Indocyanine green for leakage control in isolated limb perfusion

Objective

Sarcomas are characterized by a high metastatic potential and aggressive growth. Despite surgery, chemotherapy plays an important role in the treatment of these tumors. Optimal anti-cancer therapy with maximized local efficacy and minimized systemic side effects has been the object of many studies for a long time. To improve the local efficacy of anti-tumor therapy, isolated limb perfusion with high-dose cytostatic agents has been introduced in surgical oncology. In order to control the local distribution of substances, radiolabeled cytostatic drugs or perfusion solutions have been applied but often require the presence of specialized personnel and result in a certain exposure to radiation. In this study, we present a novel strategy using indocyanine green to track tumor perfusion with high-dose cytostatic therapy.

Methods

In a rat cadaver model, the femoral vessels were cannulated and connected to a peristaltic pump to provide circulation within the selected limb. The perfusion solution contained indocyanine green and high-dose doxorubicin. An infrared camera enabled the visualization of indocyanine green during limb perfusion, and subsequent leakage control was successfully performed.

Results

Histologic analysis of sections derived proximally from the injection site excluded systemic drug dispersion.

Conclusion

In this study, the application of indocyanine green was proven to be a safe and cost- and time-efficient method for precise leakage control in isolated limb perfusion with a high-dose cytostatic agent.

Effect of HBO therapy on adipose-derived stem cells, fibroblasts and co-cultures: In vitro study of oxidative stress, angiogenic potential and production of pro-inflammatory growth factors in co-cultures1

BACKGROUND: A key moderator of wound healing is oxygen. Wound healing is a dynamic and carefully orchestrated process involving blood cells, cytokines, parenchymal cells (i.e. fibroblasts and mesenchymal stem cells) and extracellular matrix reorganization. Human adipose derived stem cells as well as human fibroblasts produce soluble factors, exhibit diverse effects on inflammation and anti inflammation response and are involved in wound healing processes. Hyperbaric oxygen therapy is an effective adjunct treatment for ischemic disorders such as chronic infection or chronic wounds. In vitro effects of hyperbaric oxygen therapy on human cells were presented in many studies except for those on mono- and co-cultures of human adipose derived stem cells and fibroblasts. OBJECTIVE: The aim of this study was to investigate the effects of hyperbaric oxygen therapy on mono- and co-cultures of human adipose derived stem cells and fibroblasts. METHODS: Mono- and co-cultures from human adipose derived stem cells and fibroblasts were established. These cultures were exposed to hyperbaric oxygen therapy every 24 h for five consecutive days. Measuring experiments were performed on the first, third and fifth day. Therapy effects on the expression of VEGF, IL 6 and reactive oxygen species were investigated. RESULTS: After exposure to hyperbaric oxygen, cell culturess showed a significant increase in the expression of VEGF after 3 and 5 days. All cultures showed significantly reduced formation of reactive oxygen species throughout the experiments. The expression of IL-6 decreased during the experiment in mono-cultures of human adipose derived stem cells and co-cultures. In contrast, mono-cultures of human skin fibroblasts showed an overall significantly increased expression of IL-6. CONCLUSIONS: Hyperbaric oxygen therapy leads to immunmodulatory and proangiogenetic effects in a wound-like enviroment of adipose derived stem cells and fibroblasts.

Rapid and Precise Semi-Automatic Axon Quantification in Human Peripheral Nerves

We developed a time-efficient semi-automated axon quantification method using freeware in human cranial nerve sections stained with paraphenylenediamine (PPD). It was used to analyze a total of 1238 facial and masseteric nerve biopsies. The technique was validated by comparing manual and semi-automated quantification of 129 (10.4%) randomly selected biopsies. The software-based method demonstrated a sensitivity of 94% and a specificity of 87%. Semi-automatic axon counting was significantly faster (p < 0.001) than manual counting. It took 1 hour and 47 minutes for all 129 biopsies (averaging 50 sec per biopsy, 0.04 seconds per axon). The counting process is automatic and does not need to be supervised. Manual counting took 21 hours and 6 minutes in total (average 9 minutes and 49 seconds per biopsy, 0.52 seconds per axon). Our method showed a linear correlation to the manual counts (R = 0.944 Spearman rho). Attempts have been made by several research groups to automate axonal load quantification. These methods often require specific hard- and software and are therefore only accessible to a few specialized laboratories. Our semi-automated axon quantification is precise, reliable and time-sparing using publicly available software and should be useful for an effective axon quantification in various human peripheral nerves.

WITHDRAWN: The use of integrated indocyanine green fluorescence microscope camera for intraoperative lymphography of supermicrosurgery

Ahead of Print article withdrawn by publisher.

Perfusion maintains functional potential in denervated mimic muscles in early persistent facial paralysis which requires early microsurgical treatment - the histoanatomic basis of the extratemporal facial nerve trunk assessing axonal load in the context of possible nerve transfers

BACKGROUND AND OBJECTIVES

Early persistent facial paralysis is characterized by intact muscles of facial expression through maintained perfusion but lacking nerve supply. In facial reanimation procedures aiming at restoration of facial tone and dynamics, neurotization through a donor nerve is performed. Critical for reanimating target muscles is axonal capacity of both donor and recipient nerves. In cases of complete paralysis, the proximal stump of the extratemporal facial nerve trunk may be selected as a recipient site for coaptation. To further clarify the histological basis of this facial reanimation procedure we conducted a human cadaver study examining macro and micro anatomical features of the facial nerve trunk including its axonal capacity in human cadavers. Axonal loads, morphology and morbidity of different donor nerves are discussed reviewing literature in context of nerve transfers.

