        "tituloSerie" => "J Burn Care Res"
                        "fecha" => "2008"
                        "volumen" => "29"
                        "paginaInicial" => "907"
                        "paginaFinal" => "916"
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                      "titulo" => "Amniotic membrane use in dermatology"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "V&#46; Lo"
                            1 => "E&#46; Pope"
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                    0 => array:2 [
                      "doi" => "10.1111/j.1365-4632.2009.04173.x"
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                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "2009"
                        "volumen" => "48"
                        "paginaInicial" => "935"
                        "paginaFinal" => "940"
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                      "titulo" => "Amniotic membrane&#58; An innovative treatment of refractory vascular ulcers"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Pesteil"
                            1 => "M&#46; Drouet"
                            2 => "M&#46;C&#46; Rousanne"
                            3 => "P&#46; Lacroix"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Phlebolymphology"
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                      "titulo" => "Physical changes of amniotic membranes through glycerolization for the use as an epidermal substitute&#46; Light and electron microscopic studies"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Rejzek"
                            1 => "F&#46; Weyer"
                            2 => "R&#46; Eichberger"
                            3 => "W&#46; Gebhart"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1023/A:1014316232009"
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                        "tituloSerie" => "Cell Tissue Bank"
                        "fecha" => "2001"
                        "volumen" => "2"
                        "paginaInicial" => "95"
                        "paginaFinal" => "102"
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                          "etal" => true
                          "autores" => array:6 [
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                            4 => "P&#46; Kumar"
                            5 => "A&#46; Kumar"
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                    0 => array:2 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The long-term results of the use of human amnion in the treatment of leg ulcers"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;J&#46; Ward"
                            1 => "P&#46;J&#46; Bennet"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Br J Plastic Surg"
                        "fecha" => "1984"
                        "volumen" => "37"
                        "paginaInicial" => "191"
                        "paginaFinal" => "193"
                      ]
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Original Article
Amniotic Membrane Transplantation in the Treatment of Chronic Lower Limb Ulcers
Aplicación de membrana amniótica en el tratamiento de las úlceras crónicas de extremidades inferiores
M. Alsina-Giberta,
Autor para correspondencia
malsina@clinic.ub.es

Corresponding author.
, S. Pedregosa-Fausteb
a Servicio de Dermatología, Hospital Clínic, Transplant Services Foundation, Universitat de Barcelona, Barcelona, Spain
b Servicio de Dermatología, Hospital Clínic, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Venous and arterial lower limb ulcers are very common and affect approximately 1&#37; of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The standard treatment&#44; which consists of cleaning&#44; debridement&#44; and application of dressings&#44; achieves cure rates of 65&#37; to 85&#37;&#46; About 25&#37; of these ulcers become chronic&#44; resulting in pain&#44; loss of patient autonomy&#44; increased morbidity&#44; and increased health care costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The biological&#44; synthetic&#44; and biosynthetic dressings developed to promote healing include human cadaver skin and tissue-engineered skin equivalents&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> but these are not routinely used because of their high cost&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Amniotic membrane is currently used in ophthalmology to reconstruct the corneal surface in cases of corneal ulcer&#46; In this application amniotic membrane has shown protective&#44; antimicrobial&#44; and bacteriostatic properties without inducing immunological reactions because of its low expression of the HLA-A&#44; B&#44; C and DR antigens&#44; its capacity to inhibit proteases and to stimulate inflammatory cells into rapid apoptosis&#44; and the &#40;as yet not fully demonstrated&#41; presence of antibacterial factors in amniotic fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The use of human amniotic membrane in dermatology as a dressing for wounds and burns dates back to the early 20th century&#46; With the improvement in sterilization techniques in the late 20th century&#44; the possibility of using