Diagnostik von Beinödemen

Ödeme der unteren Extremitäten entsprechen immer einem pathologischen Zustand, der insbesondere bei Betroffenen mit chronischen Wunden einer Therapie bedarf. Weil die Ursachen dieser Ödeme sehr unterschiedlich und teilweise auch komplex sein können, sollte zuerst eine klinische und ggf. apparative Diagnostik erfolgen. Oft kann nach einer klinischen Untersuchung mit Testung des Stemmer- und Godet-Zeichens bereits eine klinische Verdachtsdiagnose gestellt werden. Als weiterführende apparative Diagnostik kann eine sonographische Untersuchung erfolgen. Messtechniken wie beispielsweise die Wasserplethysmographie gelten derzeit zwar als Goldstandard für Volumenmessungen, sind aber sehr aufwendig und fehleranfällig, sodass sie in der klinischen Routine heute kaum angewendet werden. Zusammenfassend wird empfohlen, für die Ödemdiagnostik eine klinische Untersuchung möglichst in Kombination mit einer Sonographie durchzuführen. Insbesondere zu Beginn der Entstauungsphase sollten regelmäßig Umfangsmessungen durchgeführt und dokumentiert werden. Diese Dokumentation ist für die Bewertung des therapeutischen Erfolgs von hoher Aussagekraft. // Edema of the lower extremities is always associated with a pathological condition that should be treated, especially in patients with chronic wounds. Because the underlying causes of edema can vary greatly and sometimes be complex, clinical and, if necessary, various diagnostic tests should also be performed. Often, a suspected clinical diagnosis can already be made after clinical inspection with testing of Stemmer's and Godet's signs. Sonographic examination should then be performed as the next diagnostic test. Although measurement techniques such as water plethysmography are currently considered gold standard for volume measurements, they are very complex and prone to error, so that they are rarely used in clinical routine today. In summary, it is recommended to perform a clinical examination, if possible in combination with sonography, for edema diagnosis. Especially at the beginning of the decongestion phase, regular circumferential measurements should be performed and documented. This documentation is of high relevance for evaluation of therapeutic success

Water displacement leg volumetry in clinical studies - A discussion of error sources

<p>Abstract</p> <p>Background</p> <p>Water displacement leg volumetry is a highly reproducible method, allowing the confirmation of efficacy of vasoactive substances. Nevertheless errors of its execution and the selection of unsuitable patients are likely to negatively affect the outcome of clinical studies in chronic venous insufficiency (CVI).</p> <p>Discussion</p> <p>Placebo controlled double-blind drug studies in CVI were searched (Cochrane Review 2005, MedLine Search until December 2007) and assessed with regard to efficacy (volume reduction of the leg), patient characteristics, and potential methodological error sources. Almost every second study reported only small drug effects (≤ 30 mL volume reduction). As the most relevant error source the conduct of volumetry was identified. Because the practical use of available equipment varies, volume differences of more than 300 mL - which is a multifold of a potential treatment effect - have been reported between consecutive measurements. Other potential error sources were insufficient patient guidance or difficulties with the transition from the Widmer CVI classification to the CEAP (Clinical Etiological Anatomical Pathophysiological) grading.</p> <p>Summary</p> <p>Patients should be properly diagnosed with CVI and selected for stable oedema and further clinical symptoms relevant for the specific study. Centres require a thorough training on the use of the volumeter and on patient guidance. Volumetry should be performed under constant conditions. The reproducibility of short term repeat measurements has to be ensured.</p

Kompressionstherapie: Wie nach der Sklerosierungsbehandlung die besten Ergebnisse erzielt werden können

$\bf Background:$ Sclerotherapy is considered to be the method of choice for the treatment of telangiectatic varicose veins (C1 veins). Whereas the use of compression stockings after sclerotherapy is recommended, little is known about the impact of compression on the outcome of sclerotherapy. The aim of this study was to assess the influence of compression on the outcome of injection sclerotherapy of C1 varicose veins. $\bf Methods:$ There were 100 legs of 50 consecutive patients with chronic venous insufficiency (C1) included. After randomization per patient, both legs were treated with sclerotherapy in a predefined area of the thigh (measuring 100 cm2), followed by eccentric compression for 24 hours. Group A received no further compression, whereas group B was additionally equipped with compression stockings of 18 to 20 mm Hg above the ankle and continued wearing these for 1 week. Photodocumentation was performed before, 1 week after, and 4 weeks after sclerotherapy, and the clinical outcome was assessed at these postprocedure follow-up dates. The photographs were reviewed by an internal unblinded rater and an independent blinded external rater. $\bf Results:$ There was no discernible difference between the groups in terms of clinical outcome or side effects after 4 weeks. Whereas inter-rater reliability was high, there was no correlation between the raters and patients in terms of outcome. In 55% of the treated legs, the patients deemed the result of the treatment to be good; in 27% of the treated legs, fair; and in 18%, poor. Postprocedure hyperpigmentation occurred in 13% of patients and was comparable in both groups. Compression therapy was found to be comfortable by the majority (58%) of patients. $\bf Conclusions:$ One week of postinterventional compression therapy had no clinical benefit compared with no compression

