Laminin ß4 is a constituent of the cutaneous basement membrane zone and additional autoantigen of anti-p200 pemphigoid.

BACKGROUND: Anti-p200 pemphigoid is a subepidermal autoimmune blistering disease (AIBD) characterized by autoantibodies against a 200 kDa protein. Laminin γ1 has been described as target antigen in 70% to 90% of patients. No diagnostic assay is widely available for anti-p200 pemphigoid, which might be due to the unclear pathogenic relevance of anti-laminin γ1 autoantibodies. OBJECTIVE: To identify a target antigen with higher clinical and diagnostic relevance. METHODS: Immunoprecipitation, mass spectrometry, and immunoblotting were employed for analysis of skin extracts and sera of patients with anti-p200 pemphigoid (n = 60), other AIBD (n = 33), and healthy blood donors (n = 29). To localize the new antigen in skin, cultured keratinocytes and fibroblasts, quantitative real-time polymerase chain reaction and immunofluorescence microscopy were performed. RESULTS: Laminin ß4 was identified as target antigen of anti-p200 pemphigoid in all analyzed patients. It was located at the level of the basement membrane zone of the skin with predominant expression in keratinocytes. LIMITATIONS: A higher number of sera needs to be tested to verify that laminin ß4 is the diagnostically relevant antigen of anti-p200 pemphigoid. CONCLUSION: The identification of laminin ß4 as an additional target antigen in anti-p200 pemphigoid will allow its differentiation from other AIBD and as such, improve the management of these rare disorders.

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.

Closing the Gap: Bridging Peripheral Sensory Nerve Defects with a Chitosan-Based Conduit a Randomized Prospective Clinical Trial.

Introduction: If tensionless nerve coaptation is not possible, bridging the resulting peripheral nerve defect with an autologous nerve graft is still the current gold standard. The concept of conduits as an alternative with different materials and architectures, such as autologous vein conduits or bioartificial nerve conduits, could not replace the nerve graft until today. Chitosan, as a relatively new biomaterial, has recently demonstrated exceptional biocompatibility and material stability with neural lineage cells. The purpose of this prospective randomized clinical experiment was to determine the efficacy of chitosan-based nerve conduits in regenerating sensory nerves in the hand. Materials and methods: Forty-seven patients with peripheral nerve defects up to 26 mm distal to the carpal tunnel were randomized to receive either a chitosan conduit or an autologous nerve graft with the latter serving as the control group. Fifteen patients from the conduit group and seven patients from the control group were available for a 12-month follow-up examination. The primary outcome parameter was tactile gnosis measured with two-point discrimination. The secondary outcome parameters were Semmens Weinstein Monofilament Testing, self-assessed pain, and patient satisfaction. Results: Significant improvement (in static two-point discrimination) was observed six months after trauma (10.7 ± 1.2 mm; p < 0.05) for chitosan-based nerve conduits, but no further improvement was observed after 12 months of regeneration (10.9 ± 1.3 mm). After six months and twelve months, the autologous nerve graft demonstrated comparable results to the nerve conduit, with a static two-point discrimination of 11.0 ± 2.0 mm and 7.9 ± 1.1 mm. Semmes Weinstein Filament Testing in the nerve conduit group showed a continuous improvement over the regeneration period by reaching from 3.1 ± 0.3 after three months up to 3.7 ± 0.4 after twelve months. Autologous nerve grafts presented similar results: 3.3 ± 0.4 after three months and 3.7 ± 0.5 after twelve months. Patient satisfaction and self-reported pain levels were similar between the chitosan nerve conduit and nerve graft groups. One patient required revision surgery due to complications associated with the chitosan nerve tube. Conclusion: Chitosan-based nerve conduits are safe and suitable for bridging nerve lesions up to 26 mm in the hand. Tactile gnosis improved significantly during the early regeneration period, and functional outcomes were similar to those obtained with an autologous nerve graft. Thus, chitosan appears to be a sufficient substitute for autologous nerve grafts in the treatment of small nerve defects in the hand.

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.

[Use of acellular allogeneic nerve transplants for nerve defects of the hand : Experience from a German hand surgery center]. / Einsatz von azellulären allogenen Nerventransplantaten bei Nervendefekten an der Hand : Erfahrung aus einem deutschen handchirurgischen Zentrum.

Peripheral nerve injuries are often encountered in traumatological care. The aim of this manuscript is to provide initial data, experiences and performance reports from Germany in the implantation of acellular human nerve transplants in peripheral sensory nerve defects of the hand and to put these data in the context of a comprehensive review of the literature. Of the patients 4 (7 digital nerves) were examined 6 months postoperatively and 5 patients (6 digital nerves) were examined 1 year after the operation (3 were also at the 6­month examination). All patients had a clinical improvement after nerve reconstruction (≥ S3 according to the classification of sensory recovery of the Medical Research Council modified by Mackinnon and Dellon). Disadvantages of our clinical study are the small number of patients, the inhomogeneity (primary and secondary nerve reconstruction) and the lack of comparison with other nerve reconstruction methods.

