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BACKGROUND: Necrotizing fasciitis (NF) can appear after various penetrating or non-penetrating skin lesions. This is the first reported case in which NF occurred after a central venous line placement. Because of intubation and sedation of the critically ill patient, only local conditions can indicate NF although other decisive symptoms, such as pain out of proportion to physical findings, are not evaluable.METHODS: Case report and review of the literature.RESULTS: A 71-y-old male patient was admitted to the intensive care unit after spine surgery due to post-operative delirium. Because of respiratory failure he had to be intubated and sedated. Ten days after central venous line placement in the right subclavian vein a reddening and swelling of the insertion site was observed but considered as extravasation. When aggravation of the local symptoms occurred, the suspected diagnosis of NF was made and a radical debridement was performed immediately. After a second-look operation, defect closure with a free-flap transfer and split-thickness skin grafting could be achieved.CONCLUSIONS: The first report on NF in a critically ill patient due to a subclavian central intravenous line aims to encourage checking for iatrogenic soft tissue condition in sedated intensive care patients. These patients may have a greater risk of developing NF, because they often have predisposing factors such as diabetes, end-stage renal failure, and immune suppression.

Gap junctions are involved in vascular growth and their expression pattern is modulated in response to hemodynamic conditions. They are clusters of intercellular channels formed by connexins (Cx) of which four subtypes are expressed in the cardiovascular system, namely Cx37, Cx40, Cx43 and Cx45. We hypothesize that high flow conditions affect vascular expression of Cx in vivo. To test this hypothesis, flow hemodynamics and subsequent changes in vascular expression of Cx were studied in an angioinductive rat arteriovenous (AV) loop model. Fifteen days after interposition of a femoral vein graft between femoral artery and vein encased in a fibrin-filled chamber strong neovascularization was evident that emerged predominantly from the graft. Blood flow through the grafted vessel was enhanced ∼4.5-fold accompanied by increased pulsatility exceeding arterial levels. Whereas Cx43 protein expression in the femoral vein is negligible at physiologic flow conditions as judged by immunostaining its expression was enhanced in the endothelium of the venous graft exposed to these hemodynamic changes for 5 days. This was most likely due to enhanced transcription since Cx43 mRNA increased likewise, whereas Cx37 mRNA expression remained unaffected and Cx40 mRNA was reduced. Although enhanced Cx43 expression in regions of high flow in vivo has already been demonstrated, the arteriovenous graft used in the present study provides a reliable model to verify an association between Cx43 expression and high flow conditions in vivo that was selective for this Cx. We conclude that enhancement of blood flow and its oscillation possibly associated with the transition from laminar to more turbulent flow induces Cx43 expression in a vein serving as an AV loop. It is tempting to speculate that this upregulation is involved in the vessel formation occuring in this model as Cx43 was suggested to be involved in angiogenesis.

BACKGROUND: The internal mammary artery and vein is often used as a site of anastomoses in microvascular breast reconstruction. This area supports lymphatic drainage of the breast and its role in breast cancer metastasis remains unclear. We hypothesize that sampling of internal mammary lymph nodes at the time of microvascular anastomoses preparation may identify persistent or recurrent local disease and mandate the need for additional treatment in this area.MATERIAL/METHODS: A retrospective chart review from 519 patients in the time between January 2006 and September 2009 was performed on all patients who underwent internal mammary lymph node sampling at the time of microvascular breast reconstruction.RESULTS: Microvascular breast reconstruction was performed in 519 patients. Enlarged internal mammary lymph nodes were found and harvested in 195 patients for histological review. Six of 195 (3.08%) were found positive for metastatic disease requiring additional oncologic treatment.CONCLUSIONS: The internal mammary lymphatic drainage system is an important and often underappreciated pathway for breast metastasis. Routine sampling of these lymph nodes at the time of microvascular breast reconstruction is easy to perform and is a useful tool to identify women, who might require additional treatment and increase cancer-free survival.

