The importance of antiphospholipid syndrome testing in venous thromboembolism after varicose vein surgery

Anticoagulation treatment after a venous thromboembolism event is usually managed on a case-by-case basis. The risk of thrombosis must be weighed against the risk of bleeding. Identifying patients who could benefit from anticoagulation therapy requires the thromboembolism event to be assessed with respect to its presentation and the severity of the triggering factors. A case report is employed to explain the important aspects of practical approaches to venous thromboembolism events after vein surgery. The Trial on Rivaroxaban in AntiPhospholipid Syndrome (TRAPS) study has prompted new considerations for anticoagulation management. Patients with antiphospholipid syndrome need to be identified early to lower the risk of thromboembolism also during anticoagulation treatment.

Stammzellen in der Regenerativen Medizin – Translationale Hürden und Möglichkeiten zur Überwindung

Der Einsatz von mesenchymalen Stammzellen in der regenerativen Medizin wird immer populärer. Nichtsdestotrotz ist ihre Anwendung im klinischen Alltag noch immer limitiert. Zahlreiche ethische, rechtliche und translationale Probleme sowie Ungewissheit bzgl. der Sicherheit hemmen noch immer die Entstehung von entsprechenden Therapien aus vielversprechenden wissenschaftlichen Ansätzen.

Diese Arbeit soll die Hauptprobleme bei der Translation von stammzellbasierten Therapien aus der Grundlagenforschung und Präklinik in den klinischen Alltag darstellen, sowie Ansätze aufzeigen, diese zu überwinden.

Risks and contraindications of medical compression treatment - A critical reappraisal. An international consensus statement

Objectives

Medical compression therapy is used for non-invasive treatment of venous and lymphatic diseases. Medical compression therapy-associated adverse events and contraindications have been reported, although some contraindications are theoretically based. This consensus statement provides recommendations on medical compression therapy risks and contraindications.

Methods

A systematic literature search of medical compression therapy publications reporting adverse events up until November 2017 was performed. A consensus panel comprising 15 international experts critically reviewed the publications and formulated the recommendations.

Results

Sixty-two publications reporting medical compression therapy adverse events were identified. The consensus panel issued 21 recommendations on medical compression therapy contraindications and adverse event risk mitigation, in addition to reviewing medical compression therapy use in borderline indications. The most frequently reported non-severe medical compression therapy-associated adverse events included skin irritation, discomfort and pain. Very rare but severe adverse events, including soft tissue and nerve injury, were also identified.

Conclusion

This consensus statement summarises published medical compression therapy-associated adverse events and contraindications, and provides guidance on medical compression therapy. Severe medical compression therapy-associated adverse events are very rarely encountered if compression is used correctly and contraindications are considered.

Lipoedema – myths and facts, Part 5

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction

INTRODUCTION

The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA).

PATIENTS AND METHODS

We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI.

RESULTS

Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41).

CONCLUSION

We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

Diagnostik des akuten und chronischen Beckenvenenverschlusses

Die akute Beckenvenenthrombose stellt ein dramatisches Krankheitsbild dar. Auf der einen Seite geht sie mit einem hohen Risiko für eine lebensbedrohliche Lungenembolie einher, auf der anderen Seite kann sie die Entwicklung einer Phlegmasia coerulea dolens bewirken, welche zum Verlust der betroffenen Extremität führen kann und ebenfalls eine vital bedrohliche Komplikation darstellt. Neben konservativen Behandlungsansätzen wie Kompressionstherapie und Antikoagulation stehen eine Reihe interventioneller Optionen zur Verfügung, welche darauf abzielen, fatale Krankheitsverläufe zu verhindern und auch die Ausprägung eines postthrombotischen Syndroms zu begrenzen.

Die Prognose der Erkrankung hängt maßgeblich von der frühzeitigen sicheren Diagnosestellung ab. Sowohl in der akuten Krankheitsphase, als auch im chronischen Stadium nimmt die Duplexsonographie die Schlüsselrolle ein. Sie gibt Aufschluss über die Pathomorphologie der Becken- und Beinvenen und liefert zusätzlich hämodynamische Informationen.

