A single application of cold atmospheric plasma (CAP) improves blood flow parameters in chronic wounds.

OBJECTIVE: To find out whether application of cold atmospheric plasma (CAP) affects microcirculation in chronic wounds. METHODS: We treated 20 patients with chronic wounds on the lower extremity with CAP. Blood flow parameters of wounds were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in tissue depth of 2 and 6-8 mm. Parameters were assessed under standardized conditions before and over the course of 30 min after application of CAP. RESULTS: Deep capillary blood flow increased significantly by up to 24.33% (percentage change) after treatment with CAP and remained significantly elevated until the end of measuring period at 30 min. Superficial oxygen tissue saturation was significantly elevated by 14.05% for the first 5 min after treatment. Postcapillary venous filling pressure was significantly elevated by 10.23% 19 min after CAP and stayed significantly elevated starting from minute 24 until the end of measuring. CONCLUSION: Cold atmospheric plasma increases microcirculation parameters in chronic wounds significantly. As CAP is known for its benefits in wound healing, the effects observed may explain the improved healing of chronic wounds after its use. Whether CAP-application can increase blood flow in chronic wounds for longer periods of time or boosts blood flow when applied more than once should be subject to further research.

Cold atmospheric plasma improves cutaneous microcirculation in standardized acute wounds: Results of a controlled, prospective cohort study.

BACKGROUND: Given the high prevalence of wounds and their challenging treatment, the research of therapies to improve wound healing is of great clinical interest. In addition, the general consequences of developing chronic wounds constitute a large health economic aspect, which underscores the interest in the development of efficient treatment strategies. Direct cold atmospheric plasma (di_CAP) has been shown to have beneficial effects on microcirculation of human tissue (Kisch et al., 2016a). It also affects microbial settlements, which may have supportive effects on wound healing processes (Balzer et al., 2015). To treat these adequately, in our view, the positive effects on wound healing should be objectified by application on standardized wounds. However, wound healing is a complex process, depending on nutrient and oxygen supply by cutaneous blood circulation. In spite of microcirculation has been shown to improve in healthy skin by CAP, a quantification of the effect in a standardized wound model has never been evaluated (Kisch et al., 2016a). Based on this, we hypothesize that CAP also influences the microcirculation in standardized acute wounds in a prospective cohort study. METHODS: Microcirculatory data of 20 healthy subjects (14 males, 6 females; mean age 40.85 ± 15.84 years; BMI 26.83 ± 7.27 kg/m2) were recorded continuously at a standardized acute wound after skin transplantation (donor site) at the thigh. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a dielectric barrier discharge (DBD) plasma device for 90 s to the acute wound area. Immediately after the application, cutaneous microcirculation was assessed for 30 min (min) at the same site. RESULTS: After CAP application, tissue oxygen saturation immediately increased by 5% (92,66 ± 4,76% vs. Baseline 88,21 ± 6,52%, p < 0,01) in the first 60 s and remained significantly elevated for 4 min. Capillary blood flow increased by 19.3% within the first minute of CAP therapy (220.14 ± 65.91 AU vs. Baseline 184.52 ± 56.77 AU, p < 0.001). The statistically highly significant increase in blood flow continued over the entire measurement time. A maximum value was shown in the blood flow in the 15th minute (232.15 ± 58.90 AU, p < 0.001) according to CAP application. With regard to the output measurement, it represents a percentage increase of 25.8%. The measurement of post-capillary venous filling pressure at a tissue depth of 6-8 mm was 59.39 ± AU 12.94 at baseline measurement. After application, there were no significant changes. CONCLUSION: CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the standardized acute wound healing model. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in chronic wounds. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

The repetitive application of cold atmospheric plasma (CAP) improves microcirculation parameters in chronic wounds.

