Gelatin-Collagen Nonwoven Scaffold Provides an Alternative to Suprathel for Treatment of Superficial Skin Defects.

OBJECTIVE: To evaluate the effect of a new biologic gelatin-collagen nonwoven scaffold compared with a more common synthetic wound dressing on the healing of superficial wounds. METHODS: Three superficial wounds with a depth of 0.5 mm and a length of 2.4 cm were created on the flanks of six minipigs using a skin dermatome. One wound on each pig was treated with the new nonwoven scaffold, one with the more common synthetic wound dressing, and one functioned as an untreated control wound. All three wounds were then covered with a semipermeable, sterile, transparent film. RESULTS: After 7 days, complete wound closure of all wounds could be detected; epidermal thickness and the number of epidermal cells of all treated wounds were significantly increased compared with the control wounds. The nonwoven dressing showed slightly better results compared with the more common dressing. CONCLUSIONS: The nonwoven scaffold is an interesting and competitive material for promoting epidermal wound healing. Because it is a biologic dressing, it degenerates completely and does not have to be removed from the wound. Further research should be conducted to compare this new dressing with other currently available wound treatments.

[Preservation of the outer ear in a complex burn injury]. / Erhalt des äußeren Ohres bei einer komplexen Verbrennung.

Saving the outer ear in burn injuries is a challenging task for the treating surgeon that should not be underestimated. Burns which are initially evaluated as superficial, particularly in this region, often have a tendency to undergo progressive tissue destruction whereby conservative treatment is often no longer sufficient to preserve the skin of the auricle with the underlying cartilage. Various possibilities for saving the ear and for ear reconstruction are described, but in the case of severely burned patients it is often necessary to carry out a quick and relatively simple treatment. In the complicated case of a severely burned patient involving the external ear, a good cosmetic result could be finally obtained with preservation of form and function by means of an economical cartilage resection with subsequent adaptation.

Quantification of the vasodilatory effect of axillary plexus block. A prospective controlled study.

BACKGROUND: Axillary plexus block is a common method for regional anesthesia, especially in hand and wrist surgery. Local anesthetics (e.g., mepivacaine) are injected around the peripheral nerves in the axilla. A vasodilatory effect due to sympathicolysis has been described, but not quantified. MATERIALS AND METHODS: In a prospective controlled study between October 2012 and July 2013, we analyzed 20 patients with saddle joint arthritis undergoing trapeziectomy under axillary plexus block. Patients received a mixture of mepivacaine 1% and ropivacaine 0.75% in a 3:1 ratio. The measurements were carried out on the plexus side and the contralateral hand, which acted as the control. Laser-Doppler spectrophotometry (oxygen to see [O2C] device) was used to measure various perfusion factors before and after the plexus block, after surgery and in 2-h intervals until 6 h postoperatively. RESULTS: Compared with the contralateral side, the plexus block produced an enhancement of tissue oxygen saturation of 117.35 ± 34.99% (cf. control SO2: 92.92 ± 22.30%, P < 0.010) of the baseline value. Furthermore, blood filling of microvessels (rHb: 131.36 ± 48.64% versus 109.12 ± 33.25%, P < 0.0062), peripheral blood flow (219.85 ± 165.59% versus 129.55 ± 77.12%, P < 0.018), and velocity (163.86 ± 58.18% versus 117.16 ± 45.05%, P < 0.006) showed an increase of values. CONCLUSIONS: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremity over the first 4 h after the inception of anesthesia.

Skin Perfusion Changes within 12 h after Axillary Plexus Block.

