Update on the risk assessment of a rehabilitation stay for patients after allogeneic stem cell transplantation

OBJECTIVE

High-dose chemotherapy with allogeneic stem cell transplantation is the only chance of cure for many haemato-oncological patients. After such therapy, the immune system is weakened, and the contact with other people should therefore be limited as much as possible. The question arises whether a rehabilitation stay can be recommended to these patients, which risk factors for complications during the rehabilitation stay can be identified, and whether physicians and patients can be provided with decision-making aids as to when the optimal time is to start rehabilitation.

METHODS

We report about 161 rehabilitation stays of patients after high-dose chemotherapy with allogeneic stem cell transplantation. Premature discontinuation of the rehabilitation was selected as the criterion for a serious complication during the rehabilitation and the underlying reasons were analysed.

RESULTS

The rate of prematurely terminated rehabilitation stays (13.6%) corresponds to our previous result from 2020. The analysis of the reasons for early termination comes to the conclusion that the rehabilitation stay is only considered as a reason for termination in very few cases, if at all. The risk factors identified for premature termination of the rehabilitation stay were male sex, the period (days) between transplantation and the beginning of the rehabilitation stay, haemoglobin value, platelets and presence of immunosuppressing agent. The most significant risk factor is a decreased platelet count at the time rehabilitation begins. The platelet count, the likelihood that it will improve in the further course and the urgency of the rehabilitation stay can be used to help decide when the optimal time for rehabilitation is given.

CONCLUSION

Rehabilitation can be recommended to patients after allogeneic stem cell transplantation. Based on various factors, recommendations can be made for the right time for rehabilitation.

S1 Guideline onychomycosis

Onychomycosis is a fungal infection of the fingernails and toenails. In Europe, tinea unguium is mainly caused by dermatophytes. The diagnostic workup comprises microscopic examination, culture and/or molecular testing (nail scrapings). Local treatment with antifungal nail polish is recommended for mild or moderate nail infections. In case of moderate to severe onychomycosis, oral treatment is recommended (in the absence of contraindications). Treatment should consist of topical and systemic agents. The aim of this update of the German S1 guideline is to simplify the selection and implementation of appropriate diagnostics and treatment. The guideline was based on current international guidelines and the results of a literature review conducted by the experts of the guideline committee. This multidisciplinary committee consisted of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the Association of German Dermatologists (BVDD), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ), the Working Group for Pediatric Dermatology (APD) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guideline was approved by the participating medical societies following a comprehensive internal and external review.

Community-associated Methicillin-Resistant Staphylococcus aureus (ca-MRSA) as a Pandemic Pathogen: Risk Factors and Implications for Healthcare

Background A diversity of risk factors for ca-MRSA manifestations has been described so far. Up to date toxic contact dermatitis induced by plants has not been identified as one.

Patients and Methods After intense skin contact with poison ivy in the US a 24-year-old Afro-American showed pronounced bullous contact dermatitis on the back of the neck and subsequently massive ca-MRSA furunculitis with proof of Panton-Valentin-leukocidin (PVL). After travelling to Germany, his German girlfriend developed a subacute ca-MRSA, PVL-positive superinfection of a mosquito bite at her lower leg. Both infections required surgical intervention.

Results While the male patient displayed contact dermatitis by poison ivy, the female patient demonstrated two risk factors for ca-MRSA: contact with a ca-MRSA positive person and a predisposing skin lesion. Both cases underpin the role of ca-MRSA transmission and the potential severeness of wound infections in young and immunocompetent persons, just to be resolved by invasive intervention.

Conclusions Marked and recalcitrant skin or soft tissue infections in otherwise healthy young patients require instant microbiological analysis and surgical intervention flanked by adequate antibiotic therapy. Contact dermatitis induced by plant toxins should be taken into consideration as possible risk factor for the acquisition of ca-MRSA.

Translational development of ABCB5+ dermal mesenchymal stem cells for therapeutic induction of angiogenesis in non-healing diabetic foot ulcers

Background

While rapid healing of diabetic foot ulcers (DFUs) is highly desirable to avoid infections, amputations and life-threatening complications, DFUs often respond poorly to standard treatment. GMP-manufactured skin-derived ABCB5⁺ mesenchymal stem cells (MSCs) might provide a new adjunctive DFU treatment, based on their remarkable skin wound homing and engraftment potential, their ability to adaptively respond to inflammatory signals, and their wound healing-promoting efficacy in mouse wound models and human chronic venous ulcers.

Methods

The angiogenic potential of ABCB5⁺ MSCs was characterized with respect to angiogenic factor expression at the mRNA and protein level, in vitro endothelial trans-differentiation and tube formation potential, and perfusion-restoring capacity in a mouse hindlimb ischemia model. Finally, the efficacy and safety of ABCB5⁺ MSCs for topical adjunctive treatment of chronic, standard therapy-refractory, neuropathic plantar DFUs were assessed in an open-label single-arm clinical trial.

Results

Hypoxic incubation of ABCB5⁺ MSCs led to posttranslational stabilization of the hypoxia-inducible transcription factor 1α (HIF-1α) and upregulation of HIF-1α mRNA levels. HIF-1α pathway activation was accompanied by upregulation of vascular endothelial growth factor (VEGF) transcription and increase in VEGF protein secretion. Upon culture in growth factor-supplemented medium, ABCB5⁺ MSCs expressed the endothelial-lineage marker CD31, and after seeding on gel matrix, ABCB5⁺ MSCs demonstrated formation of capillary-like structures comparable with human umbilical vein endothelial cells. Intramuscularly injected ABCB5⁺ MSCs to mice with surgically induced hindlimb ischemia accelerated perfusion recovery as measured by laser Doppler blood perfusion imaging and enhanced capillary proliferation and vascularization in the ischemic muscles. Adjunctive topical application of ABCB5⁺ MSCs onto therapy-refractory DFUs elicited median wound surface area reductions from baseline of 59% (full analysis set, n = 23), 64% (per-protocol set, n = 20) and 67% (subgroup of responders, n = 17) at week 12, while no treatment-related adverse events were observed.

Conclusions

The present observations identify GMP-manufactured ABCB5⁺ dermal MSCs as a potential, safe candidate for adjunctive therapy of otherwise incurable DFUs and justify the conduct of a larger, randomized controlled trial to validate the clinical efficacy.

Trial registration: ClinicalTrials.gov, NCT03267784, Registered 30 August 2017, https://clinicaltrials.gov/ct2/show/NCT03267784

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-03156-9.

