Fumaric acid ester-induced T-cell lymphopenia in the real-life treatment of psoriasis

Background

Fumaric acid esters (FAEs) are used to treat psoriasis and are known to cause lymphopenia in roughly 60% of the patients. Much remains to be elucidated about the biological effects of FAEs on lymphocytes.

Objective

To evaluate the influence of long‐term FAE (Fumaderm^®) treatment on peripheral blood CD4⁺ and CD8⁺ T cells, CD19⁺ B cells and CD56⁺ natural killer (NK) cells in psoriasis.

Methods

In this single‐centre retrospective observational subcohort study, we obtained leucocyte and lymphocyte subset counts before initiating FAE therapy in 371 psoriasis patients (mean age, 47.8 years; 63.3% males) and monitored them during treatment (mean treatment duration, 2.9 years). Multiparametric flow cytometry was used for immunophenotyping.

Results

FAEs significantly reduced the numbers of CD4⁺ T, CD8⁺ T, CD19⁺ B and CD56⁺NK cells. Among lymphocyte subsets, the mean percentage reduction from baseline was always highest for CD8⁺ T cells, with a peak of 55.7% after 2 years of therapy. The risk of T‐cell lymphopenia increased significantly with the age of the psoriasis patients at the time that FAE therapy was initiated. It was significantly decreased for the combination therapy with methotrexate and folic acid (vitamin B9) supplementation. Supporting evidence was found suggesting that T‐cell lymphopenia enhances the effectiveness of FAE therapy.

Conclusions

Monitoring distinct T‐cell subsets rather than just absolute lymphocyte counts may provide more meaningful insights into both the FAE treatment safety and efficacy. We therefore suggest optimizing pharmacovigilance by additionally monitoring CD4⁺ and CD8⁺ T‐cell counts at regular intervals, especially in patients of middle to older age. Thus, further prospective studies are needed to establish evidence‐based recommendations to guide dermatologists in the management of psoriasis patients who are taking FAEs and who develop low absolute T‐cell counts.

Long-term real-life safety profile and effectiveness of fumaric acid esters in psoriasis patients: a single-centre, retrospective, observational study

BACKGROUND

Fumaric acid esters (FAEs) are an established systemic treatment for moderate-to-severe psoriasis. However, the long-term clinical safety and effectiveness of continuous FAE monotherapy and combination therapy have not been established.

OBJECTIVE

To examine the long-term safety and effectiveness of FAEs as monotherapy and in combination with phototherapy or methotrexate in patients with psoriasis treated at a single centre in Germany.

METHODS

This monocentric, retrospective observational study, with a follow-up period of up to 32.5 years, included 859 patients: 626 received FAE monotherapy, 123 received FAEs with concomitant phototherapy and 110 received FAEs with methotrexate.

RESULTS

Approximately half of patients (49.0%) reported adverse events (566 total events), most of which involved the gastrointestinal tract. Serious adverse events were reported in 2.3% of patients, but none were deemed to have a causal relationship with any of the treatment regimens. Adverse events leading to treatment discontinuation were observed in 12.9% of patients. A median duration of 1 year was observed in all three treatment subcohorts (P = 0.70) from initiation of FAE treatment to a 50% response rate, where response was defined as achieving a cumulative static Physician's Global Assessment (PGA) score of 'light' and at least a 2-point reduction in baseline PGA. A 50% response rate for the cumulative Psoriasis Area and Severity Index 75 was achieved in the FAE monotherapy subcohort after a median of 3 years of treatment, in the FAEs + phototherapy subcohort after 6.7 years and in the FAEs + methotrexate subcohort after 8.1 years (P = 0.001).

CONCLUSION

According to our data, FAEs as monotherapy or in combination with phototherapy or methotrexate are safe and beneficial for long-term clinical use. However, multicentre, randomized controlled trials are required to establish the clinical value of monotherapy versus combination therapy and the optimal treatment duration.

Actual procedures of diagnostics and treatments of crural venous ulcer in specialized German praxis and clinics

Background: To evaluate the implementation of the guidelines of the German Society of Phlebology for venous crural ulcer a survey was conducted during the annual meeting of the German Society of Phlebology 2008 in Bochum. Methods: All 719 medical participants got an anonymized questionnaire asking for supply of crural ulcer in their institution. Results: The recurrent 66 questionnaires (9.2%) were filled by colleagues from practice or hospital, mostly surgeons, dermatologists, phlebologists and vascular surgeons. As basic diagnostics vein doppler (56.1%), duplex (75.8%) or measurement of brachial-ankleindex (83.3%) were performed. Compression therapy is used in all institutions. Mainly used wound dressings are polyurethane foam dressings, alginates, hydrocolloids and silver dressings. About 2/3 conduct surgical therapy of ulcers. Conclusion: Supply of ulcus cruris by the participants of the annual meeting of the DGP corresponds mainly, but not in all aspects to the guidelines. Further efforts for a spread of the guidelines are necessary.

Erfolgreiche Schaumsklerosierung einer Vulvavarikose

Die Vulvavarikosis im Rahmen einer Varicosis pelvis geht häufig mit Refluxen im Beckenbereich einher. Wir berichten von einer Patientin, bei der kathetergestützt ein Coiling und eine Sklerosierung einer Varikose der linken Vena ovarica vorgenommen wurden. Danach bestand noch eine größere Varize an der linken Labia major mit Druckgefühl und Schmerzen beim Sitzen. Wir verödeten diese Varize mit aufgeschäumten Verödungsmittel (Aethoxysklerol/Luft im Verhältnis 1 : 5, aufgeschäumt nach Tessari). Mit einer einzigen Injektion konnte die Varize verschlossen werden, obwohl eine lokale Kompression unmöglich war. Die Patientin ist über einen Nachbeobachtungszeitraum von 3 Monaten beschwerdefrei und zeigt keine Anzeichen eines Rezidives.

