A Single Application of Cold Atmospheric Plasma (CAP) Improves Blood Flow Parameters in Chronic Wounds

OBJECTIVE

To find out if application of cold atmospheric plasma (CAP) affects microcirculation in chronic wounds.

METHODS

We treated 20 patients with chronic wounds on the lower extremity with CAP. Blood flow parameters of wounds were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in tissue depth of 2 and 6-8 millimeters. Parameters were assessed under standardized conditions before and over the course of 30 minutes after application of CAP.

RESULTS

Deep capillary blood flow increased significantly by up to 24.33% (percentage change) after treatment with CAP and remained significantly elevated until the end of measuring period at 30 minutes. Superficial oxygen tissue saturation was significantly elevated by 14.05% for the first 5 minutes after treatment. Postcapillary venous filling pressure was significantly elevated by 10.23% 19 minutes after CAP and stayed significantly elevated starting from minute 24 until the end of measuring.

CONCLUSION

CAP increases microcirculation parameters in chronic wounds significantly. Since CAP is known for its benefits in wound healing the effects observed may explain the improved healing of chronic wounds after its use. Whether CAP application can increase blood flow in chronic wounds for longer periods of time or boosts blood flow when applied more than once should be subject to further research.

The repetitive application of cold atmospheric plasma (CAP) improves microcirculation parameters in chronic wounds

BACKGROUND

Chronic wounds, such as venous leg ulcers, diabetic foot ulcers, and pressure ulcers, impose a significant burden on patients and health care systems worldwide. Cold atmospheric plasma (CAP) accelerates wound healing and decreases bacterial load in chronic wounds in both in vitro and in vivo experiments. For the first time, we examined the effects of a repetitive application of CAP on the microcirculation in chronic wounds.

HYPOTHESIS

The repetitive application of cold atmospheric plasma application further improves microcirculation in chronic wounds.

METHODS

Twenty patients with chronic wounds were treated repetitively with CAP. The repetitive application consisted of three CAP sessions, each lasting 90 s and separated by a 10-minute microcirculation measuring period. Microcirculation parameters were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in a tissue depth of 2 mm.

RESULTS

Tissue oxygen saturation was significantly increased after the first CAP application. The effect amplitude and duration were further increased after the second and third CAP application with a maximum increase by 16,7% (percent change; p = 0,004 vs. baseline) after the third application. There was no significant increase in capillary blood flow until the third CAP application. After the third CAP application, an increase by 22,6% (p = 0,014) was observed. Postcapillary filling pressure was not significantly increased over the measuring period. The repetitive application of CAP further enhances the microcirculation in chronic wounds compared to a single application.

CONCLUSION

The repetitive application of CAP boosts and prolongs tissue oxygen saturation and capillary blood flow in chronic wounds compared to a single application. This insight could provide an impetus for new treatment protocols.

Panta Rhei: Neovascularization, Angiogenesis and Nutritive Perfusion in Wound Healing

BACKGROUND

In response to tissue damage, angiogenesis is an extremely dynamic process that is finely regulated by signals from cells, the surrounding extracellular matrix (ECM), and derived mediators. As the only process, angiogenesis remains of decisive importance in the context of the entire wound healing process and is subject to constant change. The dissolution of the endothelial basement membrane, the migration of endothelial cells, and the development of new capillary vessels during wound healing depend not only on the cells and cytokines present, but also on the production and organization of ECM components in the immediate wound.

SUMMARY

Angiogenesis in wound healing can be divided into two main phases. During the pro-angiogenic phase at the beginning of wound healing, excessive neo-formation of blood vessels, some of which are poorly differentiated, occurs, which restore blood flow and thus nutritive perfusion as quickly as possible. This is followed by an anti-angiogenic phase in which the initially established vascular network undergoes a maturing process, which, however, is accompanied by a significant reduction in the number of vessels. Key Messages: Although many mechanisms and specific cell functions in wound healing have already been described, many underlying pathophysiological processes remain unknown. Because angiogenesis and its maturation is a very fast but also very long-lasting process, the understanding of the underlying mechanisms is of crucial importance. This article will give an overview of the current understanding and controversy in this sub-step of wound healing.

Application of Circular Statistics in Pulmonary Diseases by Blood Gas Analysis

Attention is focused on the presentation of circular statistics with directional data, since biologists and physicians are often confronted with such statistical problems. The methodological properties of circular statistics are elaborated by means of data of arterial blood gas changes during exercise in children with cystic fibrosis. The present study demonstrates that performance and discrimination into different severity groups in this chronical disease can be achieved by this statistical method and that analogous problems in biology and medicine could be resolved in the same way.

Immediate Dose-Response Effect of High-Energy Versus Low-Energy Extracorporeal Shock Wave Therapy on Cutaneous Microcirculation

