Adrien Daigeler

Host defense peptides in wound healing.

Host defense peptides are effector molecules of the innate immune system. They show broad antimicrobial action against gram-positive and -negative bacteria, and they likely play a key role in activating and mediating the innate as well as adaptive immune response in infection and inflammation. These features make them of high interest for wound healing research. Non-healing and infected wounds are a major problem in patient care and health care spending. Increasing infection rates, growing bacterial resistance to common antibiotics, and the lack of effective therapeutic options for the treatment of problematic wounds emphasize the need for new approaches in therapy and pathophysiologic understanding. This review focuses on the current knowledge of host defense peptides affecting wound healing and infection. We discuss the current data and highlight the potential future developments in this field of research.

Major and Lethal Complications of Liposuction: A Review of 72 Cases in Germany between 1998 and 2002

Background: Liposuction is the most frequently performed cosmetic operation in Germany, with approximately 200,000 procedures performed in 2003. The public perception of liposuction as minor surgery fails to consider the potential of major complications or a possibly fatal outcome. Methods: A retrospective analysis of severe or lethal complications related to cosmetic liposuction is presented. To collect pertinent information, the authors sent 3500 questionnaires to departments of pathology and forensic medicine, intensive care units, and others. After the identification of cases with major complications, the second phase of the investigation consisted of interviews with the physicians performing the liposuction. Results: Two thousand two hundred seventy-five questionnaires (65 percent) were returned. The analyzed data showed 72 cases of severe complications, including 23 deaths following cosmetic liposuction in a 5-year period from 1998 to 2002. The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism. Fifty-seven of 72 complications were clinically evident within the first 24 postoperative hours; 41 of these 72 liposuction procedures were performed using tumescent anesthesia and 17 of 72 were performed using true tumescent anesthesia, with four deaths. Conclusions: Major risk factors for the development of severe complications are insufficient standards of hygiene, the infiltration of multiple liters of wetting solution, permissive postoperative discharge, and selection of unfit patients. The lack of surgical experience was a notorious contributing factor, particularly regarding the timely identification of developing complications. This is in fact the first study reporting deaths related to liposuction performed entirely under true tumescent anesthesia.

Comparison of anterolateral thigh, lateral arm, and parascapular free flaps with regard to donor-site morbidity and aesthetic and functional outcomes.

Background: The purpose of this study was to compare the morbidity and the aesthetic and functional outcomes of primarily closed donor sites of three commonly used free flaps. Methods: Sixty patients who had undergone free flap reconstruction (20 anterolateral thigh, 20 parascapular, and 20 lateral arm flaps) were included in this study. The average follow-up time was 50 months (range, 6 to 135 months). Patients assessed subjective donor-site morbidity and satisfaction with the aesthetic and overall functional result using a self-report questionnaire. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire; the Lower Extremity Functional Scale; and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire. Results: No significant differences in range of motion or in questionnaire, scale, or survey scores were detected. Sensory disorders were present in 100 percent (lateral arm), 90 percent (anterolateral thigh), and 45 percent (parascapular). No correlation to flap size was detected (187 cm2 for parascapular and anterolateral thigh, and 70 cm2 for lateral arm flaps). Postoperative complications were seromas (parascapular, n = 2), hematomas (parascapular, n = 1; lateral arm, n = 2), and dehiscence (n = 4 for each flap). Patient satisfaction with the donor site was rated 2.9 for lateral arm and anterolateral thigh flaps and 2.5 for parascapular flaps (1 = excellent, 6 = poor). Seventy percent of anterolateral thigh, 85 percent of lateral arm, and 100 percent of parascapular flap patients would choose their flap again. Conclusion: In terms of reducing donor-site morbidity, the parascapular flap represents a valuable alternative to the anterolateral thigh and lateral arm flaps, but side positioning and increased seroma are drawbacks.

Limb Salvage in Malignant Tumors

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patients specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

Synergistic apoptotic effects of taurolidine and TRAIL on squamous carcinoma cells of the esophagus