Sexuell übertragbare Infektionen (STDs) und Prävention

Auch im Lichte aktueller, infektionsimmunologischer Erkenntnisse über Entstehung und Behandlung spielen im Zeitalter der modernen Therapien einschließlich Antisepsis und Antibiotika sexuell übertragbare Erkrankungen nach wie vor, und speziell für bestimmte Risikogruppen, eine bedeutende Rolle. Die grundsätzliche Behandelbarkeit lange Zeit tödlich verlaufender Infektionen wie AIDS hat andererseits sogar vielfach zu vermehrter Sorglosigkeit geführt, wodurch nicht nur die HIV-Infektion und häufig ko-akquirierte Infektionen wie Syphilis nach wie vor wichtige Infektionskrankheiten auch in entwickelten Ländern darstellen, sondern grundsätzlich viele eindämmbare Erkrankungen z.T. auch wieder vermehrt auftreten und entsprechende Probleme bereiten. Daher ist und bleibt es unumgänglich, dass sich Ärzte und sexualmedizinisches Personal ständig auch über die Möglichkeiten der Übertragung wie der Prävention sexuell übertragbarer Krankheiten auf dem Laufenden halten.

Hygiene in der Dermatologie: SARS-CoV-2 und weitere Virus-Varianten

Die COVID-19-Pandemie hat weltweit erhebliche Beeinträchtigungen des Lebens und Arbeitens mit sich gebracht. Mit dem Beginn der Impfungen steigt die Hoffnung auf eine Kehrtwende. Dennoch sind COVID- und Intensivstationen in den Kliniken nach wie vor erheblich belastet. Häufig muss in den Kliniken aus Kapazitätsgründen auch dermatologisches Fachpersonal zur Betreuung von COVID-19-Patienten herangezogen werden. Dies führte dazu, dass im Verlauf der Pandemie dermatologische Manifestationen von COVID-19 erkannt und näher klassifiziert werden konnten. Differenzierte Hygienekonzepte, insbesondere die der Händehygiene, bringen jedoch ein weiteres, mit der Pandemie-assoziiertes dermatologisches Problem zum Vorschein: die Ausbildung von Handekzemen. Dies ist nicht nur auf medizinische Berufe beschränkt und zeigt daher eine mögliche übergeordnete Bedeutung der Dermatologie im Rahmen von zukünftigen Pandemiestrategien.

Hygiene in der Dermatologie – Teil 1: Einführung und Umgebungshygiene

Dermatologie-typische Abläufe in der Patientenversorgung werden in dieser Arbeit im Hinblick auf mögliche Hygienerisiken dargestellt. Das potenziell kontaminierte Oberflächenorgan Haut und seine Umgebung stellen in der medizinischen Versorgung in Bezug auf den intensiven, längeren und großflächigen Kontakt, der mit hautärztlichen und pflegerischen Maßnahmen einhergeht, eine Herausforderung dar.

Hygiene in der Dermatologie – Teil 2: Kommensalen und Infektionserreger, antimikrobielle Behandlung, Hygieneaspekte ausgewählter Infektionskrankheiten

In diesem Beitrag werden Kommensalen und relevante Infektionserreger des dermatologischen Patienten wie auch seiner Umgebung systematisch dargestellt und im Hinblick auf die krankenhaushygienische Bedeutung eingeordnet. Auf der antimikrobiellen Behandlung sowie Hygiene-Maßnahmen ausgewählter dermatologischer Erkrankungen liegt ein weiterer Fokus.

Methicillin-resistenter Staphylococcus aureus (MRSA) – eine zentrale Hygiene-Herausforderung in der Dermatologie

Der Methicillin-resistente Staphylococcus aureus ist ein im täglichen Alltag insbesondere für den Bereich der Dermatologie relevanter multiresistenter gram-positiver bakterieller Erreger. Chronische Wunden und atopische Dermatitis sowie der Typ II-Diabetes mellitus spielen hier als Risikofaktoren eine wichtige Rolle. Dieser Übersichtsartikel fokussiert sich neben Ausführungen zu Bedeutung und klinischem Vorkommen auf eine zusammenfassende Darstellung der Hygieneaspekte bei der Behandlung von MRSA-besiedelten oder -infizierten Patienten. Ziel einer solchen Behandlung mit etablierten Hygienekonzepten ist es, eine mögliche Verbreitung des multiresistenten Erregers von einem Patienten auf andere Personen zu verhindern. Werden diese Hygiene-Maßnahmen umgesetzt und gleichzeitig bei einer Infektion eine evidenzbasierte, nach dem Antibiotic-Stewardship ausgerichtete antibiotische Therapie initiiert, sind dies zwei wesentliche Bausteine, um auch weiterhin, wie in den letzten Jahren schon in Nord- und Mitteleuropa beobachtet, rückläufige MRSA-Prävalenzen zu erzielen.

Allogeneic ABCB5+ mesenchymal stem cells for treatment-refractory chronic venous ulcers: a phase I/IIa clinical trial

A significant number of chronic venous ulcers (CVUs) fail to heal despite of guideline-conform standard of care. Skin-derived ABCB5+ mesenchymal stem cells (MSCs) can dampen the sustained IL-1β-driven inflammation present in chronic wounds. Based on their wound healing-facilitating effects in a mouse CVU model and an autologous first-in-human study, ABCB5+ MSCs have emerged as a potential candidate for cell-based advanced therapy of non-healing CVUs. In the present interventional, multicenter, single-arm, phase I/IIa clinical trial, subjects whose CVU had emerged as standard therapy-resistant received one or two topical applications of 1×106 allogeneic ABCB5+ MSCs/cm2 wound area in addition to standard treatment. Out of 83 treatment-emergent adverse events, only three were judged related to the cell product; they were mild or moderate and recovered without sequelae. Wound size markedly decreased from baseline to week 12, resulting in a median wound size reduction of 76% (full analysis set, N=31), 78% (per-protocol set, N=27) and 87% (subset of responders; n=21). In conclusion, the study treatment was well tolerated and safe. The treatment elicited a profound wound size reduction within 12 weeks, identifying ABCB5+ MSCs as a potential candidate for adjunctive therapy of otherwise incurable CVUs. These results justify the conduct of a larger, randomized, controlled trial to confirm clinical efficacy.

Effects of cold physical plasma on oral lichen planus: An in vitro study (Effects of CAP on OLP)

OBJECTIVES

In the search for more effective and safe treatment avenues, we investigated cold physical plasma as a new treatment modality for therapy of oral lichen planus (OLP).

