A case report of cutaneous mucormycosis of the hand after minor trauma in a patient with acute myeloid leukaemia

Background: Mucormycosis is a rare but life-threatening infection, caused by fungi of the Mucorales order, which can be found in soil, rotting leaves or on animals. Through characteristic angioinvasive growth, infections with mucor spores can occur as a pulmonary, rhinocerebral or cutaneous form. Infections mainly affect immunosuppressed patients with a history of uncontrolled diabetes or haematological malignancies, among others. Treatment is multimodal and requires an immediate combination of intravenous amphotericin B therapy and serial surgical debridements. Only a limited number of cases of cutaneous mucormycosis of the hand have been documented and described previously. Case presentation: We report a cutaneous mucormycosis in an elderly patient with a therapy-resistant acute myeloid leukaemia after a minor trauma on his right hand, sustained whilst gardening. The fungal infection was treated with serial radical debridements, vacuum-assisted negative-pressure wound closure technique and intravenous antifungals. Despite successful eradication of the fungal infection, a palliative open wound care concept was implemented during the terminal course of the patient's leukaemia. Conclusions: Cutaneous mucormycosis is a rare but fulminant fungal infection mostly affecting immunosuppressed patients. Survival is possible when diagnosed and treated early, yet mortality rates remain high

Biologische und demographische Einflussfaktoren auf das Regenerationspotential nach Rotatorenmanschettenrekonstruktion