Therapie der Stammvarikose der Vena saphena magna mittels kathetergestützter Mikroschaum-Sklerosierung ohne Heparinprophylaxe

Die kathetergestützte Sklerosierungstherapie der V. saphena magna (VSM) ist bei entsprechender Indikation eine gute Alternative zur operativen Intervention. Umstritten ist die Notwendigkeit einer postinterventionellen Heparingabe. Ziel unserer Untersuchung war die Bestimmung von Effektivität und Sicherheit der kathetergestützten Sklerosierungstherapie der VSM mit 8 ml Mikroschaum ohne Heparintherapie. Patientinnen, Methoden: Bei 7 Patientinnen mit Insuffizienz der VSM Grad III-IV nach Hach wurde in einer offenen prospektiven Untersuchung eine kathetergestützte Sklerosierungstherapie durchgeführt. Befundkontrollen folgten nach 24 h, 1 Woche und 3 Monaten. Ergebnisse: Bei allen Patientinnen war nach komplikationsloser kathetergestützter Sklerosierungstherapie ein suffizienter VSM-Verschluss festzustellen. Die Nebenwirkungen waren harmlos, passager und selbstlimitierend. Thromboembolische Ereignisse traten nicht auf. Schlussfolgerung: Die kathetergestützte Sklerosierungstherapie stellt in Zusammenschau der Literatur und unseres kleinen Kollektivs ein sicheres und effektives therapeutisches Verfahren der VSM-Stammvarikose dar. Im Gegensatz zur endovenösen Laser- oder Radiowellentherapie ist sie mit geringerem technischen und zeitlichen Aufwand verbunden. Unter Berücksichtigung der Literatur sowie eigener Erfahrungen ist die kathetergestützte Sklerosierungstherapie ohne eine postinterventionelle Heparintherapie möglich, falls keine thromboembolischen Risikofaktoren vorliegen.

Prospective epidemiological study on the beginning of varicose veins

Objective: To conduct a longitudinal vein study in a young study population on when and how varicose veins develop in healthy veins. Population, method: The initial study population consisting of pupils aged 10–12 (BO I, n = 740) underwent clinical and ultrasound follow-up at the ages of 14–16 (BO II, n = 518), 18–20 (BO III, n = 459) and 29–31 (BO IV, n = 136). During BO I-IV all venous findings detected (including preclinical refluxes of the saphenous veins) were recorded. Results: The data were broken down to reveal the incidence and prevalence of venous refluxes (VR), varicose veins (VV) and venous abnormalities (VA) for each part of the study. Furthermore, the data were analyzed longitudinally to identify any correlations between VR and VV in the two saphenous veins. Conclusions: Since none of the study subjects exhibited VV during BO I, the study permits evaluation of the venous situation in the subjects from birth on. The manifestation of a truncal VV is preceded by a VR in the same vein (p = 0.039). VR occurred mainly during puberty (BO I: 2.5%, BO III: 18.5%, BO IV: 25%). A preclinical VR represents a 30% risk (95% CI: 13–53%) of developing a truncal VV within four years, as a consequence, subsequent preventive 2-year follow-up examinations are recommended.

Abheilen eines Morpheaherdes im Bereich einer Vena-saphena-magna-Varikosis nach Sklerosierungstherapie

Bei einer 65jährigen Patientin mit der Diagnose einer Seitenastvarikosis der Vena saphena magna bei Muskelpumpeninsuffizienz Grad II mit besserbarer Venenfunktion am linken Bein wurde eine Sklerosierungstherapie mit Natriumjodid/Jod (Varigloban® 4%) und Polidocanol (Aethoxysklerol® 3%) durchgeführt. Bei der Patientin bestand ein Morphea-Plaque am linken lateralen Oberschenkel im Bereich der Seitenastvarikosis der Vena saphena magna, welcher sich nach Abschluß der Sklerosierung komplett zurückbildete. Wir nehmen an, daß es bei unserer Patientin nach Änderung der lokalen Terrainfaktoren mittels Sklerosierungstherapie zu einem Abheilungsreiz für den Morphea-Plaque am Oberschenkel gekommen ist. Ob die chronische Veneninsuffizienz die Entstehung der Morphea-Plaques durch eine lokale Entzündung und/oder durch z. B. Druck begünstigt hat, muß offenbleiben.

