WALANT-Epinephrine injection may lead to short term, reversible episodes of critical oxygen saturation in the fingertips.

INTRODUCTION: Although the WALANT technique's long-term safeness has been demonstrated in many studies, there are only few data investigating its short-term effects on tissue perfusion and oxygen levels. It was hypothesized that, temporarily, critical levels of tissue perfusion may occur. METHODS: Seventeen patients, who were scheduled for different procedures in WALANT technique, were injected with 5-7 ml of 1% Articain containing 1:200,000 epinephrine at the finger base. Capillary-venous oxygen saturation, hemoglobin volume in the capillaries, and relative blood flow in the fingertips were recorded once per second by white light spectrometry and laser Doppler flowmetry before, during and after injection for an average of 32 min. RESULTS: Clinically, no persistent tissue malperfusion was observed, and there were no postoperative complications. Capillary-venous oxygen saturation was reduced by ≥ 30% in seven patients. Critical levels of oxygen saturation were detected in four patients during 13 intervals, each lasting for 132.5 s on average. Oxygen saturation returned to noncritical values in all patients by the end of the observation period. Blood flow in the fingertips was reduced by more than 30% in nine patients, but no critical levels were observed, as with the hemoglobin. Three patients demonstrated a reactive increase in blood flow of more than 30% after injection. CONCLUSIONS: Injection of tumescent local anesthesia containing epinephrine into finger base may temporarily cause a substantial reduction in blood flow and lead to critical levels of oxygen saturation in the fingertips. However, this was fully reversible within minutes and does not cause long-term complications.

[Osteophyte-induced impingement reduces range of motion in humpback deformity of incorrectly healed scaphoid reconstruction]. / Osteophytenbedingtes Impingement verringert die Beweglichkeit bei in "Humpback"-Deformität fehlverheilter Skaphoidrekonstruktion.

BACKGROUND: The gold standard in the treatment of scaphoid pseudarthrosis is reduction, interposition of an iliac crest graft and stabilization with a headless bone (Herbert) screw, aiming to reduce the frequently observed humpback deformity. This study correlated the extent of humpback deformity after scaphoid reconstruction to clinical and radiological postoperative parameters. MATERIAL AND METHODS: Between 2008 and 2010 a total of 56 patients with scaphoid pseudarthrosis were surgically treated. Of the patients 34 could be included in this retrospective study. The average follow-up period was 7.3 months. The humpback deformity was evaluated by computed tomography (CT) scan performed along the long axis of the scaphoid. The disability of the arm, shoulder and hand (DASH) score, grip strength (Jamar), range of motion (RoM), Mayo wrist score (MWS) and other parameters were used to determine the clinical outcome. The patients were divided into two groups: 1) no or only slight humpback deformity (<25°), 2) severe humpback deformity (>45°). RESULTS: The RoM and DASH scores were slightly better for the first group. The second group had a significantly increased incidence of osteophyte formation (p < 0.05) and decreased RoM (-16°). CONCLUSION: It is postulated that the main disadvantage of an nonreduced humpback deformity is the increased occurrence of osteophyte formation in the dorsal aspect of the scaphoid. This can cause an impingement during extension and leads to a significant restriction of movement of the wrist. LEVEL OF EVIDENCE: III.

[Prospective monitoring of a university rheumatology outpatient clinic throughout the first wave of the COVID-19 pandemic : What lessons can be learned?] / Prospektive Verlaufsbeobachtung einer universitären Rheumaambulanzkohorte während der ersten Welle der COVID-19-Pandemie : Welche Lehren kann man ziehen?