Einleitung: Die operative Therapie von Rotatorenmanschettenrupturen wird heutzutage standardmäßig mittels arthroskopischer Nahttechniken (Einzel- / Doppelreihe) durchgeführt. Trotz sukzessiver Verbesserung der Techniken und biomechanisch stabiler Rekonstruktion werden nach wie vor Re-Defektraten von 5-50% beschrieben. Sowohl biologische/demographische Einflussfaktoren als auch der Zeitpunkt des Auftretens von Re-Defekten bleiben bis heute insuffizient geklärt. Ziel der Publikationen waren die Evaluation des Einflusses von biologischen und demographischen Faktoren (Publikation 1) auf das Regenerationspotential nach Rotatorenmanschettenrekonstruktion, die Erfassung des Zeitpunktes von Re-Defekten mittels serieller kernspintomographischer Untersuchung (Publikation 2) sowie die Untersuchung des Effektes von Platelet Rich Plasma (PRP) auf autologe Sehnenzellen (Publikation 3). Methodik: In die verwendeten Studien wurden Patienten eingeschlossen, die eine arthroskopische Supraspinatussehnenrekonstruktion erhielten. Intraoperativ entnommene Sehnenbiopsien wurden auf Sehnenzellproliferation und Kollagen-I-Produktion untersucht und mit demographischen Daten der Patienten (Alter / Geschlecht) sowie dem klinischen und radiologischen Outcome zwei Jahre postoperativ korreliert (Publikation 1). In seriellen Magnetresonanz-tomographischen (MRT) Untersuchungen wurde die postoperative Sehnen-/ und Muskelbeschaffenheit engmaschig kontrolliert und der Zeitpunkt von Re-Defekten sowie das Auftreten von Knochenödemen oder Osteolysen dokumentiert (Publikation 2). Weiterhin wurde autologes PRP von Patienten unterschiedlichen Alters und Geschlechtes auf Sehnenbiopsien in vitro gegeben und die Tenozytenproliferation, die Kollagen-I-Synthese sowie die Kollagen-I und –III-Expression gemessen (Publikation 3). Ergebnisse: Mit zunehmendem Alter zeigte sich eine signifikante Verschlechterung der biologischen Zellparameter. Das klinische und radiologische Outcome korrelierte jedoch weder mit den demographischen Daten, noch mit den biologischen Parametern (Publikation 1). Re-Defekte der Supraspinatussehne, die überwiegend im Bereich des Muskel-/Sehnenübergangs auftraten, wurden in 5/6 Patienten zwischen 12 und 24 Monaten postoperativ festgestellt. Knochenödeme waren 6 Monate postoperativ nicht mehr nachweisbar, während das Auftreten von Osteolysen ab 3 Monate nach der Operation mit Zunahme im Verlauf zu vermerken war (Publikation 2). PRP zeigte einen signifikanten positiven Effekt auf die Tenozytenproliferation sowie die absolut gemessene Kollagen-I-Synthese, während die relativ gemessene Kollagen-I-Synthese reduziert war (Publikation 3). Zusammenfassung: Es konnte gezeigt werden, dass zunehmendes Patientenalter einen negativen Effekt auf die biologischen Ausgangsparameter von Sehnenzellen der Rotatorenmanschette, jedoch keinen Einfluss auf deren Einheilungspotential nach Rekonstruktion hat. Entgegen bisheriger Annahmen traten im untersuchten Kollektiv Re-Defekte überwiegend im Zeitraum zwischen 1 und 2 Jahren postoperativ auf. Die Augmentation von Sehnenzellen mit PRP steigert in vitro die Zellproliferation und die absolute Kollagen-I-Synthese und hat dadurch möglicherweise einen Einfluss auf die Sehnenheilung.Introduction: A possible influence of demographic and biological factors on tendon healing after rotator cuff reconstruction has been discussed in several studies. Furthermore, recurrent rotator cuff defects are described to occur in the early postoperative period. Therefore, aim of the studies was to evaluate the influence of demographic and biological factors on the regeneration of rotator cuff tears (publication 1), as well as the musculotendinous and bone structure (publication 2) after arthroscopic reconstruction. The assessment of a possible effect of autologous platelet rich plasma on rotator cuff tendon cells was the aim of publication 3. Materials and methods: Patients who underwent arthroscopic reconstruction of the supraspinatus tendon were included in all three studies. Tendon biopsies were obtained and assessed for cell growth and collagen-I-production. Furthermore, 24 months after surgery clinical scores were evaluated and magnetic resonance imaging was performed to determine the rotator cuff integrity (publication 1). Serial magnetic resonance imaging (7 days, 3, 6, 12, 26, 52 and 108 weeks postoperative) was performed to assess tendon integrity and retraction, muscular atrophy, fatty infiltration, bone marrow edema and osteolysis at all time points (publication 2). Moreover, autologous platelet rich plasma was added to biopsie tissue samples of supraspinatus tendon and its’ in vitro effect on cell proliferation, collagen I synthesis, and expression of collagen I and III was analyzed (publication 3). Results: Whereas age influenced the biological tendon cell parameters, sex showed no differences. However, neither the biological cell parameters nor age or sex correlated with the clinical and radiological outcome 24 months after surgery (publication 1). Recurrent defects of the supraspinatus tendon were observed in 5/6 patients between 12 and 24 months postoperatively. Predominant medial cuff failures were observed in 4/6 patients as a mode of failure. 6 months after surgery bone marrow edema disappeared completely. Osteolysis appeared 3 months postoperatively and increased to final follow up (publication 2). Platelet rich plasma showed a positive effect on tendon cell proliferation and absolute collagen I synthesis (publication 3). Conclusion: Neither age nor sex showed an effect on tendon healing and the clinical outcome after rotator cuff reconstruction (publication 1). In contrast to recently published studies the time of failure was predominant medial cuff failures between 12 and 24 months after surgery (publication 2). The in vitro augmentation with platelet rich plasma increased tendon cell proliferation. Therefore, an in vivo augmentation could influence tendon healing as well (publication 3)

Atypical cellular elements of unknown origin in the subbasal nerve plexus of a diabetic cornea diagnosed by large-area confocal laser scanning microscopy