Im Gegensatz zur sonographischen Befundung der tiefen und epifaszialen Beinvenen ist zur Exploration der proximalen Gefäßabschnitte neben dem Einsatz einer Linearsonde auch die Untersuchung mittels Konvexsonde erforderlich und die eingeschränkte Auflösung in der Tiefe des kleinen Beckens macht einen subtilen Umgang mit den Einstellungen des Ultraschallgerätes nötig.

Im Rahmen der Behandlung postthrombotischer Veränderungen der Beckenvenen können radiologische und funktionsdiagnostische Methoden zusätzliche Informationen liefern.

[The interdisciplinary Microsurgeon - Results of the Consensus Workshop of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels]

Plastic and reconstructive surgery is characterized by a high degree of interdisciplinarity. Although Plastic surgery offers a wide range of reliable surgical treatment options independent departments for plastic and reconstructive surgery are not present in every university clinic or leading hospital in Germany. However, the ongoing improvements especially in the field of reconstructive microsurgery enabled and enhanced the treatment of complex defects in order to restore function as well as cosmetic outcome. Knowing the fact that patients are usually referred from other medical disciplines that are familiar with the development and treatment of the primary disease, creation of an interdisciplinary reconstructive treatment plan is crucial to guarantee best patient care. Thus, one of the future major challenges in plastic surgery will be the establishment of multidisciplinary boards in order to strengthen the role of plastic surgery within the medical system with the overall aim to solve complex reconstructive cases. During the 39^th annual meeting of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels a workshop titled "The interdisciplinary microsurgeon" addressed this topic. In the present article we will highlight the consented results of the workshop and provide pitfalls and pearls concerning the implementation process of different multidisciplinary boards based on representative examples.

Laminin 332-Dependent YAP Dysregulation Depletes Epidermal Stem Cells in Junctional Epidermolysis Bullosa

Laminin 332-deficient junctional epidermolysis bullosa (JEB) is a severe genetic skin disease. JEB is marked by epidermal stem cell depletion, the origin of which is unknown. We show that dysregulation of the YAP and TAZ pathway underpins such stem cell depletion. Laminin 332-mediated YAP activity sustains human epidermal stem cells, detected as holoclones. Ablation of YAP selectively depletes holoclones, while enforced YAP blocks conversion of stem cells into progenitors and indefinitely extends the keratinocyte lifespan. YAP is dramatically decreased in JEB keratinocytes, which contain only phosphorylated, inactive YAP. In normal keratinocytes, laminin 332 and α6β4 ablation abolish YAP activity and recapitulate the JEB phenotype. In JEB keratinocytes, laminin 332-gene therapy rescues YAP activity and epidermal stem cells in vitro and in vivo. In JEB cells, enforced YAP recapitulates laminin 332-gene therapy, thus uncoupling adhesion from proliferation in epidermal stem cells. This work has important clinical implication for ex vivo gene therapy of JEB.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2017/2018]

INTRODUCTION

This report serves to publicize the research of academic institutions for Plastic Surgery within our society DGPRÄC in 2017/2018 and sequels the funding report of 2015/2016. Applications to public, non-public, or industrial funding organizations were evaluated. At the same time, this paper analyses the number of approved DFG applications in Plastic, Thoracic and Vascular Surgery in the GEPRIS system. Contrary to these specialties, Plastic Surgery is not classified as an independent speciality in the subject structure of the DFG review board which results in a lack of transparency concerning Plastic Surgery research work.

MATERIALS AND METHODS

Our previously established online database (https://docs.google.com/forms/d/1OaSnHyKTysawiI1ie7kfUxDf7nJP_RiTUJTsnb7Mq_E/edit) for reporting requested/ approved and rejected research applications to public, non-public and industrial funding organizations was continued and evaluated together with applications found in the DFG's public database GEPRIS.