BACKGROUND: Chronic wounds, such as venous leg ulcers, diabetic foot ulcers, and pressure ulcers, impose a significant burden on patients and health care systems worldwide. Cold atmospheric plasma (CAP) accelerates wound healing and decreases bacterial load in chronic wounds in both in vitro and in vivo experiments. For the first time, we examined the effects of a repetitive application of CAP on the microcirculation in chronic wounds. HYPOTHESIS: The repetitive application of cold atmospheric plasma application further improves microcirculation in chronic wounds. METHODS: Twenty patients with chronic wounds were treated repetitively with CAP. The repetitive application consisted of three CAP sessions, each lasting 90 s and separated by a 10-minute microcirculation measuring period. Microcirculation parameters were assessed with combined Laser-Doppler-Flowmetry and spectrophotometry in a tissue depth of 2 mm. RESULTS: Tissue oxygen saturation was significantly increased after the first CAP application. The effect amplitude and duration were further increased after the second and third CAP application with a maximum increase by 16,7% (percent change; p = 0,004 vs. baseline) after the third application. There was no significant increase in capillary blood flow until the third CAP application. After the third CAP application, an increase by 22,6% (p = 0,014) was observed. Postcapillary filling pressure was not significantly increased over the measuring period. The repetitive application of CAP further enhances the microcirculation in chronic wounds compared to a single application. CONCLUSION: The repetitive application of CAP boosts and prolongs tissue oxygen saturation and capillary blood flow in chronic wounds compared to a single application. This insight could provide an impetus for new treatment protocols.

Blood Flow in the Scaphoid Is Improved by Focused Extracorporeal Shock Wave Therapy.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid. QUESTIONS/PURPOSES: (1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid? METHODS: ESWT (0.3 mJ/mm, 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant). RESULTS: At baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available. CONCLUSIONS: A single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended. CLINICAL RELEVANCE: Further studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.

Improvement of cutaneous microcirculation by cold atmospheric plasma (CAP): Results of a controlled, prospective cohort study.

BACKGROUND: Cold atmospheric plasma (CAP) has proven its benefits in the reduction of various bacteria and fungi in both in vitro and in vivo studies. Moreover, CAP generated by dielectric barrier discharge (DBD) promoted wound healing in vivo. Charged particles, chemically reactive species (such as O3, OH, H2O2, O, NxOy), ultraviolet radiation (UV-A and UV-B), strong oscillating electric fields as well as weak electric currents are produced by DBD operated in air. However, wound healing is a complex process, depending on nutrient and oxygen supply via cutaneous blood circulation. Therefore, this study examined the effects of CAP on cutaneous microcirculation in a prospective cohort setting. HYPOTHESIS: Cold atmospheric plasma application enhances cutaneous microcirculation. METHODS: Microcirculatory data of 20 healthy subjects (11 males, 9 females; mean age 35.2 ± 13.8 years; BMI 24.3 ± 3.1 kg/m(2)) were recorded continuously at a defined skin area at the radial forearm. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90 s to the same defined skin area of 22.5 cm(2). Immediately after the application cutaneous microcirculation was assessed for 30 min at the same site. RESULTS: After CAP application, tissue oxygen saturation immediately increased by 24% (63.8 ± 13.8% from 51.4 ± 13.2% at baseline, p<0.001) and stayed significantly elevated for 8 min. Cutaneous blood flow increased by 73% (41.0 ± 31.2 AU from 23.7 ± 20.8 AU at baseline, p<0.001) and remained upregulated for 11 min. Furthermore, cutaneous blood flow showed two peaks at 14 (29.8 ± 25.0 AU, p=0.049) and 19 min (29.8 ± 22.6 AU, p=0.048) after treatment. Postcapillary venous filling pressure continuously increased, but showed no significant change vs. baseline in the non-specific BMI group. Subgroup analysis revealed that tissue oxygen saturation, postcapillary venous filling pressure and blood flow increased more in case of a lower BMI. CONCLUSION: CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the radial forearm of healthy volunteers. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in diabetic foot ulcers. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

The repetitive use of non-thermal dielectric barrier discharge plasma boosts cutaneous microcirculatory effects.

