[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]. / Phlebologie an deutschen Hautkliniken. Eine Bestandsaufnahme im Auftrag der Deutschen Gesellschaft für Phlebologie.

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.

Sonography of the skin at 100 MHz enables in vivo visualization of stratum corneum and viable epidermis in palmar skin and psoriatic plaques.

A main drawback of 20-25 MHz ultrasound units for skin imaging is their limited resolution. We used a transducer with a center frequency of 95 MHz and a resolution of 8.5 microm axially and 27 microm laterally - an almost 10-fold increase compared with 20 MHz. By means of a new scanning technology we reached a depth of field of 3.2 mm. We examined normal palmar skin, normal glabrous skin on the abdomen, the upper back, the calf and the dorsal forearm, and 35 lesions of psoriasis vulgaris. From 11 psoriatic plaques biopsies were taken for correlation with the sonograms. In normal palmar skin, the horny layer is represented as an echopoor band below the skin entry echo, traversed by echorich coils, which correspond to eccrine sweat gland ducts. The thickness of this band significantly increases after occlusive application of petrolatum. Its lower border is defined by an echorich line, representing the stratum corneum/stratum Malpighii-interface. Underneath, a second echopoor band is visible, which corresponds to the viable epidermis plus the papillary dermis, bordered by the scattered echo reflexes of the reticular dermis. This band is also visible in glabrous skin; however, the stratum corneum cannot be detected. In psoriatic lesions, the thickened horny layer appears echorich; after application of petrolatum, its echodensity decreases. Below, the acanthotic epidermis plus the dermis with the inflammatory infiltrate are represented as an echopoor band. There is an excellent correlation between the sonometric thickness of this band and the histometric thickness of the acanthosis plus the infiltrated dermis. Our results show that 100 MHz sonography is a valuable tool for in vivo examination of the upper skin layers.

Improved resolution of magnetic resonance microscopy in examination of skin tumors.

Magnetic resonance imaging has become increasingly important for visualization and tissue differentiation of internal organs. Because of limited resolution, investigation of skin has been of little diagnostic value so far. We combined a homogeneous magnetic field of 9.4 T, as used in magnetic resonance spectroscopy, with gradient fields of 11.7 G/cm and an imaging unit to obtain a voxel resolution of 40 x 40 x 300 microm(3). With this magnetic resonance microscopy unit, we studied normal skin, 12 nevocellular nevi, 20 basal cell carcinomas, 8 melanomas, and 8 seborrheic keratoses after excision in vitro. The specimens were visualized in spin-echo images. The proton relaxation times T1 and T2 were determined for the different skin layers and tumor tissues. Interpretation of the spin-echo images was based on comparison with the correlating histology. Epidermis, dermis, subcutaneous tissue, and hair follicle complexes could be distinguished. Stratum corneum and hairs emitted no signal. All tumors presented as distinct, signal-rich, homogeneous structures within the dark, signal-poor dermis. Their shape corresponded to their outline in the histologic sections. Buds of superficial basal cell carcinomas could be resolved. The proton relaxation times T1 and T2 were significantly different among all skin layers and tumors. Our results demonstrate that with sufficient resolution, differentiation of skin tumors is possible using magnetic resonance imaging.

20 MHz sonography, colorimetry and image analysis in the evaluation of psoriasis vulgaris.

For objective evaluation of the treatment of psoriasis vulgaris standard techniques are desirable. They should be reproducible, sensitive and non-invasive. In this study non-invasive bioengineering techniques, especially high frequency/high resolution ultrasound for measurement of the healing of psoriasis vulgaris were evaluated. Fifty patients with chronic stationary plaque type psoriasis participated in a prospective study; in each patient two psoriatic plaques were examined by means of sonography, colorimetry and image analysis during treatment until complete resolution had occurred. Skin thickness and density could be quantified by means of high frequency ultrasound. In active psoriatic lesions, an echopoor area underneath the entry echo in the ultrasound image caused by acanthosis and inflammatory infiltrate is typical. Under therapy the thickness of this echopoor area diminishes while its density increases. Intensity of the erythema especially the decrease of erythema through healing could not exactly be quantified with the colorimeter because the 'Lab'-CIE-colour representation system cannot distinguish well enough between the colours red and brown. Image analysis allowed to measure the sizes of the psoriatic plaques and to quantify their resolution under therapy. The measuring of plaque size by the aid of computer based image analysis is possible and useful.

The three-dimensional histological architecture of pustulosis palmo-plantaris.