METHODS

From 6/2015 to 9/2016 in a group of 53 fresh frozen cadavers a total of 106 facial halves were dissected. Biopsies of the extratemporal facial nerve trunk (FN) were obtained at 1 cm distal to the stylomastoid foramen. After histological processing and digitalization of 99 specimens available, 97 were selected eligible for fascicle counts and 87 fulfilled quality criteria for a semi-automated computer-based axon quantification software using ImageJ/Fiji.

RESULTS

An average of 3.82 fascicles (range, 1 to 9) were noted (n = 97). 6684±1884 axons (range, 2655- 12457) were counted for the entire group (n = 87). Right facial halves showed 6364±1904 axons (n = 43). Left facial halves demonstrated 6996±1833 axons (n = 44) with no significant difference (p = 0.73). Female cadavers featured 6247±2230 (n = 22), male showed 6769±1809 axons (n = 40). No statistical difference was seen between genders (p = 0.59). A comparison with different studies in literature is made. The nerve diameter in 82 of our specimens could be measured at 1933±424 μm (range, 975 to 3012).

CONCLUSIONS

No donor nerve has been described to match axonal load or fascicle number of the extratemporal facial nerve main trunk. However, the masseteric nerve may be coapted for neurotization of facial muscles with a low complication rate and good clinical outcomes. Nerve transfer is indicated from 6 months after onset of facial paralysis if no recovery of facial nerve function is seen.

Vascular malformations of upper and lower extremity - from radiological interventional therapy to surgical soft tissue reconstruction - an interdisciplinary treatment

This article presents our experience in managing peripheral vascular malformations of upper and lower extremities over a 4-year period in a series of 46 patients of the Department of Plastic Surgery treated in the Interdisciplinary Center of Vascular Anomalies (ICVA) at the University of Regensburg. The patients presented vascular malformations of upper and lower extremity and were selected from our prospective vascular anomalies file archive from 2012 to 2016. During this period in the ICVA at University of Regensburg were performed more than 1400 radiological interventional treatments in patients with vascular malformations.The purpose of this retrospective study was to review combined embolotherapy, sclerotherapy (embolo/sclerotherapy), and surgical procedures (surgical excision and soft tissue reconstruction) to manage vascular malformations. Treatments were principally induced to reduce pain, daily physical limitations, social discomfort and recover tegument continuity after ulceration.The 46 patients were first examined with noninvasive radiological procedures. After diagnosis was posed, embolo/sclerotherapy, surgical procedures and clinically as well as radiological follow-ups were coordinated and established by the multidisciplinary team. All vascular malformations were categorized according to the classification approved at the April 2014 General Assembly of International Society for the Study of Vascular Anomalies (ISSVA) in Melbourne, Australia. Arteriovenous malformations (AVMs) were further classified following the Cho-Do and Schobinger classification.Embolo/sclerotherapy shows to be the most appropriate procedure in vascular malformations treatment. Nevertheless was found that in case of complications or lack of improvement as well as to improve functional or aesthetical results, a following partial or complete surgical excision and immediate soft tissue reconstruction seems to be the gold-standard treatment. In addition, the precise clinical and radiological diagnosis as well as an intensive postoperative patient care have a significant positive influence on the clinical outcome and patient satisfaction while decreasing morbidity and recurrence during early and late follow-up.Vascular malformations require a multidisciplinary approach and individual treatment after complex excision and indispensable reconstruction.

A comparison of nanoparticullate CpG immunotherapy with and without allergens in spontaneously equine asthma-affected horses, an animal model

INTRODUCTION

New therapeutic strategies to modulate the immune response of human and equine allergic asthma are still under extensive investigation. Immunomodulating agents stimulating T-regulatory cells offer new treatment options beyond conventional symptomatic treatment or specific immunotherapy for human and equine allergic airway diseases, with the goal of a homoeostatic T-helper cell balance. The aim of this study was to evaluate the effects of a nebulized gelatin nanoparticle-CpG formulation (CpG-GNP) with and without specific allergens for the treatment of spontaneous allergic equine asthma as a model for human asthma.

METHODS

Twenty equine asthma-affected horses were treated either with CpG-GNP alone or CpG-GNP with allergens. Two specific allergens were selected for each horse based on history and an in-vitro test. Each horse received seven administrations of the respective nebulized composition and was examined before treatment, immediately after and 6 weeks after the treatment course.

RESULTS

Clinical parameters such as breathing rate, indirect interpleural measurement, arterial blood gases, amount of tracheal mucus and percentage of neutrophils and cytokines in tracheal washes and serum samples were evaluated. Treatment with CpG-GNP alone as well as in combinations with relevant allergens resulted in clinical improvement of nasal discharge, breathing rate, amount of secretion and viscosity, neutrophil percentage and partial oxygen pressure directly after and 6 weeks after treatment. There were no significant differences between the two treatments in clinical parameters or local cytokine profiles in the tracheal wash fluid (IL-10, IFN-g, and IL-17). IL-4 concentrations decreased significantly in both groups.

CONCLUSION

Nonspecific CpG-GNP-based immunotherapy shows potential as a treatment for equine and possibly also human allergic asthma.

Circulating serum CK level vs. muscle impairment for in situ monitoring burden of disease in Mdx-mice

BACKGROUND

Duchenne muscular dystrophy (DMD) consists of a lack in the expression of the subsarcolemmal protein dystrophin causing progressive muscle dysfunction. Among the widely applied animal models in DMD research is the C57BL/1010ScSn-Dmdmdx mouse, commonly referred to as the "mdx mouse". The potential benefit of novel interventions in this model is often assessed by variables such as functional improvement, histological changes, and creatine kinase (CK) serum levels as an indicator for the extent of in situ muscle damage.