Durchmesser der Vena saphena magna in der Krossenregion bei gesunden Venen und primärer Stammvarikosis

Ziel dieser Studie war, festzustellen, ob sich die Venendurchmesser in der Krossenregion der Vena saphena magna (VSM) bei gesunden und refluxführenden Venen unterscheiden. Methode: 100 Beine mit unauffälligem klinischen und Ultraschall-Doppler-Befund und normaler digitaler Photoplethysmographie sowie 100 Beine mit dopplersonographisch nachweisbarem Reflux in der Krosse der VSM wurden mittels farbkodierter Duplexsonographie vermessen. Alle Untersuchungen wurden am stehenden Patienten durchgeführt. Bei den gesunden Beinen betrug der Durchmesser 1 cm distal der Krosse der VSM 5,3 ± 1,2 mm sowohl in Ruhe als auch beim Valsalva-Preßversuch. Ergebnis: 3 cm distal lag der Wert bei 4,9 ± 1,1 mm. Bei einer Stammvarikosis der VSM war der Durchmesser signifikant größer (8,1 ± 2,2 mm 1 cm distal der Krosse in Ruhe, 8,8 ± 2,5 mm beim Pressen, 7,3 ± 2,6 mm 3 cm distal der Krosse). Mit zunehmendem Grad der Stammvarikosis nach Hach nahmen die Durchmesser tendenziell zu. Schlußfolgerung: Wir konnten zeigen, daß bei einem Venendurchmesser ab 7,0 mm 1 cm distal der Krosse mit einer Wahrscheinlichkeit von 92% von einer Klappeninsuffizienz ausgegangen werden kann. In die duplexsonographische Beurteilung der VSM sollte der Durchmesser in der Krossenregion als Parameter einfließen.

Optical coherence tomography of cutaneous lupus erythematosus correlates with histopathology

Diagnosis of cutaneous forms of lupus erythematosus (LE), including chronic discoid LE (CDLE) and subacute cutaneous LE (SCLE), is usually based on characteristic clinical and histopathological findings. We aimed to visualize morphological changes in lesions of cutaneous LE using optical coherence tomography (OCT), and to correlate the OCT findings with histopathology. Six patients with CDLE and five patients with SCLE were investigated. Prior to skin biopsy, OCT assessment was performed on previously marked lesions. The images of OCT and corresponding histology were evaluated side-by-side on the PC screen. The thickening and disruption of the entrance signal in OCT images correlated with the hyperkeratosis which was observed in the histological sections. Atrophy of the epidermis, which was demonstrated by histology, could also be detected in the OCT pictures showing a thinned layer below the entrance signals. On OCT, a patchy reduction of reflectivity was observed in the upper dermis corresponding to dense patchy, partly lichenoid, lymphocytic infiltrates and oedema of the upper dermis. Furthermore, OCT images displayed increased signal-free cavities which histopathologically corresponded to dilated vessels in the upper dermis. All OCT parameters studied significantly (P < 0.05) correlated with histopathological features as indicated by coefficients of correlation ranging from 0.55 to 0.94. OCT enables to demonstrate micromorphological changes in cutaneous LE which correlate with histopathological findings. Nevertheless, the current technique does not allow one to visualize definite diagnostic features of cutaneous LE. However, OCT may be a promising method for objective monitoring of LE activity and treatment effects over time in vivo

Lipolysis of Lipomas in Patients with Familial Multiple Lipomatosis: An Ultrasonography-Controlled Trial

Background:

Surgery of multiple lipomas, as in patients with familial multiple lipomatosis, is often limited by poor aesthetic outcome owing to extensive scarring. For this reason, phosphatidylcholine (PDC) has been widely used to treat areas of localized fat accumulation. However, no reports of lipoma therapy with intralesional application of PDC, that is, injection lipolysis, have been published to date.

Objective:

To investigate whether injection lipolysis with PDC is an effective therapeutic option for patients with multiple lipomas.

Methods:

Thirty lipomas in 10 patients were sonographically measured prior to treatment. Four injections at intervals of 6 to 8 weeks were done. Sonographic measurements of lipoma size were repeated before each injection. Side effects, a pain score using a visual analogue scale, and patient satisfaction were noted. In one lipoma, histologic changes after lipolysis are described.

Results:

After four injections, a significant reduction in size of 45.8% was achieved. No complete elimination was seen in any lipoma. Histology showed a mild granulomatous septal panniculitis. Hematoma occurred in eight cases (27%). Four patients described pain on pressure for 3 days after injection. No severe side effects or systemic reactions were observed.

Conclusion:

Although surgery is the gold standard for lipoma therapy, injection lipolysis with PDC can also significantly reduce lipoma size. Complete elimination was not observed in any lipoma. Given that this was a short-term study, long-lasting therapeutic effects and possible recurrence of lipoma cannot be evaluated.

Occlusion rate, venous symptoms and patient satisfaction after radiofrequency-induced thermotherapy (RFITT®): are there differences between the great and the small saphenous veins?

BACKGROUND

Previous studies on the therapy of insufficient saphenous veins mainly compare different treatment methods. Only a few investigate differences of a specific treatment option between the great (GSV) and the small saphenous vein (SSV). The aim of this study was to evaluate the efficacy, clinical improvement and patient satisfaction after radiofrequency-induced thermotherapy (RFITT®) with regard to the treated vein.

PATIENTS AND METHODS

We included 65 patients (40 women, 25 men; mean age 54.75 years) who were treated with RFITT® for incompetent saphenous veins (n = 83: 62 GSV, 21 SSV). Occlusion rates were determined by duplex-sonography. Additionally, we performed a prospective analysis of venous symptoms and signs by means of a standardized questionnaire and of patient satisfaction using a semi-quantitative rating (1 = very good, 6 = insufficient).

RESULTS

The GSV group showed a significantly greater reduction of venous symptoms in comparison to the SSV group (p = 0.005) despite no significant differences in long term occlusion rates (mean time after operation: 22 months) of 90 % in the GSV group and 81.8 % in the SSV group (p = 0.598). Following the procedure, detailed analysis revealed significantly more swelling (p = 0.022), feeling of heavy legs (p = 0.002) and nightly calf cramps (p = 0.001) in the SSV group. Additionally, RFITT® led to a significant improvement in patient satisfaction in the GSV group (from 1.93 at day 1 - 3 to 1.41 after 6 - 12 months, p = 0.009) but not in the SSV group (from 2.29 to 2.07, p = 0.43).