Fußulkus

$\textbf {Background:}$ Diabetic foot ulcers are one of the most severe and costly complications of diabetes. Foot ulcers result from a combination of multiple causes including peripheral neuropathy and peripheral arterial disease. Patients with diabetic foot ulcers frequently require amputation of the lower limb. $\textbf {Objectives:}$ The aim of this study was to assess the outcome of diabetic foot ulcers among Iraqi patients with diabetes and to examine the effect of some risk factors on healing of the ulcer. $\textbf {Methods:}$ A cohort study was conducted on 100 patients from January to August 2017 at the Diabetic Foot Clinic, Alfayha Teaching Hospital, Basrah, Iraq. $\textbf {Results:}$ A total of 100 patients with diabetic foot ulcers were included. The ulcers of 60% of the patients healed, whereas 8% persisted unhealed; 25% of the patients had a minor amputation, 5% had a major amputation, 1% had recurrent ulcers, and 1% died. The study showed statistically significant associations between diabetic foot ulcer healing and the following variables: patients' age, glycated HbA1c, duration of diabetes, complications of diabetes like peripheral neuropathy, and ulcer size. $\textbf {Conclusions:}$ Diabetic foot ulcer outcomes can be predicted by several factors, some of which are modifiable. Modification of the modifiable factors, such as better control of diabetes, treatment of peripheral neuropathy, and early management of ulcers, may improve the outcome and facilitate healing

Schlechtere Epithelisierung bei vermehrter Inflammation im Wundbereich

$\textbf {Hintergrund:}$ CFTR ist an der kutanen Wundheilung beteiligt; die zugrundeliegenden Mechanismen sind allerdings nicht vollständig geklärt. Für andere Zelltypen wird berichtet, dass CFTR den MAPK/NF-$\kappa$B-Signalweg reguliert. Wir untersuchten in der hier vorgestellten Studie die mögliche Rolle des CFTR in der Regulierung von MAPK/NF-$\kappa$B im Rahmen der kutanen Wundheilung. $\textbf {Methoden und Ergebnisse:}$ Bei Mäusen mit CFTR-Mutation (DF508) wurden Wundheilungsmodelle mit Exzision und Inzision verwendet. In einer Zelllinie humaner Keratinozyten (HaCaT) mit CFTR-Knockdown oder -Überexpression wurde ein Scratch-Modell verwendet. Die epidermale Inflammation, Keratinozyten-Proliferation und -Differenzierung sowie MAPK/NF-$\kappa$B-Signal- aktivität wurden untersucht. Auch Inhibitoren von MAPK/NF-$\kappa$B wurden verwendet. $\textbf {Ergebnisse:}$ Sowohl die DF508-Mäuse als auch die HaCaT-Zellen mit ausgeschaltetem CFTR zeigten verzögerte kutane Wundheilung mit überschießender Inflammation, verstärkter Proliferation und aberranter Differenzierung. Der CFTR-Knockdown führte in den HaCaT-Zellen zur Phosphorylierung von ERK, p38 und I$\kappa$B$\alpha$. Die Störungen der Inflammation, Proliferation und Differenzierung in HaCaT-Zellen konnten durch CFTR-Überexpression oder Hemmung von MAPK oder NF-$\kappa$B behoben werden. $\textbf {Schlussfolgerung:}$ CFTR spielt eine Rolle bei der Suppression des MAPK/NF-$\kappa$B-Signalwegs zur Reduktion der Inflammation und Proliferation sowie zur Förderung der Differenzierung von Keratinocyten und trägt so zur kutanen Wundheilung bei

Endovenöse Laserablation vs. Crossektomie und Stripping-Operation

$\bf Objective:$ The long-term results of saphenofemoral ligation and stripping (SFL/S) were compared with 980-nm bare fiber endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) incompetence. $\bf Methods:$ This was a single-center, randomized, controlled trial with a follow-up time of 10 years. Patients with GSV incompetence were randomized to undergo SFL/S or EVLA under tumescent anesthesia. The primary outcome was recurrence of groin-related varicose veins seen on duplex ultrasound imaging and clinical examination. The secondary outcomes were (changes or improvement in) CEAP clinical class, venous symptoms, cosmetic results, quality of life, reinterventions, and complications. $\bf Results:$ Between June 2007 and December 2008, 122 patients (130 limbs) were included; of these, 68 limbs were treated with SFL/S and 62 limbs with EVLA. The 10-year estimated freedom from groin recurrence as seen on duplex ultrasound imaging was higher in the SFL/S group (73% vs 44% in the EVLA group; P = .002), and the same trend was seen for clinically evident recurrence (77% vs 58%, respectively; P = .034). Nine reinterventions (17%) were deemed necessary in the SFL/S group vs 18 (36%) in the EVLA group (P = .059). All reinterventions in the SFL/S group consisted of foam sclerotherapy. Reinterventions in the EVLA group included foam sclerotherapy (n = 5), crossectomy (n = 2), and endovenous procedures (n = 11). There was no significant differences in quality of life and relief of venous symptoms. Cosmetic appearance improved, with a better cosmetic rating in the SFL/S group compared with the EVLA group (P = .026). One patient in the SFL/S group had a persisting neurosensory deficit remaining at 10 years. $\bf Conclusions:$ This study showed no clear long-term advantage of EVLA with a 980-nm wavelength and bare-tip fiber over high ligation and stripping of the GSV under local tumescent anesthesia

