Entwicklung eines Lokalisations-basierten Algorithmus zur Vorhersage der Ätiologie von Ulcera cruris

Hintergrund

Die diagnostische Abklärung des Ulcus cruris ist zeit‐ und kostenintensiv. Ziel dieser Studie war es, die Ulkuslokalisation als diagnostisches Kriterium zu bewerten und einen diagnostischen Algorithmus zur Unterstützung in der Diagnostik bereitzustellen.

Patienten und Methodik

Die Studie umfasste 277 Patienten mit Ulcera cruris. Es wurden die folgenden fünf Gruppen definiert: Ulcus cruris venosum, arterielle Ulzera, gemischte Ulzera, Arteriolosklerose und Vaskulitis. Mittels computergestütztem Oberflächenrendering wurden die Prädilektionsstellen der verschiedenen Ulkustypen bewertet. Die Ergebnisse wurden in ein multinomiales logistisches Regressionsmodell integriert, um die Wahrscheinlichkeit einer bestimmten Diagnose in Abhängigkeit von Lokalisation, Alter, bilateraler Beteiligung und Anzahl der Ulzera zu berechnen. Zusätzlich wurde eine neuronale Netzwerk‐Bildanalyse durchgeführt.

Ergebnisse

Die Mehrheit der venösen Ulzera fand sich in der medialen Malleolarregion. Arterielle Ulzera waren am häufigsten auf der dorsalen Seite des Vorfußes zu finden. Arteriolosklerotische Ulzera waren zumeist im mittleren Drittel des lateralen Unterschenkels lokalisiert. Vaskulitische Ulzera schienen zufällig verteilt zu sein und waren deutlich kleiner, häufiger multilokulär und bilateral. Das multinomiale logistische Regressionsmodell zeigte eine insgesamt zufriedenstellende Leistung mit einer geschätzten Genauigkeit von 0,68 bei ungesehenen Daten.

Schlussfolgerungen

Der vorgestellte Algorithmus auf Grundlage der Ulkuslokalisation kann als unterstützendes Instrument zur Eingrenzung potenzieller Differenzialdiagnosen und als Hilfestellung für die Einleitung diagnostischer Maßnahmen dienen.

Development of a localization-based algorithm for the prediction of leg ulcer etiology

BACKGROUND

Diagnostic work-up of leg ulcers is time- and cost-intensive. This study aimed at evaluating ulcer location as a diagnostic criterium and providing a diagnostic algorithm to facilitate differential diagnosis.

PATIENTS AND METHODS

The study consisted of 277 patients with lower leg ulcers. The following five groups were defined: Venous leg ulcer, arterial ulcers, mixed ulcer, arteriolosclerosis, and vasculitis. Using computational surface rendering, predilection sites of different ulcer types were evaluated. The results were integrated in a multinomial logistic regression model to calculate the likelihood of a specific diagnosis depending on location, age, bilateral involvement, and ulcer count. Additionally, neural network image analysis was performed.

RESULTS

The majority of venous ulcers extended to the medial malleolar region. Arterial ulcers were most frequently located on the dorsal aspect of the forefoot. Arteriolosclerotic ulcers were distinctly localized at the middle third of the lower leg. Vasculitic ulcers appeared to be randomly distributed and were markedly smaller, multilocular and bilateral. The multinomial logistic regression model showed an overall satisfactory performance with an estimated accuracy of 0.68 on unseen data.

CONCLUSIONS

The presented algorithm based on ulcer location may serve as a basic tool to narrow down potential diagnoses and guide further diagnostic work-up.

Comparative analysis of endovenous laser ablation versus ultrasound-guided foam sclerotherapy for the treatment of venous leg ulcers

BACKGROUND

Endovenous thermal and non-thermal therapeutic approaches have become standard of care for the treatment of venous insufficiency. However, comparative studies on its use in the population of venous leg ulcer patients are scarce.

METHODS

The present study aimed at a comparison of the efficacy of endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for the treatment of venous leg ulcers (VUs). We retrospectively analyzed patient records of 68 patients with active VUs (C6 of the CEAP-classification), who underwent EVLA (n=33) or UGFS (n=35) between January 2001 and January 2021.