MATERIAL AND METHODS

Healthy and diseased human mucosal tissue samples with a size of 3 mm in diameter obtained from OLP patients were subjected to plasma treatment ex vivo or were left untreated. Tissue sections were quantified for immune-infiltration of CD4+ , CD8+ , CD45RA+ , and CD45R0+ T cells. Moreover, the tissues' inflammatory profile was assessed by analyzing 12 different cytokines in the surrounding media.

RESULTS

A significantly increased infiltrate of CD8+ and CD45-R0+ T cells was detected in OLP tissue samples when compared to healthy tissue. A higher concentration of interleukin (IL) 1β, IL6, IL8, and granulocyte macrophage-colony stimulating factor (GM-CMF) was detected in OLP samples compared to healthy mucosal tissue. For all cytokines and chemokines investigated, 23 out of 24 comparisons showed a decrease in tendency (significant for IL1β, IL2, IL10, and GM-CSF) in response to plasma treatment. In ex vivo-treated tissue, a decrease of T-cell infiltrate in OLP lesions compared with healthy tissue was observed.

CONCLUSION

Our findings suggest cold physical plasma can be a promising therapeutic option for OLP that requires further validation in vivo.

Staphylococcus aureus nasal colonization among dental health care workers in Northern Germany (StaphDent study)

Methicillin-resistant Staphylococcus aureus (MRSA) can colonize dental patients and students, however, studies on the prevalence of MRSA and methicillin-susceptible S. aureus (MSSA) among dental health care workers (DHCW) including use of personal protective equipment (PPE) are scarce. We conducted an observational study (StaphDent study) to (I) determine the prevalence of MRSA and MSSA colonization in DHCW in the region of Mecklenburg Western-Pomerania, Germany, (II) resolve the S. aureus population structure to gain hints on possible transmission events between co-workers, and (III) clarify use of PPE. Nasal swabs were obtained from dentists (n = 149), dental assistants (n = 297) and other dental practice staff (n = 38). Clonal relatedness of MSSA isolates was investigated using spa typing and, in some cases, whole genome sequencing (WGS). PPE use was assessed by questionnaire. While 22.3% (108/485) of the participants were colonized with MSSA, MRSA was not detected. MSSA prevalence was not associated with size of dental practices, gender, age, or duration of employment. The identified 61 spa types grouped into 17 clonal complexes and four sequence types. Most spa types (n = 47) were identified only once. In ten dental practices one spa type occurred twice. WGS data analysis confirmed a close clonal relationship for 4/10 isolate pairs. PPE was regularly used by most dentists and assistants. To conclude, the failure to recover MRSA from DHCW reflects the low MRSA prevalence in this region. Widespread PPE use suggests adherence to routine hygiene protocols. Compared to other regional HCW MRSA rates the consequent usage of PPE seems to be protective.

Comparison of the antimicrobial efficacy of povidone-iodine-alcohol versus chlorhexidine-alcohol for surgical skin preparation on the aerobic and anaerobic skin flora of the shoulder region

Background

Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery. We hypothesized that prolonged skin preparation with an agent that penetrates deeply into the skin would be beneficial. Thus, we compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times.

Methods

Using a cross-over arrangement, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC) or alcohol-based povidone-iodine (PVP-I-ALC). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique.

Results

Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55 ± 0.75 vs. 1.94 ± 0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 4 of 32 samples after CHG-ALC application. Anaerobic flora was reduced more effectively by PVP-I-ALC than CHG-ALC after standard (RF 3.96 ± 1.46 vs. 1.74 ± 1.24, p < 0.01) and prolonged (RF 3.14 ± 1.20 vs. 1.38 ± 1.16, p < 0.01) contact times and immediate sampling, but not after 3-h sampling. No adverse events were reported.

Conclusions

PVP-I-ALC showed marginal benefits concerning the aerobic flora, but more substantial benefits over CHG-ALC concerning the anaerobic flora of the shoulder. Standard and prolonged contact times showed superiority for PVP-I-ALC for anaerobic flora at all immediate sampling points, but missed significance at 3-h sampling. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.

S1 guidelines: Tinea capitis

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Detecting Bacteria on Wounds with Hyperspectral Imaging in Fluorescence Mode

Chronic non-healing wounds represent an increasing problem. In order to enable physicians and nurses to make evidence based decisions on wound treatment, the professional societies call for supporting tools to be offered to physicians. Oxygen supply, bacteria colonization and other parameters influence the healing process. So far, these parameters cannot be monitored in an objective and routinely manner. Existing methods like the microbiological analysis of wound swabs, mean a great deal of effort and partly a long delay. In this paper 42 fluorescence images from 42 patients with diabetic foot ulcer, recorded with a hyperspectral imaging system (TIVITA®), converted for fluorescence imaging, were analysed. Beside the fluorescence images, information about the bacterial colonization is available from microbiological analysis of wound swabs. After preprocessing, principal component analysis, PCA, is used for data analysis with a 405 nm excitation wavelength, the emission wavelength range 510 - 745 nm is used for analysis. After dividing the data into a training and a test dataset it could be shown, that bacteria are detectable in the wound area. A quantification in bacterial colonization counts (BCC) was not in the focus of the research in this study stage.

Results of a randomised controlled trial between an ORC collagen hemostatic agent and a carrier-bound fibrin sealant

INTRODUCTION

Despite ongoing optimisation of surgical techniques, hemostasis continues to be a fundamental challenge in many operations today. This randomised controlled trial compared the efficacy of a new hemostatic agent made of oxidised regenerated cellulose and collagen (ORC-Coll) with that of a conventional carrier-bound fibrin sealant (CBFS).

METHODS

Hemostasis was investigated representatively in the case of post-thyroidectomy bleeding from the resection surface. To demonstrate that ORC-Coll (mediCipio® A) has at least the same hemostatic efficacy as CBFS (Tachosil®), the volume of drainage fluid at the time of drain removal was used as the primary endpoint in a non-inferiority test with a significance level of 5%. The secondary endpoints included number and size of hemostatic agents required, adhesion of the hemostatic agent to the bleeding surface, intraoperative hemostatic effect, duration of drainage and adverse events during a six-month follow-up period.

RESULTS

A total of 150 patients (ORC-Coll: 75; CBFS: 75) were included. After operation, total volume of drainage fluid was 68.20±44.56mL in the ORC group and 68.21±40.20mL in the CBFS group. The non-inferiority of ORC-Coll compared to CBFS with regard to hemostatic efficacy was shown at a significance level of 5%. The results demonstrated effectiveness in achieving hemostasis without adverse events.

