Microcirculation disorders of the skin.

Changes in the microcirculation of the skin are a frequently observed accompanying phenomenon of many diseases, far beyond the spectrum of dermatological diseases. Not all of these changes are pathological, many are transient and have no serious consequences. This is true for many inflammatory diseases such as psoriasis vulgaris or atopic eczema. However, there are also diseases in which functionally and morphologically recognizable microangiopathies lead to severe disease consequences. One of the most important diseases in this context is systemic sclerosis, an autoimmune systemic disease with multiple organ manifestations. Investigations of the cutaneous microcirculation are of great importance for the initial diagnosis as well as for prognosis and assessment of disease progression. In peripheral hemodynamic disorders such as peripheral arterial disease (PAD) and chronic venous insufficiency (CVI), understanding microcirculatory disturbances also plays an important role in therapy and in monitoring the success of therapeutic interventions.

Representing Sex and Gender Information in Biomedical Research.

In medicine and biomedical research, sex- and gender-related aspects are ubiquitous. If not considered adequately, a lower quality of research data can be expected together with a lower generalizability of study results with real-world settings. From a translational perspective, a lack of sex- and gender-sensitivity in acquired data can have negative implications for diagnosis, treatment (outcome and side effects), and risk prediction. To establish improved recognition and reward settings we set out to develop a pilot of systemic sex and gender awareness in a German medical faculty, with actions such as implementing equality in routine clinical practice and research, as well as in scientific practice (incl. science education). We believe that the change of culture will have a positive effect on research outcomes, lead to a rethinking in the scientific domain, foster sex- and gender-related clinical studies, and influence the design of good scientific practices.

Improvement of occupational leg edema and discomforts (RCT).

BACKGROUND: Edema and subjective leg complaints (e.g. pain, heaviness) after long standing or sitting, are defined as orthostatic leg complaints or occupational edema. Compression hosiery should help to prevent or decrease those symptoms. OBJECTIVE: Assess the effects on leg discomforts and leg volume and wearing comfort in two medical below-knee compression stocking types (A vs. B) with an interface pressure of 18 -20 mmHg and a below-knee-low-pressure support stocking (LPSS) with an interface pressure of 8-10mmHg (C). METHODS: Two different types of below-knee medical compression stockings and a LPSS were examined in this randomized, blinded, crossover trial in volunteers having leg discomforts and edema after being in an upright position during the day. Participants were divided into two cohorts, and each type of stocking was worn for three consecutive days in one week with a subsequent washout phase. The assessment of effects and wearing comfort was ascertained by questionnaires. Volume changes in the lower leg were measured with the Bodytronic 600® (Bauerfeind AG, Zeulenroda, Germany). RESULTS: A significant reduction of lower leg volume (mean stocking A: 204.7 ml; mean stocking B: 153.5 ml; mean stocking C: 48.2 ml) and a significant reduction of the life-quality dimension leg-complaints (p < 0.0001) was achieved by all three types of stockings. Compared to the LPSS both compression stockings decreased the lower leg volume significantly more (p < 0.001) and had a significant better fit (p < 0.001). CONCLUSION: Below-knee medical compression stockings with an interface pressure 18-21mmHg and LPSS with an interface pressure of 8-10 mmHg reduce significantly occupational orthostatic edema and leg discomforts which are due to long standing and sitting activities.

Validation of the psychometric properties of a "Modified Version of the Hornheider Screening Instrument" (HSI-MV) using a sample of outpatient and inpatient skin tumor patients.