Using computer reconstruction techniques, it is possible to study and understand the three-dimensional architecture of the histo-pathological changes in pustulosis palmo-plantaris (PPP). In PPP vesicles and pustules develop. As the vesicles move upwards, they may gain contact with a granulocytic lake above them. Through the roof of the vesicle, granulocytes then break into the vesicle thereby changing it into a pustule. The blood vessels in PPP exhibit a bulbous vascular network at the epidermal end of the dermal papillae. At lower levels, the capillaries may form loops and arches. It is suggested that this special architecture of the vascular system produces a marked retardation of the blood flow in the tips of the dermal papillae, allowing a longer contact of the blood with the capillary wall. The granulocytes can therefore easily immigrate.

20-MHz B-mode ultrasound in monitoring the course of localized scleroderma (morphea).

Ultrasonographic methods have recently provided us with the means for objective and non-invasive monitoring of the dynamics of chronic skin diseases. We examined 34 patients with localized scleroderma (morphea) using a 20-MHz B-mode ultrasound scanner (DUB 20, Taberna pro Medicum, Lüneburg). In patients with plaque-type and linear band-type localized scleroderma intraindividual comparison of sclerotic skin with corresponding areas of healthy skin showed thickening of the corium. The increase in corium thickness was between 2% and 251%. The extent of the difference in corium thickness between sclerotic and healthy skin depended on the location-originally thin skin showed a greater degree of sclerosis. We also frequently found enhanced reflexes in the lower corium and hyperechoic, widened bands of connective tissue traversing the subcutaneous fatty tissue from the corium-subcutis border in the direction of the muscle fascia. 20 patients were examined several times in the course of one year. In nine patients we found ultrasonographic evidence of regression (decrease in thickness 26%) and in nine the ultrasound examination showed progression (increase in thickness 28%). 20-MHz B-mode ultrasound imaging is a suitable non-invasive method for monitoring the course and treatment of localized scleroderma. Its routine use is strongly recommended.

The pseudo-elongation of capillaries in psoriatic plaques.

The intrapapillary vessels in the psoriatic plaque are described as elongated, twisted and multiplied. However there is neither proliferation nor necrosis of vessels in growing and dissolving psoriatic plaques. In 120 patients suffering from psoriasis vulgaris, computer-supported image analysis and in 8 patients additionally 3D reconstructions were made to investigate the regression process of the intrapapillary capillaries in the active and resolving psoriatic plaque. In acanthotic epidermis with a thickness of > 400 microns the first subpapillary horizontally oriented plexus is included in the papilla due to the down-growing of the epidermal rete pegs. In the evaluation of the computer-supported image analysis there is only little variation in the levels of the different vascular plexuses within the dermis, while the epidermis is decreasing from > 600 microns to > 100 microns. In the 3D reconstruction of the transition of a psoriatic lesion into adjacent non-involved skin it could be proved that, apart from the epidermal alterations, there is virtually no difference in the arrangement of the vessels between the psoriatic lesion and the adjacent non-involved skin. In psoriasis the vessels do not proliferate, they rest as resident structures and are embraced by the down-growing rete pegs.

Pustulosis palmo-plantaris. Clinical and histological changes during etretin (acitretin) therapy.

We examined the clinical and histological effects of etretin in pustulosis palmo-plantaris (PPP) in a multicentre study. 30 patients with PPP were treated with etretin in a double-blind study. After a 4-week interval of either etretin (50 mg/day) or placebo (randomized), all patients received etretin during a second period of 20 weeks (the dosage was individually varied). The effect of etretin was verified clinically and by immunhistochemical methods. The number of pustules in a 4 cm2 reference area diminished within the first 4 weeks from 8.5 to 1.9 (etretin group) and from 9.0 to 6.2 (placebo group). Within a maximum of 24 weeks 16% of the patients showed a complete remission, 44% a pronounced improvement, and 22% little improvement. The state of 2% of the patients deteriorated. Immunhistologically, the number of granulocytes was reduced in the inflammatory infiltrate and in the pustules. Etretin is therefore a retinoid, which is easily controlled and effective in PPP.

Psoriasis vulgaris in 50 MHz B-scan ultrasound--characteristic features of stratum corneum, epidermis and dermis.