BACKGROUND/PURPOSE: An improvement of the blood flow would be beneficial in microvascular upper-extremity reconstruction and in digit replantation. In the present work, skin perfusion changes and their duration due to axillary plexus block were quantified. METHODS: The peripheral blood flow of the upper extremities in 20 patients undergoing trapeziectomy under axillary plexus block was analyzed. RESULTS: Laser Doppler spectrophotometry was used to measure perfusion factors over a 12-h period, with the contralateral hand acting as the control. Axillary plexus block produced a significant increase of peripheral oxygen saturation (117 ± 35% vs. control 93 ± 22%, p = 0.019), peripheral blood flow (220 ± 166% vs. 130 ± 77%, p = 0.037), and velocity (164 ± 58% vs. 117 ± 45%, p = 0.011). CONCLUSION: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremities over the first 6 h after the inception of anesthesia. This suggests a potential benefit especially for critically perfused tissues.

Do prophylactic antibiotics in gynecologic surgery prevent postoperative inflammatory complications? A systematic review.

PURPOSE: The aim of this study was to systematically review the literature on antibiotic prophylaxis in gynaecologic surgeries to prevent inflammatory complications after gynaecological operations. The study was carried out as a systematic review. METHODS: Only randomised controlled trials of women undergoing gynaecological surgery were included. The Medline and the Cochrane library databases were searched from 1966 to 2016. The trials must have investigated an antibiotic intervention to prevent an inflammatory complication after gynaecological surgery. Trials were excluded if they were not randomised, uncontrolled or included obstetrical surgery. RESULTS: Prophylactic antibiotics prevent inflammatory complications after gynaecological surgery. Prophylactic antibiotics are more effective in surgery requiring access to the peritoneal cavity or the vagina. Cefotetan appears to be more capable in preventing the overall inflammatory complication rate than cefoxitin or cefazolin. No benefit has been shown for the combination of antibiotics as prophylaxis. No difference has been shown between the long-term and short-term use of antibiotics. There is no need for the primary use of an anaerobic antibacterial agent. CONCLUSION: Antibiotics help to prevent postoperative inflammatory complications after major gynecologic surgeries.

Growth Differentiation Factor 5 Accelerates Wound Closure and Improves Skin Quality During Repair of Full-Thickness Skin Defects.

BACKGROUND: A fast and stable wound closure is important, especially for extended and unstable wounds found after burn injuries. Growth can regulate a variety of cellular processes, including those involved in wound healing. Growth differentiation factor 5 (GDF-5) can accelerate fibroblast cell migration, cell proliferation, and collagen synthesis, which are essential for wound healing. Nevertheless, no standardized evaluation of the effect of GDF-5 on the healing of full-thickness wounds has been published to date. METHODS: Five full-thickness skin defects were created on the backs of 6 minipigs. Three wounds were treated with GDF-5 in different concentrations with the help of a gelatin-collagen carrier, and 2 wounds served as control group. The first was treated with the gelatin carrier and an Opsite film (Smith & Nephew, Fort Worth, Texas), and the other was treated solely with an Opsite film that was placed above all wounds and renewed every second day. RESULTS: Growth differentiation factor 5 accelerates wound closure (10.91 [SD, 0.99] days) compared with treatment with the carrier alone (11.3 [SD, 1.49] days) and control wounds (13.3 [SD, 0.94] days). Epidermal cell count of wounds treated with GDF-5 revealed a higher number of cells compared with the control group. In addition, mean epidermal thickness was significantly increased in GDF-5-treated wounds compared with the control wounds. CONCLUSIONS: Because of its ability to improve skin quality, GDF-5 should be considered when developing composite biomaterials for wound healing.

A Quantitative Analysis of Microcirculation in Skin Defects Covered with Topical Wound Dressings or a Newly Developed Collagen Matrix.