Elucidation of the precise mechanisms and therapeutic options of extracorporeal shock wave therapy (ESWT) is only at the beginning. Although immediate real-time effects of ESWT on cutaneous hemodynamics have recently been described, the dose response to different ESWT energies in cutaneous microcirculation has never been examined. Thirty-nine Sprague-Dawley rats were randomly assigned to three groups that received either focused high-energy shock waves (group A: total of 1000 impulses, 10 J) to the lower leg of the hind limb, focused low-energy shock waves (group B: total of 300 impulses, 1 J) or placebo shock wave treatment (group C: 0 impulses, 0 J) using a multimodality shock wave delivery system (Duolith SD-1 T-Top, Storz Medical, Tägerwilen, Switzerland). Immediate microcirculatory effects were assessed with the O2C (oxygen to see) system (LEA Medizintechnik, Giessen, Germany) before and for 20 min after application of ESWT. Cutaneous tissue oxygen saturation increased significantly higher after high-energy ESWT than after low-energy and placebo ESWT (A: 29.4% vs. B: 17.3% vs. C: 3.3%; p = 0.003). Capillary blood velocity was significantly higher after high-energy ESWT and lower after low-energy ESWT versus placebo ESWT (group A: 17.8% vs. group B: -22.1% vs. group C: -5.0%, p = 0.045). Post-capillary venous filling pressure was significantly enhanced in the high-energy ESWT group in contrast to the low-energy ESWT and placebo groups (group A: 25% vs. group B: 2% vs. group C: -4%, p = 0.001). Both high-energy and low-energy ESWT affect cutaneous hemodynamics in a standard rat model. High-energy ESWT significantly increases parameters of cutaneous microcirculation immediately after application, resulting in higher tissue oxygen saturation, venous filling pressure and blood velocity, which suggests higher tissue perfusion with enhanced oxygen saturation, in contrast to low-energy as well as placebo ESWT. Low-energy ESWT also increased tissue oxygen saturation, albeit to a lower extent, and decreases both blood velocity and venous filling pressure. Low-energy ESWT reduced tissue perfusion, but improved oxygen saturation immediately after the application.

The Use of Bone Graft Substitute in Hand Surgery: A Prospective Observational Study

Bone defects are a very common problem in hand surgery, occurring in bone tumor surgery, in complicated fractures, and in wrist surgery. Bone substitutes may be used instead of autologous bone graft to avoid donor site morbidity. In this article, we will review our experience with the use of Cerament bone void filler (Bonesupport, Lund, Sweden) in elective and trauma hand surgery. A prospective clinical study was conducted with 16 patients treated with this bone graft substitute in our department over a period of 3.5 years. Twelve patients (2 female, 10 male; with an average age of 42.42 years) with monostoic enchondroma of the phalanges were treated and 4 patients (1 female, 3 male; with an average age of 55.25 years) with complicated metacarpal fractures with bone defect. Data such as postoperative course with rating of pain, postoperative complications, functional outcome assessment at 1, 2, 3, 6 months, time to complete remodeling were registered. Postoperative redness and swelling after bone graft substitute use was noticed in 7 patients with enchondroma surgery due to the thin soft-tissue envelope of the fingers. Excellent total active motion of the involved digit was noticed in 10 of 12 enchondroma patients and in all 4 fracture patients at 2-month follow-up. In summary, satisfying results are described, making the use of injectable bone graft substitute in the surgical treatment of enchondromas, as well as in trauma hand surgery a good choice.

Improvement of cutaneous microcirculation by cold atmospheric plasma (CAP): Results of a controlled, prospective cohort study

BACKGROUND

Cold atmospheric plasma (CAP) has proven its benefits in the reduction of various bacteria and fungi in both in vitro and in vivo studies. Moreover, CAP generated by dielectric barrier discharge (DBD) promoted wound healing in vivo. Charged particles, chemically reactive species (such as O3, OH, H2O2, O, NxOy), ultraviolet radiation (UV-A and UV-B), strong oscillating electric fields as well as weak electric currents are produced by DBD operated in air. However, wound healing is a complex process, depending on nutrient and oxygen supply via cutaneous blood circulation. Therefore, this study examined the effects of CAP on cutaneous microcirculation in a prospective cohort setting.

HYPOTHESIS

Cold atmospheric plasma application enhances cutaneous microcirculation.

METHODS

Microcirculatory data of 20 healthy subjects (11 males, 9 females; mean age 35.2 ± 13.8 years; BMI 24.3 ± 3.1 kg/m(2)) were recorded continuously at a defined skin area at the radial forearm. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90 s to the same defined skin area of 22.5 cm(2). Immediately after the application cutaneous microcirculation was assessed for 30 min at the same site.

RESULTS

After CAP application, tissue oxygen saturation immediately increased by 24% (63.8 ± 13.8% from 51.4 ± 13.2% at baseline, p<0.001) and stayed significantly elevated for 8 min. Cutaneous blood flow increased by 73% (41.0 ± 31.2 AU from 23.7 ± 20.8 AU at baseline, p<0.001) and remained upregulated for 11 min. Furthermore, cutaneous blood flow showed two peaks at 14 (29.8 ± 25.0 AU, p=0.049) and 19 min (29.8 ± 22.6 AU, p=0.048) after treatment. Postcapillary venous filling pressure continuously increased, but showed no significant change vs. baseline in the non-specific BMI group. Subgroup analysis revealed that tissue oxygen saturation, postcapillary venous filling pressure and blood flow increased more in case of a lower BMI.