BACKGROUND: In March 2020 the SARS-CoV­2 pandemic disseminated initially especially in Bavaria. At that time data on patients with rheumatic diseases and immunomodulatory treatment was lacking. OBJECTIVE: The aim was to analyze the influence of the SARS-CoV­2 pandemic on the clinical treatment strategy. MATERIAL AND METHODS: Between 16 March and 31 July 2020 all patients who consecutively presented at the rheumatology outpatient clinic of the Klinikum rechts der Isar of the Technical University of Munich were included in the study. Individual treatment adjustments were based on clinical judgment and the recommendations for action of the German Society for Rheumatology (DGRh). RESULTS: A total of 322 patients were included. The most frequent diagnosis was rheumatoid arthritis with 17%, ANCA-associated vasculitis (AAV) with 14% and SLE with 12%. Of the patients 262 were on DMARD treatment and 77 received oral glucocorticoids. There were 5 cases of suspected SARS-CoV­2 infection; however, no patient verifiably became ill due to COVID-19. In 40 patients, treatment adjustments were done due to the pandemic, whereby 3 patients developed a flare of the underlying disease. In retrospect, treatment de-escalation occurred most frequently in AAV, IgG4-related disease, immunosuppressive treatment with rituximab and the simultaneous presence of malignant diseases. CONCLUSION: The total lack of confirmed SARS-CoV­2 infections in an otherwise strongly affected region could indicate that the infection risk for SARS-CoV­2 is not substantially increased for patients with inflammatory rheumatic diseases. A continuation of most immunosuppressive medications therefore seems reasonable during the ongoing pandemic.

[Diagnostic accuracy of conventional X-ray imaging for assessment of trapeziometacarpal joint osteoarthritis]. / Genauigkeit der konventionellen Röntgendiagnostik bei der Beurteilung der Daumensattelgelenkarthrose.

BACKGROUND: Osteoarthritis of the trapeziometacarpal joint is a common and painful affliction that can be diagnosed using conventional X­ray imaging as well as arthroscopy and if necessary treated; however, the X­ray classification often does not sufficiently demonstrate the cartilage damage found in arthroscopy. OBJECTIVE: The aim of the study was to evaluate the diagnostic accuracy of conventional X­ray imaging compared to arthroscopy for osteoarthritis of the trapeziometacarpal joint. MATERIAL AND METHODS: The preoperative conventional X­ray images of 23 patients were presented to 10 experienced hand surgeons who were blinded to the arthroscopy results. Their ratings were compared to the results found with arthroscopy. RESULTS: Of the patients 11 were found to have grade 4 cartilage lesions according to the Outerbridge classification, 8 grade 3 lesions, 4 grade 2 lesions and no grade 1 lesions. Overall, 43% (95% confidence interval, CI 37-49%) of the cartilage lesions were diagnosed correctly using conventional X­rays. For grade 4 lesions 73% (95% CI 65-81%) of the surgeons made the correct diagnosis, in the case of grade 3 lesions 38% (95% CI 27-49%) and in grade 2 lesions 13% (95% CI 3-23%). CONCLUSION: This study presents an arthroscopy classification system that is specific for osteoarthritis of the trapeziometacarpal joint and provides an additional method of assessment if the X­ray grading of osteoarthritis according to Eaton and Littler is too unspecific. Arthroscopy can be used to safely differentiate the treatment-relevant stage and also includes treatment options.

Adult macrophage activation syndrome-haemophagocytic lymphohistiocytosis: 'of plasma exchange and immunosuppressive escalation strategies' - a single centre reflection.

OBJECTIVE: In the context of systemic autoimmunity, that is systemic lupus erythematosus (SLE) or adult-onset Still's disease (AOSD), secondary haemophagocytic lymphohistiocytosis (HLH; also referred to as macrophage activation syndrome (MAS) or more recently MAS-HLH) is a rare and potentially life-threatening complication. Pathophysiological hallmarks are aberrant macrophage and T cell hyperactivation and a systemic cytokine flare, which generate a sepsis-like, tissue-damaging, cytopenic phenotype. Unfortunately, for adult MAS-HLH we lack standardized treatment protocols that go beyond high-dose corticosteroids. Consequently, outcome data are scarce on steroid refractory cases. Aside from protocols based on treatment with calcineurin inhibitors, etoposide, cyclophosphamide and anti-IL-1, favourable outcomes have been reported with the use of intravenous immunoglobulin (IvIG) and plasma exchange (PE). METHODS: Here we report a retrospective series of steroid refractory MAS-HLH, the associated therapeutic regimes and outcomes. RESULTS: In this single-centre experience, 6/8 steroid refractory patients survived (median follow-up: 54.4 (interquartile range: 23.3-113.3) weeks). All were initially treated with PE, which induced partial response in 5/8 patients. Yet, all patients required escalation of immunosuppressive therapies. One case of MAS-HLH in new-onset AOSD had to be escalated to etoposide, whereas most SLE-associated MAS-HLH patients responded well to cyclophosphamide. Relapses occurred in 2/8 cases. CONCLUSION: Together, early use of PE is at most a supportive measure, not a promising monotherapy of adult MAS-HLH. In refractory cases, conventional cytoreductive therapies (i.e. cyclophosphamide and etoposide) constitute potent and reliable rescue approaches, whereas IvIG, anti-thymoglobulin, and biologic agents appear to be less effective.