BACKGROUND: The basis for adequate psycho-oncological care is the identification of patients with psychosocial support needs. The German Working Group for Psychooncology also recommends the Hornheider Screening Instrument (HSI) for this purpose. The question, "Is anyone in your family particularly burdened by the hospital stay?" is intended to capture disease-related family stress. But is this item equally suitable for outpatients and inpatients? The study objective was to examine how replacing the original item affects the test performance of this modified version of the HSI and the frequency of psychosocial stress. PATIENTS AND METHODS: 92 outpatients and 98 inpatients with skin tumors assessed their psychosocial situation using different questionnaires. RESULTS: Compared to inpatients, less than half as many outpatients answered the item in the affirmative. If the question was replaced by: "Is someone in your family particularly burdened by your disease or the course of the disease?" this setting-related difference did not arise. The "Alternative item" and the "Modified version of the HIS" (HSI-MV) proved to be superior to the original item and the original HSI with regard to all examined criteria. CONCLUSIONS: The HSI-MV can be used as a reliable and valid instrument for the systematic assessment of psychosocial care needs in outpatient and inpatient settings. Depending on care capacity, a threshold of ≥ 5 or ≥ 4 is appropriate. In addition to screening, the desire for support should be enquired.

Improvement of dynamic venous function after thermal ablation with steam vein occlusion - 6-weeks and 1-year follow-up after 167 treatments.

BACKGROUND: In this paper, the method of steam vein occlusion for the treatment of the great/small saphenous vein (GSV/SSV) was analyzed in terms of a therapeutic influence on the dynamic parameters of global vein function, its effects on subjective symptoms based on chronic venous insufficiency (CVI) and the side effects of the steam vein sclerosis (SVS). It has been questioned whether the effects of this method lead to a recommendation for routine clinical practice. METHODS: The venous drainage and the venous refilling time (T0) of the leg treated were determined by photoplethysmography (Elcat, Wolfratshausen, Germany) before, six weeks and one year after the intervention to examine the effects on global venous function. Further changes of clinical symptoms and findings were assessed by the Venous Clinical Severity Score (VCSS), preoperatively and after one year, and the complication rate at 6-week follow-up was monitored. RESULTS: The SVS was performed on 167 veins (GSV: 124; SSV: 43) in a total of 156 patients. Eight patients (5.1%) did not attend the 6-week follow-up, while 29 patients (18.6%) were lost in the 1-year follow-up. Patients were suffering from symptoms such as leg pain and leg edema, which resulted in a VCSS of 9.4 (cumulated mean score of all patients) preoperatively. The T0 was reduced to mean values of 20.6 s (GSV cohort) and 21 s (SSV cohort). The VCSS improved to 6.0 after one year. This correlated with the hemodynamic parameters. The T0 increased in the GSV cohort after six weeks to 31.8 s, p < 0.001, and showed a nonsignificant improvement to 32.2 s, p = 0.509, in the 1-year check. The T0 also increased in the SSV cohort significantly after 6 weeks to 30.1 s, p < 0.001, and showed a nonsignificant reduction after one year, p = 0.289. A total of 71%of the GSV and 69.8%of the SSV of the patients involved no complications following the treatment. Light complications (grade 1) occurred (reddening, hematoma, hyperpigmentation) in the majority: 24.2%of the GSV and 18.6%of the SSV. We noticed one grade 3 complication with thrombosis in the SSV cohort, which led to a pulmonary embolism. Forty-seven complete questionnaires were analyzed (responder rate: 28.1%); 40.4%of the patients had light complaints after the treatment, such as pain, warmth or local pressure sensations (Fig. 7); 63%of those patients noticed only slight pain at a maximum of 3 out of 10. The majority (91%) would recommend this procedure. CONCLUSION: The SVS revealed endoluminal catheter-based intervention to abolish venous reflux of the G/SSV as safe. As one therapeutic target is to eliminate venous reflux, effectiveness of a method cannot be based on sonographic data alone; one must further assess patients' symptoms and dynamic venous function. This data shows an improvement of patients' symptoms which correlated well with the improvement of the venous function in digital photoplethysmography. The SVS can be recommended as a catheter-based treatment in the future.

Psychosocial stress of dermatology inpatients and their relatives - Comparison of patients with and without cancer.