CONCLUSION

CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the radial forearm of healthy volunteers. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in diabetic foot ulcers. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

Electrocautery Devices With Feedback Mode and Teflon-Coated Blades Create Less Surgical Smoke for a Quality Improvement in the Operating Theater

Monopolar electrocautery is a fast and elegant cutting option. However, as it creates surgical smoke containing polycyclic aromatic hydrocarbons (PAHs), it may be hazardous to the health of the surgical team. Although new technologies, such as feedback mode (FM) and Teflon-coated blades (TBs), reduce tissue damage, their impact on surgical smoke creation has not yet been elucidated. Therefore, we analyzed the plume at its source.The aim of this study was to evaluate if electrocautery FM and TBs create less surgical smoke.Porcine tissue containing skin was cut in a standardized manner using sharp-edged Teflon-coated blades (SETBs), normal-shaped TBs, or stainless steel blades (SSBs). Experiments were performed using FM and pure-cut mode. Surgical smoke was sucked through filters or adsorption tubes. Subsequently, filters were scanned and analyzed using a spectrophotometer. A high-performance liquid chromatography (HPLC-UV) was performed to detect benzo[a]pyrene (BaP) and phenanthrene as 2 of the most critical PAHs. Temperature changes at the cutting site were measured by an infrared thermometer.In FM, more surgical smoke was created using SSB compared with TBs (P < 0.001). Furthermore, differences between FM and pure-cut mode were found for SSB and TB (P < 0.001), but not for SETB (P = 0.911). Photometric analysis revealed differences in the peak heights of the PAH spectrum. In HLPC-UV, the amount of BaP and phenanthrene detected was lower for TB compared with SSB. Tissue temperature variations increased when SSB was used in FM and pure-cut mode. Furthermore, different modes revealed higher temperature variations with the use of SETB (P = 0.004) and TB (P = 0.005) during cutting, but not SSB (P = 0.789).We found that the use of both TBs and FM was associated with reduced amounts of surgical smoke created during cutting. Thus, the surgical team may benefit from the adoption of such new technologies, which could contribute to the primary prevention of smoke-related diseases.

Decline in relative plasma cell-free mitochondrial DNA levels in response to prolonged moderate aerobic and eccentric exercise (HUM1P.306)

Elevated plasma levels of cell-free mitochondrial DNA (cf-mDNA), a cell damage-associated molecular pattern (DAMP), contribute to neutrophil activation and inflammation in trauma patients, and may occur in cancer and autoimmunity. To further understand relationships between cf-mDNA released by tissue injury, inflammation, and health benefits of exercise, we conducted trial by time experiments for plasma cf-mDNA response to prolonged moderate aerobic exercise, and to eccentric exercise. Seven healthy moderately-trained young men (n=7) completed treadmill exercise trials for 90 min at 60% VO2 max, and resting control trials, and blood was sampled immediately prior to (Pre), during (at +18, +54, and +90 min), and after (R40) trials. A significant difference in cf-mDNA response was observed between exercise and control trials. Specifically, cf-mDNA levels differed at +54 and +90 (with or without plasma volume (PV) shift correction). A significant time effect was observed, with relative cf-mDNA levels declining at +54 and +90 during exercise. These results suggest increased clearance or reduced release of plasma cf-mDNA with exercise. Declines in cf-mDNA were also seen after eccentric exercise. Our finding of cf-mDNA decline with prolonged moderate treadmill and eccentric exercise contrasts with studies by others involving exhaustive short-term treadmill exercise, where cf-mDNA levels were unchanged, and highlights differences between exercise- and trauma-induced inflammation.

[Transitional cell carcinoma of the bladder: bladder-sparing therapy]

Transitional cell carcinoma of the bladder can - in the majority of cases - be safely treated by transurethral resection and bladder preservation. In case of more aggressive and genetically instable tumors, the effect of radical cystectomy depends on tumor volume. If complete resection of invasive tumors is also possible, the additional effect of radical cystectomy seems to be marginal. In patients with favorable tumor location and acceptable prostate parameters, prostate-sparing surgery seems to be oncologically safe with good quality of life.

Acute effects of local cold therapy in superficial burns on pain, in vivo microcirculation, edema formation and histomorphology

BACKGROUND

Local cold therapy for burns is generally recommended to relief pain and limit tissue damage, however, there is limited data of its physiological benefit. This study aimed to evaluate pathophysiological effects of cold therapy in superficial burn on microcirculation, edema formation, and histomorphology.

METHODS

In 12 volunteers (8f, 4m; aged 30.4±14.1 years) circumscribed superficial burn was induced on both hand back and either left untreated as control (control-group) or treated by local-cold-application (cold-treatment-group). Prior to burn (t0), immediately (t1), 15 min (t2), and 30 min (t3) following cold therapy, following parameter was evaluated using intravital-microscopy; epidermal-thickness (ET), granular-cell-size (GCS), individual-blood-cell-flow (IBCF), and functional-capillary-density (FCD).

RESULTS

Both ET and GCS increased significantly more in control-group and slightly in cold-treatment-group in t1, while turns to insignificant t2 onwards. IBCF and FCD raised up in control-group compared to dramatically decrease in cold-treatment-group in t1. In t2 both parameter remains in control-group and increased in cold-treatment-group. Comparison of both groups for IBCF and FCD indicates significant difference in t1 and t2, however, insignificant in t0 and t3.

CONCLUSIONS

Microcirculation, edema formation, and histomorphology of superficial burn has been significantly influenced through immediate cold therapy, however, this alterations are transient and turns to ineffective after 30 min.

The Speech-Language Assessment of English Language Learning Students: A Non-Standardized Approach

English language learning (ELL) children suspected of having specific-language impairment (SLI) should be assessed using the same methods as monolingual English-speaking children born and raised in the United States. In an effort to reduce over- and under-identification of ELL children as SLI, speech-language pathologists (SLP) must employ nonbiased assessment practices. This article presents several evidence-based, nonstandarized assessment practices SLPs can implement in place of standardized tools. As the number of ELL children SLPs come in contact with increases, the need for well-trained and knowledgeable SLPs grows. The goal of the authors is to present several well-establish, evidence-based assessment methods for assessing ELL children suspected of SLI.

