Wundbeurteilung durch verschiedene Kollektive im Vergleich zu einem digitalen kolorimetrischen System

Die Dokumentation chronischer Wunden wird aktuell von unterschiedlichen Berufsgruppen mit z. T. erheblichen Wissensunterschieden durchgeführt. Das Ziel unserer Untersuchung war es, die Beurteilung von 12 verschiedenen Bildern von Ulcera crurum durch fünf unterschiedlich vorgebildete Untersuchergruppen zu vergleichen. Material und Methoden: Die Probanden der Untersuchergruppen Experten, Ärzte, ambulante Pflegedienste, stationäre Pflege und Laien sollten alle relevanten Parameter der Wundbeurteilung einschätzen. Als objektive Referenz kam ein neu entwickeltes und von uns erstmalig klinisch eingesetztes digitales kolorimetrisches Wunddokumentationssystem zum Einsatz. Die Ergebnisse unserer Untersuchung belegen, dass die Beurteilung verschiedener Parameter der Wundheilung durch unterschiedlich vorgebildete Untersucher mit erheblichen Unterschieden erfolgt. Insgesamt fand sich eine unerwartet hohe Abweichung der digital berechneten Werte im Vergleich zu den von den Untersuchergruppen geschätzten, mit Abweichungen von teilweise über 100% bei der Wundoberfläche sowie den einzelnen Wundbestandteilen. Als erfahrungsabhängige Parameter zeigten sich hingegen Länge, Breite, Oberfläche, Infektion sowie das Wundstadium. Schlussfolgerung: Eine suffiziente, reliable und adäquate Wunddokumentation ist ohne technische Hilfsmittel (z. B. digitale Fotodokumentation) unmöglich.

[Malnutrition in patients with leg ulcers. Results of a clinical trial]

Chronic wounds occur in 1-2% of the population. After the age of 80 the incidence raises up to 4-5%. Leg ulcers are the most frequent diagnosed chronic wound. In this most often affected age group malnutrition develops more frequently compared to the total population. The combined presence of chronic wounds and malnutrition suggests a potential causative connection. In this clinical investigation, data evaluating the nutritional status in patients with chronic leg ulcers, derived from clinical examination, medical history and laboratory tests was analyzed for the first time for a German patient collective. Over a time period of one year we evaluated 41 patients for body mass index, diabetes mellitus, restricted mobility, diet, nicotine and alcohol use, and blood levels of vitamins, trace elements, lipids and HbA1c. We further employed the MNA-questionnaire for malnutrition. We rarely found deficiencies but often improper nutritional practices. Thus we consider that it important to evaluate nutritional status even in obese patients with leg ulcers and poorly healing wounds.

[Successful therapy of ulcerated necrobiosis lipoidica non diabeticorum with cyclosporine A]

Necrobiosis lipoidica is an inflammatory granulomatous skin disease of unknown etiology which is associated with diabetes mellitus in about 60% of the patients. In 15-35% of the affected patients painful ulcerations may occur after minimal trauma which can be extremely refractory to therapy. Because of the unknown pathomechanisms, current therapeutic options are limited. We report on a 68-year-old patient with an 18 year history of ulcerated necrobiosis lipoidica non diabeticorum of both lower limbs, which responded to systemic cyclosporine A. Based on this case, we discuss the role of cyclosporine A in patients with necrobiosis lipoidica in the context of the disease etiology.

[Successful therapy of a rheumatoid leg ulcer with intravenous immunoglobulins]

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease. Leg ulcers in rheumatoid arthritis may be caused by vasculitis and are an interdisciplinary therapeutic challenge. A 69 year old women with rheumatoid arthritis and many other medical problems presented with widespread vasculitis-induced therapy-resistant ulceration on her right lower leg. Since previous therapeutic efforts had a negative effect on wound healing, we administered intravenous immunoglobulins which led to complete healing of the ulcer was achieved. Both the serological and rheumatologic features of her rheumatoid arthritis also improved. Intravenous immunoglobulins represented an effective therapeutic option with fewer side effects in the therapy of vasculitis-induced leg ulceration in this patient with rheumatoid arthritis.