One hundred and forty fully developed, non-treated plaques of psoriasis vulgaris from the arms and legs of 22 patients were examined using 50 MHz B-scan ultrasound and compared with the images from adjacent, clinically normal skin. To visualize the dermis, high pre-amplification (digitization range 200 mV) was used, determined according to A-scan images. For evaluation of epidermal phenomena, low pre-amplification (digitization range 380 mV) was chosen in order to avoid overmodulation of the skin entry echo. In 10 patients, sonographic images were compared with histological sections from the exact same planes at the same magnification. At low pre-amplification, the skin entry echo is displayed as a markedly widened, frequently interrupted band composed of spots varying in thickness, height and echo density. Within these spots, several lamellae can be observed, represented as fine, echo-rich lines stacked one upon another. These phenomena correspond histologically to focal hyperparakeratosis, scaling and cracking of the stratum corneum. Due to the low amplification of the echo-signal the dermis is not visible. High pre-amplification allows evaluation of dermal changes. Below the entry echo there is an echopoor band (EPB) corresponding to the sum of acanthosis and infiltrate in the upper dermis. Underneath the EPB the dermis is represented as a zone with scattered internal echoes which are less intense than in normal skin. Dorsal shadows are typically present. They are artifacts emanating from epidermal regions with marked hyperkeratosis and disappear when the sonographic characteristics of the epidermis are changed, for instance by application of ointments prior to sonographic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

The hyperperfusion of the psoriatic plaque correlates histologically with dilatation of vessels.

We examined psoriatic lesions on the upper legs in 20 patients, using a two-dimensional Laser-Doppler-Scanner (Laser Doppler Perfusion Imager LDI, Lisca Development, Linköping/Sweden). The plaques were evaluated weekly during therapy with dithranol. Five plaques were reconstructed three-dimensionally before and after therapy (reconstruction program ANAT 3D, SIS, Münster, Germany). The psoriatic plaque was represented in the Laser Doppler Perfusion image as a sharply demarcated, hyperperfused area. The perfusion of the plaques dropped during therapy with dithranol to just slightly increased values, compared with normal skin (2.04 arbitrary units AU, healthy skin 1.1 AU). Using three-dimensional reconstruction, we investigated the volume of dermal vessels and the density of papillae. When compared, the volume of papillary vessels was twice as large in psoriatic as in healthy skin. The number of the papillae per square millimetre, detected by three-dimensional reconstruction, was not reduced significantly during therapy. We think that the increased perfusion of the psoriatic plaque is due to the combination of morphological (dilatation of vessels), dynamic (increased blood flow) and optical effects (reduced scattering and increased sampling depth of the laser-beam in acanthotic tissue).

Regional surface changes during the development of the telencephalic choroid plexus in the chick. A scanning-electron microscopic study.

The surface morphology of the developing chick telencephalic choroid plexus (TCP) was examined by scanning electron and light microscopy. A blunt evagination develops rostro-cranially to the foramen of Monro on the medial telencephalic septum. The pseudostratified TCP epithelium differs in its surface morphology from that of the surrounding ependyma. Subsequently the TCP becomes elongated and branches. On the 9th embryonic day (ED) the pseudostratified epithelium progressively becomes high columnar epithelium in a distal to proximal direction along the branches of the TCP. The apical poles of the high columnar epithelial cells protrude into the ventricular lumen. Later, additional branches sprout at the base of the TCP, which then resembles a tree with a bush growing at its roots. Before the time of hatching, the high columnar epithelium changes to low columnar epithelium again in a distal to proximal direction. The surface of the TCP becomes flatter, in the process of which the number of cilia per unit surface area is reduced. On the developing TCP the epiplexus cells vary in shape, depending upon their functional state. It is proposed that not only the morphological but also the functional differentiation of the TCP proceeds in a distal to proximal direction along the branches of the choroid plexus. The surface differentiation of the TCP has a more regular character than that of the diencephalic CP (DCP), described previously, which seems to be influenced in its development by other anatomical structures.

The development of the diencephalic choroid plexus in the chick. A scanning electron-microscopic study.

The surface morphology of the diencephalic choroid plexus (Pl. ch. v. III) was investigated by light microscopy and scanning electron microscopy in chicks from the 7th embryonic day (ED) to the 8th week after hatching. Pl. ch. v. III develops on the anterior ventricular roof from a sagittally oriented fold and a few posteriorly located transverse folds. On the 7th ED no significant differences in the cell surface morphology between Pl. ch. v. III and the surrounding ependyma are observed: both are covered with cilia. During the next four days, long cell prolongations (one per cell) covered with microvilli develop first on the surface of the posterior ventricular roof and then on the posterior part of Pl. ch. v. III. These structures are transitory. On the 11th ED, round cell prolongations (one per cell) appear progressively on the entire plexus, also replacing the long ones. Now the plexus surface is distinct from the surface of the surrounding ependyma. During the last week before hatching and also after hatching, the round cell prolongations become less prominent. Simultaneously, the number of cilia per unit surface area diminishes. With consideration of earlier reports, this study suggests that the following factors are involved in the increase of the surface area of Pl. ch. v. III: (1) The pseudostratified epithelium changes into columnar epithelium. (2) Ependymal elements of the posterior roof of the 3rd ventricle contribute to the anlage of Pl. ch. v. III. In later stages, however, Pl. ch. v. III grows only by mitoses.