CONCLUSIONS

With regard to the improvement of venous symptoms and patient satisfaction, the benefit of RFITT® is greater for patients with incompetent GSV compared to those with incompetent SSV.

[Seafood allergy in cooks: a case series and review of the literature]

BACKGROUND

Seafood is a very potent allergen. Epidemiological studies of seafood allergy in the highly exposed cooking profession are lacking. The objective of this first case series was to demonstrate the high relevance and consequences of seafood allergy in cooks. PATIENTS UND METHODS: Retrospective analysis of all the case files sent in which the presence of an occupational disease according to no. 5101 of the appendix of the German ordinance on industrial disease was to be clarified.

RESULTS

Thirty cooks (men 70 %) with an occupational seafood allergy were assessed between January 2008 and April 2014. Seafood allergy was observed in youngish workers(median age 24.7 yrs.) with an early manifestation of the disease (after 1.7 yrs. of occupation in median). In all except one (96.7 %) onset was localized on the hands.Most commonly documented were immediate sensitizations to cod, salmon, trout,and herring. Emergency treatment due to an anaphylactic shock at the workplace became necessary in 5 cases (16.7 %). In 27 cases (90 %) discontinuation of occupation was needed and was carried out after 6.3 yrs. of occupation in median.

CONCLUSIONS

Seafood allergy in cooks is mostly characterized by a quick progressive course of disease, already at the start of the cooking career. The prognosis for continuance in occupation is poor and an occupational disease is to be considered at a nearly stage. An emergency kit with an epinephrine auto-injector should be provided for life by the responsible accident insurer.

Neurological disorders in patients with bullous pemphigoid: clinical and experimental investigations

BACKGROUND

Previous studies have shown that patients with bullous pemphigoid (BP) are more likely to have neurological diseases (ND).

OBJECTIVES

To compare clinical findings in BP patients with and without ND and to investigate BP180 autoantibody binding in different neuronal tissues of mammalians.

METHODS

Our database was searched for clinical findings of in-patients with the definitive diagnosis of BP. Moreover, brain tissue of mammalians was treated with serum of BP patients with elevated BP180 autoantibodies using biochip mosaics.

RESULTS

Of 85/161 (52.8%) patients had a history of at least one ND (BP+ND). BP180 (P = 0.018), eosinophils (P = 0.043) and patients' accommodation in nursing homes (P < 0.0001) remained in the logistic regression model as significant independent predictors for the presence of ND in patients with BP. Subgroup analysis of community-dwelling BP patients revealed 25/93 (26.9%) patients with ND. In this population, the presence of ND also significantly correlated with BP180 (r = 0.26; P = 0.0003) and eosinophils (r = 0.19; P = 0.0087). In the animal model, no BP180-specific immunofluorescence could be detected.

CONCLUSIONS

Our data support results of previous studies detecting significantly increased frequency of ND in BP patients. We have shown that raised BP180 titres and blood eosinophils are independent predictors for the presence of ND in BP patients. However, our experimental data do not support previous results indicating that specific binding of BP180 antibodies in neuronal tissue plays a pathogenetic role in ND.

Fumarate treatment in progressive forms of multiple sclerosis: first results of a single-center observational study

OBJECTIVES

Therapeutic options in progressive forms of multiple sclerosis (MS) are still limited. Dimethyl fumarate (DMF) has immunomodulatory properties but may also exert antioxidative cytoprotective effects. Hence, it may be a therapeutic option for progressive MS. The aim of this observational study was to evaluate safety, adherence and efficacy of fumarates in patients with primary progressive MS (PPMS) or secondary progressive MS.

METHODS

Patients with progressive MS whose condition had failed to respond to standard therapies and had worsened received the fumarate mixture Fumaderm, licensed for psoriasis therapy in Germany, or DMF by pharmaceutical preparation (Bochum ethics approval no. 4797-13). At regular follow-up visits, tolerability and disease course were assessed.

RESULTS

Twenty-six patients [age 54 ± 7.8 years; female = 13 (50%); PPMS = 12 (46.2%); Expanded Disability Status Scale (EDSS) = 6.0 ± 0.4 (range 3.5-8.0); disease duration = 14.1 ± 8.7 years] were initiated on treatment with Fumaderm (n = 18) or pharmacy-prepared DMF (n=8). During a mean follow-up period of 13.2 ± 7.5 months (range 6-30) only five patients (19.2%) reported minor complaints. In 15 patients (57.7%) EDSS remained stable. In five cases (19.2%) there was even a decrease in EDSS while in six patients (23.1%) there was an increase in EDSS of more than 0.5 points, reflecting deterioration. Laboratory values were controlled for lymphopenia, renal and hepatic values, without any safety problems. We observed no significant differences between the two pharmaceutical forms.

CONCLUSION

Our pilot data indicate that fumarate therapy appears to be safe and well tolerated by patients with progressive MS. In more than 75% of cases no further disease progression was evident. However, controlled studies are warranted to evaluate the detailed therapeutic potential of fumarates and their long-term effects in progressive MS.