The gap junction channel protein connexin40 (Cx40) is crucial in vascular and renal physiology, because Cx40-deficient mice exhibit impaired conduction of endothelium-dependent dilations and pronounced hypertension. The latter precludes mechanistic insights into the role of endothelial Cx40, because long-lasting hypertension itself may affect conduction and Cx expression. We aimed to identify endothelial Cx40 functions, their dependency on the conductive capability, and to separate these from hypertension-related alterations. We assessed conduction and Cx expression in mice with cell type-specific deletion of Cx40 and in mice expressing a defective Cx40 (Cx40A96S) identified in humans, which forms nonconducting gap junction channels. Confined arteriolar stimulation with acetylcholine or bradykinin elicited local dilations that conducted upstream without attenuation of the amplitude for distances up to 1.2-mm in controls with a floxed Cx40 gene (Cx40(fl/fl)). Conducted responses in hypertensive animals devoid of Cx40 in renin-producing cells were unaltered but remote dilations were reduced in normotensive animals deficient for Cx40 in endothelial cells (Cx40(fl/fl):Tie2-Cre). Surprisingly, Cx37 expression was undetectable by immunostaining in arteriolar endothelium only in Cx40(fl/fl):Tie2-Cre; however, transcriptional activity of Cx37 in the cremaster was comparable with Cx40(fl/fl) controls. Cx40A96S mice were hypertensive with preserved expression of Cx40 and Cx37. Nevertheless, conducted responses were blunted. We conclude that endothelial Cx40 is necessary to support conducted dilations initiated by endothelial agonists and to locate Cx37 into the plasma membrane. These functions are unaltered by long-lasting hypertension. In the presence of a nonconducting Cx40, Cx37 is present but cannot support the conduction highlighting the importance of endothelial Cx40.

Tissue Engineering (TE) in the context of Regenerative Medicine (RM) has been hailed for many years as one of the most important topics in medicine in the twenty-first century. While the first clinically relevant TE efforts were mainly concerned with the generation of bioengineered skin substitutes, subsequently TE applications have been continuously extended to a wide variety of tissues and organs. The advent of either embryonic or mesenchymal adult stem-cell technology has fostered many of the efforts to combine this promising tool with TE approaches and has merged the field into the term Regenerative Medicine. As a typical example in translational medicine, the discovery of a new type of cells called Telocytes that have been described in many organs and have been detected by electron microscopy opens another gate to RM. Besides cell-therapy strategies, the application of gene therapy combined with TE has been investigated to generate tissues and organs. The vascularization of constructs plays a crucial role besides the matrix and cell substitutes. Therefore, novel in vivo models of vascularization have evolved allowing axial vascularization with subsequent transplantation of constructs. This article is intended to give an overview over some of the most recent developments and possible applications in RM through the perspective of TE achievements and cellular research. The synthesis of TE with innovative methods of molecular biology and stem-cell technology appears to be very promising.

Reliable perineal and posterior vaginal wall restoration following extensive abdominoperineal excision or pelvic exenteration is a reconstructive challenge, especially if the rectus abdominis is unavailable or insufficient for transpelvic transposition. In this short report, we present a novel combined perforator-based technique, in which an inferior gluteal perforator flap is used for perineal reconstruction whereas vaginal reconstruction is performed simultaneously by means of a pudendal artery perforator flap. This procedure circumvents functional muscle loss, permits a tension-free closure of difficult three-dimensional defects and offers a high degree of reconstructive flexibility, which allows a straightforward and independent reconstruction of two different anatomical units.

Early and reliable closure of large meningomyelocoele defects in newborns is critical to prevent severe infectious complications and neurologic deterioration. Here, we introduce a new surgical method for the reconstruction of large horizontal meningomyelocoele defects, in which we use unilateral myocutaneous tissue based on the superior gluteal artery (SGA) as a propellar flap. This procedure permits a tension-free and durable multilayer closure of difficult, large-scale horizontal defects that cannot adequately be treated by conventional myocutaneous advancement flaps. The technique is reliable and straightforward and requires no skin grafts or relaxing incisions. The SGA-based myocutaneous propeller flap might be a promising alternative for complex meningomyelocoele reconstructions in the future.