RESULTS

In 68 patients, 97 venous segments (GSV: 43, SSV: 17:, NSV: 37) were treated. Ulcer surface area at initial presentation did not differ significantly between both treatment groups (EVLA: 7.7±10.7 vs. UGFS: 8.5±16.3 cm² ; p=0.73). No significant difference regarding patient characteristics was found, with the exception of age, as patients receiving UGFS treatment were significantly older (EVLA: 61±17 vs. UGFS: 70±14 years; p=0.018). The rate of ulcer resolution was not significantly different between EVLA and UGFS groups (97.0% vs. 85.7%; p=0.20). Also, the mean time to complete ulcer healing after endovenous intervention was comparable (EVLA: 59±37 vs. UGFS: 63±41 days; p=0.68). However, the relapse rate was significantly higher for UGFS than for EVLA treated patients (31.4% vs. 3.0%; p=0.002).

CONCLUSION

Rates of ulcer resolution and ulcer healing time after endovenous intervention were comparable between both treatment modalities. However, a significantly higher relapse rate was observed in UGFS treated patients.

Differentiating Arteriolosclerotic Ulcers of Martorell from Other Types of Leg Ulcers Based on Vascular Histomorphology

Clinical differential diagnosis of arteriolosclerotic ulcers of Martorell is challenging due to the lack of clearly affirmative instrument-based diagnostic criteria. The aim of this study was to develop vascular histomorphological diagnostic criteria differentiating Martorell ulcers from other types of leg ulcers. The histomorphology of patients diagnosed with arteriolosclerotic ulcers of Martorell (n = 67) was compared with that of patients with venous leg ulcers, necrotizing leukocytoclastic vasculitis, pyoderma gangrenosum, and non-ulcerative controls (n = 15 each). In a multivariable logistic regression model, the rates of arteriolar calcification (odds ratio (OR) 42.71, 95% confidence interval (CI) 7.43–443.96, p < 0.001) and subendothelial hyalinosis (OR 29.28, 95% CI 4.88–278.21, p < 0.001) were significantly higher in arteriolosclerotic ulcers of Martorell. Arteriolar cellularity was significantly lower in Martorell ulcers than in controls (OR 0.003, 95 CI < 0.001–0.97, p = 0.05). However, the wall-to-lumen ratio was similar in all ulcers (OR 0.975, 95% CI 0.598–2.04, p = 0.929). Based on the Youden index, a wall cellularity of < 0.24 cells/100 μm² was determined as the optimum cut-off point (sensitivity 0.955, specificity 0.944). Thus, arteriolar calcification, subendothelial hyalinosis, and arteriolar cellularity revealed high discriminatory power for arteriolosclerotic ulcers of Martorell.

Varicose Vein Stripping - A Prospective Study of the Thrombotic Risk and the Diagnostic Significance of Preoperative Color Coded Duplex Sonography

Insufficiency of epifascial veins promotes venous ulceration and increases thromboembolic risk in general surgery patients. Epifascial varicose vein stripping is therefore considered the most effective prophylactic procedure. Thromboembolic risk of patients undergoing this surgical procedure has not yet been prospectively evaluated but appears to be lower than in general surgery patients. The gold standard of preoperative assessment of varicose surgery patients is ascending pressure phlebography, but this technique is invasive, time consuming and costly.

We prospectively investigated 100 consecutive varicose vein surgery patients for postoperative thrombosis. Ascending pressure phlebography (APP) and colour coded duplex sonography (CCDS) were performed before and 10 to 21 days after the stripping operation in 100 and 70 patients, respectively.

APP revealed no postoperative deep vein thrombosis in all 100 limbs investigated (0 percent; 95 percent confidence interval: 0 to 2.95). With regard to epifascial vein reflux there was good agreement between APP and CCDS (quadratic weighted kappa: 0.76). In 67 out of 73 superficial veins investigated excellent agreement of diagnostic accuracy was found for both diagnostic procedures (91.78 percent; 95 percent confidence interval: 82.96 to 96.92).

We conclude that thrombotic risk of varicose vein surgery is low in properly selected patients. CCDS provides a high degree of accuracy in diagnosis of reflux and regular vein morphology and should therefore replace APP; however, APP does remain essential in the preoperative workup of a typical anatomical variants.

