Hans-Martin Häfner

Microcirculatory Dysfunction in Chronic Venous Insufficiency (CVI)

The elevated ambulatory pressure in the peripheral venous system of chronic venous insufficiency (CVI) patients manifests itself not only in the form of disturbed macrocirculation but also and particularly in microangiopathic changes. For this reason, it is closely correlated with trophic disorders of the skin and can ultimately lead to ulceration. Using microcirculation research techniques, we are able to provide clear evidence of a typical microangiopathy in chronic venous insufficiency. Fifty CVI patients in Widmer stages I, II, and III were examined with fluorescence video microscopy, intravital video capillaroscopy, transcutaneous oxygen partial pressure measurement, TcpO2 and laser Doppler flowmetry. The effects of compression therapy with individually fitted compression stockings on capillary morphology were studied over a period of 4 weeks in 20 CVI patients in Widmer stages I and II. The capillary pressure was measured during simulated muscle contraction using a servo‐null micropressure system. We periodically drew blood from the dorsalis pedis vein and a brachial vein of 11 healthy test persons and 8 patients with stage III CVI during experimental venous hypertension in order to evaluate the expression pattern of leukocyte adhesion molecules involved in inflammation: LFA‐1 (CD11a), Mac‐1 (CD11b), p150,95 (CD11c), CD18, VLA‐4 (CD49d), and L‐selectin (CD62L). In the same patients, we used immunohistochemical methods to examine clinically unaffected skin and the skin near an ulcer, focusing on the adhesion molecules ICAM‐1, VCAM‐1, and E‐selectin. The microangiopathic changes observed with worsening clinical symptoms include a decrease in the number of capillaries, glomerulus‐like changes in capillary morphology, a drop in the oxygen content (tcpO2) of the skin, increased permeability of the capillaries to low‐molecular‐weight substances, increased laser Doppler flux reflecting elevated subcutaneous flow, and diminished vascular reserve. These microangiopathic changes worsen in linear proportion to the clinical severity of chronic venous insufficiency. In patients with venous ulcerations, the baseline expression of LFA‐1 and VLA‐4 on lymphocytes, Mac‐1 expression on the myeloid cell line, and L‐selectin expression on all three cell lines was not significantly different from that in healthy controls. During orthostatic stress, there was a significant reduction in the expression of L‐selectin in blood cells collected at foot level in the controls (p = 0.002), but not in the patients. Clinical improvement by compression therapy was accompanied by an increase in the number of nutritive capillaries, while the diameter of the capillaries and the dermal papillae was reduced. When ulcers healed in a short period (<6 weeks), we observed a concomitant increase in the number of capillaries (p < 0.05). Microangiopathy appears before trophic disorders of the skin develop. Even trophically normal skin areas may have dilated nutritive capillaries, an early sign of disturbed skin perfusion. These changes represent a plausible explanation for the development and to recurrency tendency of venous ulcers. The reduced expression of lymphocytic L‐selectin in healthy controls during the orthostatic stress test may be an indication that the cells are activated by venous stasis. Clinically effective therapeutic measures improve the impaired microcirculation of the skin in the ankle area.

Vascular dominance in the forearm.

&NA; The dominance of the radial or ulnar artery at the forearm level and their contributions to the circulation of the hand remain a matter of contention. Therefore, the authors proposed to investigate the predominance of one of these arteries first by anatomic studies on 40 fresh cadaver upper extremities, and then by dynamic studies. The dynamic studies included color Doppler sonography in 22 individuals (44 hands) and five‐channel plethysmography in 40 individuals (40 right hands). It was found that the ulnar artery is dominant at the elbow, but after originating its collateral branches, the radial artery becomes the dominant artery in the distal forearm and, consequently, constitutes the major source of vascularization to the hand. The ulnar artery is rarely dominant at the forearm level and is physiologically less important. Therefore, there is no hemodynamic reason to prefer the radial artery to the ulnar artery for any invasive maneuvers. (Plast. Reconstr. Surg. 111: 1891, 2003.)