Impact of diabetes and peripheral arterial occlusive disease on the functional microcirculation at the plantar foot

BACKGROUND

Plastic and reconstructive surgeons are commonly faced with chronic ulcerations and consecutive wound infections of the feet as complications in patients with diabetes and/or peripheral arterial occlusive disease (PAOD). Microcirculatory changes seem to play an important role. However, the evaluation of functional changes in the soft tissue microcirculation at the plantar foot using combined Laser-Doppler and Photospectrometry System has not yet been performed in patients with DM or PAOD.

METHODS

A prospective, controlled cohort study was designed consisting of a total of 107 subjects allocated to 1 of 3 groups-group A: healthy subjects (57% males, 63.3 y); group B: patients with diabetes mellitus (DM) (53% males, 59.4 y); and group C: patients with PAOD (81% males, 66.1 y). Microcirculatory data were assessed using a combined Laser-Doppler and Photospectrometry System.

RESULTS

Global cutaneous oxygen saturation microcirculation at the plantar foot of healthy individuals was 8.4% higher than in patients with DM and 8.1% higher than in patients with PAOD (both P = 0.033). Patients with diabetes did not show significant differences in global cutaneous blood flow when compared with either healthy subjects or patients suffering from PAOD.

CONCLUSIONS

Functional microcirculation at the plantar foot differs between healthy subjects and patients suffering from diabetes or PAOD of the same age. Patients with either diabetes or PAOD demonstrate deteriorated cutaneous oxygen saturation with equivalent blood perfusion at the plantar foot. More clinical studies have to be conducted to evaluate therapeutical methods that might ameliorate cutaneous oxygen saturation within diabetic foot disease and PAOD.

Anaerobic treatment of lignocellulosic material to co-produce methane and digested fiber for ethanol biorefining

Five different ratios of corn stover to swine manure were investigated to evaluate the performance of anaerobic digestion and the quality of anaerobically digested fiber (AD fiber) as a feedstock for bioethanol production. The stover-to-manure ratio of 40:60 generated 364L biogas and 797g AD fiber per kg of dry raw feedstock daily. The AD fibers after digestion were pretreated and hydrolyzed to release sugars for ethanol fermentation. The stover-to-manure ratio of 40:60 was able to produce 152g methane and 50g ethanol per kg of dry raw feedstock. The net energy generated from the ratio 40:60 was 5.5MJkg(-1) dry raw feed, which was an 18% increase on net energy output compared to the other ratios and proved to be most beneficial for a biorefinery.

Diabetes and peripheral arterial occlusive disease impair the cutaneous tissue oxygenation in dorsal hand microcirculation of elderly adults: implications for hand rejuvenation

BACKGROUND

In spite of potential implications for anti-aging therapy regarding the selection of the most suitable therapeutical method and potential perinterventional complications, cutaneous microcirculation of the aging hand in healthy individuals as well as in those with diabetes mellitus or peripheral arterial occlusive disease (PAOD) has never been evaluated.

HYPOTHESIS

Functional microcirculation of the dorsal hand differs between healthy individuals and individuals with diabetes or PAOD at the same age.

MATERIALS AND METHODS

Prospective controlled cohort study. One hundred ten individuals were allocated to group A (healthy individuals, n = 37), group B (diabetes mellitus, n = 36), and group C (PAOD, n = 37). Microcirculatory data were obtained using combined laser-Doppler and photospectrometry.

RESULTS

Cutaneous oxygen saturation at the dorsal hand of healthy individuals was 11.1% higher than of those with diabetes mellitus (p = .04) and 18.8% higher than of those with PAOD (p = .001). Cutaneous capillary blood flow in participants with PAOD was 20% higher than in healthy individuals (p = .047).

CONCLUSION

This is the first study demonstrating that capillary microcirculation of the dorsal hand differs between healthy individuals and those with diabetes or PAOD of the same age. Further studies should explore whether ameliorating cutaneous tissue oxygen saturation could emerge as a viable antiaging strategy for elderly hands.

Acute effects of remote ischemic preconditioning on cutaneous microcirculation--a controlled prospective cohort study

Background

Therapeutic strategies aiming to reduce ischemia/reperfusion injury by conditioning tissue tolerance against ischemia appear attractive not only from a scientific perspective, but also in clinics. Although previous studies indicate that remote ischemic intermittent preconditioning (RIPC) is a systemic phenomenon, only a few studies have focused on the elucidation of its mechanisms of action especially in the clinical setting. Therefore, the aim of this study is to evaluate the acute microcirculatory effects of remote ischemic preconditioning on a distinct cutaneous location at the lower extremity which is typically used as a harvesting site for free flap reconstructive surgery in a human in-vivo setting.

Methods

Microcirculatory data of 27 healthy subjects (25 males, age 24 ± 4 years, BMI 23.3) were evaluated continuously at the anterolateral aspect of the left thigh during RIPC using combined Laser-Doppler and photospectrometry (Oxygen-to-see, Lea Medizintechnik, Germany). After baseline microcirculatory measurement, remote ischemia was induced using a tourniquet on the contralateral upper arm for three cycles of 5 min.

Results

After RIPC, tissue oxygen saturation and capillary blood flow increased up to 29% and 35% during the third reperfusion phase versus baseline measurement, respectively (both p = 0.001). Postcapillary venous filling pressure decreased statistically significant by 16% during second reperfusion phase (p = 0.028).

Conclusion

Remote intermittent ischemic preconditioning affects cutaneous tissue oxygen saturation, arterial capillary blood flow and postcapillary venous filling pressure at a remote cutaneous location of the lower extremity. To what extent remote preconditioning might ameliorate reperfusion injury in soft tissue trauma or free flap transplantation further clinical trials have to evaluate.