CONCLUSIONS

ORC-Coll is an effective hemostatic agent and barrier sealant without blood components, which ensures reliable prevention of intra- and postoperative bleeding. With use of the new technique, any risks associated with the use of human blood components are a priori eliminated.

3D-perfusion analysis of burn wounds using hyperspectral imaging

BACKGROUND

Determination of the depth of burn wounds is still a challenge in clinical practise and fundamental for an optimal treatment. Hyperspectral imaging (HSI) has a high potential to be established as a new contact-free measuring method in medicine. From hyperspectral spectra 3D-perfusion parameters can be estimated and the microcirculatory of burn wounds over the first 72h after thermal injury can be objectively described.

METHODS

We used a hyperspectral imaging camera and extended data processing methods to calculate 3D-perfusion parameters of burn wounds from adult patients. The data processing results in the estimation of perfusion parameters like volume fraction and oxygenation of haemoglobin for 6 different layers of the injured skin. The parameters are presented as depth profiles. We analyzed and compared measurements of wounds of different degrees of damage and present the methodology and preliminary results.

RESULTS

The depth profiles of the perfusion parameters show characteristic features and differences depending on the degree of damage. With Hyperspectral Imaging and the advanced data processing the perfusion characteristics of burn wounds can be visualized in more detail. Based on the analysis of this perfusion characteristics, a new and better reliable classification of burn degrees can be developed supporting the surgeon in the early selection of the optimal treatment.

Long-term Risk Assessment for Medical Application of Cold Atmospheric Pressure Plasma

Despite increasing knowledge gained based on multidisciplinary research, plasma medicine still raises various questions regarding specific effects as well as potential risks. With regard to significant statements about in vivo applicability that cannot be prognosticated exclusively based on in vitro data, there is still a deficit of clinical data. This study included a clinical follow-up of five probands who had participated five years previously in a study on the influence of cold atmospheric pressure plasma (CAP) on the wound healing of CO₂ laser-induced skin lesions. The follow-up included a complex imaging diagnostic involving dermatoscopy, confocal laser scanning microscopy (CLSM) and hyperspectral imaging (HSI). Hyperspectral analysis showed no relevant microcirculatory differences between plasma-treated and non-plasma-treated areas. In summary of all the findings, no malignant changes, inflammatory reactions or pathological changes in cell architecture could be detected in the plasma-treated areas. These unique in vivo long-term data contribute to a further increase in knowledge about important safety aspects in regenerative plasma medicine. However, to confirm these findings and secure indication-specific dose recommendations, further clinical studies are required.

Eine seltene kutane Manifestation eines systemischen B-Zell-Lymphoms unter dem klinischen Bild einer seltenen Infektionserkrankung

Dargestellt wird der seltene Fall eines diffus großzelligen B-Zell-Lymphoms unter dem klinischen Verdacht einer kutanen Anthrax-Infektion. Bei Aufnahme präsentierte der 82-jährige Patient an der Stirn rechtsseitig oberhalb der Augenbraue eine ca. 3,5 cm messende ulzerierte Plaque mit zentral festhaftender schwarzer Nekrose und erhabenem livid-erythematösen Randwall. Wir sahen im Verlauf des stationären Aufenthaltes eine fulminante AZ-Verschlechterung des Patienten mit rezidivierenden Fieberschüben bis 40,0 °C und plötzlich disseminierter Aussaat neuer kutaner Herde ähnlich der Morphe der primären Läsion. In der CT zeigten sich multiple pulmonale und hepatische Rundherde sowie einzelne in den Nieren sowie in der rechten Nebenniere. In der Biopsie eines Leberrundherdes und in einer Hautbiopsie wurde die Diagnose eines diffus großzelligen B-Zell-Lymphoms vom ABC-Subtyp gesichert. Bei rezidivierenden Fieberschüben über 39 °C unter eskalierter Antibiose sowie persistierender nicht invasiver Beatmung wurde der Patient im Verlauf auf eine Intensivstation verlegt und verstarb nach 6-wöchiger Krankheitsdauer. Die Autoren schlussfolgern, dass bei sich extrem fulminant darstellenden Krankheitsverläufen, die klinisch einer dermatologischen Infektionserkrankung entsprechen können, jedoch unkontrollierbar unter antimikrobieller Therapie verlaufen, immer an die kutane Manifestation eines systemischen Lymphoms gedacht werden sollte. Hier können auch die primär der Infektionserkrankung zugeordnete B-Symptomatik und die elevierten Akute-Phase-Proteine auftreten. Lymphom-Manifestationen erscheinen an der Haut häufig unspezifisch mit ekzematöser, lichenoider oder pruriginös-nodulärer Morphe. Der Verlauf machte die Einordnung der Dignität der Erkrankung in unserem Fall dann möglich.

Does rehabilitation pose a risk to patients suffering from haemato-oncological diseases? Results of a monocentric, retrospective analysis in Germany

OBJECTIVE

Patients suffering from haemato-oncological diseases tend to have a weakened immune system after the end of their therapy. To avoid infections, patients are advised to limit contact with other people. This poses the question whether a stay at a rehabilitation facility can be recommended.

METHODS

We report about 134 rehabilitation stays of patients. Premature discontinuation of the rehabilitation stay was selected as the criterion for a serious complication during the rehabilitation, and the underlying reasons were analysed.

RESULTS

Compared to the discontinuation rates of patients suffering from solid tumours (2.4%), the percentage of haemato-oncological patients ending prematurely their rehabilitation stay (8.2%) is significantly increased. This rises to 17.1% for patients who have undergone an allogeneic stem cell transplantation. The analysis of the discontinuation reasons revealed that they were not directly connected to the rehabilitation. Apart from the already known risk factors for premature termination of the rehabilitation stay, we have identified the period (days) between the last therapy and the beginning of the rehabilitation stay as a risk factor.

CONCLUSIONS

We show for the first time that a rehabilitation stay does not pose additional risks for patients suffering from haemato-oncological diseases.

Air quality in the operating room: Surgical site infections, HVAC systems and discipline - position paper of the German Society of Hospital Hygiene (DGKH)

In recent years, there has been an ongoing discussion about the value of laminar airflow (LAF=low turbulence displacement ventilation) in the operating room for prevention of surgical site infections (SSI). Some publications, e.g., from the WHO, issued the demand to no longer build LAF ceilings in operating rooms. The present statement deals critically with this position and justifies the use of LAF ceilings in different ways: Many of the papers cited by the WHO and others for the case against LAF do not provide reliable data.The remaining studies which might be used for answering the question give quite different results, also in favor of LAF.The size of the LAF ceiling in many studies is not given or mostly too small in comparison to actual technical requirements.LAF in different countries can mean quite different techniques (e.g., the US in comparison to Germany) so that the results of studies that do not take this into account may not be comparable.LAF has positive effects in terms of reducing particulate and bacterial load, associated with increased airflow in the surgical working area. A reduction of carcinogenic substances in the air may also be assumed, which would increase workers' safety. Thus, this paper recommends building LAF ceilings in the future as well, depending on the operations intended. Further, this paper gives an overview of possible reasons for surgical site infections and highlights the importance of discipline in the operating theatre.