OBJECTIVE: Innovative skin substitutes and temporary wound dressings are frequently used in the treatment of superficial and partial-thickness wounds. The aim of this study was to compare 2 commonly used temporary skin dressings with a newly developed collagen matrix to determine changes in microcirculation as measured by blood flow, hemoglobin oxygenation, and relative hemoglobin values during healing of partial-thickness skin defects. METHODS: This animal study involved 28 adult male Lewis rats. On the back of each rat, 2 standardized partial-thickness skin defects were generated through a skin dermatome (n = 56). Then, wounds were treated with polylactide-based copolymer skin substitute (Suprathel, PolyMedics, Denkendorf, Germany; n = 14), biosynthetic skin dressing (Biobrane, Smith & Nephew, Hamburg, Germany; n = 14), or Collagen Cell Carrier (CCC; Naturin Viscofan, Weinheim, Germany; n = 14). The remaining control wounds were left untreated (n = 14). MAIN OUTCOME MEASURES: Perfusion dynamics were assessed every 10 days for 80 days with the O2C device (LEA Medizintechnik, Gießen, Germany) to determine blood flow, hemoglobin oxygenation, and relative amount of hemoglobin. MAIN RESULTS: Blood flow was increased in all wounds for at least 30 days after wound generation. The relative amounts of hemoglobin were increased in superficial layers (2 mm) for 10 to 20 days. Hemoglobin oxygenation in the superficial layers decreased in the polylactide-based copolymer skin substitute and biosynthetic skin dressing-treated groups and initially increased in the untreated wounds and CCC groups on day 10; these values also decreased. CONCLUSIONS: The presented results demonstrate the complex changes in microcirculation in the course of healing partial-thickness wounds with different wound dressings and contribute to a better understanding of these wounds. However, based on the results of the study, a clear recommendation for a specific substitute is not yet possible.

Determining the appropriate number and duration of leech therapy in congested tissues using tissue spectrophotometry and laser Doppler flowmetry.

A universal protocol determining the number of leeches and their application time does not exist. The aim of this study, therefore, is to quantify perfusion dynamics in venous congested tissues after leech application to get more detailed information about changes due to leech-induced skin microcirculation and to evaluate the usability of the Oxygen to See (O2C) device in terms of determining the appropriate number of leeches and the duration of therapy. Twelve patients with the need for leech therapy participated in the study. Perfusion dynamics of the congested tissue was assessed using the O2C device, which determines blood flow (BF), the relative amount of hemoglobin (rHB), and the oxygen saturation (SO2). Measurements were carried out before leech application and on various intervals like 10 minutes, one hour, and three hours after leech application. The leech application effectuated after 10 minutes a nonsignificant perfusion improvement, which further increased after one hour with a significant reduction of the relative amount of hemoglobin and a significant increase of blood flow and oxygen saturation (BF= +56.7%; rHB= -25.5%; SO2= +53.7%). After three hours, the values returned to the levels before leech administration. In two cases, in which further administration of leeches within the measurement period was necessary, no substantial perfusion changes were obtained. The results of this study forms a more precise pattern of microcirculatory changes of leech therapy in congested tissues. According to our measurements a venous drainage improvement can be expected in congested tissue one hour after leech administration. The O2C seems to be a useful method to determine the appropriate number and duration of leech therapy.

A Novel Collagen-Gelatin Scaffold for the Treatment of Deep Dermal Wounds-An Evaluation in a Minipig Model.

BACKGROUND: Today, autologous skin transplantation is frequently used for full-thickness skin defects. There is still a high demand for new wound-healing products to replace autologous skin transplantation. OBJECTIVE: In this context, the effect of a new collagen-gelatin scaffold on full-thickness skin defects was evaluated. MATERIALS AND METHODS: Four full-thickness skin defects were created surgically on the dorsum of 6 Göttingen minipigs. Three wounds were randomly treated with a novel collagen-gelatin scaffold in different thicknesses, whereas the fourth wound was left untreated and served as a control wound. During the experimental period of 21 days, a close-up photographic documentation was performed. Afterwards, the areas of the initial wounds were excised and examined histologically. RESULTS: The systematic evaluation of 24 wounds showed that treatment with the new collagen-gelatin scaffold led to an accelerated wound repair of 1.1 days. Compared to control wounds, it also demonstrated improved skin quality in regard to epidermal thickness. CONCLUSION: The new collagen-gelatin scaffold supports and accelerates dermal wound repair compared to untreated control wounds. Nevertheless, wound treatment with the scaffold was only performed on the first day. In further studies, the impact of multiple scaffold applications on full-thickness skin defects should be investigated.