Trial registration

ClinicalTrials.gov: NCT01235286

Microcirculatory effects of topical glyceryl trinitrate on the Achilles tendon microcirculation in patients with previous Achilles tendon rupture

Topical glyceryl trinitrate treatment has demonstrated short- to mid-term efficacy in chronic noninsertional Achilles tendinopathy. However, the underlying mechanisms are far from being understood. We hypothetized that Achilles tendon capillary blood flow changes immediately after topical glyceryl trinitrate treatment. Fifteen patients (55 + or - 15 years, VAS 5.8 + or - 2.3) with current mid-portion Achilles tendon pain 36 months after open surgical Achilles tendon repair for tendon rupture were included. On the Achilles mid-portion, 1.2 mg topical glyceryl trinitrate was sprayed. Microcirculatory monitoring included capillary blood flow, tendon oxygen saturation and postcapillary venous filling pressures at the insertion and 2, 4 and 6 cm above the insertion using a combined laser Doppler and spectrophotometry system. Baseline capillary blood-flows of the painful versus the uninjured tendon were increased [108 + or - 46 vs. 81 + or - 20 (2 cm above the insertion), 104 + or - 40 vs. 76 + or - 20 (4 cm above the insertion), 111 + or - 53 vs. 90 + or - 21 (6 cm above the insertion, P < 0.05)]. However, topical glyceryl trinitrate did not change capillary blood-flow at 2 and 8-mm tissue depths at the painful Achilles tendon or the healthy tendon. Tendon oxygenation was not changed at the painful or the healthy Achilles tendon. Postcapillary venous filling pressure was reduced at 8 mm at the mid-portion in the painful Achilles tendon only (113 + or - 37 vs. 95 + or - 31, P = 0.030). Acute topical glyceryl trinitrate facilitates capillary venous outflow in painful Achilles tendons. However, capillary blood-flow and tendon oxygenation remain unchanged following acute topical glyceryl trinitrate application. Elevated capillary blood-flow at the entire mid-portion is encountered at baseline in previously ruptured painful Achilles tendons even 3 years after surgical repair of the Achilles tendon indicating an altered microcirculatory flow pattern.

Gender and eccentric training in Achilles mid-portion tendinopathy

The role of gender in Achilles tendinopathy is yet to be determined. We hypothesized that female patients respond the same as males to 12 weeks of painful eccentric training. A total number of 75 consecutive mid-portion patients with Achilles tendinopathy (25 females, 38 males) were enrolled in a cohort study with 63 being analyzed after 12 weeks according to their gender for tendon and paratendon microcirculatory mapping. Outcome was determined by pain on visual analogue scale, VISA-A score, Foot Ankle Outcome Score (FAOS), tendon and paratendon capillary blood flow, oxygen saturation, and postcapillary venous filling pressures. Eccentric training resulted in a morning resting pain reduction by 44% in males (P = 0.001) and by 27% in females (P = 0.08). VISA-A score improved in males by 27% from 63 +/- 12 to 86 +/- 13 (P = 0.036) and by 20% in females from 60 +/- 14 to 75 +/- 11 (P = 0.043, P < 0.05 for gender difference). Among females, only one out of five FAOS items was increased (sport 72 +/- 21 to 82 +/- 15, P = 0.045), while in males, four out of five items were increased (symptoms, pain, all-day-life, and sport, all P < 0.01). The microcirculatory gender-specific response to eccentric training revealed a greater postcapillary venous filling pressure reduction among symptomatic females and inconclusive capillary blood flow changes. No change in tendon oxygenation was noted in both genders. Symptomatic females suffering Achilles tendinopathy do not benefit as much as symptomatic males from 12 weeks of eccentric training. The pain reduction is significantly lower among symptomatic females in contrast to males, and the improvement in the FAOS and VISA-A scores is significantly lower among females in contrast to males. Additional treatment options warrant scrutiny to symptomatic females suffering Achilles tendinopathy beyond eccentric training.

Human solCD39 inhibits injury-induced development of neointimal hyperplasia

Blood platelets provide the initial response to vascular endothelial injury, becoming activated as they adhere to the injured site. Activated platelets recruit leukocytes, and initiate proliferation and migration of vascular smooth muscle cells (SMC) within the injured vessel wall, leading to development of neointimal hyperplasia. Endothelial CD39/NTPDase1 and recombinant solCD39 rapidly metabolise nucleotides, including stimulatory ADP released from activated platelets, thereby suppressing additional platelet reactivity. Using a murine model of vascular endothelial injury, we investigated whether circulating human solCD39 could reduce platelet activation and accumulation, thus abating leukocyte infiltration and neointimal formation following vascular damage. Intraperitoneally-administered solCD39 ADPase activity in plasma peaked 1 hour (h) post-injection, with an elimination half-life of 43 h. Accordingly, mice were administered solCD39 or saline 1 h prior to vessel injury, then either sacrificed 24 h post-injury or treated with solCD39 or saline (three times weekly) for an additional 18 days. Twenty-four hours post-injury, solCD39-treated mice displayed a reduction in platelet activation and recruitment, P-selectin expression, and leukocyte accumulation in the arterial lumen. Furthermore, repeated administration of solCD39 modulated the late stage of vascular injury by suppressing leukocyte deposition, macrophage infiltration and smooth muscle cell (SMC) proliferation/migration, resulting in abrogation of neointimal thickening. In contrast, injured femoral arteries of saline-injected mice exhibited massive platelet thrombus formation, marked P-selectin expression, and leukocyte infiltration. Pronounced neointimal growth with macrophage and SMC accretion was also observed (intimal-to-medial area ratio 1.56 +/- 0.34 at 19 days). Thus, systemic administration of solCD39 profoundly affects injury-induced cellular responses, minimising platelet deposition and leukocyte recruitment, and suppressing neointimal hyperplasia.

