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Subiect: HIRUDOLOGIA - tratament cu lipitori

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    LEECH BIOLOGY AND BEHAVIOUR
    Volume II Feeding, Biology, Ecology and Systematics.
    fficeffice" />>>
    Roy T. Sawyer
    >>
    13.5 Endosymbiosis>>

    Hirudo medicinalis has virtually an obligatory symbiotic relationship with the bacterium Aeromonas hydrophila (= Pseudomonas hirudinis), the only species of bacteria which lives in its gut (Zirpolo 1923; Lehmensick 1941, 1942; Hornbostel 1941; Büsing 1951; Büsing et al. 1953; Wilde 1976; Jennings and Van der Lande 1967; Whitlock, O'Hare, Saunders and Morrow 1983). Aeromonas hydrophila is important in the life of H. medicinalis in several respects.
    >>
    1. It secretes an antibiotic which prevents the growth of other bacteria and accordingly retards putrefaction so that blood can be stored for long periods.
    >>
    2. It contributes enzymes which play a major role in digestion (see Digestion).
    >>
    3. A presumed role for the bacterium, and probably the context in which endosymbiosis evolved in leeches in the first place, is production of deficient vitamins. This is an inference based on the observation that animals which live exclusively on blood generally have diets deficient in certain necessary compounds, including some of the B complex vitamins (Wigglesworth 1965; Buchner 1965). Inexplicably, dietary deficiency in exclusively bloodsucking leeches has never been investigated.
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    13.6 Digestive physiology
    Digestion and absorption take place predominantly in the leech intestine, food being passed into this region a little at a time from the crop (Büsing et al. 1953; Jennings and Van Der Lande 1972; Garcia-Mas 1979ff; Redondo, Garcia-Mas, Beltram and Moreno 1980; see also Gooding 1972). In most species the crop functions primarily, if not exclusively, for food storage, but some digestion takes place in the crop of certain, mainly non-bloodsucking species, eg. Glossiphonia complanata and Helobdella stagnalis (Damas 1962; Jennings and Van Der Lande 1967).
    >>
    For the most part secretions from leech salivary cells are not involved in digestion. However, the functional significance of a salivary protease in Hirudo medicinalis (Damas 1974a) and of esterases in Poecilobdella granulosa (Dev and Mishra 1971, 1972a; Mishra and Dev 1976) and in Piscicola geometra (Van der Lande 196 remains unsolved. Interestingly, the latter species appears to be exceptional among haematophagous leeches studied in some digestion, probably aided by endopeptidases (i.e. esterases), takes place in the crop (Jennings and Van Der Lande 1967). The rate of digestion is also very rapid in this species, on the order of ten days.
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    The mid-gut of leeches is characterized by a great reduction or absence of endogenous carbohydrase, lipases, and most proteases, particularly endopeptidases (Diwany 1925; Graetz and Autrum 1935; Damas 1962; Jennings and Van Der Lande 1967; Van Der Lande 1968, 1972). An important exception is the presence of endogenous exopeptidases (arylamidases) which have been found in the intestine of all leeches studied.
    >>
    Exopeptidases are especially prominent in the non-bloodsucking species Erpobdella octoculata. In this species these enzymes are distributed evenly and uniformly through the intestine, being especially rich at the brush border (microvilli) of the endothelium. The presence of exopeptidases is independent of the animal's state of nutrition and age. Activity is optimal at about pH 7.0 but is still present in the range pH 5.0-8.7 suggesting the possibility that at least two enzymes are present. At least one of these is activated by metal ions (CO2+ and Mn2+), a characteristic of many exopeptidases. Similarity in activity of exopeptidases from a diversity of leech species suggests that leeches all share the same endogenous exopeptic enzymes. However, the degree of activity varies somewhat with species, being weakest in Haemopis sanguisuga and Pontobdella muricata among species studied.
    >>
    Deficiency of digestive enzymes (except exopeptidases) in leeches is compensated by enzymes produced by endosymbiotic microflora (see Endosymbiosis) (Table 13.5). In Hirudo medicinalis these supplementary enzymes are produced by the bacterium Aeromonas hydrophila discussed elsewhere (Lehmensick 1941, 1942; Hornbostel 1941; Büsing 1951; Büsing et al. 1953). Tests on isolated cultures of this bacterium from both the crop and intestine demonstrate the presence of potent versatile proteases, lipases, and amylases (Jennings and Van Der Lande 1967). Lecithinase is a lipase possibly involved in the breakdown of the erythrocyte wall. Haemolysin is a protease probably responsible for the degradation of haemoglobin (Büsing et al. 1953; Jennings and Van Der Lande 1967). The haemolytic properties of the bacterium is inhibited in vivo when the gut of Hirudo medicinalis is exposed to the antibiotic chloromycetin. Interestingly, the same species of Aeromonas plays a similar role in the gut of the vampire bat, Desmodus rotundus (Müller, Pinus and Schmidt 1980; Pinus and Müller 1980).
    >>
    Other haematophagous leech species also depend on endosymbiotic bacteria for digestion but the bacterial species involved and its relative contribution in digestion is species-specific (Table 13.6). Haematophagous leeches harbour only one species of endosymbiotic bacterium. Non-haematophagous leeches, such as Erpobdella octoculata, harbour more than one bacterial symbiont, but dependence on them can be considerable.