BACKGROUND: In the clinical treatment pathways of certified oncological centers, psychotherapeutic services are mandatory. Although patients with somatic, non-oncological illnesses show an equally high prevalence of psychosocial stress, these guidelines do not exist for the general hospital sector. Are these patients really less burdened and is psychological support only needed in individual cases? The example of dermatological patients will be used to show whether the need for psychosocial care and the desire for support vary between individuals with and without malignant disease. PATIENTS AND METHODS: Using the Hornheider screening instrument and distress thermometer, 216 dermatological inpatients assessed their psychosocial stress and that of a close relative. In addition, they were asked about their desire for support and preferred support provider. RESULTS: i) Patients without skin cancer were more frequently and more severely distressed than cancer patients. ii) Patients of both groups assessed their relatives to be approximately equally distressed. Compared with their own distress, cancer patients assessed their relatives as more frequently and on average more severely distressed. More than 50 % of all patients regarded their own disease as the cause of their relatives' distress. iii) The desire for support in both groups was about 18 %. iv) Doctors and psychologists were usually named as potential contact persons. CONCLUSIONS: The expansion of psychosocial support services for non-tumor patients and their relatives seems necessary. The establishment of appropriate screening methods should be considered. Further studies in other clinical areas are required.

Analysis of pigmented skin lesions and malignant melanoma by Laser Doppler flowmetry - Report of different cases and further analysis by a neuronal network.

BACKGROUND: Dermatoscopy is successfully used for the early diagnosis of suspicious skin lesions, however, correct diagnosis depends on training. There is evidence that wavelet analysis by Laser Doppler flowmetry (LDF) can identify malignant melanomas by their hypervascularization and changes in the capillary morphology. OBJECTIVE: To show the capability of LDF in the distinction of melanomas and benign pigmented skin lesions based on data collected over 16 years. METHODS: Evaluation of pigmented skin lesions was based on clinical information. The LDF measurements were taken. The suspect lesion was excised afterwards for histological work-up. Four case reports are presented. Data collected over 16 years was processed into a neuronal network to estimate the dignity of the lesion. RESULTS: A total of 517 suspicious lesions were analyzed by LDF. In the histological work-up, 114 lesions turned out to be melanomas, whereas 403 benign naevi were secured. Specificity to detect melanomas was good based on the clinical information. The LDF increases the sensitivity of melanoma detection, which is also illustrated in four case reports. CONCLUSION: In addition to clinical parameters, such as color and border, information from the LDF can help in the diagnosis of malignant melanomas. The LDF provides information on the vascularization of the skin lesion.

The course of Kaposi's sarcoma, a marker disease for the initial diagnosis of AIDS, under ongoing cART.

While Kaposi's sarcoma (KS) was common in the 1980s and early 1990s in HIV-positive patients and one of the most common AIDS-defining diseases, its prevalence today has decreased significantly due to the early and widespread use of chimeric antigen receptor T-cell (cART) therapy. The rapid initiation of cART or, if occurring during ongoing cART, an optimization of antiretroviral therapy leads to a healing of this tumour disease in most patients. The aim of the therapy is immune reconstitution, as the immunodeficiency resulting from the HIV disease (reduced CD4+-T helper cells) promotes the development and spread of KS. This case report describes the course of KS in the first diagnosis of AIDS in a 36-year-old patient. The HIV copy count was below the detection limit and the CD3+/CD4+ T-helper cell count was only slightly below the normal value in the six-month follow-up after initial diagnosis and initiation of cART therapy. However, the clinical findings in the one-year follow-up showed only a partial response, whereby it was noted that new tumour lesions also developed focally in addition to individual progressive lesions. This was demonstrated clinically, dermatoscopically and by laser Doppler fluxmetry measurements of the lesions. Such a progression was observed in about one-third of the patients affected in various studies and is called Immune Reconstitution Inflammatory Syndrome. Other therapies in addition to cART are necessary here to suppress this immunological phenomenon (including cytostatic drugs). Promising studies are currently underway, including utilising checkpoint inhibitors. These are of great therapeutic interest due to the high immunological activity of KS itself and usually of systemic inflammatory response syndrome.

A rare case of a patient with PPP syndrome presenting pancreatic pseudocysts, panniculitis, and symptoms of polyarthritis. A radicular cyst of the upper jaw could be another manifestation of the syndrome.