[Surgery of varicose vein insufficiency]

The basis of surgery of great saphenous vein insufficiency is the concept of "privat circulation" coined by Trendelenburg in 1891. It was only logical that the dissection of the insuffcient vein or it's partial or complete resection could bring about healing. Over the years varicose vein stripping was modified to finally result in the highly effectiv concept of crossectomy and stripping. For decades this was the Goldstandard in surgery of varicose vein insufficiency. All the other minimally invasive therapeutic techniques which have been developed in the last decades had to compete with crossectomy and stripping. Thanks to progress in technical development the classic stripping procedure has been replaced by highly effectiv, minimally invasiv procedures, at least in the western industrialisied countries. For a minority of patients with specific anatomical pathologies as well as countries with limited health resources vein stripping remains a surgical standard procedure.

Healing process of venous ulcers: the role of microcirculation

In order to describe adequately the process of healing in the intermediate degrees, we investigated microcirculatory changes in the venous ulcers at well-defined stages of wound repair. We investigated dynamic changes in microcirculation during the healing process of venous ulcers. Ten venous ulcers were investigated in three consecutive clinical stages of wound healing: non granulation tissue (NGTA), GTA and scar. Subpapillary microcirculation was measured by laser Doppler perfusion (LDP) imaging and expressed using LDP values in arbitrary units. Nutritive perfusion by capillary microscopy and expressed as capillary density (CD) - the number of capillaries per square millimetre. Before the development of GTA the LDP was low (median 1·35; lower-upper quartiles 0·71-1·83) accompanied with zero CD in all but one patient who had a density of 1. With the first appearance of GTA in the same area, the LDP was improved (2·22; 1·12-2·33; P = 0·0024) when compared with NGTA, in combination with a significant increase in CD (1·75; 0-3; P = 0·0054). In scar, the LDP was similar to that in the NGTA (1·03; 0·77-1·83; P = 0·278), combined with the highest CD (5·75; 4·5-8) in comparison with the previous stages of the area (for both pairs, P < 0·0001). Venous ulcers are caused by poor nutritive and subpapillary perfusion. Subpapillary perfusion plays a major role in the formation of GTA. In a scar, the increased nutritive perfusion is sufficient to cover the blood supply and keep skin viable while subpapillary perfusion is low.

[Varicose veins: disfigurement or disease?]

According to one's subjective appraisal varicose veins will be perceived as more or less disfiguring. About 60% of the population suffer from only minor variants of varicose veins which bear no risk to health. A certain percentage will develop progressive disease with the venous ulcer representing the worst variant of chronic venous insufficiency. As long as there is no progressive disease, therapeutic modalities also account for a superior cosmetic appearance. Endoluminal procedures in particular meet with the claim for a superior treatment result with respect to cosmetic outcome without diminution of efficiency. In case of progressive venous insufficiency appearance is of inferior importance. About 70% of venous ulcers are due to primary varicose veins. Surgery of all accessible superficial refluxing veins is important to prevent recurrence. Compression treatment is highly effective in preventing chronic venous insufficiency and in venous ulcer treatment. About 60% of venous ulcers heal within a 24-week treatment period.

Extended monitoring of hemostatic activation after varicose vein surgery under general anesthesia

BACKGROUND

Postoperative heparin prophylaxis after stripping of the long saphenous vein is a matter of controversial discussion, and practices vary by surgeon and country.

OBJECTIVE

The aim of this study was to assess the extent of hypercoagulability by continued monitoring of activation markers of coagulation and fibrinolysis for a period of 3 weeks after stripping of the long saphenous vein and concomitant phlebectomy.

METHODS

Including 21 patients, the following markers were measured preoperatively and on postoperative day 1, 2, 3, 7, 14, and 21: Activation products of coagulation: thrombin-antithrombin complex (TAT), thrombus precursor protein (TPP), and prothrombin-fragment F1+2 (F1+2), and markers of fibrinolysis: plasmin-alpha(2)-antiplasmin complexes (PAP), D-Dimer, tissue plasminogen activator (t-PA) antigen, and plasminogen activator inhibitor 1 (PAI-1) antigen.