OBJECTIVE

Our objective was to determine to what extent the serum CK-level serves a surrogate for muscle dysfunction.

METHODS

In this trial mdx mice were subjected to a four-limb wire-hanging test (WHT) to assess the physical performance as a reference for muscle function. As CK is a component of the muscle fiber cytosol, its serum activity is supposed to positively correlate with progressing muscle damage. Hence serum CK levels were measured to detect the degree of muscle impairment. The functional tests and the serum CK levels were analyzed for their specific correlation.

RESULTS

Although physical performance decreased during the course of the experiment, latency to fall times in the WHT did not correlate with the CK level in mdx mice.

CONCLUSION

Our data suggests that the serum CK activity might be a critical parameter to monitor the progression of muscle impairment in mdx mice. Further this study emphasizes the complexity of the DMD phenotype in the mdx mouse, and the care with which isolated parameters in this model should be interpreted.

New reconstruction for bone integration of non-vascularized autogenous bone graft with better bony union and revascularisation

INTRODUCTION

Phalangeal defects are often seen after tumor resection, infections, and in complex open hand fractures. In many cases, reconstruction is difficult and amputation is performed to avoid prolonged rehabilitation that is often associated with a poor outcome. In these cases, the maintenance of length and function presents a reconstructive challenge.

METHODS

We reviewed 11 patients who underwent extensive phalangeal reconstruction with non-vascularized bone graft from the iliac crest using a key-in-slot-joint technique to provide acceptable function and bony union.

RESULTS

In each case, non-vascularized bone graft with a length of 1.4-6.0 cm was used to reconstruct the phalanx. Follow-up ranged from 6 weeks to 5 months, and in all cases, there was bony union after 6 weeks. We evaluated range of motion, function, and as well pain and grip strength of the fingers.

CONCLUSIONS

This case series suggests that a key-in-slot technique allows non-vascularized bone graft to be used in complex large phalangeal bone defects. Due to better bone contact, a sufficient perfusion and revascularisation of the non-vascularized bone graft can be achieved for a quicker and stable bony union. This method appears to be an alternative to amputation in selected cases with a satisfactory soft-tissue envelope.

Transepidermal oxygen flux during arterial occlusion using ratiometric luminescence imaging

BACKGROUND

A physiological oxygen transport through a circulatory and microcirculatory system is essential for execution of cellular functions. Several pathological conditions e.g. infections, ischemia, cancer, diabetes, hypertension or chronic wounds show a change of oxygen distribution and oxygen tension in cellular microenvironment. Additionally complex operative procedures in order to reconstruct tissue defects require a reliable monitoring of microcirculation.

OBJECTIVE

Target of this study was to evaluate skin oxygenation during an ischemia-reperfusion experiment using transepidermal oxygen flux imaging.

METHODS

Twelve patients at the Department of Plastic and Reconstructive surgery of the University hospital of Regensburg underwent to elective hand operations. During the operation a tourniquet is standardly set on the upper arm to create ischemia in order to facilitate the operative procedure. Measurements were performed at the different time intervals: in rest, under ischemia and after reperfusion.

RESULTS

The transepidermal oxygen flux increased during the ischemic condition compared to normal condition and decreased to a lower value during reperfusion (rest: 0.043±0.007, ischemia: 0.063±0.014, reperfusion: 0.030±0.028).

CONCULSION

Transepidermal oxygen flux imaging by ratiometric luminescence imaging seems to be a reliable tool to assess skin oxygenation. However dynamic changes seem to be more informative than absolute thresholds. Further investigations are necessary to prove these promising results.

Transepidermal oxygen flux measurement - First clinical application for postoperative wound monitoring

BACKGROUND

Measurement of skin oxygen is of great interest in diverse fields of medicine. Different pathologies, e.g. infection, ischemia cancer or chronic wounds show a characteristic oxygen distribution and skin oxygen tension. Additionally diverse operative procedures require a reliable postoperative monitoring in order to ensure success of the therapy.

OBJECTIVE

Aim of this study was to assess transepidermal oxygen flux for postoperative wound monitoring after operative treatment of fractures close to the hip.

METHODS

22 patients underwent transepidermal oxygen flux measurement at the first postoperative day. Transepidermal oxygen flux measurement was performed using ratiometric luminescence imaging. Examination was conducted in close proximity to the operation wound. The corresponding area at the contralateral side served as reference.

RESULTS

Oxygen flux in the operation area was higher (0.084±0.021) than the contralateral side (0.071±0.029).

CONCLUSIONS

Transepidermal oxygen flux imaging by ratiometric luminescence imaging seems to be a reliable tool to assess postoperative wound healing. However further investigations in greater populations and under pathologic conditions have to be performed to prove these first results.

Vascularized transfer of two coherent toe joints in simultaneously reconstructing MCP and PIP of a mutilated finger

BACKGROUND

The reconstruction of metacarpal- and interphalangeal joints after severe hand injuries has been proven to be challenging. Commonly used procedures like arthrodesis, amputation or ray resection of the finger compromise the functionality of the injured finger. Especially for young patients, the restoration of all functions of the fingers is a priority. Local tissue transfers for finger joint reconstructions is not an option due to inacceptable donor site morbidity; microsurgical tissue transfers in terms of free toe joint transfers have proven to be a valuable method.