Frequent Application of the New Gelatin-Collagen Nonwoven Accelerates Wound Healing.

OBJECTIVE: Mortality after chronic wounds is high. Thus, proper and effective therapy is of critical importance. Adult mammalian skin cannot regenerate spontaneously. It heals under scar formation in a process of repair. In general, wound closure is achieved through a combination of contraction, scar formation, and regeneration. To enhance wound healing, research groups are continuously inventing and evaluating novel skin replacement products. A single application of a new gelatin-collagen nonwoven accelerates wound closure of full-thickness skin defects. Therefore, the authors' objective was to evaluate the effect of a higher application frequency of the nonwoven on wound closure in a minipig model. MATERIALS AND METHODS: Four full-thickness skin defects were created surgically on the dorsum of 12 Göttingen minipigs. Next, 3 wounds were treated randomly with a novel gelatin-collagen nonwoven in different thicknesses, while the fourth wound was left untreated and served as the control wound. Moreover, 6 minipigs achieved multiple applications of the wound dressing. During the experimental period of 21 days, a close-up photographic documentation was performed. Finally, the areas of the initial wounds were excised and examined histologically. RESULTS: More frequent application of the nonwoven achieved accelerated wound healing and better epidermis quality compared with a single application. Mean time until wound closure of all wounds treated with a multiple application of the nonwoven was 11.0 (± 1.2) days, compared with a single application of the nonwoven with 12.4 (± 1.26) days and control wounds with 13.5 (± 1.19) days. Furthermore, the epidermal thickness of all wounds treated with multiple applications of the nonwoven was increased by 10.67 µm (31.89 ± 8.86 µm, P = .0007) compared with a single application of the nonwoven and by 6.53 µm (27.75 ± 7.24 µm, P = .0435) compared with the control group. CONCLUSIONS: Multiple applications of the gelatin-collagen nonwoven may be an appropriate treatment for chronic wounds leading to a fast wound closure through a combination of contraction and re-epithelialization.

Bilateral comparison of the vascular pattern of the superficial temporal artery based on digital subtraction angiography.

PURPOSE: This study was performed to investigate any bilateral differences in the vascular pattern and microsurgical relevant parameters of the superficial temporal artery (STA) in vivo. METHODS: Digital subtraction angiographies of the STA of 38 individuals were retrospectively analyzed. A bilateral comparison of the branching pattern as well as of surgically relevant diameters and lengths of the main branches of the STA was performed. Moreover, gender-specific differences were assessed. RESULTS: Only 10 cases (26%) demonstrated an identical type and subtype of the STA pattern bilaterally. The diameters of the STA at its origin and bifurcation level as well as of its parietal branch were statistically significant wider on the right than on the left side (p(o) = 0.0009, p(b) = 0.006, p(p) = 0.030). Moreover, the diameters of the STA at its origin level on the right side, at its bifurcation level on both sides and of the frontal branch on both sides were statistically significant wider in males than females. No statistically significant differences of the lengths of the STA and its main branches between the right and the left side were identified. CONCLUSION: The occurrence of the vascular pattern of the STA in vivo is random for each side of the same person and cannot be predicted by the vascular pattern of the opposite side. The calibers of the main branches of the STA are gender specific and commonly larger on the right than on the left side.

Utilization of laser Doppler flowmetry and tissue spectrophotometry for burn depth assessment using a miniature swine model.