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    Many leech species feed more or less exclusively on vertebrate blood, a highly efficient source of food, especially proteins (Andrew 1965). The primary energy source is haemoglobin which comprises about 33 per cent of weight of erythrocytes and is the major (> 95 per cent) erythrocyte protein. Erythrocytes themselves comprise about 45 per cent by weight of vertebrate blood.
    >>
    Chemical composition of blood is similar for the respective vertebrate classes, but there are marked differences in the density of erythrocytes, being much more numerous in mammals (5,000,000-7,000,000 cm3) than in other classes (e.g. 400,000-500,000 in frogs and turtles). Thus, it is not a biological accident that erythrocyte-rich mammals play a disproportionate role in the feeding biology of bloodsucking leeches. A phylogenetic trend toward parasitism of mammals is particularly striking in the Glossophoniidae.
    >>
    Upon entering the crop ingested blood rapidly loses excess water and electrolytes with assistance of the nephridia (See Excretory system). Even while still feeding liquid droplets can be seen emerging from the nephridiopores. Most of the ingested liquid is removed within a couple of days (Fig. 2.22). Interestingly, the painful bite of the 'stinging' land leech Haemadipsa ornata (Moore 1927) is reportedly owing to such excreted liquids from the first pair of nephridia onto the oral sucker while feeding.
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    Haemolysis
    >>
    After removal of excess fluid the condensed blood is stored in the crop for a long period, depending on the age of the leech and ambient temperature. The stored blood undergoes extremely slow changes, involving gradual breakdown (haemolysis) of erythrocytes. In some cases structural integrity of erythrocytes can persist for up to 18 months (Pütter 1907).
    >>
    Haemolysis of blood stored in the crop of Hirudo medicinalis has been followed by several investigators (Stirling and Brito 1882; Korzhuev and Khudailberdiev 1937a,b; Despotov 1966; Gondko, Leyko, Majdak and Wojtas 1979; see also Van Der Lande 1983). For the first few days the blood undergoes little change, but after about two weeks the blood, still structurally intact, takes on a very deep dark-red colour and a jelly-like consistency. The colour is due to the reduction of oxyhaemoglobin to reduced haemoglobin, and the consistency apparently comes from admixture with mucus. Cellular membranes of the erythrocytes begin to dissolve an haemoglobin is released into solution. With time numerous crystals, presumably haemoglobin but possibly artefactual, becomes evident in the crop. After several months most of the erythrocytes are haemolysed in this manner. Interestingly, leucocytes and nuclei of erythrocytes (when present) greatly resist digestion.
    >>
    In Hirudo medicinalis haemolysis of erythrocytes is due to haemolytic properties of the endosymbiotic bacterium Aeromonas hydrophila discussed elsewhere (Büsing et al. 1953; Jennings and Van Der Lande 1967). The exact mechanism is not known but, as with other haemolytic bacteria, haemolysis is probably effected by an enzyme, haemolysin. The same bacterium is probably also responsible for the prolonged preservation of the intact erythrocytes by secreting an antibiotic which prevents putrefaction of the stored blood by other micro-organisms.
    >>
    Crop contents with its haemoglobin now in solution slowly pass a little at a time into the intestine where proteolysis of the haemoglobin takes place. Passage into the intestine is regulated by a sphincter muscle at XIX/XX which demarcates the crop from the intestine.
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    Proteolysis
    >>
    All vertebrate haemoglobins, with the exception of the monomeric haemoglobins of lampreys, are tetramers with molecular weights of about 64 000. In humans the tetramers consist of two identical and two identical chains; each chain is associated with an oxygen-binding porphyrin, haem, containing a single iron molecule, and is very similar to myoglobin in amino-acid residues and the chain of 146 residues. In lower vertebrates similar chains are present in the tetramer.
    >>
    The faeces of bloodsucking leeches are virtually pure haem (Fukui 1926; Windsor 1970) from which we can conclude that haemoglobin is split into globin, which is totally digested, and haem which is for the most part eliminated.
    >>
    Leeches lack endopeptidases so that the mechanism of proteolysis of globin cannot follow the same course as it would in other animals where endopeptidases and exopeptidases act in sequence. In leeches the endogenous exopeptidases (aided by proteases from endosymbiotic bacteria) (Table 13.5) in the intestine slowly degrade globin chains by progressive and terminal removal of the 300 or so amino acids.
    >>
    To what extent degradation of haemoglobin is intracellular or extracellular is unclear. That some intracellular digestion takes
    place is supported by the occasional presence of haem compounds within the intestinal endothelium (Bradbury 1959; Jennings and Van Der Lande 1967). Extracellular digestion is also likely since some exopeptidase activity is occasionally present in the intestinal lumen. Some activity may also occur in the contents of the crop but since the crop endothelium lacks exopeptidases the source of the enzyme is probably intestinal.