amniotic membrane to treat vascular ulcers was considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;11</span></a> In 2007 Mermet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> performed the first prospective study of long-standing vascular ulcers refractory to standard treatment&#44; demonstrating that amniotic membrane significantly reduced ulcer size&#44; pain intensity&#44; and reepithelialization time through its capacity to promote growth&#44; adhesion&#44; and differentiation of epithelial cells and to prevent their apoptosis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Subsequently&#44; Pesteil et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13</span></a> confirmed these results&#46; The benefits obtained by these authors and those reported in the literature for other dermatological conditions<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;18</span></a> raised the possibility of using amniotic membrane to treat vascular ulcers refractory to standard treatment&#46; In conjunction with the tissue bank at our hospital&#44; which provided us with the amniotic membrane&#44; we set up a prospective&#44; uncontrolled&#44; observational pilot study based on a series of clinical cases in order to investigate the effectiveness of amniotic membrane transplantation in the treatment of refractory chronic leg ulcers&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The study was approved by the clinical research ethics committee at Hospital Cl&#237;nic de Barcelona&#46; Following the signing of informed consent&#44; amniotic membrane was grafted onto 4 refractory chronic vascular ulcers on the lower limbs of 3 patients&#46; The patients had venous and arterial lower limb ulcers that had appeared over 6 months earlier&#46; After treatment for 1 year with hydrocolloid and polyurethane foam dressings and even&#44; in 1 case&#44; with the failed application of an autograft&#44; the patients had acheived reepithelialization of less than 0&#46;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> per month and had negative serology for hepatitis B and C viruses and human immunodeficiency virus&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ulcers with bacterial infection or presence of fibrotic or necrotic tissue were excluded&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The amniotic membrane was obtained and processed at the tissue bank of the Transplant Services Foundation of Hospital Cl&#237;nic de Barcelona&#46; The criteria for selecting amniotic membrane donors were based on the standards of the Spanish Association of Tissue Banks&#46; Specific exclusion criteria were uncontrolled pregnancy&#44; an abnormal obstetric history&#44; symptoms of infection in the newborn&#44; delivery before 34 weeks&#8217; gestation&#44; and membrane rupture more than 12<span class="elsevierStyleHsp" style=""></span>hours before delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> The donors gave written informed consent for the donation and use of the amniotic membrane and were screened antepartum for hepatitis B and C viruses and human immunodeficiency virus&#46; The placentas were obtained from elective cesarean deliveries to avoid structural defects and contamination of the placenta by the vaginal flora&#44; chlamydia&#44; herpes&#44; or other infectious agents present in the birth canal&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">After donation the placenta was washed with physiological saline to remove traces of blood and kept at 4<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; A smear was taken immediately after collection of the placenta and placed for no longer than 24<span class="elsevierStyleHsp" style=""></span>hours in RPMI medium containing 50<span class="elsevierStyleHsp" style=""></span>mg&#47;mL amphotericin&#44; 50<span class="elsevierStyleHsp" style=""></span>mg&#47;mL penicillin&#44; and 50<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL streptomycin&#46; In the laboratory&#44; the amniotic membrane was identified and separated from the placenta by dissection in a laminar flow chamber&#59; fragments with no infiltrated blood&#44; tearing&#44; or other abnormalities were considered suitable&#46; The stromal side of the membrane was located&#44; placed on the filter paper used as a support&#44; and trimmed&#46; The fragments were placed in labeled containers and a sample of each was taken for microbiological tests&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Amniotic membrane transplantation was performed on an outpatient basis in the day hospital of the dermatology department of Hospital Cl&#237;nic de Barcelona&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The causes of the ulcers were treated where possible and ulcer size was measured using the Visitrak digital system&#46; Bacterial infection was ruled out according to the clinical appearance of the ulcer&#44; the surrounding skin&#44; and the exudate&#46; Pain was assessed using a visual analog scale&#44; where 0 represented no pain and 10 represented the worst pain imaginable&#46; Data were collected at weeks 0&#44; 4&#44; 8&#44; 12&#44; and 16&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The preparation of the ulcers included sponging with