[Zoster disease after Shingrix vaccination]. / Zostererkrankung nach Shingrix-Impfung.

Shingrix is a recombinant adjuvant subunit vaccine. The vaccine is approved in Germany for prevention of zoster manifestation and postherpetic neuralgia in adults aged ≥60 years. In the case of bullous skin lesions after vaccination with Shingrix a zoster disease should be considered. Unexpected side effects associated with the vaccination should be reported to the Drug Commission of the German Medical Association.

[Pityriasis rubra pilaris : Successful treatment with ixekizumab]. / Pityriasis rubra pilaris : Eine erfolgreiche Therapie mit Ixekizumab.

Pityriasis rubra pilaris is a rare papulosquamous chronic skin disease. The disease often exists for years and is difficult to treat. Not only is it clinically similar to psoriasis vulgaris, but both diseases also have a similar cytokine profile. The successful use of biologicals is frequently reported in case reports. Studies with large numbers of cases are lacking.

Prospective multicentre cohort study on 9154 surgical procedures to assess the risk of postoperative bleeding - a DESSI study.

BACKGROUND: To date, there is still a debate how to deal with patients receiving antithrombotic agents prior to surgical procedures on the skin. OBJECTIVE: To prospectively assess complications after dermatosurgical interventions, especially bleeding, depending on anticoagulation therapy. METHODS: Patients underwent surgery consecutively as scheduled, without randomization, whether or not they were currently taking anticoagulants. Nine institutions of the DESSI (DErmatoSurgical Study Initiative) working group documented patient data prospectively on a standardized study sheet prior to and after 9154 dermatosurgical interventions. RESULTS: Bleeding complications were observed in 7.14% of cases (654/9154 surgeries). A severe bleed requiring intervention by a physician occurred in 83 surgeries (0.91%). In multivariate analysis, INR, length of the defect, perioperative antibiotic treatment, current treatment with anticoagulation therapy, age and surgery on hidradenitis suppurativa/acne inversa (HS/AI) were significant parameters independently influencing the risk of bleeding. Discontinuation of phenprocoumon therapy and subsequent switching to low molecular weight heparin was associated with the highest risk of bleeding (9.26%). CONCLUSION: Bleeding complications in skin surgery are generally rare. Even if slightly increased complication rates are found in patients taking anticoagulants during skin surgery, platelet inhibitors should not be stopped prior to surgery. If a surgical procedure in patients on a combination therapy of 2 or more antiplatelet cannot be postponed, it should be conducted with the patient remaining on combination therapy. Discontinuation of DOACs is recommended 24 h prior to surgery. Bridging of phenprocoumon should be terminated. In patients with a bleeding history, the INR value should be within the therapeutic range.

Reconstruction of nasal defects with forehead flaps in patients older than 75 years of age.

BACKGROUND: As the number of elderly patients diagnosed with non-melanoma skin cancer (NMSC) increases, the number of patients receiving dermatologic surgery also increases. Multimorbidity in this patient group is common. OBJECTIVE: The aim of this study is to assess the aesthetic and functional outcomes and complications of forehead flap (FHF) in elderly patients with NMSC. METHODS: Between 2006 and 2011, data for 28 patients 75 years of age or older who had been treated with FHFs under tumescent local anaesthesia were analysed. RESULTS: The median age of the study participants was 81 years (range, 75-95 years). Of the 28 total patients, 16 (57%) were female and 12 (43%) were male. The average defect size was 11 cm(2) (5-30 cm(2)). Cartilage grafts were used in four patients (14%). The average time to takedown was 25 days (17-45). The median follow-up for the patients was 10 months (1-60 months). There were seven treatment-related complications due to infectious causes (2), epidermal necrotic tissue (2), bleeding (1), hair on the flap (1) and alar rim notching (1). No life-threatening complications were detected. CONCLUSIONS: The FHF procedure is a safe and low-risk procedure in patients 75 years of age or older with advanced skin defects. If a defect requires an FHF to obtain a normal and aesthetic appearance, this procedure should be performed. However, dermatologists must weigh the safety of the procedure in relation to the clinical benefits when managing this patient group.

New rhinophyma severity index and mid-term results following shave excision of rhinophyma.