[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.

Split thickness skin graft versus application of the temporary skin substitute suprathel in the treatment of deep dermal hand burns: a retrospective cohort study of scar elasticity and perfusion.

Two therapeutic options for deep dermal hand burns are autologous split-thickness skin graft (STSG) following tangential excision and the application of the temporary wound dressing Suprathel following removal of burn blisters. We compared elasticity and perfusion of burn scars after both types of therapy at least one year after completion of treatment. A case series of 80 patients of our department with deep dermal hand burns between 2013 and 2018 was examined in the year 2019 at least one year after completion of treatment (24 females and 56 males with a median age of 47.6 years). The clinical assessment of the scar was performed with the Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) and the objective assessment with suction cutometry (MPA 580) and an O2C device on both hands. Our statistical analysis showed no statistically significant differences for the R2 and R5 elasticity values between the two types of therapy. The 95% confidence intervals for the ratios of elasticity, and microcirculatory perfusion parameters and scar scale scores of burn scars to respective healthy areas of skin after STSG and Suprathel-therapy mostly covered 1. Subgroup analysis of R2 viscoelasticity and analyses with adjustments for scar compression therapy, nicotine consumption, age, palmar or dorsal localization of the burn scar and interactions of age with smoking and localization gave similar results. The adjusted analysis of SO2 showed statistically significant lower SO2 values, 9% less, after STSG compared to Suprathel treatment. Split-thickness skin graft following tangential excision and the application of Suprathel following removal of burn blisters may be equivalent options for treatment of deep dermal hand burns. To detect possible small differences, further studies with larger samples are required.

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.

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.

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.

[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.

Traumatizing Oneself-Deep Wrist Injuries Self-Inflicted with Suicidal Intention are Associated with More Severe PTSD Symptomatology than Similar Injuries from Accidents.

OBJECTIVE: As suicide attempts by definition entail at least some threat to physical integrity and life, they theoretically qualify as an A1 criterion for posttraumatic stress disorder (PTSD). This study uses the unique opportunity of deep wrist injuries to quantify the effect of intentionality on PTSD rates by comparing suicide attempt survivors with patients who sustained accidental injuries similar in mechanism, localization, and extent. METHOD: Patients who had been admitted with an acute deep wrist injury from 2008 to 2016 filled out the revised Impact of Event Scale and reported other known PTSD risk factors. Mental morbidity and intentionality of the injury were determined by psychiatric consultation during the index hospitalization. RESULTS: Fifty-one patients were followed up (72.5% male, 92.2% Caucasian, mean age at injury 42.3 ± 17.5 years, 72.5% accidental injuries), on average 4.2 ± 2.9 years after their injury. The intentionality of the injury alone predicted the severity of intrusions, avoidance, hyperarousal, and probable PTSD (aOR = 14.0). CONCLUSIONS: Traumatization in the context of a suicide attempt may be a hitherto unknown PTSD risk factor. Patients after suicide attempts, especially medically serious attempts, should be monitored for PTSD symptoms.

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.

Think big - Plastic surgical treatment of complicated large sacral ulcerations: A case comparison.

OBJECTIVE: Large pressure ulcers are a well know problem occurring frequently on immobilized patients. They can develop rapidly especially over bony prominences on the elderly, ICU patients and on patients after spinal cord injury. Plastic surgical treatment can be challenging if the defects are large and complications occur like affection of anal region or development of a Marjolin's scar ulcer. Large defects of the sacral region are well known in our university hospital. Common local flaps like gluteal rotation or (double) V-Y advancement flap are often used for the treatment of smaller defects. In special cases these therapies are not sufficient. Rarely we use fillet flap of the lower extremity to cover large sacral defects on patients who were unable to walk before. SUBJECTS AND METHOD: In this case report we demonstrate two relatively young paraplegic patients (49 and 57years old) with large sacral defect wounds. One case occurred in 2017, the other in 2019. After spinal cord injury many years ago both of them developed chronic pressure ulcers of the sacral region. In the case of 2017 a Marjolin's scar ulcer developed as a complication. Both patients had previously lost a leg during the surgical treatment. We used the other remaining leg as a fillet flap in combination with interdisciplinary rectum extirpation for sufficient surgical treatment. RESULTS: In both cases adequate coverage of the sacral defect was achieved after interdisciplinary surgical treatment including rectum extirpation. Fillet flaps were safe, even after necessary surgical revisions. In one of the cases a vacuum wound therapy and several debridements were needed. After rehabilitation the patient of the earlier case is able to fully mobilize himself in everyday life and is even able to use public transport. CONCLUSION: Using a fillet flap of the lower extremity to cover large sacral ulcers is often the last possibility of surgical treatment. Though many complications can occur, full rehabilitation and social participation is possible after fillet flap surgery even with loss of both legs. Depending on patient's motivation and availability of orthopedic technology like special electric wheel chairs and other tools full mobility can be achieved.

The Reason Matters: Deep Wrist Injury Patterns Differ with Intentionality (Accident versus Suicide Attempt).