Connexins (Cx) form gap junctions and allow the coordination of cellular behaviour. In vessels, expression of Cx40, Cx37, and Cx43 is well established and specifically Cx40 serves important functions in endothelial cells. In contrast, expression and physiological functions of Cx45 is unclear although its expression has been suggested in vascular smooth muscle (VSM). Therefore, we studied expression and function of Cx45 in vessels using different mice models allowing to identify and delete Cx45. Smooth muscle cell (SMC)-specific deletion was achieved by the Cre/loxP system using Cre-recombinase driven by a Nestin promoter. Deletion of Cx45 leads concomitantly to the expression of enhanced green fluorescence protein (EGFP) in these mice. Conduction of vasomotor responses was studied in cremasteric arterioles using intravital microscopy and arterial pressure was measured telemetrically. Cx45 is transcriptionally expressed in VSM as detected by EGFP expression in SMC-specific Cx45-deficient mice (Cx45fl/fl:Nestin-Cre) but not in endothelial cells (Cx45fl/fl:TIE2-Cre). Moreover, EGFP was located at VSM cell borders in arterioles of transgenic mice carrying an EGFP-tagged Cx45. Expectedly, arteriolar conduction of dilations evoked by the endothelium-dependent agonist acetylcholine were not different between Cx45fl/fl:Nestin-Cre mice and controls carrying homozygously a floxed Cx45 gene (Cx45fl/fl). Surprisingly, the amplitude of locally initiated endothelium-independent constrictions (K(+)) and dilations (adenosine) declined similarly with distance in both genotypes indicating an intact VSM conduction pathway also in mice being deficient for Cx45 in VSM. Arterial pressure was not different between freely moving Cx45fl/fl and Cx45fl/fl:Nestin-Cre mice during day or night. We conclude that Cx45 is physiologically expressed in VSM, but not in EC in murine arterioles. However, Cx45 is dispensable for the conduction of vasomotor responses along these arterioles. Possibly, o

BACKGROUND: Nonoperative subdermal tissue augmentation is one of the most frequently performed procedures in plastic surgery and dermatological practice. Many products, from biological to synthetic filler substances, are currently available. However, none has achieved ideal clinical efficacy, especially regarding volume maintenance and longevity. We examined the use of fibrin sealant as a biological and fully degradable matrix for dermal augmentation in combination with precultured human fibroblasts and hyaluronic acid gel (HYAFF).METHODS: Four implant preparations were studied: fibrin glue only (F); 1% HYAFF mixed in fibrin glue (FH); 1.8 × 10(6) cells/ml of fibrin glue (FC); and 1% HYAFF and 1.8 × 10(6) cells/ml of fibrin glue (FHC). Each mouse was given two separate subcutaneous injections of implant material. At 1, 3, and 6 weeks two mice from each group were sacrificed, such that there was an n = 4 for each implant group at each time point. The mice were grossly examined for implant retention and the implants were evaluated by means of immunohistochemistry for fibrosis, integration into surrounding tissue, presence of elastin, and blood vessel infiltration.RESULTS: Only the implants in the cell-containing groups, FC and FHC, remained after 6 weeks. Moreover, with the exception of a mild inflammatory response, no adverse affects of the cell-seeded implants were noted.CONCLUSION: Presence of fibroblasts increases implant durability. Further studies should evaluate the ideal hyaluronic acid and fibroblast concentration for long-term longevity.