RESULTS

Compared to the previous year's report, the number of approved applications from public research organizations (DFG, BMBF, BMWi, EU) was increased from 23 to 27. We identified 19 approved DFG applications from Plastic Surgery, as compared to 9 and 8 applications by Thoracic and Vascular Surgery, respectively.

SUMMARY

Taken together, this data emphasizes that our research is at least equal to that of other newly established surgical specialties within the framework of the DFG. Accordingly, we hope to provide further arguments for an adaptation of the DFG review boards subject structure to include Plastic Surgery as an independent specialty as it is for Vascular Surgery and Thoracic Surgery.

Vascular trauma of the hand - a systematic review

Hypothenar or thenar hammer syndrome (HHS) and hand-arm vibration syndrome (HAVS) are diseases caused by acute or chronic trauma to the upper extremities. Since both diseases are generally related to occupation and are recognised as occupational diseases in most countries, vascular physicians need to be able to distinguish between the two entities and differentiate them from other diagnoses. A total of 867 articles were identified as part of an Internet search on PubMed and in non-listed occupational journals. For the analysis we included 119 entries on HHS as well as 101 papers on HAVS. A professional history and a job analysis were key components when surveying the patient's medical history. The Doppler-Allen test, duplex sonography and optical acral pulse oscillometry were suitable for finding an objective basis for the clinical tests. In the case of HHS, digital subtraction angiography was used to confirm the diagnosis and plan treatment. Radiological tomographic techniques provided very limited information distal to the wrist. The vascular component of HAVS proved to be strongly dependent on temperature and had to be differentiated from the various other causes of secondary Raynaud's phenomenon. The disease was medicated with anticoagulants and vasoactive substances. If these were not effective, a bypass was performed in addition to various endovascular interventions, especially in the case of HHS. Despite the relatively large number of people exposed, trauma-induced circulatory disorders of the hands can be observed in a comparatively small number of cases. For the diagnosis of HHS, the morphological detection of vascular lesions through imaging is essential since the disorder can be accompanied by critical limb ischaemia, which may require bypass surgery. In the case of HAVS, vascular and sensoneurological pathologies must be objectified through provocation tests. The main therapeutic approach to HAVS is preventing exposure.

[Focus on the Hand - an Interface Between Surgery and Vascular Medicine]

Damage to the hand caused by vibration has been observed with a range of trades and professions and in connection with various types of sport. Osseous, neurogenic and vascular lesions can lead to chronic ailments and permanent functional impairment. Hand-arm vibration syndrome (HAVS) and hypothenar/thenar hammer syndrome (HHS, THS) are interesting for vascular medicine. From a surgical perspective, there is a special significance in the fact that both syndromes are recognised occupational diseases (BK 2104 and BK 2114) which have to be acknowledged by an accident insurance doctor and in the medical report. Hypothenar/thenar hammer syndrome is caused by repeated force exerted in the region of the small finger or the ball of the thumb and is characterised by a trauma-induced lesion of the ulnar artery or radial artery that can lead to pain due to ischaemia in the acral area supplying blood to the arteries of the affected hand, usually the dominant hand. It is considered to be hand-arm vibration syndrome when there is a heightened sensitivity to coldness with vasospastic circulatory disturbance. The paper presents various clinical and functional diagnostic tests to enable a diagnosis. Doppler and duplex ultrasound exploration play an important role. Various radiological methods can augment diagnostic testing. The symptoms can be treated using medication or physiotherapy to improve perfusion by stimulating vasodilatation. An effective causal therapy is currently not available. Thus, when drawing up the medical report, particular attention should be paid to gathering information about the patient's medical history so that an unequivocal link can be made between the cause of the damage and the physical damage, as this could have sociomedical and pension-relevant consequences for the patient.