BACKGROUND: Non-thermal atmospheric plasma has proven its benefits in sterilization, cauterization and even in cancer reduction. Furthermore, physical plasma generated by dielectric barrier discharge (DBD) promotes wound healing in vivo and angiogenesis in vitro. Moreover, cutaneous blood flow and oxygen saturation can be improved in human skin. These effects are mostly explained by reactive oxygen species (ROS), but electric fields, currents and ultraviolet radiation may also have an impact on cells in the treated area. Usually, single session application is used. The aim of this study was to evaluate the effects of the repetitive use of cold atmospheric plasma (rCAP) on cutaneous microcirculation. HYPOTHESIS: The repetitive use of non-thermal atmospheric plasma boosts cutaneous microcirculation effects. METHODS: Microcirculatory data was assessed at a defined skin area of the radial forearm of 20 healthy volunteers (17 males, 3 females; mean age 39.1±14.8years; BMI 26.4±4.6kg/m(2)). Microcirculatory measurements were performed under standardized conditions using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90s and cutaneous microcirculation was assessed for 10min. Afterwards, a second session of CAP application was performed and microcirculation was measured for another 10min. Then, the third application was made and another 20min of microcirculatory parameters were assessed. RESULTS: Tissue oxygen saturation and postcapillary venous filling pressure significantly increased after the first application and returned to baseline values within 10min after treatment. After the second and third applications, both parameters increased significantly vs. baseline until the end of the 40-minute measuring period. Cutaneous blood flow was significantly enhanced for 1min after the first application, with no significant differences found during the remainder of the observation period. The second application improved and prolonged the effect significantly until 7min and the third application until 13min. CONCLUSION: These data indicate that the repetitive use of non-thermal atmospheric plasma boosts and prolongs cutaneous microcirculation and might therefore be a potential tool to promote wound healing.

Acute Microcirculatory Effects of Remote Ischemic Conditioning in Superficial Partial Thickness Burn Wounds.

Microcirculation is a critical factor in burn wound healing. Remote ischemic conditioning (RIC) has been shown to improve microcirculation in healthy skin and demonstrated ischemic protective effects on heart, kidney, and liver cells. Therefore, we examined microcirculatory effects of RIC in partial thickness burn wounds. The hypothesis of this study is that RIC improves cutaneous microcirculation in partial thickness burn wounds. Twenty patients with partial thickness burn wounds within 48 hours after trauma were included in this study. RIC was performed with an upper arm blood pressure cuff on a healthy upper arm using three ischemia cycles (5 min inflation to 200 mm Hg) followed by 10-minute reperfusion phases. The third and final reperfusion phase lasted 20 minutes. Microcirculation of the remote (lower/upper extremities or torso) burn wound was continuously quantified, using a combined Laser Doppler and white light spectrometry. The capillary blood flow in the burn wounds increased by a maximum of 9.6% after RIC (percentage change from baseline; P < .01). Relative hemoglobin was increased by a maximum of 2.8% (vs. baseline; P < .01), while cutaneous tissue oxygen saturation remained constant (P > .05). RIC improves microcirculation in partial thickness burn wounds by improving blood flow and elevating relative hemoglobin.

[The Emergency Classification of Hand Injuries: Analyzing Urgency Assessment among German Hand Surgeons]. / Zeitliche Dringlichkeitsstufen bei der operativen Versorgung von handchirurgischen Notfällen: Eine Umfrage unter deutschen Handchirurgen.

BACKGROUND: Emergency capacities in the operating theatre are limited and often need to be split among surgical departments. Hand injuries often have to compete with other surgical disciplines for the availability of operating capacity. For this reason, an emergency classification was introduced to define a timespan in which the injury should be taken care of in the OR in order to enable the prioritizing of emergency cases in an interdisciplinary approach when capacities are scarce. However, neither valid data nor specific recommendations concerning the medical urgency of treatment or the forensic background of different hand injuries exist to this date. PURPOSE: This work describes how emergency classifications in Germany are applied to hand surgical cases and how certain hand injuries are prioritized among different hand surgeons. MATERIAL AND METHODS: An online survey was sent to all members of the German Society for Hand Surgery twice during a time span of several months. The survey featured questions on size and type of clinic or practice and requested an assessment of urgency levels for various hand injuries (immediately - within 2 h - within 6 h - within 12 h - within 24 h or elective care). The analysis of the questionnaire and graphic presentation was carried out using Excel. RESULTS: 172 (25 %) out of 700 active members filled in the survey. Among the participants were members of university clinics, hospitals run by the German Statutory Accident Insurance, specialized clinics and primary care clinics. 15 % of participants work in a practice that offers hand-surgical treatment. First and foremost, maximum care hospitals with a hand surgical department participate in the treatment of hand injuries. 64 % of the hospitals use an emergency classification to enable the interdisciplinary prioritizing of surgical emergencies. The categorization of limb-threatening hand injuries appears to be very homogenous among participants whereas non-threatening injuries are assessed rather inconsistently. CONCLUSION: Emergency treatment of hand injuries primarily depends on available resources and surgical capacities. The assessment of urgency and severity of injuries additionally depends on experience and education. In order to maintain the ability to compete with other surgical disciplines for surgical capacities, a standard classification of hand surgical urgencies needs to be established. As valid data on the treatment of hand injuries are still missing, further studies need to evaluate possible outcomes in order to define the timespan in which surgery should take place.