AIMS: The activation of endothelial Ca2+-dependent K+-channels, KCa3.1 (IKCa), and KCa2.3 (SKCa) has been proposed to be a prerequisite for endothelial hyperpolarization, which subsequently hyperpolarizes and relaxes smooth muscle [endothelium-derived hyperpolarizing factor (EDHF)-type dilation] and initiates conducted dilations. Although EDHF is the main mediator of acetylcholine (ACh)-induced dilation in the murine skeletal microcirculation, the differential contribution of KCa3.1 and KCa2.3 is not known.METHODS AND RESULTS: We assessed agonist-induced and conducted dilations as well as endothelial hyperpolarization in the cremaster microcirculation of KCa3.1-deficient (KCa3.1-/-) and wild-type mice (wt) in vivo after blockade of NO and prostaglandins. Compared with wt, resting tone was enhanced by approximately 25% in arterioles of KCa3.1-/- mice. ACh-induced dilations in KCa3.1-/- mice were virtually abolished at low and intermediate concentrations and a remaining dilation at 10 micromol/L ACh was abrogated by blockade of KCa2.3 with UCL1684. Sodium nitroprusside- and adenosine-induced dilations were similar in wt and KCa3.1-/-. Focal application of ACh induced dilations at the local site in both genotypes, which conducted along the vessel. However, the amplitude of the dilation decreased with distance only in KCa3.1-/-. Blockade of KCa2.3 in wt did not affect conducted dilations. A KCa3.1 opener induced a conducting dilation in wt but not in KCa3.1-/-. Membrane potential recordings in vivo demonstrated endothelial hyperpolarization in response to ACh in both genotypes; however, the hyperpolarization was severely impaired in KCa3.1-/- (Delta membrane potential: -3 +/- 1 vs. -14 +/- 2 mV).CONCLUSION: We conclude that KCa3.1 is of major importance for endothelial hyperpolarization and EDHF-type responses in skeletal muscle arterioles, and its deficiency is not compensated by KCa2.3. Sole activation of KCa3.1 is capable of initiating conducted resp

BACKGROUND: It has been proposed that activation of endothelial SK3 (K(Ca)2.3) and IK1 (K(Ca)3.1) K+ channels plays a role in the arteriolar dilation attributed to an endothelium-derived hyperpolarizing factor (EDHF). However, our understanding of the precise function of SK3 and IK1 in the EDHF dilator response and in blood pressure control remains incomplete. To clarify the roles of SK3 and IK1 channels in the EDHF dilator response and their contribution to blood pressure control in vivo, we generated mice deficient for both channels.METHODS AND RESULTS: Expression and function of endothelial SK3 and IK1 in IK1(-/-)/SK3(T/T) mice was characterized by patch-clamp, membrane potential measurements, pressure myography, and intravital microscopy. Blood pressure was measured in conscious mice by telemetry. Combined IK1/SK3 deficiency in IK1(-/-)/SK3(T/T) (+doxycycline) mice abolished endothelial K(Ca) currents and impaired acetylcholine-induced smooth muscle hyperpolarization and EDHF-mediated dilation in conduit arteries and in resistance arterioles in vivo. IK1 deficiency had a severe impact on acetylcholine-induced EDHF-mediated vasodilation, whereas SK3 deficiency impaired NO-mediated dilation to acetylcholine and to shear stress stimulation. As a consequence, SK3/IK1-deficient mice exhibited an elevated arterial blood pressure, which was most prominent during physical activity. Overexpression of SK3 in IK1(-/-)/SK3(T/T) mice partially restored EDHF- and nitric oxide-mediated vasodilation and lowered elevated blood pressure. The IK1-opener SKA-31 enhanced EDHF-mediated vasodilation and lowered blood pressure in SK3-deficient IK1(+/+)/SK3(T/T) (+doxycycline) mice to normotensive levels.CONCLUSIONS: Our study demonstrates that endothelial SK3 and IK1 channels have distinct stimulus-dependent functions, are major players in the EDHF pathway, and significantly contribute to arterial blood pressure regulation. Endothelial K(Ca) channels may represent nove

Gap junctions are formed in the cardiovascular system by connexin40 (Cx40), Cx37, Cx43, and Cx45. These low resistance channels allow the transfer of ions and small molecules between cells. The longitudinal coupling of endothelial and smooth muscle cells via gap junctions allows the spread of changes in membrane potential along the vascular wall and hence provides conduction pathways within the vessel itself. Functionally, this tight coupling is reflected by the spread of locally initiated vasomotor responses along the arteriole which are termed conducted responses. Conducted dilations are initiated by the application of endothelium-dependent stimuli which result in local hyperpolarization. This signal spreads along the wall, most likely along the endothelial cell layer, to elicit a coordinated dilation of the arteriole over a considerable distance. Likewise, the opposite signal (depolarization) spreads along the vessel giving rise to a conducted constriction. The latter response is however most likely transmitted along the smooth muscle cell layer. Thus, conducted responses reflect the synchronized behavior of the cells of the vascular wall. It is assumed that conducted responses are critical for the matching of oxygen delivery and tissue needs because they contribute to an ascending dilation which lowers resistance along the length of the arterioles and upstream vessels in a well-tuned fashion. Herein, Cx40 is of special importance because it is critically required for intact signal transduction along the endothelial cell layer. In addition, Cx40 mediates pressure feedback inhibition on renin synthesis in the kidney. Both, vascular and renal function of Cx40, may be involved in the hypertension that is observed in Cx40-deficient animals. In this review, we will summarize physiologic function of connexins in arterioles and briefly address their role in the kidney with respect to renin secretion.