In vivo large-area confocal laser scanning microscopy (CLSM) of the human eye using EyeGuidance technology allows a large-scale morphometric assessment of the corneal subbasal nerve plexus (SNP). Here, the SNP of a patient suffering from diabetes and associated late complications was analyzed. The SNP contained multiple clusters of large hyperintense, stellate-shaped, cellular-like structures. Comparable structures were not observed in control corneas from healthy volunteers. Two hypotheses regarding the origin of these atypical structures are proposed. First, these structures might be keratocyte-derived myofibroblasts that entered the epithelium from the underlying stroma through breaks in Bowman’s layer. Second, these structures could be proliferating Schwann cells that entered the epithelium in association with subbasal nerves. The nature and pathophysiological significance of these atypical cellular structures, and whether they are a direct consequence of the patient’s diabetic neuropathy/or a non-specific secondary effect of associated inflammatory processes, are unknown

Morphological characterization of the human corneal epithelium by in vivo confocal laser scanning microscopy

Background: Regarding the growing interest and importance of understanding the cellular changes of the cornea in diseases, a quantitative cellular characterization of the epithelium is becoming increasingly important. Towards this, the latest research offers considerable improvements in imaging of the cornea by confocal laser scanning microscopy (CLSM). This study presents a pipeline to generate normative morphological data of epithelial cell layers of healthy human corneas. Methods: 3D in vivo CLSM was performed on the eyes of volunteers (n=25) with a Heidelberg Retina Tomograph II equipped with an in-house modified version of the Rostock Cornea Module implementing two dedicated piezo actuators and a concave contact cap. Image data were acquired with nearly isotropic voxel resolution. After image registration, stacks of en-face sections were used to generate full-thickness volume data sets of the epithelium. Beyond that, an image analysis algorithm quantified en-face sections of epithelial cells regarding the depth-dependent mean of cell density, area, diameter, aggregation (Clark and Evans index of aggregation), neighbor count and polygonality. Results: Imaging and cell segmentation were successfully performed in all subjects. Thereby intermediated cells were efficiently recognized by the segmentation algorithm while efficiency for superficial and basal cells was reduced. Morphological parameters showed an increased mean cell density, decreased mean cell area and mean diameter from anterior to posterior (5,197.02 to 8,190.39 cells/mm²; 160.51 to 90.29 µm²; 15.9 to 12.3 µm respectively). Aggregation gradually increased from anterior to posterior ranging from 1.45 to 1.53. Average neighbor count increased from 5.50 to a maximum of 5.66 followed by a gradual decrease to 5.45 within the normalized depth from anterior to posterior. Polygonality gradually decreased ranging from 4.93 to 4.64 sides of cells. The neighbor count and polygonality parameters exhibited profound depth-dependent changes. Conclusions: This in vivo study demonstrates the successful implementation of a CLSM-based imaging pipeline for cellular characterization of the human corneal epithelium. The dedicated hardware in combination with an adapted image registration method to correct the remaining motion-induced image distortions followed by a dedicated algorithm to calculate characteristic quantities of different epithelial cell layers enabled the generation of normative data. Further significant effort is necessary to improve the algorithm for superficial and basal cell segmentation

The effect of autologous platelet rich plasma on tenocytes of the human rotator cuff