Analysis of recurrence and complications after percutaneous needle fasciotomy in Dupuytren's disease.

INTRODUCTION: The partial aponeurectomy for treatment of Dupuytren's contracture represents the gold standard for treatment of Dupuytren's contracture. In selected cases, the alternative is the percutaneous needle fasciotomy (PNF). MATERIALS AND METHODS: Between 2008 and 2018, 80 rays in 64 patients were treated using PNF. 53 patients (68 rays) were reviewed with a mean follow-up of 31 months. RESULTS: The recurrence rate was 18.9%. 49 patients with 62 rays had a totally free extension intra-operatively (92.4%). There were no complications. Only one patient reported a transient dysesthesia (1.8%) in the zone of operation. 86% of all patients would undergo the treatment again, if necessary. Patients were able to return to their job in an average of 5.5 days. CONCLUSIONS: PNF is reliable and relatively simple to perform compared to partial aponeurectomy. Therefore, the PNF could be seen as a serious alternative for selected cases.

Three-dimensional fat-saturated T1-weighted Cartesian volumetric interpolated breath-hold examination (VIBE) for the diagnosis of aortitis in patients with suspected large vessel vasculitis: a comparative study with 18F-FDG PET applying fully integrated PET/MRI.

AIM: To evaluate the feasibility of T1-weighted (T1W) three-dimensional (3D) fat saturated Cartesian volumetric interpolated breath-hold examination (VIBE) magnetic resonance imaging (MRI) sequence for the diagnosis of aortitis in patients with suspected large vessel vasculitis (LVV) applying fully integrated 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) positron-emission tomography (PET)/MRI. MATERIAL AND METHODS: Fourteen patients with aortitis and 14 patients with a negative study for aortitis using 18F-FDG PET as the standard of reference for the evaluation of inflammatory aortic involvement were included retrospectively. All patients were imaged at 3 T using T1W VIBE pre- and post-contrast. Four aortic segments were evaluated for image quality (IQ), diagnostic confidence (DC), and the degree of inflammatory activity (IA) using a Likert scale. Binomial and generalised estimating equation model tests were used to assess the diagnostic performance of T1W VIBE. Cohen's k was applied to test for interobserver reproducibility with respect to IA. Spearman's rank correlation coefficient was calculated to examine correlations between IQ, DC, IA, and PET results. RESULTS: On a patient- and segment-based analysis, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 85.7% and 59.8%, 100% and 100%, 100% and 100%, 87.5% and 68%, and 92.9% and 82.1%, respectively. IQ and DC were acceptable to good in all examinations and substantial interobserver agreement was observed for IA (Cohen's k = 0.69). IQ and DC as well as IA and 18F-FDG vessel wall uptake were significantly correlated (r=0.763 and 0.679, respectively; p<0.0001). CONCLUSION: T1W 3D fat saturated VIBE MRI allows diagnosis of aortitis and may aid in the management of patients with suspected LVV.

Assessment of autonomic function in a cohort of patients with ANCA-associated vasculitis.