METHODS

We present the case of a patient who suffered an excessive injury from a circular saw to his dominant hand. The MCP Joints of D2-D4 were fully destroyed, along with the PIP joint of a subtotally amputated D4. Arteries, nerves and tendons could be coapted directly, while primarily reconstructing of the finger joints was impossible. To ensure a possible regain of full functionality, two coherent joints, the MTP and the PIP of one toe, were transferred to the ring finger as a single transplant, reconstructing the MCP and the PIP joints of the injured finger in a one step procedure. Additionally the MCP joint of the D2 was reconstructed by the use of a free PIP-joint transfer, further the MCP joint of the D3 was replaced by an MCP endoprosthesis.

RESULTS

After a follow up of 3 years the patient displayed full function of his dominant hand including sensitivity, and has gone back to manual work without limitations. The result was cosmetically acceptable and the donor site defect was easily being tolerated by the patient who is playing soccer in the regional soccer league.

CONCLUSION

Free double toe joint transfer has been proven feasible in this patient. While transferring a single toe joint to reconstruct a finger joint is a well-established method, our review of the latest literature showed no case of a free transfer of two coherent joints and three transplanted joints in one hand. The applied microsurgical technique should be considered by microsurgically trained hand surgeons for the treatment of comparable severe hand injuries. In comparison to the most common procedures described for the repair and reconstruction of severely injured finger joints this method showed superior results.

Evidence based postoperative treatment of distal radius fractures following internal locking plate fixation

Originally, the treatment method of choice for distal radial fractures (DRF) has been a non-operative approach with six to eight weeks of plaster casting. The introduction of volar locking plate systems at the beginning of the 21 st century has pushed trends towards open reduction and internal fixation (ORIF). While the introduction of fixed angle locking plates together with the increasing knowledge on wrist function and related variable outcomes has led to consensus that operative fixation in instable DRF is the treatment method of choice, there is no agreement on a postoperative care of these injuries. The authors will discuss the available evidence for current concepts of postoperative treatment of DRFs following fixed angle fixation under socioeconomical, biomechanical and burden of disease aspects. Further, relevant randomized controlled trials are evaluated with regard to applied postoperative treatment regimes and related risks for complications.

Postoperative monitoring of local and free flaps with contrast-enhanced ultrasound (CEUS)--analysis of 112 patients

PURPOSE

Tissue defects are a common problem in trauma surgery and oncology. Flap transplantation is often the only therapy to cover such defects. Several monitoring systems are currently available but none has made it to the clinical routine. The aim of this study was to assess perfusion disturbances of local and free flaps using contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

112 patients were examined during the first 72 hours after operation. CEUS was performed by one experienced examiner with a linear transducer (6 - 9 MHz, LOGIQE9/GE) after a bolus injection of 2.4 ml sulfohexa-fluoride microbubbles (SonoVue®, Bracco, Italy). Retrospective vascular perfusion was quantified by evaluating the stored DICOM cine loops using the perfusion software QONTRAST® (Bracco, Italy). Over a total penetration depth of 3 cm, every centimeter was analyzed separately. 27 complications were observed. Complete flap loss was only seen in 4 cases, while 23 flaps had to undergo minor revision and survived.

RESULTS

Regarding the complete flap size, quantitative analysis showed significantly higher perfusion values in patients without complications compared to patients with complications: PEAK 16.5 vs. 10.0 (p = 0.001), TTP 32.6 vs. 22.2 (p = 0.001), RBV: 738.8 vs. 246.2 (p < 0.001), RBF 17.5 vs. 10.1 (p < 0.001) and MTT 43.1 vs. 29.5 (p = 0.001). Analysis of the correlation of the different flap types, age, sex and etiology of the tissue defect to the complication rate showed no statistical correlation.

CONCLUSION

CEUS was capable of detecting vascular disturbances after flap transplantation. TTP, RBV and MTT seem to be the most accurately parameters and are not susceptible to malfunction during measurement.

Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS)

BACKGROUND

Extensive wound defects frequently have to be covered by free flap transplantation. A monitoring device for measuring capillary level perfusion of bone is currently not available.

OBJECTIVE

The aim of the study was to detect complications after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS). Additionally quantitative analysis was performed by special perfusion software (QONTRAST®; Bracco, Italy).

METHODS

22 patients were examined after osteocutaneous flap transplantation during the first 72 h after operation. CEUS was performed with a linear transducer (6-9 MHz, LOGIQ E9/GE) after bolus injections of 2.4 ml ultrasound contrast agent (SonoVue®; Bracco, Italy). The osseous perfusion and soft tissue perfusion were analyzed separately and quantitative perfusion analysis was performed. Five patients had to undergo reoperation due to compromised flap microvascularization.

RESULTS

In all 5 complications reduced osseous and soft tissue perfusion was seen using CEUS. Additionally using the perfusion parameters TTP (time to PEAK), RBV (regional blood volume), RBF (regional blood flow) und MTT (mean transit time), significantly lower soft tissue and osseous perfusion was detected.

CONCLUSION

CEUS seems to be capable of detecting vascular disturbances and of assessing microvascularization of the osseous component after osteocutaneous flap transplantation.

Contrast enhanced ultrasound (CEUS) and time intensity curve (TIC) analysis in compartment syndrome: first results

OBJECTIVE

Purpose of this study was to monitor changes of microcirculation in acute compartment syndrome using contrast enhanced ultrasound (CEUS) and to assess the modified perfusion with a special quantification software.