Currently, the diagnosis of burn depth is primarily based on a visual assessment and can be dependent on the surgeons' experience. The goal of this study was to determine the ability of laser Doppler flowmeter combined with a tissue spectrophotometer to discriminate burn depth in a miniature swine burn model. Burn injuries of varying depth, including superficial-partial, deep-partial, and full thickness, were created in seven Göttingen minipigs using an aluminium bar (100 °C), which was applied to the abdominal skin for periods of 1, 3, 6, 12, 30, and 60 seconds with gravity alone. The depth of injury was evaluated histologically using hematoxylin and eosin staining. All burns were assessed 3 hours after injury using a device that combines a laser light and a white light to determine blood flow, hemoglobin oxygenation, and relative amount of hemoglobin. The blood flow (41 vs. 124 arbitrary units [AU]) and relative amount of hemoglobin (32 vs. 52 AU) were significantly lower in full thickness compared with superficial-partial thickness burns. However, no significant differences in hemoglobin oxygenation were observed between these depths of burns (61 vs. 60%). These results show the ability of laser Doppler flowmeter and tissue spectrophotometer in combination to discriminate between various depths of injury in the minipig model, suggesting that this device may offer a valuable tool for burn depth assessment influencing burn management.

Treatment Algorithm and Clinical Outcome of Venous Malformations of the Limbs.

BACKGROUND: Venous malformations of the limbs are congenital low-flow vascular anomalies. A treatment is reasonable if they are symptomatic or if a progressive lesion may affect functional structures. OBJECTIVE: The purpose of this work is the presentation of clinical results after treatment of venous malformations of the limbs according to the standard algorithm used at the University Hospital of Tuebingen, Germany. PATIENTS AND METHODS: Between January 2008 and June 2015, patients with venous malformations of the limbs were subjected to either percutaneous sclerotherapy or surgical excision according to this treatment algorithm. Remaining symptoms such as pain level and disturbing appearance before and after treatment as well as overall satisfaction was assessed the earliest 3 months after last treatment. RESULTS: Thirty-nine patients with venous malformations of the limbs were subjected to either 1 or more percutaneous sclerotherapies (n = 19) or surgical excision (n = 21). There were no serious complications that needed surgical revision. There was a statistically significant reduction in the pain level and disturbing appearance after both sclerotherapy and surgical excision (p < .05) in 30 cases in total. The overall treatment satisfaction was rated 7.9/10 and 8.8/10 after sclerotherapy and surgical excision, respectively. CONCLUSION: A low complication rate with a high patient satisfaction could be achieved after this treatment algorithm for venous malformations of the limbs.

Work related etiology of de Quervain's tenosynovitis: a case-control study with prospectively collected data.

BACKGROUND: The etiology of de Quervain's tenosynovitis (dQ) has been based on conflicting small case series and cohort studies lacking methodological rigor. A prospective case-control study was conducted to analyze the most common risk factors for dQ. METHODS: Between January 2003 and May 2011, 189 patients surgically treated for dQ vs. 198 patients with wrist ganglia (WG) (controls) were identified in our clinic's electronic database. Sample characteristics, exertional, anatomical, and medical risk factors were compared between groups. RESULTS: dQ vs. WG differed by average age (52 vs. 43 years) and gender ratio (15/62 vs. 26/39). No significant difference between dQ vs. WG was found after subgrouping professional activities (manual labor: 18 % vs. 26 %, respectively, p = 0.23). No asymmetric distribution of comorbidities, wrist trauma, forceful or repetitive manual work, or medication was observed. CONCLUSIONS: Neither heavy manual labor nor trauma could be shown to be predisposing risk factors for dQ.

Improvement of Split Skin Graft Quality Using a Newly Developed Collagen Scaffold as an Underlayment in Full Thickness Wounds in a Rat Model.