soap&#44; mechanical debridement of fibrinous debris or slough with a scalpel or curette when necessary&#44; and a compression bandage in cases without contraindications&#46; The membrane preservation solution was removed by washing with physiological saline and the membrane was applied directly onto the ulcer bed&#46; The graft was immediately covered with petrolatum-impregnated gauze and a secondary polyurethane foam dressing&#46; Patients were confined to bed for 2<span class="elsevierStyleHsp" style=""></span>hours and then allowed to do moderate activity for the next 5 days&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In all cases a single amniotic membrane transplantation was performed and 2 follow-up visits were held per week to assess progress and to perform standard wound care&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Stat Crunch computer program was used to record ulcer size and pain intensity prior to amniotic membrane transplantation and 4&#44; 8&#44; 12&#44; and 16 weeks after treatment&#46; The data were analyzed descriptively using absolute and relative frequencies&#44; means &#40;SD&#41;&#44; and medians &#40;range&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">In 3 patients we performed a single amniotic membrane transplantation on a total of 4 ulcers located on the distal third of the lower limbs&#44; 2 on the left leg and 2 on the right leg&#46; The mean age of the patients was 71&#46;3 years&#46; The ulcers were venous in 3 cases &#40;ankle-arm index&#44;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;9&#41; and arterial in 1 case &#40;ankle-arm index&#44;&#160;0&#46;48&#41;&#46; The mean ulcer size was 9&#46;15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;range&#44;&#160;4&#46;6-18&#46;8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#41; and the mean time since onset was 126 months with a maximum of 180 months &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The ulcer size decreased progressively after the amniotic membrane transplantation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the follow-up visit in week 8 complete reepithelialization of 1 of the ulcers was observed&#46; The mean reduction in ulcer size compared with baseline was 81&#46;93&#37; &#40;range&#44; 61&#46;70&#37;-100&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">One patient &#40;ulcer 3&#41; reported no pain at any time during the study&#46; Two patients reported the disappearance of pain perceived after the procedure&#46; However&#44; the patient with ulcer 2 reported an increase in pain in the follow-up visit at week 12 and this pain continued until the end of the study&#46; Taking into account all cases the pain intensity decreased by 86&#46;66&#37; compared with baseline &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Two of the patients had perilesional irritant dermatitis at week 4&#44; so the foam dressing was replaced with a carbon and colloidal silver dressing and betamethasone and gentamicin cream was applied to the damaged skin as needed&#44; with a follow-up visit after 7 days&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">No clinical infection or increase in size was observed in any of the ulcers&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The use of amniotic membrane for treating skin lesions can be traced back to the early 20th century&#46; Interest in their use in vascular ulcers of the lower limbs began to increase in the 1990s&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;11&#8211;13&#44;16</span></a> This interest stems from the fact that the membrane&#39;s antimicrobial&#44; antiinflammatory&#44; analgesic&#44; antiangiogenic&#44; and reepithelializing properties<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#44;9&#44;10&#44;12&#44;17&#8211;21</span></a>are considered ideal characteristics for a dressing&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Amniotic membrane is also easy to obtain and does not require invasive application techniques&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">This study is the first in Spain that has used amniotic membrane transplantation to foster or accelerate healing of refractory leg ulcers&#46; It was a pilot study designed to test the advantages reported in the literature and therefore included only 4 cases&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The ulcers treated were mainly venous&#46; The age of the patients&#44; the time since onset&#44; and the size of the ulcers were similar to those of other published cases&#46; Complete reepithelialization was achieved in 1 of the 4 cases in approximately 6 weeks&#59; a reduction in size of over 60&#37; was achieved in the remaining ulcers at the end of the study period&#46; These data are consistent with those obtained by other authors&#46; Mermet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> used amniotic membrane in 15 patients with mainly venous leg ulcers&#44; observing after 3 months a reduction of not less than 50&#37; in 12 patients &#40;80&#37;&#41;&#44; of whom 3 &#40;20&#37;&#41; achieved complete reepethelialization&#46; Pesteil et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13</span></a> used amniotic membrane in 8 patients with refractory arterial