METHODS

8 patients with trauma of the lower limb or the upper extremity were enrolled after acute compartment syndrome was diagnosed clinically and by intracompartmental pressure measurement. The qualitative analysis of the corresponding compartment was assessed using B-scan mode and CEUS simultaneously. CEUS was performed using a multifrequence probe (6-9 MHz, LOGIQ E9 GE) after a i.v. bolus injection of 2 × 2.4 ml contrast agent (SonoVue(®), Bracco, Italy). Digital raw data were stored as cine loops up to 2 minutes. Retrospectively semiquantitative perfusion analysis was performed using time intensity curve analysis and the quantification software QONTRAST(®).

RESULTS

6 out of 8 patients had to be operated due to clinical symptoms and to a pressure perfusion gradient lower than 30 mm Hg. 2 out of 8 were treated conservatively. In all patients haematomas were seen in B-scan mode. No necrosis could be detected. In the TIC analysis low levels of time to peak (20.0 ± 12.1) and area under the curve (118.4 ± 87.8) were observed in acute compartment syndrome. Similarly results have been obtained using the perfusions parameter PEAK (11.1 ± 5.7), time to PEAK (14.7 ± 9.7), regional blood volume (257.1 ± 192.6), and regional blood flow (12.1 ± 6.5) in QONTRAST(®) perfusion software.

CONCLUSION

CEUS may be capable of differing between acute compartment syndrome and imminent compartment syndrome.

Resequencing of the auxiliary GABA(B) receptor subunit gene KCTD12 in chronic tinnitus

Tinnitus is a common and often incapacitating hearing disorder marked by the perception of phantom sounds. Susceptibility factors remain largely unknown but GABA_B receptor signaling has long been implicated in the response to treatment and, putatively, in the etiology of the disorder. We hypothesized that variation in KCTD12, the gene encoding an auxiliary subunit of GABA_B receptors, could help to predict the risk of developing tinnitus. Ninety-five Caucasian outpatients with a diagnosis of chronic tinnitus were systematically screened for mutations in the KCTD12 open reading frame and the adjacent 3′ untranslated region by Sanger sequencing. Allele frequencies were determined for 14 known variants of which three (rs73237446, rs34544607, and rs41287030) were polymorphic. When allele frequencies were compared to data from a large reference population of European ancestry, rs34544607 was associated with tinnitus (p = 0.04). However, KCTD12 genotype did not predict tinnitus severity (p = 0.52) and the association with rs34544607 was weakened after screening 50 additional cases (p = 0.07). Pending replication in a larger cohort, KCTD12 may act as a risk modifier in chronic tinnitus. Issues that are yet to be addressed include the effects of neighboring variants, e.g., in the KCTD12 gene regulatory region, plus interactions with variants of GABA_B1 and GABA_B2.

Osteocutaneous free flaps: a critical analysis of quantitative evaluation of bone microcirculation with contrast-enhanced high resolution ultrasound (hrCEUS) and TIC analysis

PURPOSE

Osteocutaneous free flaps (OFF) are widely used to reconstruct large bone defects in trauma and cancer surgery. Currently no monitoring method is available to detect blood circulation around and inside the bone after transplantation. Therefore we used for the first time contrast-enhanced high-resolution ultrasound (hrCEUS) to gain evidence for the microcirculation of the transplanted bone.

MATERIALS AND METHODS

15 patients transplanted with OFF because of large bone defects at different sites were examined postoperatively with hrCEUS with a high resolution linear probe (6-9 MHz, LOGIQ E9/GE) and a bolus injection of 2.4 ml of contrast agent (SonoVue®, Bracco, Italy). Operation and examination were performed by either an experienced plastic surgeon or an experienced ultrasound examiner. Microcirculation of the periost and bone was analyzed in different regions of interest (ROIs) and quantitative microcirculation analysis was performed using time intension curve analysis (TIC). We further analyzed clinical outcome of the patients in respect to revision-surgery, necrosis of the OFF and flap survival as well as viability on standard x-rays 2 months after surgery.

RESULTS

The most representative parameter by TIC analysis of hrCEUS were the area under the curve (AUC) and the time to peak (Ttop). The AUC of the periost and central part of the bone showed a high correlation (Pearson's r = 0.831). Mean AUC for the periost was 163.92 dB ± 49.44 and for the central part of the bone 70.42 dB ± 25.33. The Ttop of the periosteal ROI was 33.04 sec. ± 6.71 and the bone ROI 41.01 sec. ± 9.24. There was a high correlation of the Ttop of the periost and bone (Pearson's r = 0.937). One revision had to be performed due to haematoma and microcirculation defect of the distal part of the transplanted bone graft which was detected early by hrCEUS and the distal part of the avital bone could be removed timely.

CONCLUSION

For the first time we could show that hrCEUS is a reliable method to evaluate the viability of OFF. The AUC and Ttop seem to be a valuable parameter to detect the microcirculation around and inside the bone transplant.

Post-operative monitoring of tissue transfers: advantages using contrast enhanced ultrasound (CEUS) and contrast enhanced MRI (ceMRI) with dynamic perfusion analysis?

BACKGROUND

The immediate evaluation of microvascular tissue flaps with respect to microcirculation after transplantation is crucial for optimal monitoring and outcome. The purpose of our investigation was to evaluate the clinical value of contrast-enhanced ultrasound (CEUS) and contrast-enhanced MRI (ceMRI) for monitoring the integrity of tissue flaps in plastic surgery.