BACKGROUND: Rhinophyma is a progressive nasal deformity resulting from hyperplasia of the sebaceous glands and connective tissue, with a negative effect on quality of life. Partial-thickness shave excision has been used for the treatment of rhinophyma, but the mid- and long-term efficacy of the treatment is unknown. OBJECTIVES: We analysed the clinical outcomes of shave excision in patients with rhinophyma in our centre between 2005 and 2009. METHODS: The entire nose was shaved using a scalpel while under tumescent anaesthesia. The clinical assessment was scored using a novel Rhinophyma Severity Index. RESULTS: Thirty-three patients with rhinophyma and shave excision were recruited for the study. A mid-term follow-up examination was possible in 23/33 (69.7%) patients. After a mean follow-up of 37.4 ± 13.2 months, 21 (91.3%) patients showed an improved Rhinophyma Severity Index (3.3 ± 1.1 to 1.7 ± 0.9, p < 0.0001). All patients reported a high level of satisfaction after surgery (excellent or good result). Eleven (47.8%) patients developed rhinophyma recurrence. CONCLUSION: Shave excision under tumescent anaesthesia is an effective treatment for rhinophyma. The treatment is associated with high patient satisfaction and minimal side effects. A possible recurrence of rhinophyma must be addressed, however, while obtaining informed consent.

No clinical benefit of preoperative fluorescence diagnosis of basal cell carcinoma localized in the H-zone of the face.

BACKGROUND: Basal cell carcinoma (BCC) is the most common malignant skin carcinoma. Fluorescence diagnosis (FD) has been suggested as a promising method for noninvasive detection of subclinical tumour cell dissemination in BCC. OBJECTIVES: In this prospective study, we evaluated the clinical performance of a preoperative definition of the lateral borders of BCC by FD in comparison with its definition by purely clinical diagnosis (CD). The fluorescence intensity on the skin was recorded using a digital light-emitting diode-based fluorescence imaging system. METHODS: Twenty-six patients with BCC (22 with nodular subtype) of the H-zone were included. The tumour area was determined 3 h after application of methyl aminolaevulinate by inspection and photographic documentation (CD) and FD. Subsequently, BCCs were excised according to the complete area defined by CD and FD with a security margin of 3 mm; surgical specimens were sectioned horizontally and subjected to meticulous histological mapping. The tumour areas as determined by FD, CD and histology were superimposed to map the entire lateral tumour margin. RESULTS: The tumour area could be visualized by FD in 24 of 26 patients. The mean tumour area as determined by FD was significantly smaller than the tumour area as determined by CD [80 mm(2) , 95% confidence interval (CI) 50-110 mm(2) vs. 101 mm(2) , 95% CI 76-125 mm(2) ; P < 0·012]. The superimposition of FD and histology showed in 10 of 26 patients a complete detection of the tumour margin by FD; thus sensitivity of FD was calculated as 38·5%. In only three of 26 patients FD revealed a tumour extent greater than determined by CD. Specificity of FD was calculated as 88·4%. CONCLUSIONS: On aggregate, this study suggests that preoperative FD of nodular BCC localized in the H-zone offers no additional benefit to define subclinical tumour infiltration compared with CD alone.

Surgical excision of basal cell carcinoma with complete margin control: outcome at 5-year follow-up.

BACKGROUND: The incidence of skin cancer and especially basal cell carcinoma (BCC) has increased in the last few decades. The gold standard of care is usually a surgical excision, but it also has the risk of local recurrence depending on tumor characteristics. OBJECTIVES: We analyzed the 5-year cure rates after surgical excision of BCC with complete margin control using paraffin-embedded sections. METHODS: A retrospective analysis of 671 patients (45.3% male, 54.7% female) with 777 primary and 85 with recurrent BCC were collected during 2001-2003. All patients underwent surgery with complete margin control using paraffin-embedded sections. When the histological examination revealed a positive margin, another surgical step was performed in the area of residual tumor. RESULTS: Five-year follow-up examinations were possible in 630/862 (73.1%) of patients with BCC. In the group with primary BCC (n = 562), 3 tumor recurrences (0.5%) were identified; in the group with recurrent BCC (n = 68), 2 tumor recurrences (2.9%) were seen, resulting in an overall 5-year recurrence rate of 0.8% for all patients with BCC. The mean tumor recurrence time after surgery was 36.6 months. CONCLUSION: Local complete tumor resection confirmed by complete margin control using paraffin-embedded sections can achieve excellent cure rates for both primary and recurrent BCC.

[Desmoplastic fibroma on arm of 22-year-old woman]. / Desmoplastisches Fibroblastom bei einer 22-jährigen Patientin im Bereich des Oberarms.