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    LEECHES
    Leeches are a gift of nature that may help people to surmount numerous health disorders. The secretion of leech saliva contains about 100 biologically active substances having favourable effect on human organism. These substances reduce blood coagulation, dissolve thrombi, reduce cholesterol and sugar content in blood, have antiphlogistic and anaesthetic effects, decrease blood-pressure, improve the immune system, diminish edemas and improve microcirculation.
    Medicinal leech - Hirudo medicinalis Linnaeus, 1758 – is a bilaterally symmetrical annelid worm of a rather complex structure, which according to the features of embryo development belongs to the group of protostome, coleomate, trochophore animals.
    A body of annelid worm consists of many segments. The segmentation asserts itself not only in the outward, but also in the internal structure. These worms have a well-developed blood circulation; segmentally set eliminative organs– nephridiums, nervous system –a typical ventral nervous cord. Annelid worms have the secondary body cavity - coelom, which is also segmented. Annelid worms’ body is flattened dorsoventrally.
    Leeches living at large are predators or temporal ectoparasites. During blood sucking they stick to the animals. Some species of leeches live in fresh waters, the others- in the sea or on the land.
    BREEDING
    Reproduction of medicinal leeches is a long and complex process. Like other leech species, medicinal leeches are hermaphroditic, but reproduce only by cross-fertilization. They do not exhibit direct development - the larvae hatch and for some time remain within the cocoon where they undergo metamorphosis. When the juvenile leeches leave the cocoon, they already have a species-specific pigmentation, are very lively and can live independently.