METHODS

To this end, we investigated 10 patients (47 ± 16 a) between postoperative day 7 and 14 who underwent flap surgery in order to cover tissue defects in various body regions. For CEUS we utilized the GE LOGIQ E9 equipped with a linear transducer (6-9 MHz). After application of 2.4 ml SonoVue, the tissue perfusion was detected in Low MI-Technique (MI < 0.2). The perfusion curves were quantitatively analyzed using digital video sequences (QONTRAST, Bracco, Italy) regarding peak % and relative blood flow (RBF). Furthermore, we investigated all tissue flaps using contrast-enhanced MRI (Magnetom Symphony TIM, Siemens) with a 3D-VIBE sequence and a time resolution of 7s. Thus, the transplants were completely captured in all cases. As perfusion parameters, the positive enhancement integral (PEI) as well as the maximum intensity projection time (MIP-time) were collected. For comparison of both applications, all parameters were displayed in color-coded resolution and analyzed by three independent readers. Depending on the flap thickness, 1-3 regions of interest (ROI) were investigated. Each ROI measured 1 × 3 cm.

RESULTS

The subcutaneous ROI-1 showed a significantly lower rating regarding RBF in the ceMRI compared to CEUS (Mann-Whitney Rank-Sum test, p < 0.05). ROI-2 and -3 did not show any significant differences between the two applications. The frequency distribution showed good accordance in both modalities. Both imaging techniques detected 1 partial flap necrosis within the random area of cutaneous and subcutaneous layers, 1 hematoma as well as 1 insufficient perfusion over all tissue layers. After subsequent reoperation, graft loss could be prevented.

CONCLUSION

At present, both technologies provide an optimal assessment of perfusion in cutaneous, subcutaneous and muscle tissue layers, whereby the detection of fatty tissue perfusion is currently more easily detected using CEUS compared to ceMRI.

[Timely registration of fatalities in the state of Hessen. Experiences during the influenza A/H1N1 pandemic]

Timely registration of fatalities is important for the assessment of course, extent, risk of age groups, and magnitude or severity of health threats. Nevertheless, timely data of casualties are not available on the state or national level. The current paper describes the implementation and structure of a surveillance system for the timely registration of casualties in the state of Hesse (Germany) and the experience obtained during the pandemic 2009/10. The delay of the case-based registration appears tolerable and after 2 weeks more than 80% of all deaths for a given week are registered. In 2008, the forwarding of the electronically registered data from the registry offices (95% of all cases) to the state statistical office (HSL) had been accelerated from a monthly to a weekly base. The HSL provides--on a weekly basis--this case-based data in accordance with data protection rules to the Hesse State Health Office (HLPUG, "Hessischer Landesprüfungs- und Untersuchungsamt im Gesundheitswesen"). During the pandemic, the data allowed assessment of the excess mortality with a delay of 2 weeks. No significant excess mortality was apparent; however, a slight increase was observed in the age groups 15-34, 35-49, and 50-59. Correlation of time with the severity of the A/H1N1v epidemic was not very strong. Hence, the data did not indicate an excess significantly exceeding the number of death cases registered with the mandatory reporting system of 21 cases for Hesse.

What will the next influenza season bring about: seasonal influenza or the new A(H1N1)v? An analysis of German influenza surveillance data

For the next influenza season (winter 2009-10) the relative contributions to virus circulation and influenza-associated morbidity of the seasonal influenza viruses A(H3N2), A(H1N1) and B, and the new influenza A(H1N1)v are still unknown. We estimated the chances of seasonal influenza to circulate during the upcoming season using data of the German influenza sentinel scheme from 1992 to 2009. We calculated type and subtype-specific indices for past exposure and the corresponding morbidity indices for each season. For the upcoming season 2009-10 our model suggests that it is unlikely that influenza A(H3N2) will circulate with more than a low intensity, seasonal A(H1N1) with more than a low to moderate intensity, and influenza B with more than a low to median intensity. The probability of a competitive circulation of seasonal influenza A with the new A(H1N1)v is low, increasing the chance for the latter to dominate the next influenza season in Germany.

What will the next influenza season bring about: seasonal influenza or the new A(H1N1)v? An analysis of German influenza surveillance data

For the next influenza season (winter 2009-10) the relative contributions to virus circulation and influenza-associated morbidity of the seasonal influenza viruses A(H3N2), A(H1N1) and B, and the new influenza A(H1N1)v are still unknown. We estimated the chances of seasonal influenza to circulate during the upcoming season using data of the German influenza sentinel scheme from 1992 to 2009. We calculated type and subtype-specific indices for past exposure and the corresponding morbidity indices for each season. For the upcoming season 2009-10 our model suggests that it is unlikely that influenza A(H3N2) will circulate with more than a low intensity, seasonal A(H1N1) with more than a low to moderate intensity, and influenza B with more than a low to median intensity. The probability of a competitive circulation of seasonal influenza A with the new A(H1N1)v is low, increasing the chance for the latter to dominate the next influenza season in Germany.