BACKGROUND: Despite the clinical importance of suicidal deep wrist injuries (DWIs), we currently do not know whether their injury patterns differ from accidental injuries. METHODS: This retrospective study included all patients admitted to the Clinic of Plastic Surgery for acute treatment of a DWI from 2008 to 2016, except for isolated injuries to the palmaris longus (PL) and amputations. Intentionality of the injury was determined using documentation of psychiatric evaluations; cases that could not be categorized regarding intentionality were excluded. RESULTS: About 20% of DWIs stemmed from suicide attempts, which involved the nondominant hand in 94.5%. Suicidal DWIs were more likely to involve the median nerve, radial artery, PL, and flexor carpi radialis (FCR), especially on the nondominant hand, but were less likely to involve the ulnar artery and nerve on the dominant hand. The effect of the protective structures PL/flexor carpi ulnaris on the median nerve/ulnar artery could be confirmed for suicidal DWIs, but intactness of the FCR was associated with increased radial artery injuries. Longitudinal cut orientation in suicidal DWIs was associated with more radial artery injuries, but fewer injuries to tendons and nerves. Frequencies of various other injury constellations are tabulated to aid in clinical assessment. CONCLUSIONS: Suicidal and accidental DWIs differed in various aspects of injury pattern. Suicidal injuries were mostly localized to the nondominant radial side, and accidental injuries to the ulnar side. Also, the so-called protective structure FCR had the opposite effect in suicidal injuries. Thus, findings regarding injury patterns in accidental DWIs cannot be generalized to suicidal injuries.

Optical coherence tomography provides an optical biopsy of burn wounds in children-a pilot study (Erratum).

This erratum corrects a misspelling of an author's name.

Reversible dilative cardiomyopathy after electrical injury: a case report.

BACKGROUND: Dilative cardiomyopathy is an uncommon cardiac complication of electric shock. CASE PRESENTATION: We report a case of a 12-year-old German boy with a high voltage injury who developed a four-chamber dilative cardiomyopathy, which was diagnosed on the 13th week postburn. One year after the accident, echocardiography showed a normal function of his heart with 64% ejection fraction and normal cavities' dimensions. CONCLUSIONS: Despite the fact that dilative cardiomyopathy is not very common in electrical injuries but can be fatal, a prolonged echocardiography follow-up for patients with electrical injury could be recommended. Until now this case is the first child with severe burns after electrocution, who developed a reversible dilative cardiomyopathy.

Optical coherence tomography provides an optical biopsy of burn wounds in children-a pilot study.

Thermic injuries are among the most severe injuries in childhood. Burn depth is the most relevant prognostic factor, and still its assessment is both difficult and controversial. This diagnostic uncertainty results in repeated wound assessments over a 10-day period and carries a relevant risk for over- and undertreatment. Precise wound assessment would thus be a significant step toward improved care. Optical coherence tomography (OCT) is a noninvasive laser-based technique with a penetration depth of ∼2 mm. It provides structural images of the skin while dynamic OCT (D-OCT) shows blood vessels. In this study, we investigated burns and scalds in 130 children with OCT and D-OCT to identify patterns of injury related to the depth of the burn wound. OCT and D-OCT images from burned skin differed consistently from normal skin. We observed several not formerly described morphologic patterns associated with burn injuries. Superficial wounds are characterized by a loss of the epidermal layer and a smooth surface. With deeper wounds, surface irregularity, loss of the dermal papillary pattern, disappearance of skin lines, and characteristic changes in the microvascular architecture were observed. This is the first systematic study of D-OCT in the assessment of burn wounds in children. A number of burn-associated patterns of injury were identified. Thus, D-OCT provided an "optical biopsy" of burn wounds that adds significant information about the severity of a burn wound.

Radiation Sensitivity of Adipose-Derived Stem Cells Isolated from Breast Tissue.

Within their niche, adipose-derived stem cells (ADSCs) are essential for homeostasis as well as for regeneration. Therefore, the interest of physicians is to use ADSCs as a tool for radiation oncology and regenerative medicine. To investigate related risks, this study analyses the radiation response of adult stem cells isolated from the adipose tissue of the female breast. To avoid donor-specific effects, ADSCs isolated from breast reduction mammoplasties of 10 donors were pooled and used for the radiobiological analysis. The clonogenic survival fraction assay was used to classify the radiation sensitivity in comparison to a more radiation-sensitive (ZR-75-1), moderately sensitive (MCF-7), and resistant (MCF10A) cell lines. Afterwards, cytotoxicity and genotoxicity of irradiation on ADSCs were investigated. On the basis of clonogenic cell survival rates of ADSCs after irradiation, we assign ADSCs an intermediate radiation sensitivity. Furthermore, a high repair capacity of double-strand breaks is related to an altered cell cycle arrest and increased expression of cyclin-dependent kinase (CDK) inhibitor p21. ADSCs isolated from breast tissue exhibit intermediate radiation sensitivity, caused by functional repair mechanisms. Therefore, we propose ADSCs to be a promising tool in radiation oncology.