Angiokeratoma Fordyce of the Glans Penis: Combined Treatment with Erbium: YAG and 532 nm KTP (Frequency Doubled Neodynium: YAG) Laser

A rare case of angiokeratoma Fordyce localized on the margin of the glans penis in a 52-year-old Caucasian patient is reported. Combined treatment with Erbium: YAG and 532 nm KTP (frequency doubled Neodynium: YAG) laser led to excellent cosmetic results.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]

BACKGROUND

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).

METHODS

To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.

RESULTS

In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.

CONCLUSIONS

Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

MicroRNA in non-melanoma skin cancer

MicroRNAs (miRNAs) are a fairly novel class of 17- to 23-nucleotide (nt), short, non-coding RNA molecules that have revolutionized our understanding of gene regulation and opened new possibilities in the future of gene therapy. Here, we review the potential role of miRNAs in non-melanoma skin cancer (NMSC) and summarize the current studies available in this new aspect of NMSC research.

Prevalence of human polyomaviruses in common and rare types of non-Merkel cell carcinoma skin cancer

BACKGROUND

Little is known about the association of human polyomaviruses (HPyVs) other than Merkel cell polyomavirus (MCPyV) with nonmelanoma skin cancer.

OBJECTIVES

To evaluate the presence of HPyV6, HPyV7, trichodysplasia spinulosa-associated polyomavirus (TSV), also called HPyV8, and the recently discovered HPyV9 in basal cell carcinoma (BCC), actinic keratosis (AK), squamous cell carcinoma in situ (SCCis), squamous cell carcinoma (SCC), keratoacanthoma (KA), microcystic adnexal carcinoma (MAC) and atypical fibroxanthoma (AFX).

METHODS

Archival paraffin-embedded samples (n = 193: 41 BCC, 31 AK, 8 SCCis, 52 SCC, 42 KA, 5 MAC and 14 AFX) were analysed for the presence of the respective HPyV by polymerase chain reaction (PCR). HPyV DNA loads (HPyV DNA copies per β-globin gene copy) were determined in all HPyV-positive samples by quantitative real-time PCR. Immunohistochemical analysis of MCPyV large T-antigen (LTA) expression was performed using the monoclonal antibody CM2B4.

RESULTS

MCPyV DNA was found in 29% of BCC, 19% of AK, 25% of SCCis, 27% of SCC, 29% of KA, 0% of MAC and 29% of AFX. MCPyV DNA loads never exceeded 0·3 MCPyV DNA copies per β-globin gene copy (median 0·004). In the immunohistochemical analysis of MCPyV LTA expression, all evaluated samples (32 MCPyV DNA-positive samples) were LTA negative. HPyV6 DNA was found in 7% of BCC, 3% of AK, 12% of SCCis, 4% of SCC, 5% of KA, and 0% of MAC and AFX. HPyV6 DNA loads never exceeded 0·7 HPyV6 DNA copies per β-globin gene copy (median 0·015). None of the 193 samples was positive for HPyV7, TSV or HPyV9 DNA.

CONCLUSIONS

Our findings argue against a pathogenic role for MCPyV, HPyV6, HPyV7, TSV and HPyV9 in the analysed types of non-Merkel cell carcinoma skin cancer.

New Concept: Different Types of Insufficiency of the Saphenofemoral Junction Identified by Duplex as a Chance for a More Differentiated Therapy of the Great Saphenous Vein

Even though the item ‘saphenofemoral junction’ (SFJ) is anatomically well defined, the incontinence of the SFJ is often incompetently described in clinical practice and studies. Especially with regard to the optimal therapy of the great saphenous vein, it might be of importance to have a more distinct regard to the SFJ as it is known that about 10–30% of the saphenous refluxes have no femoral origin. Considering the terminal and preterminal valve three types of incompetence of the SFJ may be differentiated: Type 1: Incompetent terminal, but competent preterminal valve; Type 2: Competent terminal, but incompetent preterminal valve; Type 3: Incompetent terminal and preterminal valve (complete incompetence). A review on prior studies and reports leads to the assumption that the differentiation of the distinct types of SFJ-incompetence allows a more individual and – perhaps – more effective therapy. Finally, studies are necessary to evaluate the here given new concept.

Efficacy and comfort of medical compression stockings with low and moderate pressure six weeks after vein surgery

OBJECTIVE

The first two authors contributed equally to this work. A prospective, randomized study to evaluate efficacy, safety, and comfort of thigh-high, round knitted medical compression stockings (MCSs) with different pressure six weeks after vein surgery.

METHODS

Female patients undergoing vein surgery were randomized for a compression therapy with low (18-21 mmHg, group A) or moderate (23-32 mmHg, group B) pressure MCSs. Follow-up was done by a phlebological experienced, blinded physician (pressure control, clinical aspect, duplex scan, and questionnaire) one and six weeks after surgery.

RESULTS

Totally, 88 patients (41 in group A and 47 in group B) were analyzed. One week after surgery, patients of group B had significantly lower edema scores than patients of group A either in the clinical assessment (0.7 vs. 0.3; p = 0.016) or in the B-mode scan (0.9 vs. 0.4; p = 0.013). Significant less patients of group B had a feeling of "tightness" (p = 0.01) and significant more a reduction of discomfort (p = 0.01) after week 1 but with no significance in week 6. There was no significant difference according to other clinical and ultrasound findings such as hematoma, infection, hyperpigmentation, cording, or thrombosis after one or six weeks. In week 1 and week 6, more patients suffered from pain in group A (week 1 p = 0.24, week 6 p = 0.063). Application of the MCSs was easier in group A in week 1 but similar in groups A and B in week 6. Muscle vein thrombosis occurred in one patient of group A.