Rhazes contribution to the development and progress of medical sciences.

Rhazes was fond of music since his childhood, then studied philosophy and wrote several books about it. Later on he indulged himself in the study of chemistry and medicine. After finishing his studies, Rhazes went back to his home town and practised medicine and soon became very famous. He wrote more than 224 books on various subjects. His most important work is the medical encyclopaedia "continens" (Al-Hawi) which greatly effected the human civilization specially in Europe.

Avicenna's contribution to the development and progress of medical sciences.

Avicenna was born in the village of Belkh near Bukhara in Persia. He was a very famous philosopher, wiseman and an efficient physician. He wrote more than one hundred books on all aspects and sciences known in his time i.e. philosophy, wisdom, religion, mathematics, sophism, literature, poetry and medicine. In medicine, the most celebrated of them is "Al-Qanun fil Tibb", which surpassed other similar books on medicine and considered the biggest medical encyclopaedia of his time. Those orientalists who believe in Greek medicine consider this book as the only textbook on the art of curing and recovery.

Ancient Egyptian roots in the modern medical and pharmaceutical civilisation.

The Egyptian civilisation was long before any of the neighbouring countries. Medicine and pharmacy in ancient Egypt were deeply rooted since mellenia of years. The ancient Egyptian medical papyri, discovered more than a century ago, proved that the Egyptians were the first to attain civilisation, which was copied and adopted by all the neighbouring countries and not the reverse as believed by the Europeans that the ancient Greece was the cradle of civilisation.

The role of Galen in the development and progress of medical sciences.

Early Roman medicine was a mixture of religion and witchcraft, but as time went by, it became more influenced by the Greek medical sciences, which were more developed. The most famous Greek physician during the Roman period was Galen (129-200 AD). In the 4th century A. D. The Byzantine physicians of the Emperor Julian, made the Galenic writings available to ordinary practitioners, and so Greek medicine spread throughout Syria and was carried by the Nestorians into Persia, where it became available to the Islamic World.

Pharmacy and medicine education in ancient Egypt.

The ancient Egyptians knew many of the therapeutical effects of the medicinal plants. This knowledge was taught at home from father to son. So, these houses formed the first primitive pharmacy and medicine schools. Century after century, the ancient Egyptians became more and more interested in medical sciences. Temples began to establish medical and pharmaceutical schools. Priests of good and honest character with scientific background were chosen to become teachers and professors in these schools. Another medical and pharmaceutical schools teaching all the scientific courses were the Per Ankh or Houses of Life. Special schools were erected inside the Royal palaces for the education of the Royal family children, the nobles and the court officials comprising all sorts of sciences and arts, specially taught in its own Per Ankh, as in Heliopolis and Memphis palaces.

The role of Hippocrates in the development and progress of medical sciences.

Greek relations with Egypt dates back to before 2000 B.C. The early Greek known systematic medicine began with the legendary Asclepios, the Greek God of Medicine. Round the 7th century B.C. many Greeks migrated to Egypt. Many of them came to Egypt to study all kinds of sciences. Greek and thence the European medicine started with the age of Pericles. Its progress centered in Hippocrates, the most Greek physician. He founded the Coan school at Cos about 430 B.C. Hippocrates separated Greek medicine from superstitions, magic and religion. He is called the father of Greek medicine. He wrote several books, the most famous of them is "The Collection" formed of 30 volumes. He exacted an oath of medical ethics also. After 300 B.C. the Hippocratic collection began to circulate, and in it was thrown everything that could by any device be passed off as of Hippocratic origin. Many medical schools were founded in Greece, which pushed medical sciences into much progress and development.

Hormones throughout history.

Since remote ages man believed that, the different parts of his body and that of the animals, contained therapeutical elements, with effective powers like magic, and that he can fortify his own personality by consuming some parts of the bodies of human beings or animals. He also believed that his organic diseases were due to deficiency in these organs concerning ailments, so he treated them with similar organs of different animals.