ulcers&#44; observing complete reepithelialization in 2 of the patients &#40;25&#37;&#41; after 26 weeks&#44; a reduction of not less than 50&#37; in a further 3 patients &#40;about 35&#37;&#41; after 32 weeks&#44; and no response in 3 patients&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In all cases amniotic membrane transplantation reduced pain significantly&#46; This beneficial effect is also reported in the literature<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;12&#44;13</span></a>&#59; its basis is unknown&#44; but it could result from the covering of the sensory nerve endings&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The increase in pain intensity in 1 patient in our series suggests that it might be advisable to repeat the procedure in those cases in which pain increases&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No clinical infection was detected in any of the cases treated&#46; This finding confirms that amniotic membrane can be safely grafted when it is harvested and handled following the strictest procedures&#46; Its well-known antibacterial activity<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;19</span></a>may be due to several factors&#58; presence of antibacterial substances in amniotic fluid&#44; expression of antimicrobial peptides of the innate immune system&#44; biological closure of the wound&#44; or good adherence to the wound&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">One of the most valued features of amniotic membrane is its low immunogenicity<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#58; no adverse reactions have been reported after its use&#46; However&#44; in the first few weeks of the study 2 of our patients developed irritant dermatitis&#44; which responded to topical corticosteroids and a dressing change aimed at improving control of the exudate&#46; We therefore considered that the dermatitis was not caused by a reaction to the membrane but by excess exudate&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Amniotic membrane is more expensive than common dressings&#46; However&#44; in a previous study comparing the cost-effectiveness of amniotic membrane with that of autografts and allografts of biocompatible skin substitutes for the treatment of vascular ulcers on the lower limbs&#44; we concluded that amniotic membrane transplantation was the second most efficient option&#44; after autografts&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results suggest that amniotic membrane may be an effective and safe alternative for treating refractory leg ulcers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">Dr&#46; M&#46; Alsina is currently director of the skin bank of the Transplant Services Foundation of Hospital Cl&#237;nic de Barcelona but obtains no financial benefit from this post&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">S&#46; Pedregosa-Fauste reports no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xres96169"
          "titulo" => array:6 [
            0 => "Abstract"
            1 => "Introduction"
            2 => "Objectives"
            3 => "Patients and methods"
            4 => "Results"
            5 => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec83327"
          "titulo" => "Keywords"
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        2 => array:2 [
          "identificador" => "xres96168"
          "titulo" => array:6 [
            0 => "Resumen"
            1 => "Introducci&#243;n"
            2 => "Objetivos"
            3 => "Pacientes y m&#233;todos"
            4 => "Resultados"
            5 => "Conclusiones"
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        3 => array:2 [
          "identificador" => "xpalclavsec83328"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Patients and Methods"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflict of Interests"
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        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-07-06"
    "fechaAceptado" => "2012-01-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec83327"
          "palabras" => array:3 [
            0 => "Amniotic membrane"
            1 => "Venous ulcer"
            2 => "Therapy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec83328"
          "palabras" => array:3 [
            0 => "Membrana amni&#243;tica"
            1 => "&#218;lcera venosa"
            2 => "Terapia"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Approximately 1&#37; of the general population have venous or arterial lower limb ulcers&#46; These lesions can be treated with biological skin substitutes such as cadaver skin or tissue-engineered skin equivalents&#44; but treatment fails in 25&#37; of cases&#44; resulting in pain and loss of patient autonomy&#44; as well as increased morbidity and health care costs&#46; In the treatment of corneal ulcers&#44; amniotic membrane has been shown to have antimicrobial and bacteriostatic properties&#44; and to protect the wound without eliciting an immune response&#46; The same properties have been reported in the treatment of burns and postthrombotic ulcers&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness of amniotic membrane transplantation in the treatment of refractory