Transcutaneous pO2 measurement during tourniquet-induced venous occlusion using dynamic phosphorescence imaging

A sufficient oxygen supply in skin grafts requires a functioning microcirculation. Venous occlusion impairs the microcirculation and is therefore a major threat of healing. Luminescence life time imaging (LLI) enables the non-invasive and two-dimensional assessment of the transcutaneous oxygen partial pressure (p(tc)O2). In the current trial this new device was applied for monitoring of venous congestion. A tourniquet on the upper arm was inflated up to 40-50 mmHg and released after 10 min in eight healthy volunteers. The p(tc)O2 was measured at the lower arm every minute prior to, during and up to 10 min after cuff occlusion (40 degrees C applied skin temperature) using LLI of platinum(II)-octaethyl-porphyrin immobilized in a polystyrene matrix. For validation the polarographic Clark electrode technique was applied in close proximity and measurement was performed simultaneously. p(tc)O2 measurements prior to (Clark: 50.68+/-5.69 mmHg vs. LLI: 50.89+/-4.96 mmHg) and at the end of the venous congestion (Clark: 16.41+/-4.54 mmHg vs. LLI: 23.82+/-3.23 mmHg) did not differ significantly using the Clark electrode vs. LLI. At the initial congestion respectively reperfusion phase the Clark electrode measured faster decreases respectively increase of p(tc)O2 due to oxygen consumption of this method. This experimental trial demonstrates the applicability of LLI to quantify the p(tc)O2 under changing venous blood flow. The use of planar transparent sensors allows the non-invasive generation of two-dimensional maps of surface pO2 what makes this method particular suitable for monitoring of skin grafts.

Contrast harmonic ultrasound and indocyanine-green fluorescence video angiography for evaluation of dermal and subdermal microcirculation in free parascapular flaps

PURPOSE

Contrast harmonic ultrasound (CHI) with a linear transducer is a new diagnostic approach that allows dynamic and quantitative flow detection of tissue perfusion in microsurgery. The aim of the study was the evaluation of perfusion of the dermal and subdermal layers of microvascular tissue transplants with CHI in comparison to ICG-fluorescence angiography.

MATERIAL AND METHOD

In a prospective clinical study Indocyanine-Green Fluorescence Video Angiography and Contrast Enhanced High Resolution Ultrasound (5-10 MHz; linear transducer; Logiq 9; GE) were used for evaluation of the microcirculation in 10 transplanted free parascapular flaps. Two regions were analysed, the centre of the flap and the region of the anastomosis. The perfusion patterns of both methods were compared.

RESULTS

The perfusion indexes measured by ICG-fluorescence angiography correlated very precisely in all patients with the quantitative perfusion curves of contrast-enhanced US with CHI. Two flaps with slow filling and low dye intensity showed low contrast enhancement in CHI with modified perfusion curves with slow increase. In two cases a reduced perfusion and filling were found. There were no statistical differences between the two diagnostic methods (p>0.01).

CONCLUSION

CHI improves US detections of dermal and subdermal microcirculation in comparison to ICG fluorescence angiography. CHI is a new diagnostic method for postoperative monitoring of free flaps.

[Acute febrile disease with splenomegaly and pancytopenia. A 66-year-old Greek patient with a prosthetic mitral valve]

We report on a 66-year-old patient originating from Greece and living in Germany with a prosthetic mitral valve because of a combined vitium following juvenile rheumatic fever. The patient fell ill with acute fever, splenomegaly, and pancytopenia. After unsuccessful antibiotic therapy because of presumed endocarditis or sepsis with unknown focus, visceral leishmaniasis was suspected because of recent travel to Greece. Subsequently, this diagnosis was confirmed by serology. Considering thrombocytopenia and concurrent anticoagulation after prosthetic mitral valve replacement, we avoided a bone marrow biopsy usually required for definite proof of leishmania infection. Instead, infection with Leishmania infantum was diagnosed by PCR of a peripheral blood sample. After treatment with liposomal amphotericin B the patient recovered fully.

Detection of mycobacterial lipoarabinomannan with an antigen-capture ELISA in unprocessed urine of Tanzanian patients with suspected tuberculosis

A direct antigen-capture ELISA based on the detection of mycobacterial lipoarabinomannan (LAM) in unprocessed urine was evaluated for its usefulness in clinical practice. In Tanzania, 231 patients with suspected pulmonary tuberculosis (TB) and 103 healthy volunteers were screened with standard TB tests and with the new LAM-ELISA. Of 132 patients with confirmed pulmonary mycobacterial disease (positive sputum culture), 106 were positive using the LAM-ELISA (sensitivity 80.3%). In comparison, the sensitivity of acid-fast bacilli (AFB) sputum microscopy was 62.1% (82 of 132 confirmed cases). Of the 231 patients, 17 were both culture- and AFB-negative, but had typical radiographic signs of pulmonary mycobacterial infection and did not respond to antibiotic treatment. Of these 17 patients, 13 (76.5%) had positive LAM-ELISA test results. To define the specificity of the assay, urine samples from 103 healthy volunteers were also screened using LAM-ELISA. All but one had an optical density below the cut-off (specificity 99%). Of interest was a significant correlation between level of microscopic density of mycobacteria in sputum and LAM antigen concentration in urine (chi2=8.44). The LAM-ELISA is a field-adapted tool that can improve screening standards in countries with a high incidence of TB.