OBJECTIVE: To assess symptoms and objective parameters of autonomic dysfunction (AD) in patients with ANCA-associated vasculitides. METHODS: Symptoms and objective parameters of AD were assessed in patients with ANCA-associated vasculitis and in age-matched healthy controls. Autonomic symptoms were explored by COMPASS31, a validated questionnaire addressing symptoms of six autonomic domains (orthostatic, vasomotor, secretomotor, gastrointestinal, pupillomotor, and bladder dysfunction). Objective autonomic parameters consisted of expiratory/inspiratory (E/I) ratio during the deep breathing test (DBT), blood pressure response to cold pressor test (CPT), and skin conductance changes during mental arithmetic. RESULTS: 27 patients and 27 healthy controls have been enrolled. 27 patients and 27 controls completed COMPASS31. 21 patients and 18 controls underwent objective autonomic testing. Vasculitis patients had significantly higher COMPASS31 total scores than controls (median 10.4 vs 3.0; p = 0.005). In the sub-domain analysis, significant differences were seen in the vasomotor and the bladder domain (p = 0.004; p < 0.001, respectively). No correlation was found between COMPASS31 score and disease duration, number of affected organs, or Birmingham vasculitis activity score (BVAS). There was no significant difference in any of the objective autonomic parameters between patients and controls. In a subgroup analysis, no difference in objective autonomic parameters was found between patients with active disease (n = 12) and patients in remission (n = 7). CONCLUSION: Patients with ANCA-associated vasculitides commonly have symptoms of autonomic dysfunction that are independent of disease duration and disease severity. However, at least in this single-centre observation, there was no evidence of impaired autonomic regulation in three autonomic function tests in vasculitis patients.

Single-dose rituximab for remission induction and maintenance therapy in ANCA-associated vasculitis: a retrospective analysis of 17 patients.

OBJECTIVES: The aim of this study was to evaluate the efficacy of a repeated single-dose rituximab (RTX) regimen for remission induction and maintenance in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). METHOD: We performed a retrospective analysis of all patients with an established diagnosis of AAV who were treated with single-dose RTX infusions at our institution. Clinical outcome data were assessed over a period of 24 months. RESULTS: Sixteen patients were treated for remission induction and maintenance and one patient was treated for only maintenance therapy. Remission (absence of disease activity during the past 3 months and a prednisolone dose of ≤ 7.5 mg) was achieved in 11 patients (68%) with a mean time to remission of 9.4 (range 3-24) months. At 6 months, six patients (37.5%) were in remission and the mean prednisolone dose of all responding patients was 8.2 mg. Five patients had treatment failure due to early relapsing (n = 4) or persistently active (n = 1) disease. At 24 months, nine of the 11 responding patients (82%) were in remission. All patients still had concomitant steroid and/or disease-modifying anti-rheumatic drug (DMARD) therapy at 24 months. Overall, 11 relapses were seen in nine patients (five non-responders and four responders) with a mean time to relapse of 5.3 (range 4-24) months. No major relapses were observed in the responding patients. Severe infections were only seen in patients who had been previously treated with cyclophosphamide (CYC). CONCLUSIONS: The combination of single-dose RTX with other immunosuppressants seems less effective than the standard RTX regimen for the induction of remission of AAV.

Cell-free carrier system for localized delivery of peripheral blood cell-derived engineered factor signaling: towards development of a one-step device for autologous angiogenic therapy.

Spatiotemporally-controlled delivery of hypoxia-induced angiogenic factor mixtures has been identified by this group as a promising strategy for overcoming the limited ability of chronically ischemic tissues to generate adaptive angiogenesis. We previously developed an implantable, as well as an injectable system for delivering fibroblast-produced factors in vivo. Here, we identify peripheral blood cells (PBCs) as the ideal factor-providing candidates, due to their autologous nature, ease of harvest and ample supply, and investigate wound-simulating biochemical and biophysical environmental parameters that can be controlled to optimize PBC angiogenic activity. It was found that hypoxia (3% O2) significantly affected the expression of a range of angiogenesis-related factors including VEGF, angiogenin and thrombospondin-1, relative to the normoxic baseline. While all three factors underwent down-regulation over time under hypoxia, there was significant variation in the temporal profile of their expression. VEGF expression was also found to be dependent on cell-scaffold material composition, with fibrin stimulating production the most, followed by collagen and polystyrene. Cell-scaffold matrix stiffness was an additional important factor, as shown by higher VEGF protein levels when PBCs were cultured on stiff vs. compliant collagen hydrogel scaffolds. Engineered PBC-derived factor mixtures could be harvested within cell-free gel and microsphere carriers. The angiogenic effectiveness of factor-loaded carriers could be demonstrated by the ability of their releasates to induce endothelial cell tubule formation and directional migration in in vitro Matrigel assays, and microvessel sprouting in the aortic ring assay. To aid the clinical translation of this approach, we propose a device design that integrates this system, and enables one-step harvesting and delivering of angiogenic factor protein mixtures from autologous peripheral blood. This will facilitate the controlled release of these factors both at the bed-side, as an angiogenic therapy in wounds and peripheral ischemic tissue, as well as pre-, intra- and post-operatively as angiogenic support for central ischemic tissue, grafts, flaps and tissue engineered implants.