    Leech Cocoons

    Newly hatched leeches are picked up from the boxes

    Juvenile leeches

    Each box is carefully inspected

    Tanks where medicinal leeches are kept

    Biofarm
    LEECH THERAPY
    Patients who have already tried this method of treatment report improvements in sleep quality, mood, work capacity and increased energy levels. When a leech is applied to biologically active areas of the human body, the bite itself gives a positive effect similar to reflexotherapy. The substances relieved with leech saliva have an effect on the entire body, not just one particular organ or symptom. For example, if leeches are used to treat patients suffering from varicose veins, they also cause a simultaneous decrease in blood pressure and cholesterol levels, improve mood and digestive tract function, heal hemorrhoids. This may sound quite incredible, but it’s true.
    When does disease begin? When a cell gets sick. And a healthy cell gets sick when it is deprived of needed oxygen and nutrition, and cannot clear toxins out. Biologically active substances in leech saliva help the cells to absorb the necessary nutrition and to eliminate toxic waste. Therefore, there is a long list of diseases that can be treated by this method. First of all, leeches are particularly useful in treating a number of cardiovascular diseases: hypertension, atherosclerosis, hypercoagulation, stenocardia, myocardial infarct, varicose veins, arterial blood flow disorders in lower limbs and their complications, such as trophic lesions and oedemas. The healing qualities of leeches are also helpful in gynaecology – they reduce various inflammation processes in the uterus and its adnexa, and can be useful in cases of ovarian cysts, endometriosis, climacteric syndrome, various adhesions in the pelvis, and even in cases of frigidity, infertility and mastopathy. For men, the application of leeches is successful in treating prostate and scrotum diseases, erectile dysfunctions, bladder and urinary tract inflammations. Good results can be achieved using leeches to treat headache of various origin, even migraine. Neurologists should consider leech therapy in the treatment of neuritis, neuralgia, radiculitis, spinal disorders (disc hernias), brain atherosclerosis, pre-stroke condition and stroke.
    Since substances contained in leech saliva can lower blood sugar levels and improve pancreatic function, leeches can be effectively used in the integrated treatment of diabetes and its complications.
    Many of the benefits of leech therapy derive from the anti-inflammatory and antibacterial properties of leech secretion that can be applied in treatment of ear, nose & throat (ENT) diseases, various skin diseases (teen acne, abscesses, eczemas, erysipelas, psoriases), as well as in the treatment of allergic diseases of respiratory tract (bronchial asthma, bronchitis, pneumonia).
    Leeches are especially valuable in surgery. If a leech is attached immediately after any surgical intervention, it stimulates a quicker healing of the wound and prevents the formation of large scars and adhesions. A further benefit of leeches is that they can serve as first aid remedy for joint sprain, strain or injury. They also speed the healing of broken bones.
    This list of diseases and conditions that can be cured using leeches is far from being complete. In view of the curative effects of biologically active leech substances, specialists in any medical fields may consider including leech therapy in the treatment of their patients.
    However, leech therapy is contraindicated in the treatment of certain medical conditions and diseases. These include decreased blood clotting, hemophilia, severe anemia, hypotension, pregnancy, general fatigue, allergy to leeches, active tuberculosis, mental disorders (during acute episodes), high temperature, ulcero-necrotic processes in the intestinal tract. Also, a leech may not attach to an extremely fearful patient. Therefore, before going to the hirudotherapist try to calm down and think that those tiny natural creatures will do you much more good than a few handfuls of chemical medicines.
    Another advantage is that leech therapy has a long-term effect. In cases of chronic diseases, the course of treatment should be repeated after 4 - 6 months, whereas in most of acute cases, one course is usually sufficient. The older the disease, the longer treatment is required, more leeches are needed, and it takes longer to achieve the desired effect.
    A leech bite is similar to a mosquito sting. A leech, however, really bites as it has hundreds of tiny teeth, and when it starts injecting biologically active substances into a human body, a slight or moderate burning or stinging sensation is often felt. This lasts up to 5-10 minutes until a leech starts sucking blood and all unpleasant sensations disappear. When satiated, a leech detaches itself or is removed and immediately disposed of. No leech is ever used on more than one patient to prevent the spread of blood borne infections.
    For medical purposes, only farm-raised medicinal leeches can be used, as on leech farms the highest hygienic standards are observed, and bacteriological tests of leeches and water in which they breed are regularly performed. This strict quality control ensures that the patient receives safe and effective medical product.
    Nature has endowed leeches with a wonderful feature to suck blood. In return for that they inject into a human body a valuable range of natural medicines without side effects. The use of medicinal leeches, like other forms of natural medicine, is now re-entering the mainstream of modern medical practice.

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    Diseases that can be treated with leech therapy
    The use of leeches in medicine, for bloodletting, dates back to the ancient civilizations of India and Egypt. Bloodletting in ancient Greece was used to restore the balance of the four humors: blood, lymph, black bile and yellow bile. In medieval Europe, religious and superstitious ideas caused a surge in the popularity of bloodletting. In 1833 alone France had to import ‘over 40 million leeches’ from Russia!
    With the development of microsurgical techniques leeches now have a vital place in plastic and reconstructive surgery, particularly where venous congestion hinders healing.

    Leeches have a decidedly bad public image, but these blood suckers have played an important medical role for centuries in treating everything from laryngitis to yellow fever. Today, plastic surgeons usually call upon them to rescue skin flaps compromised by poor circulation.
    The leeches used for medical purposes are a European variety called Hirudo Medicinalis and are raised on special leech farms. The Hirudo leech works some additional magic by secreting a chemical in its saliva that acts as an anti-coagulant to prevent blood clotting.
    Leeches have more than 100 biologically active substances in their saliva that help the cells to absorb the necessary nutrition and to eliminate toxic waste. Therefore, there is a long list of diseases that can be treated by this method.


    First of all, leeches are particularly useful in treating a number of cardiovascular diseases: hypertension, arterioscleroses, hypercoagulation, stenocardia, myocardialinfarct, varicose veins, arterial blood flow disorders in lower limbs and their complications, such as trophic lesions and oedemas.
    The healing qualities of leeches are also helpful in gynecology – they reduce various inflammation processes in the uterus and its adnexa, and can be useful in cases of ovarian cysts, endometriosis, climacteric syndrome, various adhesions in the pelvis, and even in cases of frigidity, infertility and mastopathy.
    For men, the application of leeches is successful in treating prostate and scrotum diseases, erectile dysfunctions, bladder and urinary tract inflammations.
    Good results can be achieved using leeches to treat headache of various origin, even migraine. Neurologists should consider leech therapy in the treatment of neuritis, neuralgia, radiculitis, spinal disorders (disc hernias), brain arterioscleroses, pre-stroke condition and stroke. Since substances contained in leech saliva can lower blood sugar levels and improve pancreatic function, leeches can be effectively used in the integrated treatment of diabetes and its complications.
    Researchers have isolated a dozen compounds from leech saliva to prevent blood clots, treat inflammation (osteoarthritis for example), dilate blood vessels, kill bacteria, and relieve pain.