Abstract Background Platelet rich plasma (PRP) is widely used in rotator cuff repairs but its effect on the healing process is unclear. Several cell culture studies on the effect of allogenic PRP have reported promising results but are not transferable to clinical practice. The aim of the present study is to assess the possible effect of autologous PRP on rotator cuff tendon cells. The amount of growth factors involved with tendon-bone healing (PDGF-AB, IGF-1, TGF-β1, BMP-7 and -12) is quantified. Methods Rotator cuff tissue samples were obtained from (n = 24) patients grouped by age (>/< 65 years) and sex into four groups and cells were isolated and characterized. Later, autologous PRP preparations were obtained and the effect was analyzed by means of cell proliferation, collagen I synthesis and expression of collagen I and III. Furthermore, the PRPs were quantified for growth factor content by means of platelet-derived growth factor (PDGF-AB), insulin-like growth factor (IGF-1), transforming growth factor (TGF-β1), as well as bone morphogenetic protein (BMP) -7 and − 12. Results Cell proliferation and absolute synthesis of collagen I were positively affected by PRP exposure compared to controls (p < 0.05), but expression and relative synthesis of collagen I (normalized to cell proliferation) were significantly reduced. PRP contained high amounts of IGF-1 and lower levels of TGF-β1 and PDGF-AB. The amounts of BMP-7 and -12 were below the detection limits. Conclusions PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect on the human rotator cuff tenocytes of the same individual in vitro by means of cell proliferation and absolute, but not relative collagen I synthesis. These results encourage further studies on clinical outcomes with more comparable standards in terms of preparation and application methods. Level of evidence Controlled laboratory study

The Antibiotic Kitasamycin&mdash;A Potential Agent for Specific Fibrosis Preventing Therapy after Fistulating Glaucoma Surgery?

One major complication after fistulating glaucoma surgeries are fibroblast-mediated scarring processes and their specific prevention is key in the development of novel pharmaceutical concepts. Within this study a possible antifibrotic potential of kitasamycin (KM) in a transforming growth factor (TGF)-&beta;1-mediated fibroblast model was evaluated in vitro. Primary ocular fibroblasts were isolated, cultivated and a dose&ndash;response test including determination of the half maximal effective concentration (EC50) for KM was conducted. Transformation of fibroblasts into myofibroblasts was induced by TGF-&beta;1and immunofluorescence (IF), and Western blot (WB) analyses were performed with fibroblasts and myofibroblasts. IF analyses were carried out using antibodies against &alpha;-smooth muscle actin (&alpha;-SMA) and fibronectin, and protein detection of intracellular and extracellular proteins was performed by WB. Using the dose&ndash;response test, the viability, cytotoxicity and EC50 of KM after 24 and 48 h were determined. Fibroblasts exposed to various KM concentrations showed no increase in &alpha;-SMA and extracellular matrix expression. In TGF-&szlig;1-stimulated myofibroblasts, KM inhibited the expression of &alpha;-SMA and fibronectin in a concentration-dependent manner. These findings demonstrate that KM could impair the transformation of fibroblasts into myofibroblasts and the expression of proteins involved in fibrotic processes, representing a potential agent for specific fibrosis prevention in future therapeutic concepts

The Antibiotic Kitasamycin—A Potential Agent for Specific Fibrosis Preventing Therapy after Fistulating Glaucoma Surgery?

One major complication after fistulating glaucoma surgeries are fibroblast-mediated scarring processes and their specific prevention is key in the development of novel pharmaceutical concepts. Within this study a possible antifibrotic potential of kitasamycin (KM) in a transforming growth factor (TGF)-β1-mediated fibroblast model was evaluated in vitro. Primary ocular fibroblasts were isolated, cultivated and a dose–response test including determination of the half maximal effective concentration (EC50) for KM was conducted. Transformation of fibroblasts into myofibroblasts was induced by TGF-β1and immunofluorescence (IF), and Western blot (WB) analyses were performed with fibroblasts and myofibroblasts. IF analyses were carried out using antibodies against α-smooth muscle actin (α-SMA) and fibronectin, and protein detection of intracellular and extracellular proteins was performed by WB. Using the dose–response test, the viability, cytotoxicity and EC50 of KM after 24 and 48 h were determined. Fibroblasts exposed to various KM concentrations showed no increase in α-SMA and extracellular matrix expression. In TGF-ß1-stimulated myofibroblasts, KM inhibited the expression of α-SMA and fibronectin in a concentration-dependent manner. These findings demonstrate that KM could impair the transformation of fibroblasts into myofibroblasts and the expression of proteins involved in fibrotic processes, representing a potential agent for specific fibrosis prevention in future therapeutic concepts