Gap junctions interconnect vascular cells homocellularly, thereby allowing the spread of signals along the vessel wall, which serve to coordinate vessel behavior. In addition, gap junctions provide heterocellular coupling between endothelial and vascular smooth muscle cells, creating so-called myoendothelial gap junctions (MEGJs). Endothelial cells control vascular tone by the release of factors that relax vascular smooth muscle. Endothelial factors include nitric oxide, prostaglandins, and an additional dilator principle, which acts by smooth muscle hyperpolarization and is therefore named endothelium-derived hyperpolarizing factor (EDHF). Whether this principle indeed relies on a factor or on intact MEGJs, which allow direct current transfer from endothelial to smooth muscle cells, has recently been questioned. Careful studies revealed the presence of vascular cell projections that make contact through the internal elastic lamina, exhibit the typical GJ morphology, and express connexins in many vessels. The functional study of the physiological role of MEGJs is confined by the difficulty of selectively blocking these channels. However, in different vessels studied in vitro, the dilation related to EDHF was sensitive to experimental interventions that block MEGJs more or less specifically. Additionally, bidirectional electrical coupling between endothelial and smooth muscle cells was demonstrated in isolated small vessels. In marked contrast, similar approaches used in conjunction with intravital microscopy, which allows examination of vascular behavior in the intact animal, did not verify electrical or dye-coupling in different models investigated. The discrepancy between in vitro and in vivo investigations may be due to size and origin of the vessels studied using these distinct experimental approaches. Additionally, MEGJ coupling is possibly tightly controlled in vivo by yet unknown mechanisms that prevent unrestricted direct signaling between endothelial and

Intercellular communication through gap junctions coordinates vascular tone by the conduction of vasomotor responses along the vessel wall. Gap junctions in arterioles are composed of different connexins (Cxs) (Cx40, Cx37, Cx45, Cx43), but it is unknown whether Cxs are interchangeable. We used mice with a targeted replacement of Cx40 by Cx45 (Cx40KI45) to explore whether Cx45 can functionally replace Cx40 in arterioles. Arterioles were locally stimulated using acetylcholine, bradykinin, adenosine, and K(+) in the cremaster of Cx40KI45, Cx40-deficient (Cx40ko), and wild-type mice, and diameter changes were assessed by intravital microscopy. Additionally, arterial pressure was measured by telemetry and Cx expression verified by immunofluorescence. Acetylcholine initiated a local dilation of a similar amplitude in all genotypes ( approximately 50%), which was rapidly conducted to upstream sites (1200 mum distance) without attenuation in wild type. In marked contrast, the remote dilation was significantly reduced in Cx40ko (25+/-3%) and Cx40KI45 (24+/-2%). Likewise, dilations initiated by bradykinin application were conducted without attenuation up to 1200 mum in wild type but not in Cx40ko and Cx40KI45. Adenosine-induced dilations and K(+)-induced constrictions were conducted similarly with decaying amplitude in all genotypes. Arterial pressure was strongly elevated in Cx40ko (161+/-1 versus 116+/-2 mm Hg) but only moderately in Cx40KI45 (133+/-8 mm Hg). This demonstrates that Cx40 function is critical for the conduction of acetylcholine and bradykinin dilations and cannot be substituted by Cx45. Therefore, unique properties of Cx40 are required for endothelial signal conduction, whereas nonspecific restoration of communication maintains additional functions related to blood pressure control.