CONCLUSION

Compression stockings with a pressure of 23-32 mmHg facilitate a faster resolution of clinical and ultrasound verified edema and the subjective feelings of pain, tightness, and discomfort of the leg in the early period after surgery but have no difference in the longer post-surgical period compared to stockings with a pressure of 18-21 mmHg.

Clinical characteristics and survival data of melanoma patients with nevus cell aggregates within sentinel lymph nodes

Histopathologic differentiation of nevus cell aggregates and metastatic melanoma in lymph nodes is challenging. Patients with melanoma who had undergone sentinel lymph node (SLN) biopsy were evaluated using univariate and multivariate analyses as well as Kaplan-Meier statistics. Of the 651 patients, 50 (7.7%) had a nodal nevus in the SLN. In the logistic regression model, primary melanoma on the lower extremities proved to be the strongest independent negative predictor of nodal nevi with an odds ratio of 0.11 (95% confidence interval, 0.034-0.36; P = .0002). Overall 5-year survival (P = .17) and 5-year disease-free survival (P = .45) of patients with nodal nevi did not significantly differ from that of patients with negative SLNs. The frequency and anatomic localization of nodal nevi observed in the present study are in line with previous studies. Our 5-year survival data clearly demonstrate that nevus cell aggregates in lymph nodes have to be considered a benign condition even though it occurs in patients with melanoma. This study provides an indirect proof of validity and accuracy of current histopathologic methods for differentiation between nodal nevi and melanoma metastasis.

Association of autoimmune diseases with lichen sclerosus in 532 male and female patients

Lichen sclerosus is a relatively common chronic inflammatory skin disease that predominantly affects the anogenital area. Accumulating evidence indicates that lichen sclerosus in women may be associated with other autoimmune disease, whereas this association seems to lack in male patients. We retrospectively evaluated the prevalence of autoimmune diseases and serological parameters indicative for autoimmunity in male and female patients with lichen sclerosus. Of the 532 patients (396 women, 136 men; 500 adults, 32 children; mean age: 49 years; range 1-89 years; female:male ratio 3:1), 452 (85%) had genital and 80 (15%) had extragenital disease. In women, lichen sclerosus was significantly more often associated with at least one autoimmune disease as compared to men (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.9-9.6; p<0.0001). Moreover, female patients with lichen sclerosus had sinificantly more often associated autoimmune thyroid diseases (OR 4.7, 95% CI 1.8-11.9; p<0.0002), antithyroid-antibodies (OR 2.7, 95% CI 1.1-6.5; p=0.023), and elevated autoantibodies (OR 4.1, 95% CI 1.9-9.3; p<0.0001) as compared to male patients. This observation is suggestive for a different pathogenetic background in male and female patients.

Compression and venous ulcers

Compression therapy is considered to be the most important conservative treatment of venous leg ulcers. Until a few years ago, compression bandages were regarded as first-line therapy of venous leg ulcers. However, to date medical compression stockings are the first choice of treatment. With respect to compression therapy of venous leg ulcers the following statements are widely accepted: (1) Compression improves the healing of ulcers when compared with no compression; (2) Multicomponent compression systems are more effective than single-component compression systems; (3) High compression is more effective than lower compression; (4) Medical compression stockings are more effective than compression with short stretch bandages.

Healed venous leg ulcers show a high relapse rate without ongoing treatment. The use of medical stockings significantly reduces the amount of recurrent ulcers. Furthermore, the relapse rate of venous leg ulcers can be significantly reduced by a combination of compression therapy and surgery of varicose veins compared with compression therapy alone.

Foam sclerotherapy with enoxaparin prophylaxis in high-risk patients with postthrombotic syndrome

BACKGROUND

According to the current guidelines for sclerotherapy hypercoagulability and thrombophilia with or without deep venous thrombosis are seen as relative contraindication for this treatment. But often such patients have an indication for a sclerotherapy. Recommendations for additional anticoagulation for sclerotherapy are missing.

PATIENTS AND METHODS

In this retrospective analysis (2009 - 2010), 54 patients with deep venous thrombosis and/or pulmonal embolism in their medical history that had had foam-sclerotherapy of truncal or tributary veins with polidocanol 0.5 - 3 % without prior anticoagulation therapy were included. In addition to compression treatment (23 - 32 mmHg) for 3 weeks patients were treated with enoxaparin 40 mg once a day for 3 days after sclerotherapy. Clinical and duplex controls were conducted before every treatment and 2 - 3 weeks after the last injection.

RESULTS

Sclerotherapy was done on one (30/54) or on both (24/54) legs. In 2/54 legs a truncal vein and in all patients tributaries were treated. The volume per treatment session averaged 3.3 ml foam (2 - 6 ml). The patients had undergone an average of 4.9 treatments (1 - 11); altogether 262 sessions. There were no cases of deep venous thrombosis or symptomatic pulmonary embolism. In 7/262 treatments (2.7 %) symptomatic localized phlebitis occurred and in 2/262 (0.8 %) patients an ascending phlebitis beyond the sclerotherapy region was observed.

CONCLUSIONS

Based on current data, foam sclerotherapy can be regarded as safe in patients with anamnestic thromboembolism when co-treated with compression therapy (23 - 32 mmHg) and enoxaparin 40 mg once per day for 3 days post sclerotherapy. The current study is the first with a standardized regime. In view of the limitations of this study there should be further randomized controlled trials.