Vaskulitische Ulcera cruris bei primärem Sjögren-Syndrom

Sjögren syndrome is a rare chronic systemic autoimmune disease characterized by progressive dryness of the mucous membranes. There are many variable clinical manifestations. A 40-year-old woman presented with painful leg ulcers refractory to various therapies. She had a history of xerostomia and xerophthalmia for several years. Based on clinical, serologic and histopathologic findings, we diagnosed leg ulcers in primary Sjögren syndrome. Combing immunosuppressive therapy with phase-adapted modern wound-therapy resulted in a complete healing of the ulcers. In the case of clinically atypical leg ulcers, Sjögren syndrome should be considered as a rare differential diagnostic possibility.

Ulcus bei AV-Fisteln im Rahmen eines Stewart-Bluefarb-Syndroms: Therapie der Arterien und/oder Venen?

Wir berichten über eine 46-jährige Patientin mit einem seit 2 Jahren bestehenden, therapieresistenten Ulcus am rechten Fußrücken bei kongenitaler komplexer AV-Fistel. Bereits vor 12 Jahren hatte sich in der gleichen Lokalisation erstmals ein Ulcus entwickelt. Eine Coil-Embolisation führte trotz unvollständiger Okklusion der AV-Fistel zu einer Abheilung über einen Zeitraum von 10 Jahren. Aktuell imponierte um das Ulcus eine Hyperpigmentierung im Sinne eines klinischen Hinweises auf eine venöse Insuffizienz. Durch eine ausschließlich konservative Therapie der venösen Komponente der AV-Fistel konnte eine vollständige Abheilung des Ulcus erzielt werden. Wir diskutieren anhand dieses Fallberichtes die unterschiedlichen Aspekte in der Entstehung und Therapie eines Ulcus bei AV-Fistel im Rahmen eines Stewart-Bluefarb-Syndroms.

[Skin and mucosal ulcerations in heparin-induced thrombocytopenia (HIT) II]

About 0.1-2% of patients receiving heparin develop heparin-induced thrombocytopenia type II (HIT II) which is caused by antibodies directed against heparin-platelet factor 4 (PF4) complexes. Activation of thrombocytes and endothelial cells can lead to thrombocytopenia, venous and arterial thrombosis or thromboembolic events 10-14 days after the first dose. HIT II has a high mortality rate because of pulmonary emboli, cerebrovascular accidents, myocardial and limb infarctions. A 55-year-old patient with HIT II presented with arterial and venous thromboses and a silent myocardial infarction. In addition, he showed extensive skin and mucosal necrosis, an uncommon complication. Rheologic therapy with danaparoid Natrium, alprostadil alfadex and acetylsalicylic acid in combination with percutaneous transluminal angioplasties as well as local and systemic antiinflammatory therapy prevented further progression of the disease.

Auftreten von Ulcera crurum in Zusammenhang mit der Einnahme von Anagrelid

ANAMNESIS AND CLINICAL FINDINGS

Extremely painful leg ulcers on the lateral aspect of both ankles developed in a 38-year-old man for the first time six weeks after starting treatment with anagrelide for thrombocythemia.

INVESTIGATIONS

Extensive diagnostic tests, including laboratory tests, Doppler and duplex ultrasound of the superficial and deep leg veins, histopathology and bacteriological and mycological tests excluded vascular disease, vasculitis and metabolic causes.

THERAPY AND COURSE

Despite adequate local treatment the ulcerations did not improve until anagrelide was discontinued and replaced by hydroxyurea.

CONCLUSION

Anagrelide administration was the most likely cause of the leg ulcerations, even though this possible side effect has only been described once in the literature.

Moderne Wundauflagen für die Therapie chronischer Wunden

The incidence of chronic wounds is increasing in developed Western countries. There are many causes for chronic or non-healing wounds. A multidisciplinary diagnostic approach and attention to underlying disorders are essential. A modern, moist, and phase adapted wound therapy is also essential. Modern wound dressings include activated charcoal, alginates, hyaluronic acid, hydrofibers, hydrogels, hydrocolloids, impregnated gauze, collagen, moist methods, proteolytic enzymes, foams, semipermeable membranes and silver dressings. Because of the lack of comparative investigations the phase-adapted use of wound dressings is still empiric. Application of modern wound dressings may help to create an optimized wound milieu and accelerate healing. Treatment of the underlying causes is an absolute requirement for long-term complete healing.