    Venous diseases is one of the best-established traditional indications for leech therapy. In most cases, leech application has a significantly positive effect on the course of disease.

    Complicated varicose veins, with edema and ulceration, can pose challenges for medical treatment. Researchers in India conducted a study in which they evaluated the effectiveness of leech therapy in reducing venous congestion, reversing edema and hyperpigmentation, and healing of varicose ulcers. Twenty patients were treated with leeches applied to the area surrounding the varicose ulcers and the patients monitored. The results following leech therapy were impressive:
    • 100% of ulcers showed healing
    • 95% showed a decrease in edema and limb girth
    • 75% demonstrated a decrease in hyperpigmentation

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    Plastic and reconstructive Surgery


    Use of leeches in surgery
    In a world where medical advances are dominated by developments in drugs and surgery it seems that in certain fields these humble creatures cannot be beaten.
    They are highly prized as a tool for healing skin grafts or restoring circulation, especially in reconstructive surgery.
    Leeches are especially valuable in surgery. The surgeon usually has little difficult connecting the two ends of small arteries, since arteries are thick-walled and relatively simple to suture. However, veins are thin-walled, fragile, and difficult to suture. The surgeon may thus get blood flowing in the reattached arteries but not in the veins. With the venous circulation severely compromised, the blood going to the reattached body part becomes congested and stagnant. The reattached part turns blue and lifeless and is at risk of being lost. It is then that leeches are summoned to treat the threatening venous insufficiency, but only when there is adequate arterial flow. If a leech is attached immediately after any surgical intervention, it stimulates a quicker healing of the wound and prevents the formation of large scars and adhesions. A further benefit of leeches is that they can serve as first aid remedy for joint sprain, strain or injury. They also speed the healing of broken bones.
    Surgeons who do plastic and reconstructive surgery find leeches especially valuable when regrafting amputated appendages, such as fingers or toes. Severed blood vessels in such cases often are so damaged that they lack the ability to clear the area of blood. In these cases, it is difficult for the surgeon to make a route for blood to leave the affected part and return to circulation.
    Packing a one-two chemical punch, the benefit of leech therapy comes not from the amount of blood that is extracted, but in the powerful anti-clotting agent hirudin, contained in the parasite's saliva, which keeps blood flowing freely. At the same time, leeches emit a natural anesthetic that minimizes pain during their feast.
    Modern clinical uses:
    • Digital replantation
    • Total auricular replantation
    • Penile replantation
    • Nasal replantation
    • Tissue flap replantation

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    Use of Medicinal Leeches in Reconstructive and Plastic Surgery

    Case 1
    Medicinal leech, Hirudo medicinalis, has been used in plastic and reconstructive
    surgery, to relieve venous congestion and to improve the microrevascularization of flaps.

