Dimitra Kotsougiani

T lymphocytes in acute bacterial infection: increased prevalence of CD11b+ cells in the peripheral blood and recruitment to the infected site

T‐cell activation, particularly of CD8+ cells, is invariably associated with viral infections. We now provide evidence for the activation of T cells in patients with localized bacterial soft tissue infections. During acute disease we detected in the peripheral blood of these patients, small though conspicuous populations of CD4+ CD28+ CD11b+ and CD8+ CD28+ CD11b+ cells, indicative of an expansion of effector T cells. Moreover, we identified CD4+ and CD8+ cells at the infected site, in addition to highly activated polymorphonuclear neutrophils (PMN). In keeping with their role as first‐line defence, PMN were preponderant, but T cells amounted to 20% of the infiltrated cells. The majority of the infiltrated T cells expressed CXCR6, a homing receptor for non‐lymphoid tissue. The infiltrated T cells produced interferon‐γ (IFN‐γ), while the peripheral blood cells obtained at the same time did not. In conclusion, in response to localized bacterial infections, T cells are activated and recruited to the infected site. We propose that these T cells, e.g. by producing IFN‐γ, enhance the efficiency of the infiltrated phagocytic cells, particularly of the PMN, thereby supporting the local host defence.

Activation of T Lymphocytes in Response to Persistent Bacterial Infection: Induction of CD11b and of Toll-Like Receptors on T Cells.

T cell activation is invariably associated with virus infections, but activation of T cells is also noted, for example, in patients with persistent bacterial infections with intracellular pathogens or localised bacterial biofilms. The latter is characterised by a destructive inflammatory process. Massive infiltration of leukocytes, predominantly of polymorphonuclear neutrophils (PMNs) and of T lymphocytes, is seen. While PMN influx into sites of bacterial infection is in line with their role as “first-line defence” a role of T cells in bacterial infection has not yet been delineated. We now found evidence for activation and expansion of peripheral blood T cells and an upregulation of Toll-like receptors 1, 2, and 4 on small portions of T cells. T cells recovered from the infected site were terminally differentiated and produced interferon gamma, a cytokine known to enhance functions of phagocytic cells, leading to the conclusion that infiltrated T cells support the local immuner defence.

Prävalenz und Koprävalenz des Komplexen Regionalen Schmerzsyndromes (CRPS) und des Karpaltunnelsyndromes (KTS) in der Handrehabilitation

BACKGROUND In the current literature, there are reports of associations between complex regional pain syndromes (CRPS) and carpal tunnel syndromes (CTS). The aim of this study was to determine the prevalence of both disease patterns in hand rehabilitation patients and to investigate whether there is a correlation between CTS and CRPS. Furthermore, differences in the healing process of patients with and without additional CTS, and the effectiveness of the rehabilitative therapy for both diseases, were investigated. PATIENTS AND METHODS The computerised medical records of 791 patients in the years 2009-2015 who had been in hand rehabilitation were retrospectively analysed. At the beginning and end of rehabilitation, measurements were made of pain by visual analogue scales (VAS, 0-10), grip strength and finger mobility (mean distance from finger pulp to palmar D2-D5). The clinical course was statistically analysed. CRPS diagnosis was confirmed clinically by a pain therapist, CTS diagnosis was confirmed by neurological and neurophysiological examination. Surgical therapy was performed despite CRPS diagnosis. RESULTS The prevalence of CRPS was 161/1000 and of CTS 62/1000; the co-prevalence of the 2 diagnoses was 24/1000 (p<0.0001). In the CRPS group, after a mean of 8 (1-21) weeks of rehabilitative therapy, mean pain was reduced from 5 (1-10) to 3 (0-9), grip strength improved from 10 (0-39)kg to 18.5 (2.5-45.5)kg and finger mobility increased from 2.9 (0-7.6)cm to 1.8 (0-7.8)cm. In the CRPS+CTS group, after a mean of 6.8 (3-23) weeks of rehabilitative therapy, mean pain was reduced from 5 (0-8) to 2.6 (0-5), grip strength improved from 9.7 (2.4-25.5)kg to 17.4 (0.9-47.4)kg and finger mobility increased from 2.7 (0-5.3)cm to 1.7 (0-5.3)cm. Improvement over the period of rehabilitation was significant in both groups, though the period of therapy was significantly shorter in the CRPS+CTS group. CONCLUSION CRPS and CTS are often associated. Rehabilitative therapy was effective for CRPS- and CRPS+CTS patients.

Ultrasound in hand and wrist: approach for a standardized examination

New very high-frequency ultrasound probes allow highly detailed imaging of superficial structures and thus are especially suitable for examination of the hand. For successful application, specific knowledge and experience as well as standardized examination techniques are required. Based on 11 determined sections of the flexor and extensor side of the hand, the authors present one approach to a standardized ultrasound examination allowing a quick view of all structures. An additional presentation of the most typical traumatic and degenerative disease patterns underlines the potency of this examination technique. With adequate equipment, training and expertise, ultrasound should be regarded as the first-line imaging modality for the assessment of a wide range of pathological conditions affecting the wrist and hand. An exact knowledge of the anatomical relation of the structures to each other gained from ultrasound experience is equally useful for following surgery of the cases.