RESULTS

TAT levels increased significantly until day 3 (p=.008) and normalized within 14 days. TPP levels increased significantly until day 7 (p=.02), decreasing to initial values within 21 days. PAP complexes increased significantly until day 2 (p=.02) reducing to baseline within the observation period. D-Dimer levels increased immediately after surgery (p<.001) until day 14 (p<.001) and returned to baseline until day 21.

CONCLUSIONS

Significant hemostatic activation after varicose vein surgery was observed and persisted until 3 weeks postoperatively, indicating that heparin prophylaxis for 2 to 3 weeks is advisable for at-risk patients.

Presence of 14Hz spindle oscillations in the human EEG during deep anesthesia

OBJECTIVE

To report on presence of human EEG spindle oscillations on the cortical level within flat periods of the burst-suppression pattern during propofol-induced anesthesia; to search for corresponding oscillations and possible functional connections.

METHODS

Artefact-free epochs of spindle activation were selected from the electroencephalograms of opiate-dependent patients undergoing rapid opiate detoxification. Power spectral analysis and source localization using low-resolution-brain-electromagnetic-tomography (LORETA(Key)) were performed.

RESULTS

Sinusoidal rhythms with waxing and waning amplitudes appeared after propofol-induced narcosis but no direct correlations could be determined between individual dosage and characteristic spindle attributes. The power maximum stood midline over the cortical areas, especially around C(z). We calculated a peak frequency of 14(+/-1.2) Hz. Motor fields, particularly in the frontal, parietal, and various cingulate areas, were found to be the primary sources of spindle oscillations in the cortex.

CONCLUSIONS

The frequent occurrence of these localized spindle sources demonstrates the preference for motor fields. Spindle oscillations observed during propofol-induced narcosis were similar in frequency and shape to those observed in natural sleep.

SIGNIFICANCE

The results lend support to models that postulate a close link between the motor system and the organization of behavior. In addition, spindle rhythms under propofol bore some resemblance to spindle types which occur during sleep.

Paraneoplastic pemphigus in association with hepatocellular carcinoma

Paraneoplastic pemphigus (PNP) is an autoimmune mucocutaneous blistering disease associated with neoplasms, most frequently of the lymphoproliferative type. Rare PNP cases related to nonhematological solid tumors have been reported. The patient in this report presented with severe mucocutaneous involvement of PNP associated with hepatocellular carcinoma. Histopathology showed vacuolar interface dermatitis with keratinocyte necrosis and intraepidermal acantholysis. Direct immunofluorescence exhibited deposition of intercellular IgG and complement and granular complement at the dermoepidermal junction. Indirect immunofluorescence testing showed a typical intercellular staining on monkey esophagus and rat bladder epithelium. Immunoprecipitation showed characteristic target antigens of 250, 210, and 190 kDa molecular weights. This patient met all diagnostic criteria for paraneoplastic pemphigus and is, to our knowledge, the first report of a case associated with hepatocellular carcinoma.

Microcirculation is similar in ischemic and venous ulcers

Microcirculation of 15 ischemic and 15 venous ulcers, their scars, and intact surrounding skin were examined in order to demonstrate their similarities in the development and healing process. Subpapillary and nutritive perfusion of four areas were investigated by a laser Doppler perfusion imager (arbitrary units) and capillary microscopy (capillaries/mm2): one ulcer area without granulation tissue (no wound healing) and one with granulation tissue (ulcer healing); one skin area adjacent to the ulcer (1-8 mm) (scar developed from ulcer areas) and one distant (12-25 mm; intact skin). Areas without granulation tissue in ischemic and venous ulcers were similar, demonstrating a lack of capillaries (0.13 +/- 0.52; 0.93 +/- 2.09) and low laser Doppler flux (0.81 +/- 0.69; 1.47 +/- 1.17; P > 0.05 for each). In granulation tissue of both ulcers there was a tendency to a higher capillary density (0.67 +/- 1.40; 5.60 +/- 2.32; P < 0.0001 for venous ulcers) and a higher laser Doppler flux (1.15 +/- 0.67; 4.04 +/- 1.62; P < 0.0001 for venous ulcers) than in areas without granulation tissue. In scars of ischemic and venous ulcers capillary density (8.18 +/- 8.84; 13.60 +/- 5.45) and laser Doppler flux (1.72 +/- 1.00; 1.94 +/- 1.45) were similar (P > 0.05). In skin distant from ischemic ulcers very high capillary density (24.63 +/- 1.89) was associated with low laser Doppler flux (0.99 +/- 0.59); distant from venous ulcer capillary density was moderate (10.47 +/- 3.42) while laser Doppler flux was high (3.77 +/- 1.62; P < 0.0001 between both groups). The development and healing process of ischemic and venous ulcers is similar. Nutritive and subpapillary perfusion are involved in ulcer healing. In intact skin surrounding ischemic and venous ulcers, microcirculation is different due to the underlying pathophysiology.