Achilles tendon suture deteriorates tendon capillary blood flow with sustained tissue oxygen saturation - an animal study

BACKGROUND

Treatment of ruptured Achilles tendons currently constitutes of conservative early functional treatment or surgical treatment either by open or minimal invasive techniques. We hypothesize that an experimental Achilles tendon suture in an animal model significantly deteriorates Achilles tendon microcirculation immediately following suturing.

METHODS

Fifteen Achilles tendons of eight male Wistar rats (275-325 g) were included. After preparation of the Achilles tendon with a medial paratendinous approach, Achilles tendon microcirculation was assessed using combined Laser-Doppler and spectrophotometry (Oxygen-to-see) regarding:- tendinous capillary blood flow [arbitrary units AU]- tendinous tissue oxygen saturation [%]- tendinous venous filling pressure [rAU]The main body of the Achilles tendon was measured in the center of the suture with 50 Hz. 10 minutes after Achilles tendon suture (6-0 Prolene), a second assessment of microcirculatory parameters was performed.

RESULTS

Achilles tendon capillary blood flow decreased by 57% following the suture (70 +/- 30 AU vs. 31 +/- 16 AU; p < 0.001). Tendinous tissue oxygen saturation remained at the same level before and after suture (78 +/- 17% vs. 77 +/- 22%; p = 0.904). Tendinous venous filling pressure increased by 33% (54 +/- 16 AU vs. 72 +/- 20 AU; p = 0.019) after suture.

CONCLUSION

Achilles tendon suture in anaesthetised rats causes an acute loss of capillary perfusion and increases postcapillary venous filling pressures indicating venous stasis. The primary hypothesis of this study was confirmed. In contrast, tendinous tissue oxygen saturation remains unchanged excluding acute intratendinous hypoxia within the first 10 minutes after suture. Further changes of oxygen saturation remain unclear. Furthermore, it remains to be determined to what extent reduced capillary blood flow as well as increased postcapillary stasis might influence tendon healing from a microcirculatory point of view in this animal setting.

A soccer-specific balance training program for hamstring muscle and patellar and achilles tendon injuries: an intervention study in premier league female soccer

BACKGROUND

A soccer-specific balance training has been shown to decrease injury incidence of the anterior cruciate ligament and ankle sprains in randomized controlled trials. However, hamstring injuries and tendinopathy remain significant issues in soccer.

HYPOTHESIS

Proprioceptive training can reduce the incidence of hamstring muscle injuries and tendinopathy in elite soccer. There is a dose-effect relationship between balance training duration and injury incidence.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-four elite female soccer players (body mass index, 21.7 +/- 1.2; age, 21 +/- 4 years) of a German premier league soccer team were prospectively included. Starting in January 2004, an additional soccer-specific proprioceptive multistation training was initiated over 3 years. Injury data/1000 hours of exposure with documentation of all occurred injuries, detailed training, and match exposure data as well as time loss data were 100% complete.

RESULTS

At the end of the 3-year proprioceptive balance training intervention, noncontact hamstring injury rates were reduced from 22.4 to 8.2/1000 hours (P = .021), patellar tendinopathy from 3.0 to 1.0/1000 hours (P = .022), and Achilles tendinopathy from 1.5 to 0.0/1000 hours (P = .035). There was no effect of balance training on contact injuries. Mean time loss of all assessed injuries significantly decreased from 14.4 days during the control period to 1.5 days during intervention periods (P = .003). The more minutes of balance training performed, the lower the rate of overall injuries (r = -0.185, P = .001), hamstring injuries (r = -0.267, P = .003), patellar tendinopathy (r = -0.398, P = .02), and gastrocnemius strains (r = -0.342, P = .002).

CONCLUSION

Soccer-specific balance training (protective balancing) can reduce noncontact hamstring injuries and patellar and Achilles tendinopathy. A dose-effect relationship between duration of balance training and injury incidence is evident. A proprioceptive training program reduced the rehabilitation time in noncontact injuries, which warrants further investigation.

Affective responses to exercise are dependent on intensity rather than total work

PURPOSE

The purpose of the study was to compare affective responses for two bouts of cycle ergometry with differing duration and intensity, but equal total work in kilocalories.

METHODS

Thirty-seven participants (20 male, 17 female, mean age 23.9 yr) completed a multistage cycle ergometer protocol to determine ventilatory threshold (VT) and peak oxygen consumption (mean = 34.9 mL.kg(-1).min(-1)). Two cycling trials were prescribed: 30 min at 85% of VT (50.1% VO2 reserve) and an average of 24 min at 105% of VT (64.7% VO2 reserve). The length of the 105% of VT bout was adjusted to yield equal total work in each exercise trial.

RESULTS

Using repeated-measures ANOVA, heart rate and exertion were significantly higher, and affective valence was significantly less positive (P < 0.01) for the higher-intensity, shorter-duration bout, with no differences in felt arousal (P > 0.05). Additionally, affective valence became less positive during the higher-intensity bout (P < 0.01) but not the lower-intensity bout (P > 0.05).

CONCLUSION

These data extend previous findings by showing that the decline in ratings of pleasure during higher-intensity exercise is not dependent on differences in total caloric expenditure. Additionally, results from this study support continued promotion of prescriptions that focus on exercise intensity that does not exceed the VT.