Biochemical responses to iron deficiency in kiwifruit (Actinidia deliciosa).

A comparative study of two kiwifruit genotypes (Actinidia deliciosa (A. Chev.) C.F. Liang et A.R. Ferguson var. deliciosa) with different tolerance to iron (Fe) deficiency was conducted to identify biochemical features associated with tolerance to Fe deficiency. After 14 days of growth in hydroponic culture under Fe-deficient and Fe-sufficient conditions, leaf chlorophyll concentration, activities of ferric chelate reductase (FCR), phosphoenolpyruvate carboxylase (PEPC) and citrate synthase in root extracts, concentrations of organic acids in roots, leaves and xylem sap, and xylem sap pH were measured. In response to Fe deficiency, the tolerant genotype D1 showed: (i) higher FCR activity associated with a longer lasting induction of FCR; (ii) higher PEPC activity; (iii) higher concentrations of citric acid in roots; and (iv) lower xylem sap pH compared with the susceptible genotype Hayward. These findings imply that induction of FCR and PEPC activities in roots in response to Fe deficiency are important physiological adaptations enabling Fe-efficient kiwifruit plants to tolerate Fe deficiency.

Technical advance: reduction of Fe(III)-chelates by mesophyll leaf disks of sugar beet. Multi-component origin and effects of Fe deficiency.

The characteristics of the Fe(III)-chelate reductase activity have been investigated in mesophyll disks of Fe-sufficient and Fe-deficient sugar beet leaves. The Fe(III)-chelate reductase activity of mesophyll disks was light dependent and increased markedly when the epidermis was removed. Iron(III)-citrate was photo-reduced directly by light in the absence of plant tissue. Total reductase activity was the sum of enzymatic mesophyll reduction, enzymatic reduction carried out by organelles exposed at the disk edge and reduction caused by the release of substances both by exposed mesophyll cells and at the disk edge. Compounds excreted were shown by HPLC to include organic anions, mainly oxalate, citrate and malate. When expressed on a leaf surface basis, Fe deficiency decreased the total mesophyll Fe(III)-chelate reductase activity. However, Fe-sufficient disks reduced less Fe than the Fe-deficient ones when expressed on a chlorophyll basis. The optimal pH values for Fe(III) reduction were always in the range 6.0-6.7. In control leaves Fe(III)-citrate and Fe(III)-malate were the substrates that led to the highest Fe reduction rates. In Fe-deficient leaves Fe(III)-malate led to the highest Fe reduction rates, followed by Fe(III)-EDTA and then Fe(III)-citrate. K:(m) values for the total reductase activity, enzymatic mesophyll reduction and enzymatic reduction carried out by organelles at the disk edge were obtained.

Responses to iron deficiency in Arabidopsis thaliana: the Turbo iron reductase does not depend on the formation of root hairs and transfer cells.

Arabidopsis thaliana (L.) Heynh. Columbia wild type and a root hair-less mutant RM57 were grown on iron-containing and iron-deficient nutrient solutions. In both genotypes, ferric chelate reductase (FCR) of intact roots was induced upon iron deficiency and followed a Michaelis-Menten kinetic with a Km of 45 and 54 microM FeIII-EDTA and a Vmax of 42 and 33 nmol Fe2+.(g FW)-1.min-1 for the wild type and the mutant, respectively. The pH optimum for the reaction was around pH 5.5. The approximately four fold stimulation of FCR activity was independent of formation of root hairs and/or transfer cells induced by iron deficiency. Iron-deficiency-induced chlorosis and the development of a rigid root habit disappeared when ferric chelate was applied to the leaves, while FCR activity remained unchanged. The time course of the responses to iron deficiency showed that morphological and physiological responses were controlled separately.

[Circumscribed detachment of Descemet's membrane after cataract operation (author's transl)]. / Umschriebene Descemetabhebung nach Staroperation

A circumscribed central bullous detachment of Descemet's membrane occuring on day 8 after an uncomplicated cataract extraction is reported. The lesion responded to conservative management and resolved without sequelae.