[Colour duplex sonography and "Power-Duplex" in Perforator Surgery - Improvement of patients safety by efficient planning]

INTRODUCTION

There are many techniques to identify vessels in perforator surgery, each with specific disadvantages. Handheld Dopplers are easy to use, but inaccurate with respect to the exact localisation of the perforator. Angio-CT is invasive, time consuming, and expensive. In contrast, duplex sonography is a reliable, easy-to-use and availabe alternative for pre-, intra-, and postoperative visualisation of vessels. Power Doppler further increases sensitivity and allows visualisation of vessels smaller than 0.5 mm in diameter.

MATERIAL AND METHODS

The use of duplex sonography and power Doppler in preoperative planning is illustrated in photographs that show how to identify the course of the septal vessel in free ALT flaps, to ensure that there are competent recipient vessels and to plan pedicled perforator flaps. In all 33 free flaps (21 ALT, 5 DIEAP, 4 FCI, 2 MSAP, 1 tib. post. perf. flap) for lower leg and breast reconstruction and 19 pedicled perforator flaps at the trunk and the extremities were harvested with this technique and used to cover post traumatic and tumour defects.

RESULTS

The detection accuracy of duplex sonography was 100 % with reference to the perforator being found within 0.5 cm of the duplexed point and the correct detection of the vessel course (septal vs. intramuscular). No flap loss was observed in this series. This is a non-invasive, reliable, and inexpensive, but time consuming and investigator-dependent technique.

DISCUSSION

By direct visualisation of the arteries and veins, the exact localisation of fascia penetration can be detected and flaps can then be better designed. Perforators can be centred in the flaps. The course of perforators can be visualised - especially in ALT flaps - and time consuming dissections through muscle can be avoided.

Methacrylated gelatin/hyaluronan-based hydrogels for soft tissue engineering

In vitro–generated soft tissue could provide alternate therapies for soft tissue defects. The aim of this study was to evaluate methacrylated gelatin/hyaluronan as scaffolds for soft tissue engineering and their interaction with human adipose–derived stem cells (hASCs). ASCs were incorporated into methacrylated gelatin/hyaluronan hydrogels. The gels were photocrosslinked with a lithium phenyl-2,4,6-trimethylbenzoylphosphinate photoinitiator and analyzed for cell viability and adipogenic differentiation of ASCs over a period of 30 days. Additionally, an angiogenesis assay was performed to assess their angiogenic potential. After 24 h, ASCs showed increased viability on composite hydrogels. These results were consistent over 21 days of culture. By induction of adipogenic differentiation, the mature adipocytes were observed after 7 days of culture, their number significantly increased until day 28 as well as expression of fatty acid binding protein 4 and adiponectin. Our scaffolds are promising as building blocks for adipose tissue engineering and allowed long viability, proliferation, and differentiation of ASCs.

Regeneration of the entire human epidermis using transgenic stem cells

Junctional epidermolysis bullosa (JEB) is a severe and often lethal genetic disease caused by mutations in genes encoding the basement membrane component laminin-332. Surviving patients with JEB develop chronic wounds to the skin and mucosa, which impair their quality of life and lead to skin cancer. Here we show that autologous transgenic keratinocyte cultures regenerated an entire, fully functional epidermis on a seven-year-old child suffering from a devastating, life-threatening form of JEB. The proviral integration pattern was maintained in vivo and epidermal renewal did not cause any clonal selection. Clonal tracing showed that the human epidermis is sustained not by equipotent progenitors, but by a limited number of long-lived stem cells, detected as holoclones, that can extensively self-renew in vitro and in vivo and produce progenitors that replenish terminally differentiated keratinocytes. This study provides a blueprint that can be applied to other stem cell-mediated combined ex vivo cell and gene therapies.