Extended Perfusion Parameter Estimation from Hyperspectral Imaging Data for Bedside Diagnostic in Medicine

Background: Hyperspectral Imaging (HSI) has a strong potential to be established as a new contact-free measuring method in medicine. Hyperspectral cameras and data processing have to fulfill requirements concerning practicability and validity to be integrated in clinical routine processes. Methods: Calculating physiological parameters which are of significant clinical value from recorded remission spectra is a complex challenge. We present a data processing method for HSI remission spectra based on a five-layer model of perfused tissue that generates perfusion parameters for every layer and presents them as depth profiles. The modeling of the radiation transport and the solution of the inverse problem are based on familiar approximations, but use partially heuristic methods for efficiency and to fulfill practical clinical requirements. Results: The parameter determination process is consistent, as the measured spectrum is practically completely reproducible by the modeling sequence; in other words, the whole spectral information is transformed into model parameters which are easily accessible for physiological interpretation. The method is flexible enough to be applicable on a wide spectrum of skin and wounds. Examples of advanced procedures utilizing extended perfusion representation in clinical application areas (flap control, burn diagnosis) are presented.

[Role of the microbiome in chronic wounds]

BACKGROUND

The microbiome, collective microbial life in defined areas of the body, is of great importance.

OBJECTIVE

What is the significance of the wound microbiome in the treatment of chronic wounds? Which interactions exist with other microbiomes and which conclusions can be drawn for wound management?

MATERIALS AND METHODS

Swabs or debridement samples from wounds were analysed for microbial growth by culture or gene-based techniques. The genetic results are used to determine the wound microbiome. The pathogens were evaluated according to proportion of different species and related to different factors like type and location of wound, disease and underlying illnesses and to define the wound microbiome.

RESULTS

In comparison with conventional microbiological detection methods the wound microbiome comprises many more types and quantities of species. The wound microbiome is related to skin microbiome showing complex and time-dependent composition, as well as inter- and intraindividual differences. Diabetic wounds exhibit disease-related changes, e.g. staphylococcal species dominate whereas streptococcal species dominate in nondiabetic wounds.

CONCLUSIONS

The analysis of wound microbiome is still at an early stage; however it has already been shown that in hemodynamic disorders there are disease-specific relationships with the wound microbiome, which can also provide clues about the course of the disease. Phenomena from the skin microbiome should also be effective in wounds. In this context modern antimicrobial treatment options beyond conventional chemotherapy like colonization modulation become possible.

Vasculitis allergica – ein nicht-IgE-vermitteltes Hypersensitivitätssyndrom

Die Diagnose „Vasculitis allergica“ suggeriert eine klassisch allergische IgE-vermittelte Genese. Dies ist jedoch nicht der Fall, vielmehr handelt es sich um einen hochkomplex ablaufenden Mechanismus, der häufig das eigentlich auslösende Antigen vor der Detektion bewahrt.

Die aktuelle Nomenklatur für dieses dermatologische Erkrankungsbild lautet kutane IgM oder IgG Immunkomplex-Vaskulitis, es handelt sich um eine leukozytoklastische Vaskulitis der postkapillären Venolen 3. Diese neue Einordnung legt die mit dem ursprünglichen Namen einhergehende Assoziation mit einer typisch IgE-vermittelten allergischen Erkrankung ab.

Vaskulitiden werden immunologisch betrachtet den Immunkomplex-Erkrankungen, der sogenannten Typ III Reaktion nach Coombs und Gell, zugeordnet 14, 15, 16. Sie werden als entsprechend dem dahinter liegenden immunologischen Prozess als „non-IgE-mediated allergic hypersensitivity Syndrom“ eingestuft 14, 15, 16. Viele Vaskulitiden machen sich klinisch zuerst an der Haut u. a. durch akut auftretende, rasch progrediente Ulzerationen bemerkbar, häufig assoziiert mit starker Schmerzhaftigkeit. Sie sind damit in der Ursachenabklärung eines Ulcus cruris bedeutsam, rangieren hier aber unter den seltenen Diagnosen.

Der lange bestehende Begriff einer „leukozytoklastischen Vaskulitis“ für diese Erkrankung steht entsprechend nicht länger für ein einzelnes Erkrankungsbild, sondern vielmehr für ein histologisches Muster einer Gruppe von Vaskulitiden, den sogenannten Immunkomplexvaskulitiden. 3 Hierbei handelt es sich von Gefäßkaliber überwiegend um „small vessel“ Vaskulitiden, diese können als „single organ vasculitis“ (SOV) mit alleiniger Manifestation an der Haut oder auch als kutanes Teilsymptom einer anderen „multi organ vasculitis“ (MOV) zum Beispiel im Rahmen eines systemischen Lupus erythematodes auftreten 1. Die kutane IgM oder IgG Immunkomplex-Vaskulitis zeigt den für Vaskulitiden klassisch plötzlich auftretenden, rasch progredienten Verlauf und ist klinisch durch eine typische Primäreffloreszenz, die palpable Purpura, mit hoher Inflammation charakterisiert. 2 Im Therapiekonzept steht an erster Stelle das auslösende Agens zu identifizieren und zu eliminieren 2, 42, 44. In der Regel zeigt dieser Typ von Vaskulitis eine überwiegend residuenfreie Abheilung mit niedrigem Rezidivrisiko unter der Voraussetzung, dass das auslösende Agens identifiziert und beseitigt ist 2, 41, 42, 44.