INTRODUCTION: Frequently, full thickness skin defects were treated through split skin graft (SSG) transplantation. However, this is usually associated with a reduction of skin quality and scarring. In this context, a newly developed collagen cell carrier (CCC) has been evaluated as an underlayment in SSG transplantations in a rat model. MATERIALS AND METHODS: Twenty-eight standardized full thickness skin defects were generated on the back of 28 adult male Lewis rats. The wounds were randomized and treated with SSG transplantation solitarily (n = 14) or SSG transplantation using CCC as an underlayment (n = 14). For skin quality analysis, a histological evaluation was performed 3 months postoperative in regard to epidermal cell count and epidermal and dermal thickness. RESULTS: Wounds treated with SSG and CCC demonstrated a thicker epidermis and significantly higher epidermal cell count compared to SSG solitarily. At the time of evaluation, epidermal thickness of SSG and CCC was comparable to untreated, healthy skin (no statistically significant differences). DISCUSSION: As split skin grafting is frequently associated with skin quality reduction, the presented results reveal the beneficial effects of CCC in terms of skin graft quality improvement. This may offer unique opportunities in wound management and encourages further evaluation of CCC in surgical applications and regenerative medicine.

In vivo analysis of the vascular pattern of the superficial temporal artery based on digital subtraction angiography.

BACKGROUND: Existing anatomic descriptions of the superficial temporal artery (STA) are mainly based on cadaver studies and do not accurately reflect the in vivo situation. In this study, the anatomical course and branching pattern of the STA were analyzed with digital subtraction angiographies (DSAs). METHODS: DSAs of 93 Caucasian individuals between 16- and 79-years old were retrospectively analyzed regarding the course and branching pattern of the STA as well as surgically relevant inner diameters and lengths of its main branches. RESULTS: In total, 11 variations in the branching pattern of the terminal STA were found. About 89% of the examined individuals demonstrated the classic variation in which the main trunk of the STA bifurcates into a single frontal and parietal branch. In 60% of cases with an existing bifurcation, the division of the main trunk of the STA was located above the zygoma. The mean inner diameters of the STA main trunk, the frontal branch and the parietal branch were 2.4 ± 0.6 mm, 1.3 ± 0.6 mm and 1.2 ± 0.4 mm, respectively. The surgically relevant "working lengths" of the frontal and parietal branches above the upper margin of the zygoma up to an inner diameter of 1 mm were 106.4 ± 62.1mm and 99.7 ± 40.9 mm, respectively. CONCLUSIONS: The common variations of the branching pattern of the STA are described in this study. Furthermore, surgically relevant inner diameters and lengths of the main branches of the STA are determined. These findings should improve our understanding of the suitability and usefulness of the STA for various surgical procedures.

Evaluation of commonly used temporary skin dressings and a newly developed collagen matrix for treatment of superficial wounds.

OBJECTIVE: In the authors' experience, extended superficial-thickness wounds often were treated with the application of synthetic temporary wound dressings. There is a broad range of expensive products available in this market. The aim of this study was to compare commonly used temporary skin dressings with a newly developed collagen matrix. METHODS: A total of 56 standardized superficial skin defects were generated on the back of 28 adult male Lewis rats using a skin dermatome. The wounds were treated with Biobrane (Smith & Nephew, St Petersburg, Florida) (n = 14), Suprathel (PolyMedics, Denkendorf, Germany) (n = 14), and newly developed Collagen Cell Carrier (Naturin Viscofan, Weinheim, Germany) (CCC; n = 14). Histological evaluation was performed at 3 months' postoperative in regard to quality of newly formed skin. RESULTS: In regard to epidermal cell count and thickness of skin, Biobrane and Suprathel demonstrated comparable values, whereas CCC demonstrated higher epidermal cell count and thicker neoepidermis. The epidermal thickness of CCC was comparable to untreated, healthy skin. CONCLUSIONS: The presented results reveal the potential of CCC in the treatment of superficial skin defects and encourages further evaluation of CCC in surgical applications and regenerative medicine.

Fetuin-A influences vascular cell growth and production of proinflammatory and angiogenic proteins by human perivascular fat cells.