Microcirculation in venous ulcers and the surrounding skin: findings with capillary microscopy and a laser Doppler imager

BACKGROUND

To obtain more information about microcirculatory disturbances in venous ulcers, we studied their laser Doppler flux images and capillary densities.

MATERIALS AND METHODS

On photographs of venous ulcers and the adjacent skin of 17 patients, four regions of interest were marked: one non-granulation tissue area (NGTA) within the venous ulcer, one granulation tissue area (GTA) within the ulcer, one adjacent skin area (ASA) and one distant skin area (DSA). Within these four regions the average laser Doppler area fluxes and capillary densities were determined for each patient using a laser Doppler imager and capillary microscopy respectively.

RESULTS

The laser Doppler area flux (mean +/- SD in AU) was significantly lower in NGTA (1.39 +/- 1.12) than in GTA (4.06 +/- 1. 52) or DSA (3.86 +/- 1.54) (P < 0.00001). In addition, the ASA flux (1.95 +/- 1.39) was significantly lower than the GTA or DSA flux (P < 0.0001). Capillary density (capillaries per mm2) in NGTA (0.82 +/- 1.98) was significantly lower than that in GTA (6.00 +/- 2.55), ASA (13.88 +/- 5.16) or DSA (10.29 +/- 3.41) (P < 0.0001). In addition, the capillary density of ASA was significantly higher than that of GTA or DSA (P < 0.05).

CONCLUSION

The four areas showed the following characteristics: NGTA, low laser Doppler area flux and lowest capillary density (possible sign of ulcer area without healing tendency); GTA, high laser Doppler area flux and second lowest capillary density (possible sign of wound healing); ASA, low laser Doppler area flux and highest capillary density (possible sign of healing process nearly completed; scar); DSA, high laser Doppler area flux and second highest number of capillaries (sign of microcirculation of chronic venous disorder).

Systemic activation of coagulation and fibrinolysis during varicose vein stripping

BACKGROUND

Elevation of activation markers of blood coagulation (thrombin-antithrombin complex [TAT], prothrombin fragment 1 + 2 [F1 + 2], D-Dimer] has not only been found in clinically overt thrombosis but also reflects a prethrombotic state.

OBJECTIVE

The purpose of our study was to evaluate whether varicose vein stripping, an operative procedure with an extremely low risk of postoperative thromboembolism, induces a prethrombotic state by activation of the hemostatic system.

METHODS

In a prospective, observational study we compared the baseline and postoperative values of TAT, F1 + 2, and D-Dimers in 15 patients undergoing varicose vein stripping and in 11 control patients undergoing surgical procedures associated with only minor soft tissue trauma.

RESULTS

A highly significant postoperative elevation of TAT (P < 0.001), F1 + 2 (P = 0.006), and D-Dimer (P < 0.001) was observed in the varicose vein stripping group. No significant postoperative change of the respective parameters was detected in the control group.

CONCLUSION

We therefore conclude that varicose vein stripping induces a significant hemostatic system activation although postoperative thrombotic events are rare.