A compact hyperspectral camera for measurement of perfusion parameters in medicine

Worldwide, chronic wounds are still a major and increasing problem area in medicine with protracted suffering of patients and enormous costs. Beside conventional wound treatment, for instance kinds of oxygen therapy and cold plasma technology have been tested, providing an improvement in the perfusion of wounds and their healing potential, but these methods are unfortunately not sufficiently validated and accepted for clinical practice to date. Using hyperspectral imaging technology in the visible (VIS) and near infrared (NIR) region with high spectral and spatial resolution, perfusion parameters of tissue and wounds can be determined. We present a new compact hyperspectral camera which can be used in clinical practice. From hyperspectral data the hemoglobin oxygenation (StO2), the relative concentration of hemoglobin [tissue hemoglobin index (THI)] and the so-called NIR-perfusion index can be determined. The first two parameters are calculated from the VIS-part of the spectrum and represent the perfusion of superficial tissue layers, whereas the NIR-perfusion index is calculated from the NIR-part representing the perfusion in deeper layers. First clinical measurements of transplanted flaps and chronic ulcer wounds show, that the perfusion level can be determined quantitatively allowing sensitive evaluation and monitoring for an optimization of the wound treatment planning and for validation of new treatment methods.

[Hyperspectral imaging demonstrates microcirculatory effects of postoperative exercise therapy in Dupuytren's disease]

BACKGROUND

Dupuytren's disease (DD) is a common connective tissue disorder of the hand. To prevent recurrence of contractures, patients usually receive early postoperative ergotherapy (ET). However, it is yet unknown how this measure impacts on local blood flow and hence on the occurrence or prevention of postoperative complications. Hyperspectral imaging (HSI) allows for a quantitative evaluation of tissue perfusion by measuring oxygen saturation and tissue water content.

OBJECTIVE

The aim of this work was to evaluate the microcirculatory effects of early ET after partial fasciectomy in DD using HSI for optimised treatment and prevention.

PATIENTS AND METHODS

In five patients, the oxygen saturation and tissue water content of the hand were measured before and 20 min after exercise therapy on the first two postoperative days using HSI.

RESULTS

HSI demonstrated improved tissue perfusion in terms of quantity and quality following ET in all patients. After ET, all patients showed a relative increase in oxygen saturation of up to 20 % and a reduction in tissue water of up to 17 %.

CONCLUSION

HIS allows for a fast and non-invasive evaluation of increased oxygen supply and decreased tissue water content in the surgical site after partial fasciectomy in DD following postoperative exercise therapy. This may improve wound healing and decrease the rate of recurrence in DD.

Primary leptomeningeal melanocytic tumors of the spine: report of two cases and review of the literature

Primary leptomeningeal melanocytic tumors of the central nervous system are rare and especially in the spine less frequent compared to other entities. There is no consensus regarding the best care of these tumors. We report two cases of primary leptomeningeal melanocytic tumors, one PLM (Primary Leptomeningeal Melanoma) and one PLMC (Primary Leptomeningeal Melanocytoma) of the upper cervical spine and emphasize different surgical findings and clinical courses of these patients. A review of the literature according to primary leptomeningeal melanocytic tumors of the spine was done, especially to compare different treatment modalities in the younger history. Primary melanocytic tumors of the spine are exceedingly rare. Prior to surgery it is difficult to make a correct diagnosis. Usually an unexpected intraoperative finding with consecutive histopathological analyses lead to the final diagnosis. An accurate search for melanocytic tumors outside the CNS as primary source is mandatory. PLMC have a better prognosis than PLM. There is no consensus regarding the adjuvant therapy, but PLM patients should be given radiotherapy, chemotherapy and immunotherapeutical approaches as immune checkpoint blockade after surgery. Communicating hydrocephalus is highly associated to PLM, but may occur in PLMC as well.

Influence of Treatment Caused Impairments on Anxiety and Depression in Patients with Cancer of the Esophagus or the Esophagogastric Junction

PURPOSE

After therapy of cancer of the esophagus or the esophagogastric junction, patients often suffer from anxiety and depression. Some risk factors for elevated anxiety and depression are reported, but the influence of steatorrhea, the frequency of which has only recently been reported, has not yet been investigated.

METHOD

Using the Hospital Anxiety and Depression Scale (HADS), we analyzed the correlation of anxiety and depression with steatorrhea, appetite, and weight loss in 72 patients with cancer of the esophagus or of the esophagogastric junction, who were treated at our rehabilitation clinic between January 2011 and December 2014. In addition, effectiveness of psychological interviews was analyzed.

RESULTS

We have evaluable anxiety questionnaires from 51 patients showing a median anxiety value of 5 (range 0-13). As for the depression, results from evaluable questionnaires of 54 patients also showed a median value of 5 (range 0-15). Increased anxiety and depression values (> 7) were observed in 25.4% and 37.0% of the patients respectively. Patients who were admitted with steatorrhea for rehabilitation showed a statistically higher anxiety value (median 6.3 vs. 4.7, p < 0.05), reduced appetite, and a weight loss above 15 kg depicting a correlation to anxiety and depression. Psychological conversations helped lowering the depression but had no influence on anxiety.

CONCLUSIONS

Impairments after cancer treatment, such as steatorrhea, appetite loss, and weight loss, should be interpreted as an alarm signal and should necessitate screening for increased anxiety and depression. Psychological therapy can help improving the extent of the depression.

Improved Wound Healing of Airway Epithelial Cells Is Mediated by Cold Atmospheric Plasma: A Time Course-Related Proteome Analysis

The promising potential of cold atmospheric plasma (CAP) treatment as a new therapeutic option in the field of medicine, particularly in Otorhinolaryngology and Respiratory medicine, demands primarily the assessment of potential risks and the prevention of any direct and future cell damages. Consequently, the application of a special intensity of CAP that is well tolerated by cells and tissues is of particular interest. Although improvement of wound healing by CAP treatment has been described, the underlying mechanisms and the molecular influences on human tissues are so far only partially characterized. In this study, human S9 bronchial epithelial cells were treated with cold plasma of atmospheric pressure plasma jet that was previously proven to accelerate the wound healing in a clinically relevant extent. We studied the detailed cellular adaptation reactions for a specified plasma intensity by time-resolved comparative proteome analyses of plasma treated vs. nontreated cells to elucidate the mechanisms of the observed improved wound healing and to define potential biomarkers and networks for the evaluation of plasma effects on human epithelial cells. K-means cluster analysis and time-related analysis of fold-change factors indicated concordantly clear differences between the short-term (up to 1 h) and long-term (24-72 h) adaptation reactions. Thus, the induction of Nrf2-mediated oxidative and endoplasmic reticulum stress response, PPAR-alpha/RXR activation as well as production of peroxisomes, and prevention of apoptosis already during the first hour after CAP treatment are important cell strategies to overcome oxidative stress and to protect and maintain cell integrity and especially microtubule dynamics. After resolving of stress, when stress adaptation was accomplished, the cells seem to start again with proliferation and cellular assembly and organization. The observed strategies and identification of marker proteins might explain the accelerated wound healing induced by CAP, and these indicators might be subsequently used for risk assessment and quality management of application of nonthermal plasma sources in clinical settings.