Anwendung, Wirkung und Risiken von Antiseptika

Wound antisepsis has undergone a renaissance due to the introduction of highly effective wound-compatible antimicrobial agents and the spread of multidrug-resistant organisms (MDROs). However, a strict indication must be set for the application of these agents. An infected or critically colonized wound must be treated antiseptically. In addition, systemic antibiotic therapy is required in case the infection spreads. If applied preventively, the Wounds-at-Risk Score allows an assessment of the risk for infection and thus appropriateness of the indication. The content of this updated consensus recommendation still largely consists of discussing properties of octenidine dihydrochloride (OCT), polihexanide, and iodophores. The evaluations of hypochlorite, taurolidine, and silver ions have been updated. For critically colonized and infected chronic wounds as well as for burns, polihexanide is classified as the active agent of choice. The combination 0.1% OCT/phenoxyethanol (PE) solution is suitable for acute, contaminated, and traumatic wounds, including MRSA-colonized wounds due to its deep action. For chronic wounds, preparations with 0.05% OCT are preferable. For bite, stab/puncture, and gunshot wounds, polyvinylpyrrolidone (PVP)-iodine is the first choice, while polihexanide and hypochlorite are superior to PVP-iodine for the treatment of contaminated acute and chronic wounds. For the decolonization of wounds colonized or infected with MDROs, the combination of OCT/PE is preferred. For peritoneal rinsing or rinsing of other cavities with a lack of drainage potential as well as the risk of central nervous system exposure, hypochlorite is the superior active agent. Silver-sulfadiazine is classified as dispensable, while dyes, organic mercury compounds, and hydrogen peroxide alone are classified as obsolete. As promising prospects, acetic acid, the combination of negative pressure wound therapy with the instillation of antiseptics (NPWTi), and cold atmospheric plasma are also subjects of this assessment

Varikose

$\textbf {Objective:}$ To reach consensus on which complications of varicose vein treatments physicians consider major or minor, in order to standardize the informed consent procedure and improve shared decision-making. $\textbf {Methods:}$ Using the e-Delphi method, expert physicians from 10 countries were asked to rate complications as "major" or "minor" on a 5-point Likert scale. Reference articles from a Cochrane review on varicose veins were used to compose the list of complications. $\textbf {Results:}$ Participating experts reached consensus on 12 major complications: allergic reaction, cellulitis requiring intravenous antibiotics/intensive care, wound infection requiring debridement, hemorrhage requiring blood transfusion/surgical intervention, pulmonary embolism, skin necrosis requiring surgery, arteriovenous fistula requiring repair, deep venous thrombosis, lymphocele, thermal injury, transient ischemic attack/stroke, and permanent discoloration. $\textbf {Conclusion:}$ An international consensus was reached about what physicians consider to be major complications of varicose vein treatments. This consensus may assist in standardizing the information physicians discuss with patients prior to varicose vein treatment

Obliterierende subkutane Arteriolosklerose nicht spezifisch für ein Ulcus hypertonicum Martorell

$\textbf {Background:}$ The histological characteristic of hypertensive leg ulcers (HLU) is the presence of "arteriolosclerosis". The pertinence of performing a skin biopsy to diagnose HLU is questionable, as cutaneous arteriolosclerosis may be related to patient comorbidities. The objective here was to evaluate the frequency of arteriolosclerosis in skin leg biopsies performed in patients without ulcer and in control patients with HLU. $\textbf {Methods:}$ We performed a retrospective study between January 2013 and July 2014. Patients were included if they had undergone a deep skin biopsy on the lower limbs, in the absence of any leg ulcer. Controls were patients with typical HLU. $\textbf {Results:}$ Fifty-eight patients and 6 controls were included. Hypertension was present in 25 patients (43%). Arteriolosclerosis, defined as fibrous endarteritis, was present in 35 out of 58 patients (60%) and in all of the controls. No hyalinosis or hyperplastic proliferative arteriolosclerosis was observed in the patients or controls. Only age was an independent factor associated with the presence of cutaneous arteriolosclerosis (p < 0.0001). $\textbf {Conclusion:}$ Cutaneous arteriolosclerosis is significantly and independently associated with age. Thus, skin biopsy seems not to be necessary for the diagnosis of HLU but only for a differential diagnosis