Preoperative imaging of lower extremity varicose veins: color coded duplex sonography or venography

We prospectively examined 137 limbs in 112 consecutive patients with clinical evidence of severe varicosis by color coded duplex sonography and ascending venography (including varicography in 48 limbs) to evaluate the diagnostic capabilities of color coded duplex sonography in the assessment of venous anatomy, variant varicosis, postthrombotic changes, and incompetence of the superficial and perforating venous system. Additionally, descending venography was performed in the first 52 limbs and compared to color coded duplex sonography in the diagnosis of deep and superficial venous reflux. Variant venous anatomy (21 cases) was missed in two limbs and misinterpreted in one limb by ascending venography compared to surgery. Color coded duplex sonography was inconclusive in two cases. Variant varicosis (59 cases) was missed in seven surgically proved cases by venography and in one case by color coded duplex sonography. Color coded duplex sonography was inconclusive in five cases. Ascending venography was slightly superior to color coded duplex sonography in the detection of postphlebitic changes. Good agreement was found between color coded duplex sonography and descending venography in the grading of superficial (k = 0.75) and deep venous reflux (k = 0.79). Excellent agreement was found between ascending venography in the grading of long (k = 0.96) and short (k = 0.94) saphenous vein reflux. More incompetent perforating veins were detected by ascending venography, (and varicography) than by color coded duplex sonography, but the latter technique allows direct preoperative marking of the skin, which is beneficial for the surgeon. We conclude that color coded duplex sonography is a valuable imaging tool before venous stripping and is capable of replacing invasive ascending and descending venography. Only patients with inconclusive color coded duplex sonographic results (e.g., complex variant venous anatomy) should proceed to venography.

Ocular side effects associated with 13-cis-retinoic acid therapy for acne vulgaris: clinical features, alterations of tearfilm and conjunctival flora

Isotretinoin (13-cis-retinoic acid) is commonly used for the treatment of acne vulgaris. We included 55 patients in this prospective study, and inspected them before, while and after therapy with isotretinoin regarding ocular side effects. Careful slit-lamp inspection, measurement of break-up-time and Schirmer-test and microbiological investigations of the conjunctival flora were performed. While staphylococcus aureus was cultured from the conjunctival sac before application of isotretinoin in 7.3%, this percentage increased to 61.8% during therapy. A pathological decrease of break-up-time was realized in 69.1% of the cases, the development of blepharitis in 40%. But in spite of the alteration of conjunctival flora, bacterial conjunctivitis developed in just 7.3% of the cases. However, only 34.5% of the patients showed symptoms of a conjunctivitis sicca, in spite of the impressive diminution of break-up-time in so many cases. All ocular side effects of isotretinoin were treatable and disappeared completely within 1 month after stopping therapy.

Varicose vein stripping--a prospective study of the thrombotic risk and the diagnostic significance of preoperative color coded duplex sonography

Insufficiency of epifascial veins promotes venous ulceration and increases thromboembolic risk in general surgery patients. Epifascial varicose vein stripping is therefore considered the most effective prophylactic procedure. Thromboembolic risk of patients undergoing this surgical procedure has not yet been prospectively evaluated but appears to be lower than in general surgery patients. The gold standard of preoperative assessment of varicose surgery patients is ascending pressure phlebography, but this technique is invasive, time consuming and costly. We prospectively investigated 100 consecutive varicose vein surgery patients for postoperative thrombosis. Ascending pressure phlebography (APP) and colour coded duplex sonography (CCDS) were performed before and 10 to 21 days after the stripping operation in 100 and 70 patients, respectively. APP revealed no postoperative deep vein thrombosis in all 100 limbs investigated (0 percent; 95 percent confidence interval: 0 to 2.95). With regard to epifascial vein reflux there was good agreement between APP and CCDS (quadratic weighted kappa: 0.76). In 67 out of 73 superficial veins investigated excellent agreement of diagnostic accuracy was found for both diagnostic procedures (91.78 percent; 95 percent confidence interval: 82.96 to 96.92). We conclude that thrombotic risk of varicose vein surgery is low in properly selected patients. CCDS provides a high degree of accuracy in diagnosis of reflux and regular vein morphology and should therefore replace APP; however, APP does remain essential in the preoperative workup of atypical anatomical variants.