Effect of surgical margins on prognosis in aggressive fibromatosis: A single-institutional analysis of 90 patients

The treatment of aggressive fibromatosis poses a therapeutic challenge in an interdisciplinary setting. The extent of surgical resection is still discussed controversially. The present retrospective analysis aimed to determine prognostic factors leading to recurrence. Between 2000 and 2014, 114 patients with aggressive fibromatosis were treated surgically at BG-University Hospital Bergmannsheil (Bochum, Germany). Univariate and multivariate analyses were restricted to 90 participants with information available on surgical margins at the initial procedure. The median follow-up time was 7.7 years. A total of 45 patients (50%) developed recurrence during follow-up. Primary tumors were resected with negative margins (R0) in 50 patients (68%) and with microscopically positive margins (R1) in 28 patients (25%). In addition, tumors in 12 patients (7%) were resected with macroscopically positive margins at the initial surgical procedure. The rates of recurrence-free survival (RFS) after 5 years were 68.8% [95% confidence interval (CI), 53.5–79.9%] in patients with R0-resected primary tumors and 34.1% (95% CI, 19.9–48.9%) in patients with R1/R2-status (P=0.001). Narrow and wide clear margins within the R0-group were not associated with significantly different outcomes. Adjuvant radiation, tumor site and patient age were not associated with a significant alteration of RFS. The current results suggest that the attainment of microscopically negative surgical margins at the initial surgical treatment is associated with a significantly improved prognosis. A conservative surgical approach involving the attainment of narrow negative margins while preserving function should be sought in patients in whom tumor resection is indicated. The decision for resection should be made interdisciplinary in each case based on tumor progression, available treatment alternatives and the decision of the informed patient.

[Radiation-induced angiosarcoma of the breast]

Background Radiation-induced angiosarcomas of the breast are rare secondary malignancies that occur after adjuvant radiation of breast cancer. They grow in a multifocal manner and frequently develop local recurrences. Therefore, they often pose a surgical challenge. Due to their rarity it is still unclear whether a radical surgical approach leads to a beneficial outcome. The aim of this study was to determine the prognostic significance of surgical margins. Patients and methods We retrospectively assessed the outcome of 18 patients who underwent surgical treatment at our institution. The median follow-up was 4.4 years. Univariate analyses were performed to determine the prognostic significance of the assessed factors on local recurrence-free survival (LRFS) and overall survival (OS). Results The median patient age was 66.3 years. The median latency between radiation and angiosarcoma occurrence was 6.9 years. The estimated 5-year rates for LRFS and OS were 25.0% (95% confidence interval [CI]: 7.8-47.2) and 53.8% (95% CI: 26.8-74.8). R0 resection of the primary lesion was associated with a significant improvement in LRFS (p=0.017) and OS (p=0.013). Moreover, R0 resection of the last local recurrence was also associated with a more favourable OS (p=0.040). Conclusions Due to their aggressive growth pattern and pronounced tendency to local recurrence, a radical surgical approach should be sought in the treatment of radiation-induced angiosarcomas. Wherever feasible, surgical treatment should aim at R0 margins in order to improve local control and OS.

Excitation power dependent population pathways and absolute quantum yields of upconversion nanoparticles in different solvents

The rational design of brighter upconversion nanoparticles (UCNPs) requires a better understanding of the radiationless deactivation pathways in these materials. Here, we demonstrate the potential of excitation power density (P)-dependent studies of upconversion (UC) luminescence intensities, slope factors, and absolute quantum yields (Φ_UC) of popular β-NaYF₄:20% Yb³⁺,2% Er³⁺ UCNPs of different surface chemistries in organic solvents, D₂O, and water as a tool to gain deeper insight into the UC mechanism including population and deactivation pathways particularly of the red emission. Our measurements, covering a P regime of three orders of magnitude, reveal a strong difference of the P-dependence of the ratio of the green and red luminescence bands (I_g/r) in water and organic solvents and P-dependent population pathways of the different emissive energy levels of Er³⁺. In summary, we provide experimental evidence for three photon processes in UCNPs, particularly for the red emission. Moreover, we demonstrate changes in the excited population dynamics via bi- and triphotonic processes dependent on the environment, surface chemistry, and P, and validate our findings theoretically.