AIMS/HYPOTHESIS: Fetuin-A (alpha2-Heremans-Schmid glycoprotein), a liver-derived circulating glycoprotein, contributes to lipid disorders, diabetes and cardiovascular diseases. In a previous study we found that perivascular fat cells (PVFCs) have a higher angiogenic potential than other fat cell types. The aim was to examine whether fetuin-A influences PVFC and vascular cell growth and the expression and secretion of proinflammatory and angiogenic proteins, and whether TLR4-independent pathways are involved. METHODS: Mono- and co-cultures of human PVFCs and endothelial cells were treated with fetuin-A and/or palmitate for 6-72 h. Proteins were quantified by ELISA and Luminex, mRNA expression by real-time PCR, and cell growth by BrDU-ELISA. Some PVFCs were preincubated with a nuclear factor κB NFκBp65 inhibitor, or the toll-like receptor 4 (TLR4) inhibitor CLI-095, or phosphoinositide 3-kinase (PI3K)/Akt inhibitors and/or stimulated with insulin. Intracellular forkhead box protein O1 (FoxO1), NFκBp65 and inhibitor of κB kinase ß (IKKß) localisation was visualised by immunostaining. RESULTS: PVFCs expressed and secreted IL-6, IL-8, plasminogen activator inhibitor 1 (PAI-1), basic fibroblast growth factor (bFGF), platelet-derived growth factor (PDGF)-BB, monocyte chemotactic protein-1 (MCP-1), vascular endothelial growth factor (VEGF), placental growth factor (PLGF) and hepatocyte growth factor (HGF). Fetuin-A upregulated IL-6 and IL-8, and this was potentiated by palmitate and blocked by CLI-095. Immunostaining and electrophoretic mobility shift assay (EMSA) showed partial NFκBp65 activation. MCP-1 was upregulated and blocked by CLI-095, but not by palmitate. However, HGF was downregulated, which was slightly potentiated by palmitate. This effect persisted after TLR4 pathway blockade. Stimulation of insulin-PI3K-Akt signalling by insulin resulted in nuclear FoxO1 extrusion and HGF upregulation. Fetuin-A counteracted these insulin effects. CONCLUSIONS/INTERPRETATION: Fetuin-A and/or palmitate influence the expression of proinflammatory and angiogenic proteins only partially via TLR4 signalling. HGF downregulation seems to be mediated by interference with the insulin-dependent receptor tyrosine kinase pathway. Fetuin-A may also influence angiogenic and proinflammatory proteins involved in atherosclerosis.

Reimbursement for reconstruction by tissue transfer-a European comparison.

BACKGROUND: Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. Our purpose was to analyse the reimbursement for different types of tissue transfer in five European countries. METHODS: We looked at common surgical options for pedicled and free flaps. The recipient site of a flap and the principal diagnosis were systematically modified and processed with national grouper software in order to identify Diagnosis-Related Groups from which the proceeds were derived. The primary data originated from the database of the German Institute for the Hospital Remuneration System as aggregate information. We conducted eight specialist interviews to transfer the available data into clinical practice. Data of real patients were not available and we rather simulated standard patients to avoid dilution of results. RESULTS: Altogether, payment for pedicled flaps averaged 5933€ and was 8517€ for free flaps. The comparison of both flap types within a country revealed significant differences in Germany, Austria and Sweden only (p < 0.001). Italy has the highest mean proceeds for pedicled flaps, followed by Sweden, Germany, Austria and the UK. This relationship changes for free flaps with Sweden achieving the highest payments. Overall, reimbursement conformity is higher for free flaps. CONCLUSIONS: Most countries have procedure-driven payment systems for flap surgery, which additionally can strongly depend on the diagnosis. Nevertheless the latter does not always justify existing price differences. For the first time, clinical cases in tissue transfer were compared internationally. In today`s dynamic world of health care, we should observe other countries` compensation systems to identify ways of improving our own.