[Isotretinoin administration in treatment of acne vulgaris. A prospective study of the kind and extent of ocular complications]

Isotretinoin (13-cis-retinoic acid) is commonly used for the treatment of acne vulgaris. In the skin this substance causes an atrophy of sebaceous gland acini and a decrease in sebum production. Systemic treatment also alters meibomian gland function and structure. These alterations seem to be responsible for ocular complications (dryness of the eye, blepharitis, conjunctivitis) during therapy with isotretinoin. We inspected 30 patients before, during and after therapy with isotretinoin with regard to ocular side effects. Examination included careful slit-lamp inspection, measurement of break-up time (BUT) and the Schirmer test. Conjunctival smears were taken from every patient. The most frequently observed side-effects were decreased tear break up time and alterations of the lid margin. In addition, an enormous increase of Staphylococcus aureus in conjunctival flora was noticed. However, all ocular complications of systemic treatment with isotretinoin were reversible after cessation of therapy.

Zinc levels of serum and cervicovaginal secretion in recurrent vulvovaginal candidiasis

OBJECTIVE

To determine whether zinc deficiency in serum or vulvovaginal secretion is a risk factor for recurrent vulvovaginal candidiasis.

DESIGN

Prospective and controlled study.

SETTING

Department of Dermatology, University of Vienna.

SUBJECTS

21 women who had experienced at least three documented episodes of acute vulvovaginal candidiasis within the previous 12 months. Fifteen women without anamnesis of vulvovaginal candidiasis as a control group.

INTERVENTIONS

Blood samples were drawn for measurement of plasma zinc levels. Lavage of the vagina and ectocervix was performed with sterile saline solution for measurement of cervicovaginal zinc levels.

MAIN OUTCOME MEASURES

Zinc levels of serum and cervicovaginal secretions were determined by flame atomic absorption spectrophotometry.

RESULTS

We found no significant difference in the mean zinc concentration of plasma and cervicovaginal secretions between the recurrent vulvovaginal candidiasis and the control group. (p value for serum = 0.71, p value for secretion = 0.80). Zinc levels of plasma and cervicovaginal secretions showed no correlation (patient group: r = -0.05, control group: r = -0.07).

CONCLUSION

It is well known that zinc not only exerts a major impact on different immune functions, but also participates in growth and morphogenesis of Candida albicans. Our results could not confirm the previous hypothesis that zinc deficiency of serum is a risk factor in recurrent vulvovaginal candidiasis. It is possible that the local zinc level of cervicovaginal secretions essentially influences antifungal activity of third generation azole antimycotics.

Studies on the effect of short-term oral dihydroergotamine and troxerutin in patients with varicose veins

OBJECTIVE

To evaluate the clinical efficacy and pharmacologic effects of dihydroergotamine and troxerutin on varicose veins.

METHODS

A double-blind, randomized, placebo-controlled parallel-group study was conducted in 53 patients with primary varicose veins. Patients received either a fixed combination of 3 mg dihydroergotamine and 300 mg troxerutin three times a day or placebo for 3 weeks. Symptomatic improvement was assessed by a self-assessment score, venocontracting effects on a varicose vein were quantified by the venous compliance technique (VCT), and changes in venous dysfunction were measured by digital photoplethysmography (DPPG).

RESULTS

A significant reduction (p < 0.01) of subjective symptoms was observed in both groups. Results from VCT and DPPG after the therapy with dihydroergotamine and troxerutin or placebo were not significantly different (p > 0.05) from pretreatment values. Furthermore, no significant intergroup difference was observed when the before- and after-therapy differences of values of the self-assessment scores (VCT and DPPG) were compared.

CONCLUSION

In our study, 3 weeks of treatment with a fixed drug combination of 3 mg dihydroergotamine plus 300 mg troxerutin three times a day had no measurable effect compared with placebo on any of the evaluated end points.

Immunohistochemical study of in vivo and in vitro IgA coating of candida species in vulvovaginal candidiasis

OBJECTIVE

To evaluate whether quantitative or qualitative IgA deficiencies in cervicovaginal secretions can be identified in patients with recurrent vulvovaginal candidiasis.

DESIGN

Prospective and controlled study.

SETTING

Department of Dermatology, University of Vienna.

SUBJECTS

30 patients with symptomatic and recurrent vulvovaginal candidiasis at the time of their presentation. 30 healthy women as a control group.