    Case 2
    A 37-year-old male presented to the Thomas Jefferson University emergency department following the traumatic avulsion of his nasal tip by a human bite during an altercation.
    Case 3
    A 22-year-old male patient who suffered a severe crush injury to his right ear.
    Case 4
    A 22-year-old male patient who suffered a severe crush injury to his right ear. Injury was caused by a concrete mixer resulting in almost complete avulsion of his right ear.
    Case 5
    A 25-year-old male fell off a ladder sustaining a ring avulsion injury beginning at the junction of the distal one third, proximal two-third level of the proximal phalanx.
    Case 6
    A patient was admitted to a plastic surgical unit having had his ear bitten off by a dog.
    2000 Years of Leeches in Medicine, the acknowledged world authority on therapeutic
    leeching, Roy T. Sawyer, credits two Slovenian surgeons for pioneering the use of leeches in modern plastic and reconstructive surgery. Their paper in the British
    Journal of Plastic Surgery in 1960 described leech-assisted tissue flap surgery. Medicinal leeches have since become indispensable to microvascular surgery, including soft tissue transfers and replants.
    In France, doctors in Bordeaux, Nancy and Strasbourg use leeches as an adjunct to microsurgery. Over the last three years at the Hopital Saint Andre in Bordeaux, Prof. Jacques Baudet and Dr. Jean-Louis Bovet have prescribed leeches for certain plastic surgery patients when blood clots and congestion jeopardize the operation's success.
    Leeches are also used to help save fingers amputated in accidents. Surgeons, aided by microscopes, can restore blood circulation by sewing together tiny arteries severed in such accidents. But when microsurgeons cannot reconnect the delicate veins in the finger tips, blood can accumulate beneath the fingernail. The pressure can cause clots in the arteries, stopping the flow of blood and depriving the cells in the affected area from receiving oxygen and other vital nourishment.
    Yet if blood congestion can be avoided long enough, the body can form new blood vessels that will drain the blood and allow the reimplanted finger to survive.
    Before the Bordeaux team used leeches in such cases, the doctors often nicked the finger tip and applied cotton swabs to soak up the blood. But the technique did not work in all cases and blood transfusions had to be given to compensate for the excessive bleeding that occasionally resulted.
    “We’ve been using leeches since microvascular surgery came about in about 1972,” says Hill Hastings II, MD, a surgeon and a partner at the Indiana Hand Center in Indianapolis.
    Surgeons like Hastings will do as much as possible in the operating room to repair the bones, tendons, nerves, and blood supply of a severed or crushed body part like a finger.
    Problems with reestablishing blood flow occur about 10% of the time when "we can get the artery hooked up, but not the vein," explained Louis P. Bucky, M.D., a plastic and reconstructive surgeon at the University of Pennsylvania in Philadelphia.
    But good blood inflow is easier to restore than outflow because veins are more friable and less stiff than arteries, and thus, harder to suture together.
    The result can be venous congestion — a perfect scenario for applying a medicinal leech, which anesthetizes the area around its bite, drains the accumulated venous blood, and introduces hirudin — a powerful blood thinner — to keep the venous blood flowing.
    A medicinal leech detaches itself when engorged with blood in a few hours and is replaced with a new leech. After three to five days, the body will have started growing a new arteriole/venule network at the attachment site and leech therapy can be stopped.
    "The idea behind the leeches is to cause blood to ooze so that the body's own blood supply will eventually take over and the limb can go on and survive," says Rod J. Rohrich, M.D., president of the American Society of Plastic Surgeons and chairman of the Department of Plastic Surgery at the University of Texas Southwestern Medical Center. Leeches apply the perfect amount of suction to get the blood flowing.
    Similarly, a tram flap, abdominal tissue used to create a new breast after a mastectomy, may also become engorged with blood that cannot find its way out of the affected area. Leeches work by "removing extra venous blood and increasing blood flow" to the region, according to Ira D. Papel, M.D., a plastic surgeon in private practice in Owings Mills, Md., and associate professor at John Hopkins University, Division of Facial Plastic Surgery, in Baltimore.
    Leeches have helped save several fingers treated at Montefiore Hospital in the Bronx, according to Dr. Jane A. Petro ''it's virtually a part-saving procedure.''
    There are potential hazards associated with leech therapy, such as infections caused by bacteria from the leech's gut. Yet, according to Papel, the commercial availability of the animals has dissipated many surgeons' fears that leeches will infect their patients.

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    Case 1
    Medicinal leech, Hirudo medicinalis, has been used in plastic and reconstructive
    surgery, to relieve venous congestion and to improve the microrevascularization of flaps

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    Case 2


    A 37-year-old male presented to the Thomas Jefferson University emergency department following the traumatic avulsion of his nasal tip by a human bite during an altercation. The amputated nasal tissue was located several hours later at the scene of the altercation and brought to the emergency department, where it remained on iced saline until the time of surgery approximately 8 hours after the altercation. Physical examination at the time of presentation revealed a nasal defect encompassing the nasal tip with a portion of the right lower lateral cartilage, the soft triangle and a portion of the anterior columella (figure 1). No venous or arterial vessels were identified in the defect or amputated tissue for microvascular anastamosis. The amputated tissue contained skin, cartilage, and nasal mucosa and measured approximately 2.5cm x 2.5cm (figure 2).
    The patient was treated with intravenous fluids and antibiotics including cefavolin in the emergency department. In addition, the wound was copiously irrigated with an antibiotic solution. The patient was then taken to the operating room for further debridement of the wound and surgical replantation of the amputated nasal tissue as a composite graft under general anesthesia. Total tissue ischemic time was approximately 8 hours. The graft was re-implanted by approximating the cartilage on the amputated nasal tip to the intact lower lateral cartilage using interrupted 6-0 Monocryl (Ethicon&reg suture. The skin was then approximated with an interrupted closure (figure 3). The graft immediately developed vascular congestion and bruising (figure 4), so medicinal leeches were placed on the graft. They quickly became engorged and resolved the majority of the bruising in the area (figure 5). A dressing of Xeroform (Kendall&reg gauze was applied and covered with an Aquaplast (WFR Aquaplast Co. &reg shield conformed to the nasal tip.