Comparative microarray analysis of microRNA expression profiles in primary cutaneous malignant melanoma, cutaneous malignant melanoma metastases, and benign melanocytic nevi

Perturbations in microRNA (miRNA) expression profiles have been reported for cutaneous malignant melanoma (CMM) predominantly when examined in cell lines. Despite the rapidly growing number of newly discovered human miRNA sequences, the availability of up-to-date miRNA expression profiles for clinical samples of primary cutaneous malignant melanoma (PCMM), cutaneous malignant melanoma metastases (CMMM), and benign melanocytic nevi (BMN) is limited. Specimens excised from the center of tumors (lesional) from patients with PCMM (n=9), CMMM (n=4), or BMN (n=8) were obtained during surgery. An exploratory microarray analysis was performed by miRNA expression profiling based on Agilent platform screening for 1205 human miRNAs. The results from the microarray analysis were validated by TaqMan quantitative real-time polymerase chain reaction. In addition to several miRNAs previously known to be associated with CMM, 19 unidentified miRNA candidates were found to be dysregulated in CMM patient samples. Among the 19 novel miRNA candidates, the genes hsa-miR-22, hsa-miR-130b, hsa-miR-146b-5p, hsa-miR-223, hsa-miR-301a, hsa-miR-484, hsa-miR-663, hsa-miR-720, hsa-miR-1260, hsa-miR-1274a, hsa-miR-1274b, hsa-miR-3663-3p, hsa-miR-4281, and hsa-miR-4286 were upregulated, and the genes hsa-miR-24-1*, hsa-miR-26a, hsa-miR-4291, hsa-miR-4317, and hsa-miR-4324 were downregulated. The results of this study partially confirm previous CMM miRNA profiling studies identifying miRNAs that are dysregulated in CMM. However, we report several novel miRNA candidates in CMM tumors; these miRNA sequences require further validation and functional analysis to evaluate whether they play a role in the pathogenesis of CMM.

Medical emergencies on board commercial airlines: is documentation as expected?

Introduction

The purpose of this study was to perform a descriptive, content-based analysis on the different forms of documentation for in-flight medical emergencies that are currently provided in the emergency medical kits on board commercial airlines.

Methods

Passenger airlines in the World Airline Directory were contacted between March and May 2011. For each participating airline, sample in-flight medical emergency documentation forms were obtained. All items in the sample documentation forms were subjected to a descriptive analysis and compared to a sample "medical incident report" form published by the International Air Transport Association (IATA).

Results

A total of 1,318 airlines were contacted. Ten airlines agreed to participate in the study and provided a copy of their documentation forms. A descriptive analysis revealed a total of 199 different items, which were summarized into five sub-categories: non-medical data (63), signs and symptoms (68), diagnosis (26), treatment (22) and outcome (20).

Conclusions

The data in this study illustrate a large variation in the documentation of in-flight medical emergencies by different airlines. A higher degree of standardization is preferable to increase the data quality in epidemiologic aeromedical research in the future.

Association of CD69 up-regulation on CD4+ Cla+ T cells versus patch test, strip patch test and clinical history in nickel sensitization

Objective

The patch test (PT) with its modification - the strip patch test (SPT) - is the standard in vivo procedure to diagnose an allergic contact dermatitis (ACD). To date, none of the in vitro tests for the diagnosis of ACD fulfils the requirements of an easy, valid and reliable test. To investigate the prediction ability of a flow cytometric assay of CD69 up-regulation on CD4+ CLA+ T cells in nickel-sensitive and non-nickel-sensitive patients.

Methods

In a prospective, investigator-blinded, clinical study a total of 85 nickel-sensitive (n = 44; 51.8%) and non-nickel-sensitive patients (n = 41; 48.2%) were enrolled. The association between CD69 up-regulation on CD4+ CLA+ T cells on the one hand and PT, SPT, and clinical history on the other hand was measured. Association is expressed with c statistic values (receiver operating characteristic analysis) and corresponding 95% CIs.

Results

The associations were c = 0.57 (95% CI: 0.42-0.72) between CD69 up-regulation and PT, c = 0.49 (95% CI: 0.36-0.62) between CD69 up-regulation and SPT, and c = 0.51 (95% CI: 0.37-0.64) between CD69 up-regulation and clinical history.

Conclusions

CD69 up-regulation on CD4+ CLA+ T cells in vitro could not predict neither a positive PT or SPT result nor a positive clinical history to nickel sulfate. The combination of clinical history and patch testing still remains the basis for diagnosing ACD.

Thick legs - not always lipedema

Due to its increased presence in the press and on television, the diagnosis of lipedema is on the way to becoming a trendy diagnosis for those with thick legs. Despite this, one must recognize that lipedema is a very rare disease. It is characterized by disproportional obesity of the extremities, especially in the region of the hip and the legs, hematoma development after minimal trauma, and increased pressure-induced or spontaneous pain. Aids for making the correct diagnosis are (duplex) sonography, the waist-hip index or the waist-height index and lymphoscintigraphy. Important differential diagnoses are constitutional variability of the legs, lipohypertrophy in obesity, edema in immobility, edema in chronic venous insufficiency and rheumatic diseases. The symptom-based therapy of lipedema consists of conservative (compression, manual lymphatic drainage, exercise) and surgical treatments (liposuction). Until now there is no curative therapy. Obesity is an important risk factor for the severity and prognosis of lipedema. Further studies for a better understanding of the pathogenesis of lipedema and in the end possible curative treatments are urgently needed.