Subjective language aptitude linked to distinct neural patterns in Broca’s area BA44

In mental disorders the language dimension, including speech and thought, is often impaired. In psychosis, the dimension of language symptoms represents a great variability between the patients. To study language as continuum from health to psychosis a dimensional approach is needed. Consequently, we examined the heterogeneity of a healthy population during a language task in functional magnetic resonance imaging (fMRI), in relation to a subjective rating of one’s language aptitude. The aim was to study the spectrum of inter-individual differences and its connectivity from Broca’s area with language-related brain areas. The observed heterogeneity in the healthy group would enable an extrapolation to observable clinical side of the continuum. In this study, 102 healthy adult participants were asked to rate on a 7-ponit Likert scale, how they perceived their own language aptitude. Allowing us to separate participants, according to their rating, into groups of high, mid or low language aptitude. Furthermore, they completed a lexical priming task, while measuring brain activity in functional magnetic resonance imaging (fMRI). Participants had to decide, if a visually presented target word would reflect the generic term of a previously presented a prime word, in terms of its category (e.g. Apple – Fruit) or its relation (e.g. Apple – Pear). Although reaction time (RT) and accuracy showed no significant differences between all three groups, the psychophysiological interaction (PPI) analysis of BA44 and reaction time revealed distinct connectivity patterns from BA44 among the high and low language aptitude groups in the preparation phase (waiting for the target after the indication of task type). We found that a stronger connectivity from BA44 to the left posterior middle temporal gyrus (MTG) was associated with faster RT in the high group. The low group showed a similar pattern, but from BA44 to the left fusiform gyrus, also known as the visual word form area. These results show that, according to subjective evaluation of their own language aptitude, different neural connectivity routes are activated. These insights into the dimension of language is helping future research, that analyzes the continuum from the healthy population profiles to the profiles of the population with psychosis

«Subjective language aptitude is linked to neural activity in Broca’s area, but not to objective performance during a semantic priming task»

Language, including speech and thought, is often affected in mental illnesses. In psychosis, the dimension of language symptoms shows a great variability between patients. A dimensional approach allows to study language as continuum from health to psychosis. Therefore, in the current study, we investigated the heterogeneity of a healthy population during a language task, additionally to a subjective rating of one’s language aptitude. The aim was to analyze the spectrum of inter-individual differences and its association with language-related brain networks, specifically Broca’s area. The observed heterogeneity in the healthy group would enable an extrapolation to clinical end of the spectrum. To this end, 102 healthy adult subjects performed a lexical priming task while measuring brain activity with fMRI. Subjects had to indicate whether a visually presented target word would form the generic term of a previously shown a prime word, in terms of its category (e.g. Apple – Fruit) or its relation (e.g. Apple – Pear). To see the difference in language aptitude, we asked the participants to rate on 7-point Likert scale, how they thought their language abilities are. According to the rating they were then grouped into high, mid or low language aptitude groups. Although reaction time (RT) and accuracy showed no significant differences between all three groups, we found differences in brain activation in BA45 among the language aptitude groups. We looked at activation in the Broca areas (BA45, BA44) during preparation (waiting for the target after the indication of task type) and processing (target word processing) phases. We found differences between the groups in BA45 during the preparation and processing phases. The Post hoc analysis revealed that the high group showed significantly greater activation in BA45 compared to the low group, while there was no significant difference between the groups in BA 44. Furthermore, the RT was correlated with activation of BA 45 in the high language aptitude group during the preparation phase, indicating that increased activation in BA45 reflects faster responses in the high language aptitude group. Moreover, for the other two groups correlations with RT were found in BA44. These results show that, according to subjective evaluation of their own language aptitude, one differently utilizes the language-related brain areas during the language task. These insights into the dimension of language is facilitating upcoming research, that compares these healthy population profiles to the profiles of a population with psychosis