Regulation of the new coexpressed CD55 (decay-accelerating factor) receptor on stomach carcinoma cells involved in antibody SC-1-induced apoptosis

The human monoclonal antibody SC-1 was isolated from a patient with a diffuse-type adenocarcinoma of the stomach using somatic cell hybridization. The immunoglobulin (Ig)M antibody reacts specifically with diffuse- (70%) and intestinal-type (25%) gastric adenocarcinoma and induces apoptosis in vitro and in vivo. When used in clinical trials with stomach carcinoma patients, significant apoptotic and regressive effects in primary tumors have been observed with the antibody SC-1. The SC-1 receptor is a new 82 kd membrane-bound isoform of glycosylphosphatidylinositol (GPI)-linked CD55 (decay-accelerating factor, DAF). CD55 is known to protect cells from lysis through autologous complement and is coexpressed with the ubiquitously distributed 70 kd isoform. The SC-1-specific CD55 isoform is up-regulated shortly after antibody binding, followed by an internalization of the antibody/receptor-complex, whereas the membranous expression of wild-type CD55 remains unchanged. The apoptotic process is marked by cleavage of cytokeratin 18, indicating the involvement of caspase-6 in the apoptotic process. In contrast to other apoptotic pathways, a cleavage of poly(ADP-ribose)polymerase (PARP) is not observed. The expression of the cell-cycle regulator c-myc becomes up-regulated, whereas expression of topoisomerase IIalpha is down-regulated. Induction of apoptosis leads to an increase in the internal Ca(2+) concentration, which is not necessary for the apoptotic process but for the transport of newly synthesized SC-1-specific CD55 isoform to the membrane.

Double-blind comparison of the efficacy of diclofenac/misoprostol and diclofenac in the treatment of rheumatoid arthritis

A double-blind, randomised, parallel-group study was conducted in eight countries to compare the efficacy of a fixed combination of diclofenac sodium (50 mg) and misoprostol (200 mcg) with a fixed combination of diclofenac sodium (50 mg) and placebo in treating the signs and symptoms of rheumatoid arthritis (RA). A total of 346 patients with RA who had been stabilised on diclofenac for at least 30 days were randomly assigned to receive either diclofenac/misoprostol BID or TID (n = 177) or diclofenac/placebo BID or TID (n = 169) for 12 weeks. Primary analyses of efficacy, made upon admission and at 4-week intervals, consisted of physician's global assessment of the arthritic condition, patient's global assessment of the arthritic condition, patient's global assessment of joint tenderness/pain, and physician's assessment of joint swelling. In this study, the fixed combination tablet of diclofenac sodium 50 mg/misoprostol 200 mcg administered BID or TID demonstrated no statistically significant difference in efficacy in the treatment of the signs and symptoms of RA compared with diclofenac sodium 50 mg/placebo administered BID or TID.

A double-blind placebo-controlled comparison of the efficacy and safety of 50, 100, and 200 micrograms of misoprostol QID in the prevention of ibuprofen-induced gastric and duodenal mucosal lesions and symptoms

Ibuprofen, a commonly proscribed nonsteroidal anti-inflammatory drug that is also available in many countries, including the United States, without a prescription, is known to cause hemorrhage and erosion of the gastroduodenal mucosa. This study was conducted to compare the efficacy of 200, 100, and 50 micrograms of misoprostol and placebo administered qid for 6 days, with a final dose on the morning of the 7th day, in the prevention of gastric and duodenal lesions induced by the concurrent administration of 800 mg of ibuprofen qid. A total of 120 healthy subjects with endoscopically normal gastric and duodenal mucosae were enrolled in the study. The endoscopic examination was repeated 2 h after the final dose on day 7, and the mucosae were graded on a 0 to 4+ scale. In the stomach, all three misoprostol groups were significantly more protective than placebo and did not differ significantly from each other. In the duodenum, the endoscopic scores of the 200- and 100-micrograms misoprostol groups, but not the 50-micrograms group differed significantly from placebo. The 200- and 100-microgram groups did not differ significantly from each other, but both differed from the 50-micrograms group for duodenal mucosal injury. Subjective symptoms thought to be primarily attributable to the NSAID (e.g., pain, indigestion/heartburn and nausea) were recorded by each subject in a diary. Subjects in the 200-micrograms misoprostol group attained the greatest degree of mucosal protection and had a significantly higher incidence of indigestion/heartburn and abdominal pain than the placebo group. One can conclude that misoprostol in both antisecretory (200- and 100-micrograms) and non-antisecretory (50-micrograms) doses protects the gastric mucosa from injury from high anti-inflammatory doses of ibuprofen (3200 mg/day). Only the antisecretory doses (100 and 200 micrograms qid) were effective in the duodenum, suggesting that acid suppression is necessary for mucosal protection to occur in the duodenum.

The impact of the first gay AIDS patient on hospice staff

AIDS, a recently discovered, contagious, potentially fatal disease has created alarm in some segments of our society. Policy makers in hospices and all facilities that care for dying patients can benefit from the experience of others who have already cared for AIDS patients. This article is a report about the experiences of care givers in hospice settings that have received only a few AIDS patients, all of whom were young, gay males. The psychosocial impact of AIDS patient care on hospice staff is one of the issues that must be addressed if the experience is going to be a positive one for both the hospice and the patient/patient family. Three suggestions are made about hospice procedures that may decrease problems: successful acknowledgement of institutional and personal fear and anxiety; adequate inservice training; development of strong support networks.

The significance of skin color of a newborn infant

The concern for the health, development, and well-being of infants and children is one shared by pediatricians and child psychiatrists. At times, parents present issues to either one specialist or the other that need to be shared to meet the goal of fostering physical and psychological health in children. One of the seldom shared issues is the meaning of the skin color of a newborn in a minority (black) or interracial (black-white) family and the implications for the nonminority pediatrician. Through a description and discussion of four clinical cases, we delineate the parental, familial, and societal issues involved and suggest interventions.

Retinitis pigmentosa associated with a defect in the production of interferon-gamma

Peripheral lymphocytes from patients with retinitis pigmentosa have a deficiency in their ability to produce the lymphokine, interferon-gamma. In 12 patients we found that peripheral leukocytes produced subnormal levels of interferon-gamma. These findings suggested that altered immune reactivity is one of the abnormalities associated with retinitis pigmentosa.