Desmoplastic fibroblastoma ("collagenous fibroma") is a rare benign, slowly progressive fibrous soft tissue tumor that ranges 1-20 cm in size. The tumor occurs in all ages, predominantly in the upper part of the body. Children are rarely affected. The tumor often infiltrates the subcutis; less often it invades the fascia and skeletal muscle or causes bone erosions. Histologically, the tumor is composed of spindle-shaped cells embedded in a densely collagenous stroma, sometimes forming a pseudo-capsule. Magnetic resonance imaging and computed tomography as well as ultrasonography are used to define the extensions of the tumor. Because it is clinically extremely difficult to determine if soft tissue tumors are benign or malignant, all should be excised with a margin of safety and examined histologically. We report a 22-year old woman with desmoplastic fibroblastoma located on the upper arm. Clinical and histopathological findings and treatment options are discussed.

Medium dose long-wavelength ultraviolet A (UVA1) phototherapy for the treatment of acute and chronic graft-versus-host disease of the skin.

Long-wavelength ultraviolet A (340-400 nm UVA1) phototherapy has been reported to be effective in atopic dermatitis, localized scleroderma and other T-cell-derived skin diseases. UVA1 as an adjunct to systemic immunosuppressive treatment was found to be safe, and effective in 10 patients with chronic cutaneous (seven lichenoid and three sclerodermoid) graft-versus-host disease (GVHD) after stem cell transplantation. Complete and partial responses were achieved in six (60%), and in three (30%) patients, respectively. One patient had improvement of sclerotic skin lesions. At a median follow-up of 14 months, two patients with lichenoid lesions relapsed. Both responded to another treatment cycle. Furthermore, we treated seven patients with UVA1 as primary therapy for acute cutaneous GVHD grades II and III in a pilot experience. Five patients had a complete response with no relapse at a median follow-up of 9 months after UVA1. Two patients showed no response and systemic steroids had to be started. UVA1 therapy is feasible, well tolerated and can be effective in treating chronic as well as acute GVHD confined to the skin thereby avoiding systemic steroids. Our results should be confirmed in larger studies and the effectiveness of UVA1 compared to other established treatment modalities.

[Reactions of the skin to solar radiation]. / Von der Verbrennung bis zum Melanom. Sonnenbad mit bösen Folgen.

When spending time out of doors in summer, certain rules of behavior need to be observed. Environmental factors such as, for example, water, the beach and the midday sun all have a major influence on the UV radiation burden to which people may be subjected. In addition, the sun's rays can interact with certain medications, alcohol and drugs, as also cosmetics, and trigger pathological skin reactions. A permanently sun-damaged skin is not only very difficult to treat, but is also frequently associated with malignant changes. Moderate exposure to the sun after prior gradual acclimatization is to be recommended. Patients with increased photosensitivity require special photoprotective agents.

Serum levels of soluble Fas/APO-1 receptor are increased in systemic sclerosis.

It has been suggested that rheumatic diseases may result from a deficit in Fas-mediated T-cell apoptosis. Recent studies have demonstrated increased soluble Fas in sera from lupus erythematosus patients. We were interested to determine whether elevated soluble Fas levels are associated with systemic sclerosis. Soluble Fas levels were retrospectively assayed using a sandwich enzyme-linked immunosorbent assay in serum from 30 patients with systemic sclerosis and 15 normal controls. Hospital medical records were retrospectively reviewed for clinical and laboratory characteristics of the patients. Soluble Fas levels were analysed in subsets of patients with limited (lcSSc) versus diffuse cutaneous systemic sclerosis (dcSSc) and correlated with inflammatory activity. In systemic sclerosis soluble Fas serum levels (lcSSc, 2.19 +/- 0.71 ng/ml, dcSSc 2.53 +/- 1.37 ng/ml) were significantly higher than in normal controls (1.26 +/- 0.36 ng/ml). However, there were no significant differences in soluble Fas levels between lcSSc and dcSSc and poor correlation between soluble Fas levels and inflammatory activity status. Detection of elevated soluble Fas might serve as a clinical marker for immunological dysregulation in systemic sclerosis, but not for inflammatory disease activity.

[Measurement and analysis of monophasic action potentials using fractally coated electrodes--I]. / Messung und Analyse monophasischer Aktionspotentiale mit Hilfe fraktal beschichteter Elektroden--Teil I.

The monophasic action potential (MAP) contains a wealth of information about the stat of the myocardium, which makes it very useful for numerous diagnostic and therapeutic applications in patients with heart disease. The silver-silver chloride electrodes which are currently used for the measurement of MAP have poor long-term stability in contact with biological tissue. This study was therefore undertaken with the aim of investigating the electrochemical behaviour of fractally coated leads in terms of their signal-detection performance. Experience gained with these leads in cardiac pacemakers has already demonstrated the long-term stability and biocompatibility of the fractally coated leads. Present results show that, due to their large electrochemically active surface area, fractally coated leads have a very low impedance over a wide frequency range. The negligible polarization artifact of these leads permits the measurement of cardiac potentials immediately after a stimulus. Fractally coated leads are thus highly suitable for the measurement of MAP, and have clear advantages over Ag/AgCl electrodes. The second part of this study reports on the results of MAP measurements using fractally coated leads.