Evaluation of 389 patients following free‐flap lower extremity reconstruction with respect to secondary refinement procedures

Primary functional and aesthetic results after free‐flap salvage of lower extremities are occasionally suboptimal. The objective of this study was to identify predictors for secondary refinement procedures such as liposuction, dermolipectomy, or direct excision. In addition, patient‐reported long‐term satisfaction with the final reconstructive result was analyzed.

Evaluation of perfusion by near-infrared fluorescence imaging in late pedicle obstruction of a parascapular flap to the lower extremity: A case report

Late free flap failures due to pedicle obstruction are rare adverse events. The purpose of this report is to present a case in which the near‐infrared indocyanine green video angiography (ICG‐NIR‐VA) was used to evaluate the perfusion in a compromised fasciocutaneous flap in the late postoperative period. A 55‐year‐old male patient, who initially suffered from an open tibial fracture, developed concurrent osteomyelitis with fistulae of the proximal tibia requiring excision. Reconstruction was achieved using a parascapular flap of 25 × 8 cm, anastomosed to an arterio–venous (AV) Loop in the adductor canal. On the 2nd postoperative day the patient developed a thrombosis of the AV‐Loop. After thrombectomy, the postoperative course was uneventful. Seven weeks postoperatively the patient presented with a mottled, partially bluish and cold flap. Anticoagulation prophylaxis was stopped 2 days earlier. Angiography confirmed a thrombus in the arterial pedicle leading to flap ischemia. Near infrared guided fluorescence imaging revealed a delayed recapillarization of the proximal part of the flap closest to the vascular pedicle, albeit flap overall perfusion remained intact. Thus, no surgical intervention was undertaken. However, anticoagulation and prostaglandin therapy was initiated and the flap was salvaged. Genetic analysis uncovered a polymorphism in the prothrombin genes. The flap remained viable and without further complications until the last follow‐up visit at 36 weeks after microsurgical reconstruction. The patient was fully mobilized with complete return to function. Near‐infrared guided fluorescence imaging may be a viable tool for the assessment of late fasciocutaneous free flap complications and guide the decision‐making process.

The conjoined parascapular and latissimus dorsi free flap for reconstruction of extensive knee defects

Extensive soft‐tissue defects affecting the knee region pose a significant reconstructive challenge and may require separate or multiple flaps for coverage. We evaluated the conjoined parascapular and latissimus dorsi free flap as an alternative reconstructive option.

Software-based video analysis of functional outcomes of face transplantation

Assessment of outcomes after face transplantation (FT) is necessary to provide sound evidence on the benefits of this life‐giving surgery. Current methods for outcomes assessment, however, are imprecise or prone to subjectivity. Software‐based video analysis may allow fast, objective and retrospective assessment of restoration of facial movements and functions after FT.

Low-energy extracorporeal shockwave therapy (ESWT) improves metaphyseal fracture healing in an osteoporotic rat model

Purpose As result of the current demographic changes, osteoporosis and osteoporotic fractures are becoming an increasing social and economic burden. In this experimental study, extracorporeal shock wave therapy (ESWT), was evaluated as a treatment option for the improvement of osteoporotic fracture healing. Methods A well-established fracture model in the metaphyseal tibia in the osteoporotic rat was used. 132 animals were divided into 11 groups, with 12 animals each, consisting of one sham-operated group and 10 ovariectomized (osteoporotic) groups, of which 9 received ESWT treatment. Different energy flux intensities (0.15 mJ/mm2, 0.35 mJ/mm2, or 0.55 mJ/mm2) as well as different numbers of ESWT applications (once, three times, or five times throughout the 35-day healing period) were applied to the osteoporotic fractures. Fracture healing was investigated quantitatively and qualitatively using micro-CT imaging, quantitative real-time polymerase chain reaction (qRT-PCR) analysis, histomorphometric analysis and biomechanical analysis. Results The results of this study show a qualitative and quantitative improvement in the osteoporotic fracture healing under low-energy (energy flux intensity: 0,15 mJ/mm2) ESWT and with fewer treatment applications per healing period. Conclusion In conclusion, low-energy ESWT seems to exhibit a beneficial effect on the healing of osteoporotic fractures, leading to improved biomechanical properties, enhanced callus-quantity and -quality, and an increase in the expression of bone specific transcription factors. The results suggest that low-energy ESWT, as main treatment or as adjunctive treatment in addition to a surgical intervention, may prove to be an effective, simple to use, and cost-efficient option for the qualitative and quantitative improvement of osteoporotic fracture healing.