Long-term outcome of open surgery in CVI patients concerning postoperative complications, perioperative hemodynamics and clinical efficacy, Part II1

BACKGROUND

Chronic venous disease (CVD) is extremely common worldwide with prevalence increasing with age. It is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. In this retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany a holistic evaluation of varicose vein surgeries has been undertaken. Part I covered postoperative complications in relation to co-morbidities, co-medication and clinical presentation. Part II of this article presents now the hemodynamic results in relation to the perioperative evolution of CVI specific symptoms.

METHODS

Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed with regards to perioperative hemodynamics. Evolution of CVI symptomology was accessed postoperatively with the help of a questionnaire and patient records in the case of complication development. Venous hemodynamics was analysed in the whole patient population and with regards to complication subgroups: no events (NE), neglectable adverse events (NAE) and non-neglectable adverse events (NNAE).

RESULTS

Postoperatively, patients' CVI-symptoms like pain (p < 0.001), swelling (p < 0.001) and itching (p = 0.003) significantly improved. The venous refill time and venous pump capacity improved significantly after open vein surgery (p < 0.05). Regardless of the development of postoperative complications there was a significant improvement of venous function at 6 weeks- and one-year postoperative in follow-up (p < 0.05). Symptom regression was strongly correlated with hemodynamic improvement.

CONCLUSION

A significant improvement of patients' symptoms was achieved by means of open-surgery, regardless of postoperative complication development. This was in accordance with the improvement of venous hemodynamics. A strong correlation between symptom regression and improvement in venous hemodynamics could be proven.

["Decoratively figured blisters" on the whole integument in initially diagnosed ulcerative colitis]

The rare case of a 61-year-old patient suffering from linear IgA dermatosis is presented. The patient was previously hospitalized with chronic inflammatory bowel disease. The correct diagnosis of the disease was based on clinical and histological findings. Serological methods, such as indirect immunofluorescence, ELISA and immunoblotting are suitable for identification of the autoantibodies. In this case the detection of IgA antibodies along the basal membrane was achieved by direct immunofluorescence. Other bullous dermatoses with similar symptoms, such as an IgG-mediated bullous pemphigoid have to be excluded. The therapy of linear IgA dermatosis is ensured by steroid-containing topical agents, alongside antiseptic measures as well as systemic dapsone p.o.

Long-term outcome of open surgery in CVI patients concerning postoperative complications, perioperative hemodynamics and clinical efficacy, Part I

BACKGROUND

Chronic venous disease (CVD) is extremely common worldwide. The prevalence is increasing with age and is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. To our knowledge up to now no coherent study has been undertaken in patients with CVI who underwent an open venous surgery concerning complications, venous hemodynamics and perioperative symptomology in one study population. This was undertaken in our retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany. Part I covers postoperative complications in relation with co-morbidities, co-medication and clinical presentation. Part II will focus on pre- and postoperative hemodynamics and evolution of symptoms.

METHODS

Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed. Number and type of complication were evaluated with regards to demographic parameters, co-existing medical conditions and procedure related aspects. Complications were grouped as no events (NE), neglectable adverse events (NAE), non-neglectable adverse events (NNAE) and severe (life-threatening) adverse events (SAE).

RESULTS

In 467 extremities of 429 patients with CVI 130 (27,84%) postoperative complications were observed after open surgery, thereof 64 (13,7%) NAE, 66 (14,14%) NNAE and 0 SAE. 29 (6,76%) patients developed a postoperative surgical site infection, thereof 4 (0,9%) with consecutive septicaemia. Except one case with nerval lesion and paraesthesia and hypoesthesia not resolving after 12 months all complications resolved within surveillance time span of 12 months. Patients developing NAE had a higher BMI (p = 0.003), were more likely to have diabetes mellitus (p < 0.001), and co-morbidities leading to the intake of anti-platelet or anticoagulation drugs (p < 0.001). Metabolic syndrome (p < 0.001) and anti-platelet or anticoagulation (p < 0.001) could be defined as independent risk factors for the development of complications. Patients receiving open surgery of small saphenous veins had 8 times higher risk of calf muscle venous thrombosis (p = 0.001).

CONCLUSION

Patients with a metabolic syndrome or receiving anti-platelet therapy or anticoagulation medication should undergo open venous surgery under hospital conditions with routine postinterventional surveillance visits. Patients undergoing an open surgery of SSV are definite candidates for postoperative subcutaneous heparin thromboprophylaxis. In general stripping below knee increases the risk of postoperative sensory deficit. This resolves in almost all patients within one year.

Hyperspectral imaging as a possible tool for visualization of changes in hemoglobin oxygenation in patients with deficient hemodynamics – proof of concept

There is a lack of imaging tools for the evaluation of spatial alterations in microcirculation including blood oxygen saturation and hemoglobin distribution but recent innovative developments in hyperspectral technology may offer a solution. We examined different hemodynamic disorders in patients suffering from scleroderma, Dupuytren surgery, chronic foot ulcera and skin infections. Superficial and deeper blood oxygen saturation, hemoglobin distribution and water content were determined using hyperspectral imaging (HSI). In the patient with scleroderma, distinct cutaneous low perfused regions correlated with macroscopic skin aspects and seem to be potential therapy control marker. With HSI accurate clinical evaluation of a macroscopic conspicuous wound after Dupuytren surgery was possible and influenced further surveillance decisions. HSI clearly revealed the spatial geometry and also the clinically related perfusion parameters of abscess formation and chronic ulcer wounds. The hemodynamically relevant parameters like blood oxygen saturation (1 mm to approx. 6 mm subcutaneous), total hemoglobin distribution and tissue water content can be easily determined and visualized with HSI in near real time. Hence, this technique seems to be suitable for routine diagnostics of acute and chronic wounds as well as for the examination of systemic hemodynamic disturbances. Special indications may be transplant surveillance and monitoring of therapeutical interventions.

[Multiresistant Pathogens in Oncological and Cardiological Rehabilitation - Results of a Surveillance Study in Brandenburg]

We investigated the prevalence of multidrug resistant pathogens in patients of oncologic and cardiologic rehabilitation units with 155 oncologic and 157 cardiologic patients undergoing microbiologic screening. It was found that 4.5% of oncologic as well as cardiologic patients were colonized with multidrug resistant pathogens. 2-MRGN and ESBL were the most encountered species (2.9%). 3-MRGN were found twice as frequent in oncologic patients (2.6 and 1.3%). Overall oncologic and cardiologic patients exhibit comparatively low prevalence rates for multidrug resistant pathogens.