[10 years of hand traumatology - an epidemiological, structural and economic analysis at a maximum care provider]. / 10 Jahre Handtraumatologie ­ eine epidemiologische, strukturelle und ökonomische Standortanalyse an einem Krankenhaus der Maximalversorgung.

BACKGROUND: Hand surgery in Germany has been subject to structural changes that strongly affect the balance between medicine and economics. On the one hand there is a shift of elective hand surgery from the inpatient to the outpatient sector. On the other hand - so our observations - emergency hand trauma cases are more concentrated in bigger hospitals. Given this background there is a lack of statistical data on the management of hand trauma care and treatment of patients with hand injuries. This article discusses a 10-year-analysis of hand traumatological cases treated at a maximum care hospital regarding epidemiological, structural and economic aspects. MATERIAL AND METHODS: Using a database query using ICD codes, inpatient hand trauma cases were identified between 2009-2018 and analyzed with regard to epidemiological and economic indicators (age, gender, comorbidities, case-mix-index (CMI), revenue, length of stay, length of surgery) using PIVOT tables. Patients under the age of 16 years, forearm fractures and intensive care patients were excluded. RESULTS: In the study period the typical hand surgical trauma patient was male with an average age of 44 years. The Patient-Clinical-Complexity-Level (PCCL) was 0 in 80 % of all cases. The proportion of work-related injuries averaged around 25 %. The three top diagnose related groups (DRG) were the I32F (18.5 %), X01B (11.3 %) and the I32A (7.2 %). A striking point was the massive increase in the overall number of trauma cases over the years from approx. 300 cases in 2009 to over 1000 cases per year in 2018 with a shift of the main workload to on-call and night-shift hours away from core working times. In the study period 4 of 5 others hospitals located in a distance of 100 km reduced and stopped treatment of emergency hand cases. The average length of a hospital stay was approx. 4-5 days, the average cut/suture time less than 60 minutes and the average CMI 1.23. Those cases generate an average proceed of € 4370 in 2018, whereby the cases generated by the work-related injuries averaged € 387 less. DISCUSSION: On the assumption that the number of emergency hand trauma cases did not really increase in the study period we think that there was a concentration of such cases in a few centres still providing extensive treatment for hand injuries while in smaller hospitals care for emergency hand trauma cases is progressively reduced. However, hand injuries may be worth a second thought for economic reasons because they can create reasonable revenues with rather little effort.If a critical number of patients is exceeded, costs of service provisions can be significantly amortized by the proceed generated by treatment. In those hospitals still taking care for acute hand injuries the workload especially in standby duty increased. What may have a negative input on the numbers of treated elective hand surgery cases.

Smart Scar Care-Industry 4.0 in Individualized Compression Garments: A Randomized Controlled Crossover Feasibility Study.

BACKGROUND: We tested the workflow and comparability of compression garments (CG) automatically knitted from 3D-body-scan data (3DBSD) versus manually measured data for scar treatment. Industry 4.0 has found its way into surgery, enhancing the trend toward personalized medicine, which plays an increasingly important role in CG scar therapy. Therefore, we conducted a study to evaluate the workflow from 3DBSD to fast and precisely knitted CG and compared it with standard of care. METHODS: A randomized controlled crossover feasibility study was conducted as part of the individual medical technology research project "Smart Scar Care." Objective and patient-reported outcome measures were documented for 10 patients with hypertrophic burn scars at baseline and after wearing CG automatically knitted from 3DBSD versus CG from manually measured data for one month. RESULTS: The "scan-to-knit" workflow and the study design were feasible in 10 of 10 patients. No adverse effects were found. 3DBSD showed a bias of half a centimeter compared with manually measured data and wider limits of agreement. With respect to fit, comfort, suitability, Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, stiffness and microcirculation, this was a promising pilot study. Stiffness and blood flow were increased in scars compared with normal skin. The highest rank correlations were found between pain and itch, stiffness and Patient and Observer Scar Assessment Scale, Vancouver Scar Scale, and pain. CONCLUSIONS: These results indicate that automatically knitted CG using 3DBSD could become an alternative to the standard of care, especially with regard to economical and faster patient care. The produced scan data opens the door for objective scar science.