Acne inversa: evaluating antimicrobial peptides and proteins

Background

Acne inversa is a chronic, suppurative relapsing inflammatory skin disease that primarily affects the axillae, perineum and inframammary regions. Evidence suggests that the innate immune system is involved in the pathogenesis of acne inversa.

Objective

To investigate the role of the innate immune system in acne inversa.

Methods

Skin biopsies were obtained from inflammatory skin lesions (n=17) and from non-lesional skin (intraindividual control, n=17) of patients with acne inversa. Additional skin lesions were taken from patients with chronic venous leg ulcers (interindividual control, n=5). Quantitative real-time reverse transcription-polymerase chain reaction was used to determine the mRNA levels of antimicrobial peptides and proteins (AMPs), including human β-defensin (hBD)-1, hBD-2 and hBD-3, LL-37 (cathelicidin) and Ribonuclease 7 (RNase 7). mRNA levels were also determined for inflammatory and anti-inflammatory cytokines, including tumor necrosis factor-alpha (TNF-α), matrix metalloproteinase-1 (MMP1), interleukin (IL)-1β, IL-6, IL-8 and IL-10.

Results

The mRNA levels of hBD-2, LL-37, IL-1β, IL-6, IL-8, IL-10 and MMP1 were significantly higher in acne inversa lesions compared to non-lesional skin (p<0.05). A significant positive correlation expression was observed between hBD-2 mRNA expression and LL-37 (ρ=0.53, p=0.03), and between hBD-2 and RNAse 7 (ρ=0.68, p=0.006). When compared to the chronic venous leg ulcer lesions, acne inversa lesions showed a significantly higher expression of RNase 7 mRNA, while IL-1 β, IL-6, IL-8, TNF-α and MMP1 mRNA expression was significantly higher in the chronic venous leg ulcer lesions (p<0.05).

Conclusion

The AMP, cytokine milieu and tissue proteases in acne inversa lesions differ significantly from non-lesional skin and chronic venous leg ulcers. The positively correlating up-regulation of AMPs in acne inversa indicates an important role of the innate immune system in the pathogenesis of this disorder.

The miRNA machinery in primary cutaneous malignant melanoma, cutaneous malignant melanoma metastases and benign melanocytic nevi

Although several studies have shown a dysregulation of microRNA (miRNA) expression profiles in cutaneous melanoma, there has been little research on the miRNA machinery itself. In this study, we investigated the mRNA expression profiles of different miRNA machinery components in primary cutaneous malignant melanoma (PCMM), cutaneous malignant melanoma metastases (CMMM) and benign melanocytic nevi (BMN). Patients with PCMM (n = 7), CMMM (n = 6) and BMN (n = 7) were included in the study. Punch biopsies were harvested from the centers of tumors (lesional) and from BMN (control). In contrast to previous reports exploring specific clusters of miRNAs in PCMM, the present study investigates mRNA expression levels of Dicer, Drosha, Exp5, DGCR8 and the RISC components PACT, argonaute-1, argonaute-2, TARBP1, TARBP2, MTDH and SND1, which were detected by TaqMan real-time reverse transcription polymerase chain reaction (RT-PCR). Argonaute-1, TARBP2 and SND1 expression levels were significantly higher in BMN compared to PCMM (p < 0.05). TARBP2 expression levels were significantly higher in CMMM compared to PCMM (p < 0.05). SND1 expression levels were significantly higher in CMMM compared to PCMM and BMN (p < 0.05). Dicer, Drosha, DGCR8, Exp5, argonaute-2, PACT, TARBP1 and MTDH expression levels showed no significant differences within groups (p > 0.05). The results of this study show that the miRNA machinery components argonaute-1, TARBP2 and SND1 are dysregulated in PCMM and CMMM compared to BMN and may play a role in the process of malignant transformation.

Microarray analysis of microRNA expression in cutaneous squamous cell carcinoma

BACKGROUND

MicroRNAs (miRNAs) are a novel class of short RNAs that are capable epigenetically regulating gene expression in eukaryotes. MicroRNAs have been shown to be dysregulated in a variety of cancers. The data on miRNA expression in cutaneous squamous cell carcinoma (cSCC) are very limited, and microarray-based miRNA expression profiles of cSCC have not yet been determined.

OBJECTIVE

To describe differentially expressed miRNAs in cSCC.

METHODS

Seven patients with cSCC were enrolled in the present study. Tumor biopsies (n=7) were taken from the center of each tumor. Adjacent healthy skin (n=7) was biopsied as a control (intraindividual control). miRNA expression profiles of all specimens were detected by microarray miRNA expression profiling based on miRBAse 16 scanning for 1205 potential human miRNA target sequences. The microarray results were confirmed by TaqMan quantitative real-time polymerase chain reaction (qRT-PCR).

RESULTS

Non-stringent filtering with a non-adjusted p ≤ 0.05 revealed thirteen up-regulated and eighteen down-regulated miRNAs. Non-stringent filtering with a non-adjusted p ≤ 0.01 revealed three up-regulated (hsa-miR-135b, hsa-miR-424 and hsa-miR-766) and six down-regulated (hsa-miR-30a*, hsa-miR-378, hsa-miR-145, hsa-miR-140-3p, hsa-miR-30a and hsa-miR-26a) miRNAs in cSCC.

CONCLUSION

This study reveals differentially expressed miRNAs that may play a role in the molecular pathogenesis of cSCC and that are excellent candidates for further validation and functional analysis.