INTERVENTION

Blood samples were drawn for measurement of serum IgA levels. Smears of the cervix and vagina were taken for direct microscopy and microbiological culture. Lavage of the vagina and ectocervix was performed with sterile saline solution for measurement of cervicovaginal IgA levels.

MAIN OUTCOME MEASURES

IgA levels of serum and cervicovaginal secretion evaluated by Single Radial Immunodiffusion. IgA labelling was demonstrated on fungal elements in vaginal smears and subcultured blastospores after incubation with vaginal secretions by immunohistochemistry.

RESULTS

We could not find any significant difference of IgA levels in serum and cervicovaginal secretions between the symptomatic group and healthy controls (p value for serum = 0.5796, p value for secretion = 0.2381). In vaginal smears yeasts revealed IgA coating on their surfaces, whereas three of the 61 subcultures were negative. Negative subcultures were assigned to three patients with recurrent candidiasis. No correlation was found between IgA levels of cervicovaginal secretions and staining intensity of subcultured blastospores after incubation with vaginal secretions (r = -0.0578). IgA levels of serum and vaginal secretion showed no correlation (r = -0.00012).

CONCLUSION

Recurrent vulvovaginal candidiasis cannot be attributed to IgA deficiency. In some cases an IgA coating defect of yeasts might be involved. In addition inactivation of the IgA molecule by candida proteases might be of pathogenetic importance.

[Imaging procedures in varicosities]

A prospective study was performed to compare the diagnostic potential of color-coded duplex sonography (CCDS) and that of ascending pressure phlebography (APP) in 61 patients before venous stripping. Varicosis of the long saphenous vein was correctly diagnosed and graded by CCDS in 87% of cases, and varicosis of the short saphenous vein in 97%. CCDS was inaccurate in 3 of 4 cases of recurrent varicosis of the long saphenous vein. Anterior femoral cutaneous varicosis (n = 3), mild postthrombotic syndrome (n = 1) and variant venous anatomy (n = 1) were not diagnosed on CCDS. One Baker cyst was diagnosed by CCDS. In the assessment of venous reflux CCDS seems to be superior to APP. Our results suggest that CCDS is a valuable diagnostic tool for routine imaging before venous stripping. However, patients with ambiguous or inconclusive CCDS results (eg. recurrent varicosis, venous variants) should be examined by APP.

Treatment of traumatic tattoos with various sterile brushes

BACKGROUND

Various types of brushes are efficient for the removal of foreign material accidentally projected into the skin by explosive or abrasive trauma.

OBJECTIVE

To evaluate how different times between injury and treatment influenced esthetic results, we retrospectively evaluated 14 patients subjected to the brushing technique.

METHODS

Two groups were identified. Group I had been treated within 24 hours of injury. In group II debridement had been performed later.

RESULTS

Cosmetic results were strikingly better in group I.

CONCLUSION

Our results demonstrate that debridement of traumatic tattoos should be carried out as soon as possible to achieve favorable cosmetic results.

Primary defect in alpha-adrenergic responsiveness in patients with varicose veins

Responsiveness of superficial hand veins to local infusions of noradrenaline was compared in patients with primary varicose veins and in healthy volunteers by use of the dorsal hand vein technique. Patients with varicose veins required significantly higher doses of noradrenaline for half-maximal venoconstriction than the dose required by control subjects (geometric mean, 11.6 ng/min in patients compared with 4.8 ng/min in control subjects; p = 0.006). Noradrenaline responsiveness in varicose veins was not significantly different from hand vein responsiveness in the same patients. Our findings indicate a constitutional decrease in venous alpha-adrenergic receptor responsiveness in patients with varicosities. Dilation of varicose veins does not further affect noradrenaline-induced venoconstriction.

Cutaneous aspergillosis

We report a cutaneous infection by Aspergillus flavus in a tetraplegic but otherwise healthy young man. He presented with multiple erythematous to violaceous indurated papules and plaques which had progressed to central ulcers or black eschars. Lesional scrapings, biopsies and cultures demonstrated a fungus, Aspergillus flavus, as the aetiological agent. As the patient had to leave for his home country before diagnosis had been established, we cannot report on the results of therapy in this case.