[Simulation of myocardial action potentials of various cell types in relation to neural parameters]. / Simulation myokardialer Aktionspotentiale verschiedener Zelltypen in Abhängigkeit von nervalen Einflussfaktoren.

Action potentials of various myocardial cell types were simulated in a computer model based on current knowledge of the electrical properties of ionic channels and pumps in the ventricular cell membrane and the sarcoplasmic reticulum. The transport mechanisms of sodium, potassium, calcium and chlorine ions through the cell membrane are described mathematically, as is the exchange of calcium between the myoplasm and sarcoplasmic reticulum. Ten ionic channels and three pumps of the cell membrane are taken into account, while three channels and one pump of the sarcoplasmic reticulum are considered in the computations. For the first time, the transient outward potassium current IK,to was simulated, the effect of which on the early repolarisation phase of the action potential was reproducible in the model. Calcium buffers in the myoplasm and the sarcoplasmic reticulum are also considered. From the resulting ionic currents through the channels and pumps, the membrane potential is computed using an equivalent circuit diagram of the cell membrane. In particular the influence of neural activity on channel conductance and the probability of channel patency were taken into account. By means of this model, different shapes of ventricular action potentials were simulated. The action potentials of epicardial cells, M-cells, endocardial cells and Purkinje fibres were accurately simulated. In addition, the effects of sympathetic drive and various drugs were demonstrated in the model as well as the shortening of the action potential duration with increasing stimulation frequency.

[Analysis of myocardial evoked potentials in relation to ergometric load and heart rate for use in frequency-adaptive cardiac pacemakers]. / Analyse evozierter Myokardpotentiale in Abhängigkeit von ergometrischer Belastung und Schlagfrequenz für die Anwendung in frequenzadaptiven Herzschrittmachern.

The aim of this study was to evaluate the ventricular evoked response (VER) measured with unipolar fractally coated pacing leads for use with rate-responsive pacemakers. To this end, the morphology of the VER, its variation with pacing rate and various levels of physical loading, and the long-term stability of the signal were studied using the telemetric features of implantable pacemakers. Fractally coated electrodes were used in order to minimize the stimulation artefact, thus enabling a reliable unipolar measurement of the VER. The VER shows uniform basic morphology, and remains virtually unchanged after 3 months; moreover, frequency and load-dependent changes of VER morphology were identical for all patients. A special programming device has been developed to evaluate a rate adaptive algorithm for optimizing the pacing rate to the current loading situation, and was successfully tested in two patients. The algorithm was shown to be capable of calculating a heart rate adequate for haemodynamic demand.

[Measurement and analysis of monophasic action potentials using fractally coated electrodes--II]. / Messung und Analyse monophasischer Aktionspotentiale mittels fraktal beschichteter Elektroden--Teil II.

The monophasic action potential (MAP) represents a summed signal formed by overlapping action potentials of myocardial cells close to the tip of the lead. Analysis of the MAP therefore provides detailed information about the electrophysiological effects of autonomous nervous and pharmacological influences on the myocardium, for example adrenergic or cholinergic stimulation of the heart. All known MAP recordings were obtained with Ag/AgCl electrodes, which, thanks to their low polarization properties, ensure reliable MAP measurement. Owing to their toxicity and inadequate long-term stability, however, Ag/AgCl electrodes cannot be implanted. With the aim of making MAP measurement available for implantable devices, fractally coated leads were therefore developed. The aim of the present study was to evaluate the in vivo measurement of fractally coated leads which are characterized by negligible polarization, low impedance over a wide frequency range, high biocompatibility and good long-term stability. In addition, as a result of their extremely high Helmholtz capacities (up to 50 mF/cm2), fractally coated leads permit stimulation and virtually undisturbed recording of MAP with the same pair of electrodes. For the evaluation of MAP measurements with fractally coated leads, a quadrupolar catheter enabling simultaneous MAP recordings with 2 Ag/AgCl electrodes and 2 fractally coated leads was devised. The stimulation pulses were always applied via the fractally coated leads. With both types of electrode, with spontaneous excitation and stimulation, the well-known MAP morphology, with amplitudes of between 10 and 25 mV in the ventricle, and between 5 and 10 mV in the atrium, was seen.(ABSTRACT TRUNCATED AT 250 WORDS)