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    Post-operative care included continued antibiotic coverage with IV ampicillin/sulbactam and prophylactic HIV treatment with Combivir® and Hepatitis B vaccination. He was discharged home on post-operative day 2. At discharge the graft looked pink with minimal residual bruising.
    One month following his initial repair, the patient exhibited substantial flap survival as depicted by the purple outlined area in figure 6. Failure occurred along the soft triangle. This was ultimately repaired with a turn-in flap from the grafted skin edges to permit lining of the internal nasal valve and a staged medial crura composite flap from the right collumela to reconstruct the soft triangle (figure 7).
    Peter Seymour, Ron Winokur, Greg Artz, Edmund Pribitkin: Successful Non-Microvascular Nasal Tip Replantation After Traumatic Avulsion. The Internet Journal of Plastic Surgery. 2006. Volume 2 Number

    • Conclusion

      Nasal amputations present difficult management problems. These problems have prompted the development of several different methods for restoring function and appearance. Although many cases have reported the use of microsurgical techniques to create a vascular anastamosis for graft replantation, few recent reports of non-microvascular nasal replantation exist. We have described a successful case of replantation of a moderate size nasal tip defect crossing several subunits. In addition, we have demonstrated how leech therapy may provide a successful means of relieving the venous congestion commonly encountered with this reconstructive therapy.

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    Case 3
    A 22-year-old male patient who suffered a severe crush injury to his right ear. Injury was caused by a concrete mixer resulting in almost complete avulsion of his right ear with multiple and extensive contusion crush-type lacerations. The ear was reattached. About 10 hours postoperatively, obvious venous congestion was noted. It was felt that medicinal leeches were required to salvage the ear.

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    Case 4
    A 27-year-old male patient who suffered a severe crush injury to his right ear resulting in almost complete avulsion of his right ear with multiple and extensive contusion crush-type lacerations. The ear was reattached. It was felt that medicinal leeches were required to salvage the ear.

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    Case 5
    A 25-year-old male fell off a ladder sustaining a ring avulsion injury beginning at the junction of the distal one third, proximal two-third level of the proximal phalanx.
    Following failed venous reconstruction with vein grafts, leeches were applied and color improved dramatically. Application continued every 4 to 6 hours. 5 days postoperatively, active range of motion was begun. 8 days postoperatively, venous flow was sufficiently restored.


    3 weeks postoperatively, a skin graft was performed. 6 weeks postoperatively, following treatment with active and passive movement as well as coban taping, the finger has a TAM of 224 degrees.

    Procedure illustrated in case one was performed successfully by Dr. D.H. Lalonde, B.Sc, M.Sc.,M.D., FRCSC Plastic and Reconstructive Surgery, St.John, N.B., Canada

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    Implicit Re: HIRUDOLOGIA - tratament cu lipitori

    patient was admitted to a plastic surgical unit having had his ear bitten off by a dog. The dog was caught and the ear retrieved. The ear was then taken to hospital with the patient. Its surgical reattachment included finding a small divided arteriole and suturing it to restore arterial blood flow into the ear. But no veins of sufficient size could be found for such suturing. This left a precarious situation which, if left that way, would have led to engorgement of the re-attached ear and failure. But leeches were applied to the rim of the ear for a sufficiently long period to allow capillary re-growth across the wound, with ultimate restoration of normal circulation (Plate 2). So this patient regained his ear, by dint of prompt action at the roadside, meticulous micro-vascular surgery, and the judicious application of hungry leeches.

    Plate 2: 2(a) Detached ear, due to a dog bite; (a) and (b) pre-op; 2(c) fully recovered.
    Modern hirudotherapy includes the use of leeches over arthritic joints, in venous ulcers, in a variety of ophthalmic and neurological conditions.4 A number of physiologically active biochemical agents in the leech saliva have been studied in the search for mechanisms for the beneficial effects of this treatment in these conditions. A word of caution must however be added. In spite of meticulous culture in dedicated laboratories it is impossible to fully eradicate bacteria from leech secretions, and appropriate antibiotic cover is advised during hirudotherapy.