Optimized temperature and deadspace correction improve analysis of multiple breath washout measurements by ultrasonic flowmeter in infants

BACKGROUND

Assessment of lung volume (FRC) and ventilation inhomogeneities with ultrasonic flowmeter and multiple breath washout (MBW) has been used to provide important information about lung disease in infants. Sub-optimal adjustment of the mainstream molar mass (MM) signal for temperature and external deadspace may lead to analysis errors in infants with critically small tidal volume changes during breathing.

METHODS

We measured expiratory temperature in human infants at 5 weeks of age and examined the influence of temperature and deadspace changes on FRC results with computer simulation modeling. A new analysis method with optimized temperature and deadspace settings was then derived, tested for robustness to analysis errors and compared with the previously used analysis methods.

RESULTS

Temperature in the facemask was higher and variations of deadspace volumes larger than previously assumed. Both showed considerable impact upon FRC and LCI results with high variability when obtained with the previously used analysis model. Using the measured temperature we optimized model parameters and tested a newly derived analysis method, which was found to be more robust to variations in deadspace. Comparison between both analysis methods showed systematic differences and a wide scatter.

CONCLUSION

Corrected deadspace and more realistic temperature assumptions improved the stability of the analysis of MM measurements obtained by ultrasonic flowmeter in infants. This new analysis method using the only currently available commercial ultrasonic flowmeter in infants may help to improve stability of the analysis and further facilitate assessment of lung volume and ventilation inhomogeneities in infants.

Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic achilles tendinopathy

STUDY DESIGN

A controlled, randomized, prospective study,

OBJECTIVE

To assess the changes in paratendon microcirculation after 12 weeks of daily painful eccentric training in individuals with chronic Achilles tendinopathy.

BACKGROUND

Changes in tendon and paratendon microcirculation are evident in insertional and midportion Achilles tendinopathy. Whether the paratendon is involved in eccentric training response is not known.

METHODS

Twenty patients with chronic Achilles tendinopathy were recruited for a prospective, controlled trial using eccentric exercise. A laser Doppler system assessed capillary blood flow (flow), tissue oxygen saturation (SO2), and postcapillary venous filling pressure (rHb) at 8 paratendon locations at depths of 2 and 8 mm.

RESULTS

Pain in the eccentric-training group was reduced by 48% (from a mean of 4.1 +/- 2.9 to 2.1 +/- 2.2, P<.05). Deep paratendon blood flow decreased at the midportion paratendon location (P<.05). Superficial blood flow at the medial distal midportion position (by 31%, P = .008) and the lateral proximal midportion location (by 45%, P = .016) were significantly decreased postintervention, No significant change of superficial or deep paratendon oxygenation was found after intervention as compared to baseline. Deep paratendon postcapillary venous filling pressures were significantly reduced following eccentric training (P<.05).

CONCLUSION

An eccentric-training program performed daily over 12 weeks reduced the increased paratendinous capillary blood flow in Achilles tendinopathy by as much as 45% and decreased pain level based on a visual analog scale. Local paratendon oxygenation was preserved while paratendinous postcapillary venous filling pressures were reduced after 12 weeks of eccentric training, which appears to be beneficial from the perspective of microcirculation.

Microcirculation of the ankle after Cryo/Cuff application in healthy volunteers

The aim of the study was to assess the combination of compression and cryotherapy (Cryo/Cuff ankle device) on parameters of ankle microcirculation in healthy volunteers over 30 min. In 21 volunteers (12 males, 29 +/- 10 years [incl. females], BMI 24 +/- 3) the Cryo/Cuff ankle device (AIRCAST, Summit, NJ, USA) was applied with continuous assessment of parameters of ankle microcirculation, such as tissue oxygen saturation (SO2), relative postcapillary venous filling pressures (rHb), and microcirculatory blood flow at 2- and 8-mm tissue depths during 30 min with the Oxygen-to-see System, a laser-Doppler-spectrophotometry-system (LEA Medizintechnik, Giessen, Germany). Superficial tissue oxygen saturation (SO2, 48 +/- 19 %) immediately dropped to 23 +/- 15 % (-52 %, p < 0.05) within the first 2 min after Cryo/Cuff activation with a consecutive slow decrease to 32 +/- 23 % (- 32 %, p < 0.05 vs. baseline) after 30 min. Deep SO2 (8 mm, 69 +/- 5 %) did not change within 30 min of Cryo/Cuff application (70 +/- 4 %, n.s.). Superficial postcapillary venous filling pressures (61 +/- 17 relative units) showed an immediate and sustained decrease after Cryo/Cuff application within four minutes to 37 +/- 18 relative units (-39 %, p < 0.05). Deep postcapillary venous filling pressures (85 +/- 20 relative units) dropped within the first four minutes of Cryo/Cuff application to 68 +/- 19 relative units (-20 %, p < 0.05). Superficial microcirculatory blood flow (21 +/- 36 relative units) decreased significantly to 7 +/- 5 relative units after 30 min (-69 %, p < 0.05 vs. baseline). Deep microcirculatory blood flow at 8 mm tissue depth (63 +/- 43 relative units) significantly decreased over the 30 min to 39 +/- 23 relative units (-47 %, p < 0.05 vs. baseline). Using the Oxygen-to-see system we could demonstrate significant effects of the Cryo/Cuff device on the ankle level in healthy volunteers with reduced superficial tissue oxygen saturation with preserved deep tissue oxygen saturation, reduced superficial and deep postcapillary venous filling pressures, and reduced superficial and deep microcirculatory blood flow as a function of time. Further clinical studies are mandatory to elucidate the effects of the Cryo/Cuff device on the microcirculatory environment in injured ankles.

Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes

BACKGROUND

Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial.

PURPOSE

To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 +/- 8 years), 14 patients had insertional pain (7 men, 29 +/- 8 years), and 11 patients had midportion tendinopathy (7 men, 38 +/- 13 years, not significant).

RESULTS

Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 +/- 79 vs 132 +/- 42, P < .05) as well as in midportion tendinopathy (150 +/- 74 vs 119 +/- 34, P < .05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 +/- 42 insertional asymptomatic vs 119 +/- 34 mid-portion vs 120 +/- 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different.

CONCLUSION

Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.

Changes in speech and language development of a young child after decannulation

This report reviews the speech and language development of a child who, as result of complete subglottic stenosis, was aphonic from birth until 2 years and 11 months of age at which time laryngotracheal reconstruction provided normal respiration. The boy had congenital subglottic stenosis requiring neonatal tracheostomy. The congenital subglottic stenosis progressed to complete subglottic stenosis during the neonatal period. The child's speech and language development was monitored for a 24-week period following airway reconstruction.

LEARNING OUTCOMES

The reader will learn about and be able to describe: (1) the speech and language development of a child who was aphonic from birth until 35 months of age, (2) the effects of surgical repair of a tracheotomy on the child's speech and language development, (3) the likely importance of babbling in speech and language development.

Classification and management of early complications in open lumbar microdiscectomy

Complications and side effects in any kind of surgery, especially in spine surgery, should be evaluated to prevent those problems in the future. Since retrospective studies are of minor value and randomized controlled studies for complications are impossible to perform because of ethical and legal reasons, so-called "expert opinion" has to take their place in evidence-based medicine. On the basis of an analysis of the results of three spine centers together with the opinions of experienced spine surgeons, the authors have drawn up a classification of complications in open lumbar disc surgery and recommendations on how to manage common complications such as excessive bleeding, dural opening, nerve root lesions and recurrent disc herniation. The management of intraoperative complications should have the same training in microdiscectomy instructional courses as the operation itself.

Osmosensing and osmoregulatory compatible solute accumulation by bacteria

Bacteria inhabit natural and artificial environments with diverse and fluctuating osmolalities, salinities and temperatures. Many maintain cytoplasmic hydration, growth and survival most effectively by accumulating kosmotropic organic solutes (compatible solutes) when medium osmolality is high or temperature is low (above freezing). They release these solutes into their environment when the medium osmolality drops. Solutes accumulate either by synthesis or by transport from the extracellular medium. Responses to growth in high osmolality medium, including biosynthetic accumulation of trehalose, also protect Salmonella typhimurium from heat shock. Osmotically regulated transporters and mechanosensitive channels modulate cytoplasmic solute levels in Bacillus subtilis, Corynebacterium glutamicum, Escherichia coli, Lactobacillus plantarum, Lactococcus lactis, Listeria monocytogenes and Salmonella typhimurium. Each organism harbours multiple osmoregulatory transporters with overlapping substrate specificities. Membrane proteins that can act as both osmosensors and osmoregulatory transporters have been identified (secondary transporters ProP of E. coli and BetP of C. glutamicum as well as ABC transporter OpuA of L. lactis). The molecular bases for the modulation of gene expression and transport activity by temperature and medium osmolality are under intensive investigation with emphasis on the role of the membrane as an antenna for osmo- and/or thermosensors.

Tracheal-innominate artery fistula caused by the endotracheal tube tip: case report and investigation of a fatal complication of prolonged intubation

CASE REPORT

A patient with extensive burns was intubated with an 8.0 mm internal diameter endotracheal tube (ETT) equipped with a subglottic suction port (Mallinckrodt HiLo Evac). The ETT was secured to a left upper molar with wire sutures throughout the hospitalization course to ensure airway stability. On the 40th day of intubation, the patient exsanguinated and died from a tracheo-innominate artery fistula. Postmortem examination revealed a 1 cm lesion of the left anterior tracheal wall at the position of the ETT tip. The prolonged stationary position of the ETT was considered the primary factor responsible for the fistula. Yet tracheo-innominate artery fistula normally is associated with high cuff pressures rather than with the tube tip. The special ETT construction required for the subglottic suction feature was suspected to have increased tube rigidity and may have played a contributory role.

METHODS

The rigidity of the Mallinckrodt HiLo Evac was measured with a mechanical model and compared to 5 other commercially-available ETTs. Rigidity was expressed as the force generated by the ETT tip when the tube curvature was altered by 5 cm and 10 cm of flexion from its resting position.

RESULTS

The mean force exerted by the Mallinckrodt HiLo Evac was 10.1 +/- 2.8 g at 5 cm of flexion and 17.7 +/- 5.1 g at 10 cm of flexion. This was significantly greater than all other ETT brands tested (by one-way analysis of variance and Student-Newman-Kuels test, p < 0.05).

CONCLUSION

This case of fatal tracheo-innominate artery fistula formation associated with an ETT tip was unusual because of the extended duration of endotracheal intubation and the complexity of the patient's airway management problems. Our data suggest that the higher rigidity of the HiLo Evac ETT may have contributed to fistula development at the tube tip. However, we do not believe that the higher rigidity of the HiLo Evac ETT necessarily poses any greater risk than other ETTs under normal circumstances, in which the tube tip is not fixed in a stationary position for an extended period.