Exoproteome Analysis of Human Pathogenic Dermatophyte Species and Identification of Immunoreactive Proteins

PURPOSE

Increasing incidence of onychomycosis and tinea pedis in humans of industrialized countries together with deep tissue infections are a therapeutic challenge in clinical mycology. For a better understanding of the pathology and immunology of infection, the authors analyze the exoproteomes of three reference strains of the most common clinical dermatophyte species (Trichophyton rubrum, Trichophyton interdigitale, Arthroderma benhamiae) and of Trichophyton strains isolated from affected patients.

EXPERIMENTAL DESIGN

Extracellular proteins of those in vitro grown strains are separated via 2D High Performance Electrophoresis and identified by mass spectrometry to find proteins with provoked host immune reactivity.

RESULTS

More than 80 secreted proteins including virulence factors such as peptidases and other hydrolases are identified. By Western blotting with respective patient sera, up to 31 proteins with significant antigen-antibody reactions are detected in comparison with control sera, for example, peptidases as well as several oxidoreductases. One protein, beta-glucosidase F2SZI9 seems to be a commonly processed antigen in all Trichophyton infections.

CONCLUSIONS AND CLINICAL RELEVANCE

These first global exoproteome data of three dermatophyte species can be a stepping stone on the way to further study the molecular mechanisms of Trichophyton pathogenicity-associated traits. Possible candidates for potential new diagnostic methods or vaccination have to be validated in further investigations.

Hyperspectral imaging: innovative diagnostics to visualize hemodynamic effects of cold plasma in wound therapy

An important clinical potential of cold atmospheric plasma (CAP) lies in tumor and wound treatment, whereby the last-mentioned is well-referenced already. However, the underlying mechanisms of improved wound healing have not been sufficiently clarified yet, in particular the influence of CAP on microcirculation. Hyperspectral imaging (HSI) enables the visualization of microcirculation of large tissue areas, thus this technique seems to be a candidate to examine CAP effects on perfusion and oxygen saturation in wounds. During clinical wound management, one chronic wound caused by peripheral arterial occlusive disease and one acute wound after surgical removal of cervical lymph nodes were examined using HSI before and after CAP treatment. HSI was able to demonstrate CAP effects on microcirculation showing a relevant increase of superficial and deeper cutaneous oxygen saturation together with elevated hemoglobin concentration in treated and also surrounding wound area. For the first time, it was shown that CAP improves the superficial and deeper oxygenation and hemoglobin perfusion in and around the treated area of acute and chronic wounds. This effect may contribute to healing support by CAP in wounds. HSI seems suitable for evaluating and monitoring CAP effects in clinical settings.

Hyperspectral imaging as a novel diagnostic tool in microcirculation of wounds

Monitoring of perfusion is a cornerstone in surgery, phlebology and basic science to proof wound healing by interventions. In chronic wound management it is of utmost importance to realize and parametrize wound bed perfusion to verify actual, and plan further treatment by noninvasive diagnostics. Up to now monitoring is based on visual inspection of wounds as conventionally practiced over more than decades. The main problems of visual inspection are the lack of standardization and comparability because of interindividual variations. Therefore technical performance with contact free probes based on standardized perfusion measuring is strongly needed. Hyperspectral imaging (HSI) was investigated to overcome manual and visual wound inspection in monitoring of wound healing. HSI works noninvasive, and imaging of relevant perfusion parameters is possible without the need of contrast enhancing drugs.

METHODS

HSI technology uses imaging spectroscopic analysis in visual and near infrared spectrum to get information on imaged tissue in less than 10 s. Tissue is radiated by broad spectrum light and the following parameters are calculated from remitted spectra: the grade of oxygenation and the volume proportion of hemoglobin (in superficial and also deeper (8 mm) tissues. The calculated data comprise the "Tissue hemoglobin oxygen saturation" (StO2) as percental oxygenation index to assess superficial perfusion (VIS-spectrum), the "Near infrared perfusion" (NIR) to assess deeper perfusion (near infrared spectrum) and the "Tissue hemoglobin index" (THI) to measure the percental volume of hemoglobin of surface perfusion (VIS-spectrum). The measurements of these parameters are calculated as false color-coded perfusion results on screen.We investigated different kind of wounds (combustion, infection, ulcer wounds, wounds in immune disorders, trauma wounds) determining superficial and deeper oxygen saturation, hemoglobin distribution and water content using hyperspectral imaging with TIVITA™ Tissue system.

RESULTS

Hyperspectral Imaging allowed easy real time determination and visualization of hemodynamically relevant parameters- superficial and deeper oxygen saturation, total hemoglobin and tissue water content. In the patient with scleroderma, acral lesions with decreased perfusion correlated well with necrotic skin aspects.HSI clearly revealed macroscopic conspicuous suture wounds after Dupuytren surgery, infected soft tissue wounds with strong inflammatory hyperemia, edema in burn injuries, spatial geometry of abscess formation and chronic ulcer wounds. All measurements influenced further surveillance decisions. Hyperspectral imaging seems suitable for routine diagnostics and monitoring of skin and soft tissue lesions like acute and chronic wounds. It allows surveillance of postoperative suture wounds and burn wounds. Special indications may be transplant surveillance and monitoring of therapeutical interventions.

Rheopheresis as a causal therapy option for systemic scleroderma (SSc)

A complex pathomechanism accounts systemic sclerosis as a form of collagenosis. A triad of vasculopathy, autoinflammation, and dysbalance of the fibroblast function can be seen as cause, as well as symptomatic appearance. Comparative with other collagenoses, e.g. Lupus erythematosus, vasculopathy, instead of autoinflammation, appears to be clinically important in systemic scleroderma. The fact that autoinflammation does not represent the major role in the maintenance of the disease is also evident by the lack of therapeutic effects of classical systemic immunosuppressants. Therapeutic approaches with regard to vasculopathy show better effects. In consideration of therapeutic options, such principles are therefore most important. Apheretic methods filter out plasma proteins in the sense of plasmapheresis. Fibrinogen as a plasma viscosity factor is predominantly targeted and filtered out. In addition other accompanying plasma proteins are also reduced. This occurs on the one hand by dilution effects and on the other by unspecific binding. By this mechanism, acute phase proteins such as the C-reactive protein and various cytokines, especially interleukin-6 are reduced by this method. Looking more closely at these random adjunctive plasma proteins, a possible central role of interleukin-6 in the development and maintenance cascade of systemic scleroderma becomes clear.