In rare cases, pancreatic enzymes can enter the bloodstream and cause fat necrosis in the bone and tissue leading to a disorder called pancreatitis, panniculitis, and polyarthritis syndrome. Clinicians should have this syndrome in mind when treating patients with pancreatitis.

["Decoratively figured blisters" on the whole integument in initially diagnosed ulcerative colitis]. / "Schmuckvoll konfigurierte Blasen" am gesamten Integument bei erstdiagnostizierter Colitis ulcerosa.

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

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

BACKGROUND: Chronic venous disease (CVD) is extremely common worldwide. The prevalence is increasing with age and is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. To our knowledge up to now no coherent study has been undertaken in patients with CVI who underwent an open venous surgery concerning complications, venous hemodynamics and perioperative symptomology in one study population. This was undertaken in our retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany. Part I covers postoperative complications in relation with co-morbidities, co-medication and clinical presentation. Part II will focus on pre- and postoperative hemodynamics and evolution of symptoms. METHODS: Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed. Number and type of complication were evaluated with regards to demographic parameters, co-existing medical conditions and procedure related aspects. Complications were grouped as no events (NE), neglectable adverse events (NAE), non-neglectable adverse events (NNAE) and severe (life-threatening) adverse events (SAE). RESULTS: In 467 extremities of 429 patients with CVI 130 (27,84%) postoperative complications were observed after open surgery, thereof 64 (13,7%) NAE, 66 (14,14%) NNAE and 0 SAE. 29 (6,76%) patients developed a postoperative surgical site infection, thereof 4 (0,9%) with consecutive septicaemia. Except one case with nerval lesion and paraesthesia and hypoesthesia not resolving after 12 months all complications resolved within surveillance time span of 12 months. Patients developing NAE had a higher BMI (p = 0.003), were more likely to have diabetes mellitus (p < 0.001), and co-morbidities leading to the intake of anti-platelet or anticoagulation drugs (p < 0.001). Metabolic syndrome (p < 0.001) and anti-platelet or anticoagulation (p < 0.001) could be defined as independent risk factors for the development of complications. Patients receiving open surgery of small saphenous veins had 8 times higher risk of calf muscle venous thrombosis (p = 0.001). CONCLUSION: Patients with a metabolic syndrome or receiving anti-platelet therapy or anticoagulation medication should undergo open venous surgery under hospital conditions with routine postinterventional surveillance visits. Patients undergoing an open surgery of SSV are definite candidates for postoperative subcutaneous heparin thromboprophylaxis. In general stripping below knee increases the risk of postoperative sensory deficit. This resolves in almost all patients within one year.

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

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

Psychosocial distress and desire for support among skin cancer patients - impact of treatment setting.

BACKGROUND: Diagnosis and treatment of malignancies are frequently associated with a variety of problems for affected individuals and their relatives. In order to ensure adequate psycho-oncological and social care, it is recommended to routinely assess patients' psychosocial distress. While psychosocial services for inpatients have been expanded in recent years, the outpatient care structure in terms of psycho-oncological support is far from satisfactory, especially in Mecklenburg-Western Pomerania. We therefore set out to investigate the following questions: Does the need for psychosocial care vary in relation to (a) the treatment setting (inpatients vs. outpatients) and (b) the diagnosis? (c) Do patients experiencing psychological distress desire support? PATIENTS AND METHODS: We asked both inpatients and outpatients to rate their psychosocial situation using the Hornheide Questionnaire. Patients were also asked about their desire for psychological support and the preferred contact person. RESULTS: (a) The treatment setting had no impact on the need for psychosocial care and the desire for support. (b) Depending on the type of skin cancer, there were significant differences in the need for such care among the 251 patients surveyed. (c) Despite a certain discrepancy, there was a significant correlation between psychosocial distress (39.0 %; n = 98/251) and desire for support (14.3 %; n = 35/245). (d) Patients experiencing distress primarily chose physicians (n = 21) and psychologists (n = 20) as potential contact persons. CONCLUSIONS: (1) In addition to the level of distress, the desire for support should be inquired. (2) Recommendations by physicians represent an important means of access to psycho-oncological services. (3) Services for outpatient support should be expanded.

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

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

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

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