The treatment of choice for esophageal cancer is considered surgical resection, but a median survival of around 20 months after treatment is still discouraging. The value of adjuvant or neoadjuvant radiation or chemotherapy is limited and to date, benefits have only been described for certain tumor stages. Therefore, new therapeutic options are required. As alternative chemotherapeutics, we tested the antibiotic taurolidine (TRD) on KYSE 270 human esophageal carcinoma cells alone and in combination with rhTRAIL (TNF related apoptosis-inducing ligand). Viability, apoptosis and necrosis were visualized by TUNEL assay and quantitated by FACS analysis. Gene expression was analysed by RNA microarray. The most effective concentration of TRD as single substance (250 micromol/l) induced apoptosis to a maximum of 40% after 12-h dose dependently, leaving 4% viable cells after 48 h; by comparison, rhTRAIL did not have a significant effect. The combination of both substances doubled the effect of TRD alone. Gene expression profiling revealed that TRD downregulated endogenous TRAIL, TNFRSF1A, TRADD, TNFRSF1B, TNFRSF21, FADD, as well as MAP2K4, JAK2 and Bcl2, Bcl2l1, APAF1 and caspase-3. TNFRSF25, cytochrome-c, caspase-1, -8, -9, JUN, GADD45A and NFKBIA were upregulated. TRAIL reduced endogenous TRAIL, Bcl2l1 and caspase-1 expression. BIRC2, BIRC3, TNFAIP3, and NFKBIA were upregulated. The combined substances upregulated endogenous TRAIL, NFKBIA and JUN, whereas DFFA and TRAF3 were downregulated compared to TRD as single substance. We conclude that TRD overcomes TRAIL resistance in KYSE 270 cells. Synergistic effects are dependent on the same and on distinct apoptotic pathways which, jointly triggered, result in an amplified response. Several apoptotic pathways, including the TNF-receptor associated and the mitochondrial pathway, were differentially regulated by the substances on gene expression level. Additionally transcription factors seem to be influenced, NFKB in particular. Endogenous TRAIL expression is increased by the combination of substances, whereas it is reduced by each single substance. Taking into consideration that the non-toxic TRD was able to reduce rhTRAIL toxicity and dose, combined therapy with TRD and rhTRAIL may offer new options for treatment in esophageal cancer.

[Importance of specialized centers in diagnosis and treatment of extremity-soft tissue sarcomas. Review of 603 cases].

ZusammenfassungDie onkologiegerechte Therapie maligner Weichgewebstumoren setzt eine korrekte Diagnosestellung inklusive Angabe des Gradings voraus. Aufgrund der Seltenheit dieser Tumoren, einer Vielzahl verschiedener Subtypen, dem teilweise uneinheitlichen histologischen Erscheinungsbild und nicht repräsentativen Biopsiepräparaten ist diese Klassifikation oft erschwert.Sechshundertdrei konsekutive Patientenakten mit der Diagnose „maligner Weichgewebstumor“ der Extremitäten inklusive Schulter und Glutealbereich wurden im Hinblick auf Diagnoseabweichungen der Primär- und Referenzpathologie sowie deren Abhängigkeit von der Tumorentität, der Befundung aus Primär- oder Rezidivtumor und der beurteilenden pathologischen Einrichtung ausgewertet. Als referenzpathologische Institute dienten das auf Weichgewebstumoren spezialisierte Institut für Pathologie der Ruhr-Universität Bochum am BG-Universitätsklinikum Bergmannsheil in Kooperation mit dem Institut für Pathologie der Universität Jena.Liposarkome und pleomorphe („not otherwise specified“, NOS-)Sarkome stellten mit 24 und 22,6% die größten Gruppen. Von den acht am häufigsten diagnostizierten Sarkomen wurden maligne periphere Nervenscheidentumoren und Leiomyosarkome mit 78,4 und 74,2% der Fälle am häufigsten diskordant diagnostiziert. Die Quote lag für nicht spezialisierte Pathologiepraxen und Einrichtungen an Allgemein- und Universitätskrankenhäusern über 60%. Für eine individuelle, adäquate chirurgische und neo-/adjuvante Therapie ist die referenzpathologische Begutachtung sarkomverdächtiger Tumorproben zu fordern.AbstractCorrect histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder’s rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorders rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.

The pedicled gastrocnemius muscle flap: a review of 218 cases.

Background: Data regarding donor-site morbidity, postoperative clinical course, and functional and aesthetic outcome after gastrocnemius muscle flaps are rare. Methods: Data regarding 218 consecutive patients treated with gastrocnemius muscle flaps were acquired from patients’ charts and from contact with patients, with special reference to treatment and clinical course. Eighty-two were interviewed with a standardized questionnaire, 40 were examined physically, and 34 underwent dynamometric muscle function tests. Results: The authors observed wound-healing difficulties in 7 percent, wound infections in 4 percent, and one flap loss; 4.5 percent of the lateral gastrocnemius patients suffered from postoperative palsy of the peroneal nerve. Eighty-seven percent were not significantly limited walking on even ground, but only 42 percent could run, and 40 percent complained about pain when walking more than 200 m. The average range-of-motion deficit in the ankle joint for flexion and extension was 11 percent and 10 percent, respectively. The maximal plantar flexion force in the ankle joint of the operated leg was 76.2 percent. Strength endurance was reduced approximately 24.4 percent in the operated leg compared with the nonaffected side. Conclusions: Gastrocnemius muscle transfer represents a safe and simple procedure in the treatment of lower leg defects and in limb preservation. The strength loss and functional impairment (and sensation disorders) are considerable but may not be exclusively attributable to the muscle transfer but rather the result of the preceding trauma, infection, or tumor resection. The donor-site morbidity is well tolerated by the majority of the patients.