chronic leg ulcers&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Amniotic membrane was grafted onto 4 refractory ulcers in 3 patients&#46; The mean time required for partial and complete reepithelialization was calculated by measuring the wound area at weeks 0&#44; 4&#44; 8&#44; 12&#44; and 16&#46; Pain intensity was assessed at the same intervals using a visual analog scale&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complete wound reepithelialization was achieved for 1 ulcer by week 8&#59; in the other 3 cases&#44; there was a 50&#37; reduction in size compared to baseline&#46; At week 16&#44; the mean reduction in wound size for the 4 ulcers was 81&#46;93&#37;&#46; The corresponding reduction in pain intensity was 86&#46;6&#37;&#46; No adverse effects were observed&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Amniotic membrane transplantation might be an effective alternative for the treatment of refractory chronic vascular ulcers on the lower limbs&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las &#250;lceras vasculares &#40;venosas y arteriales&#41; de las extremidades inferiores afectan aproximadamente al 1&#37; de la poblaci&#243;n&#46; Para su tratamiento pueden utilizarse equivalentes cut&#225;neos vivos procedentes de donantes cadav&#233;ricos o desarrollados mediante bioingenier&#237;a tisular&#46; Un 25&#37; de las &#250;lceras no se resuelven&#44; lo que conlleva dolor y p&#233;rdida de autonom&#237;a para los pacientes&#44; adem&#225;s de un aumento de la morbilidad y de los costes sanitarios&#46; La membrana amni&#243;tica aplicada en &#250;lceras corneales ha demostrado poseer propiedades antimicrobianas y bacteriost&#225;ticas&#44; y ser capaz de proteger la herida sin inducir respuesta inmunol&#243;gica&#46; En &#250;lceras postromb&#243;ticas y quemaduras tambi&#233;n se han descrito estas mismas cualidades&#46;</p> <span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Valorar la eficacia de la aplicaci&#243;n del injerto de membrana amni&#243;tica en las &#250;lceras vasculares cr&#243;nicas refractarias de extremidades inferiores&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se aplic&#243; el injerto de membrana amni&#243;tica en cuatro &#250;lceras refractarias de tres pacientes&#46; Se calcul&#243; el tiempo medio de epitelizaci&#243;n total o parcial de la lesi&#243;n mediante el registro del &#225;rea y se valor&#243; el dolor mediante escala visual anal&#243;gica&#44; en las semanas 0&#44; 4&#44; 8&#44; 12 y 16&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En la semana 8 se observ&#243; la epitelizaci&#243;n completa de una &#250;lcera y la reducci&#243;n del 50&#37; de las otras tres&#46; En la semana 16 la reducci&#243;n del &#225;rea fue de media un 81&#44;93&#37; en los cuatro casos&#46; La intensidad del dolor percibido se redujo un 86&#44;6&#37;&#46; No se detectaron efectos adversos&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La membrana amni&#243;tica puede ser una alternativa eficaz en el tratamiento de las &#250;lceras vasculares cr&#243;nicas refractarias de extremidades inferiores&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Alsina-Gibert M&#44; Pedregosa-Fauste S&#46; Aplicaci&#243;n de membrane amni&#243;tica en el tratamiento de las &#250;lceras cr&#243;nicas de extremidades inferiores&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;608&#8211;613&#46;</p>"
      ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Ulcer size&#46; A&#44; week 0&#46; B&#44; week 16&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Changes in the size of the 4 ulcers following amniotic membrane transplantation&#46;</p>"
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      2 => array:7 [
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        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Changes in the pain intensity reported by patients following amniotic membrane transplantation&#46;</p>"
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      ]
      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; VAS&#44; visual analog scale &#40;0 being no pain and 10 the worst pain imaginable&#41;&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Ulcer 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Ulcer 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Ulcer 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Ulcer 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age of patient&#44; y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Venous insufficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arterial vasculopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Time since onset&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">156</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower right leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower left leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower left leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower right leg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ankle-arm index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial size&#44; cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;6&nbsp;\t\t\t\t\t\t\n
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