Comparison and evaluation of the current staging of cutaneous carcinomas

Background: Recently the “Union for International Cancer Control” (UICC) and the “American Joint Committee on Cancer” (AJCC) changed their TNM (tumor, node, metastasis) classification of cutaneous carcinomas. Methods: We compared these classifications, tested their practicability with 615 prospectively collected, unselected, primary cutaneous squamous cell carcinomas, and introduced additional classification criteria.

Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures.

Introduction: Local anesthetics supplemented with epinephrine are generally regarded as contraindicated for surgical procedures involving the fingers, toes, penis, outer ear and the tip of the nose [ 1 ], but epinephrine is essential if automated tumescence local anesthesia (Auto‐TLA) is used.

Microscopically controlled surgery (MCS)

To confirm a local R0 resection of tumors with infiltrative growth at problem sites and for sparing of tissue, microscopically controlled surgery represents a safe and proven method, particularly when there are no gaps between the tissue taken at the incision margins.

3D histology-guided surgery for basal cell carcinoma and squamous cell carcinoma: recurrence rates and clinical outcome

In a prospective study, a large number of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) underwent surgery using three dimensional (3D) histology and were evaluated with respect to local recurrence. The excised tumours were treated using 3D-histology with a routine paraffin procedure until the surgical margins were clear of tumour. Prospective evaluation of recurrence-free survival and overall survival of 5227 primary BCCs in 3320 patients and 615 invasive primary SCCs in 600 patients was conducted in the form of a letter-based follow-up with feedback from the patients and the referring physicians. The mean follow-up period was 5 years. In the BCC collective, 36 out of 3320 patients developed local recurrence (1%, calculated as a percentage of treated BCCs: 0.7%). In the SCC collective, 20 local recurrences appeared (3%). The recurrence rate for SCCs with desmoplasia was 24%, whilst the recurrence rate for common types of SCC without desmoplasia was 1%. Surgery followed by 3D histology results in very low recurrence rates for BCC and SCC with no additional effort compared with the normal histopathological procedure.

Wavelet analysis of skin perfusion in healthy volunteers.

Objective: Rhythmical changes in microvascular perfusion of the skin depend on various influences, which appear continuously but not in a predictable manner. For identifying and quantifying different physiological influences the authors used wavelet transformation, analyzing continuously and simultaneously measured data.

Long-term life and partnership satisfaction in infertile patients: a 5-year longitudinal study

OBJECTIVE To describe the long-term effects of infertility on life and partnership satisfaction. DESIGN Longitudinal cohort study. SETTING A university outpatient andrology and gynecology infertility clinic. PATIENT(S) 275 men and 272 women treated for infertility between August 2000 and December 2001. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The Life Satisfaction Questionnaire (FLZ), the Partnership Questionnaire (PFB), and sociodemographic items at baseline (T1) and 5 years later (T2). RESULT(S) Compared with a representative sample, our male and female participants had higher Finance and Partnership scores and lower Health scores on the FLZ at T1. They also had markedly higher PFB scores, with the exception of Conflict Behavior. After 5 years (T2), 101 men and 113 women rated the Partnership and Sexuality FLZ subscales as well as all the PFB subscales statistically significantly lower than at baseline. Only the women rated the Self-esteem FLZ subscale lower than at baseline (T1). Participants who became parents had lower Leisure and Partnership FLZ subscale scores, and fathers had lower Finance FLZ subscale scores. CONCLUSION(S) Satisfaction declined over 5 years for both men and women, but only in the partnership-related domains. Women were more affected than men. The success of infertility treatment had only a minor influence on a couples future satisfaction.

S3-Leitlinie zum Umgang mit Antikoagulation bei Operationen an der Haut.

Hintergrund: Immer häufiger sind Patienten aufgrund verschiedener Erkrankungen auf die Einnahme von Antikoagulanzien und Thrombozytenaggregationshemmern angewiesen. Besteht bei diesen Patienten die Notwendigkeit einer Operation an der Haut, stellt sich die Frage des perioperativen Umgangs mit Antikoagulation.

Sun protection by red wine

Background: There is increasing evidence that polyphenols, antioxidants from plants such as green tea or grapes, may impair the UV‐induced erythema reaction as well as carcinogenesis and metastasis of melanoma and epithelial skin cancer. The UVB‐protective potential of wine polyphenols has not been studied so far in humans.