Die Bedeutung von Referenzzentren in Diagnose und Therapie von Weichgewebssarkomen der Extremitäten

ZusammenfassungDie onkologiegerechte Therapie maligner Weichgewebstumoren setzt eine korrekte Diagnosestellung inklusive Angabe des Gradings voraus. Aufgrund der Seltenheit dieser Tumoren, einer Vielzahl verschiedener Subtypen, dem teilweise uneinheitlichen histologischen Erscheinungsbild und nicht repräsentativen Biopsiepräparaten ist diese Klassifikation oft erschwert.Sechshundertdrei konsekutive Patientenakten mit der Diagnose „maligner Weichgewebstumor“ der Extremitäten inklusive Schulter und Glutealbereich wurden im Hinblick auf Diagnoseabweichungen der Primär- und Referenzpathologie sowie deren Abhängigkeit von der Tumorentität, der Befundung aus Primär- oder Rezidivtumor und der beurteilenden pathologischen Einrichtung ausgewertet. Als referenzpathologische Institute dienten das auf Weichgewebstumoren spezialisierte Institut für Pathologie der Ruhr-Universität Bochum am BG-Universitätsklinikum Bergmannsheil in Kooperation mit dem Institut für Pathologie der Universität Jena.Liposarkome und pleomorphe („not otherwise specified“, NOS-)Sarkome stellten mit 24 und 22,6% die größten Gruppen. Von den acht am häufigsten diagnostizierten Sarkomen wurden maligne periphere Nervenscheidentumoren und Leiomyosarkome mit 78,4 und 74,2% der Fälle am häufigsten diskordant diagnostiziert. Die Quote lag für nicht spezialisierte Pathologiepraxen und Einrichtungen an Allgemein- und Universitätskrankenhäusern über 60%. Für eine individuelle, adäquate chirurgische und neo-/adjuvante Therapie ist die referenzpathologische Begutachtung sarkomverdächtiger Tumorproben zu fordern.AbstractCorrect histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder’s rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorders rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.

Nucleofection: A New Method for Cutaneous Gene Transfer?

Background. Transfection efficacy after nonviral gene transfer in primary epithelial cells is limited. The aim of this study was to compare transfection efficacy of the recently available method of nucleofection with the established transfection reagent FuGENE6. Methods. Primary human keratinocytes (HKC), primary human fibroblasts (HFB), and a human keratinocyte cell line (HaCaT) were transfected with reporter gene construct by FuGENE6 or Amaxa Nucleofector device. At corresponding time points, β-galactosidase expression, cell proliferation (MTT-Test), transduction efficiency (X-gal staining), cell morphology, and cytotoxicity (CASY) were determined. Results. Transgene expression after nucleofection was significantly higher in HKC and HFB and detected earlier (3 h vs. 24 h) than in FuGENE6. After lipofection 80%–90% of the cells remained proliferative without any influence on cell morphology. In contrast, nucleofection led to a decrease in keratinocyte cell size, with only 20%–42% proliferative cells. Conclusion. Related to the method-dependent increase of cytotoxicity, transgene expression after nucleofection was earlier and higher than after lipofection.

TRAIL and Taurolidine induce apoptosis and decrease proliferation in human fibrosarcoma

BackgroundDisseminated soft tissue sarcoma still represents a therapeutic dilemma because effective cytostatics are missing. Therefore we tested TRAIL and Tarolidine (TRD), two substances with apoptogenic properties on human fibrosarcoma (HT1080).MethodsViability, apoptosis and necrosis were visualized by TUNEL-Assay and quantitated by FACS analysis (Propidiumiodide/AnnexinV staining). Gene expression was analysed by RNA-Microarray and the results validated for selected genes by rtPCR. Protein level changes were documented by Western Blot analysis. NFKB activity was analysed by ELISA and proliferation assays (BrdU) were performed.Results and discussionThe single substances TRAIL and TRD induced apoptotic cell death and decreased proliferation in HT1080 cells significantly. Gene expression of several genes related to apoptotic pathways (TRAIL: ARHGDIA, NFKBIA, TNFAIP3; TRD: HSPA1A/B, NFKBIA, GADD45A, SGK, JUN, MAP3K14) was changed. The combination of TRD and TRAIL significantly increased apoptotic cell death compared to the single substances and lead to expression changes in a variety of genes (HSPA1A/B, NFKBIA, PPP1R15A, GADD45A, AXL, SGK, DUSP1, JUN, IRF1, MYC, BAG5, BIRC3). NFKB activity assay revealed an antipodal regulation of the several subunits of NFKB by TRD and TRD+TRAIL compared to TRAIL alone.ConclusionTRD and TRAIL are effective to induce apoptosis and decrease proliferation in human fibrosarcoma. A variety of genes seems to be involved, pointing to the NFKB pathway as key regulator in TRD/TRAIL-mediated apoptosis.