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    References
    • Beyond Bloodletting: FDA Gives Leeches a Medical Makeover; FDA Consumer Magazine, Sept-Oct 2004 Issue; Carol Radoshttp://www.fda.gov/fdac/features/2004/504_leech.html
    • Leech Therapy for Patients With Surgically Unsalvageable Venous Obstruction After Revascularized Free Tissue Transfer Link
    • Successful Non-Microvascular Nasal Tip Replantation After Traumatic Avulsion.The Internet Journal of Plastic Surgery
    • Alternative Treatments for Wounds: Leeches, Maggots, and Bees; Medscape Article, Nov 8, 2007; Karen Dente, MD
    • Hand, Amputations and Replantation; eMedicine Article, June 28, 2006; Bradon J Wilhelmi MDWhen Modern Medicine Needs Some Help - Jack McClintock (PDF file)
    • (Gordon L, Leitner DW, Buncke HJ, Alpert BS. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J Hand Surg [Am]. May 1985;10(3):360-4. [Medline]
    • Salvage of Partial Facial Soft Tissue Avulsions with Medicinal Leeches; Otolaryngol Head Neck Surg, 2004; 131 (6):934-9; Frodel JL, Barth P, Wagner J (abstract)
    • UCLA Louise M Darling Biomedical Library; History & Special Collections--very nice online exhibit on Bloodletting
    • BMC Infectious Diseases http://www.biomedcentral.com/content...-2334-4-28.pdf
    • [SIZE=size]THE EVOLUTION OF BIOTHERAPY LEECHES,[/SIZE]John C T Church MD FRCSE

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    • An Alaskan boy was recently saved with the help of leeches. He was suffering with an infection that was preventing his internal organs from getting the blood flow they needed. Blood was not reaching his hands and feet and they were turning black and cold. He had a high fever, but his hands and feet felt like ice. The doctor decided that using medicines could be dangerous to the boy so he ordered leeches to improve the blood flow in the boy’s hands and feet. He attached them to the boy’s hands and feet, hoping for blood flow. Immediately the boy’s skin color improved and blood started flowing. The therapy was continued for seven days, requiring dozens of leeches. After a month, the boy recovered fully. Unfortunately, some fingers and toes had to be amputated, but the boy’s life was saved. The doctor said that without the leeches the boy would have lost large chunks of his feet and most of his hands.

    • Postman Brian Evans lost about an inch from the top of his left index finger when a well-sprung letter box snapped shut on his hand.
      Brian Evans: finger healed perfectly
      "It was quite early in the morning and, fortunately, the owners were in. I had to knock on their door and ask for my finger back," says Evans, above, who lives and works in Cardigan, Wales . "They were horrified, as my hand was covered in blood."
      His brother then drove him 20 miles to Carmarthen , but the hospital could do nothing for him. Finally, at about 5pm, they got to Morriston Hospital in Swansea.
      Fortunately for Evans, the resident plastic surgeon, Professor Alan McGregor, shared his love of the guitar and, on that basis, decided it was worth trying to save the finger.
      "By this time, the finger had been cut off and sitting in my pocket for nearly 10 hours and they were very doubtful as to whether it could be saved," says Evans.
      While Professor McGregor was able to reconnect the blood vessel feeding the finger, the veins draining the finger were too damaged to be connected. However, leeches, which were applied to the re-sewn finger, acted as an "external vein," preventing swelling and infection.
      "When they asked me if I wanted to try leeches, I thought they were pulling my leg, but then along came the nurse with a jar of them," says Evans.
      "I got rather attached to them, if you’ll excuse the pun, but the nurses didn’t seem to like them, particularly when they dropped off and had to be recovered from the bedclothes."
      Within a few days, his veins had repaired themselves and could function properly without any assistance from the leeches.
      "The finger has healed perfectly and now you can barely see the join," he says.

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    Effectiveness of Leech Therapy in Osteoarthritis of the Knee

    A Randomized, Controlled Trial

    Andreas Michalsen, MD; Stefanie Klotz, RN; Rainer Lüdtke, PhD; Susanne Moebus, PhD, MPH; Günther Spahn, MD; and Gustav J. Dobos, MD


    4 November 2003 | Volume 139 Issue 9 | Pages 724-730

    Background: Leech therapy was commonly used in traditional medicine for treating localized pain. Clinically significant pain relief after leech therapy for osteoarthritis of the knee has been demonstrated by preliminary data.
    Objective: To evaluate the effectiveness of leech therapy for symptomatic relief of osteoarthritis of the knee.
    Design: Randomized, controlled trial.
    Setting: Outpatient department for integrative medicine of an academic teaching hospital.
    Patients: 51 patients with osteoarthritis of the knee (leech therapy: 24 patients, mean age [±SD], 62.5 ± 10.2 years; topical diclofenac therapy: 27 patients, mean age [±SD], 65.5 ± 6.7 years).
    Intervention: A single treatment with 4 to 6 locally applied leeches (leech therapy group) or a 28-day topical diclofenac regimen (control group).
    Measurements: Mean of the pain, function, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index and physical sum score of the Medical Outcomes Study 36-Item Short-Form Health Survey with group comparisons at days 3, 7, 28, and 91.
    Results: The primary end point, pain at day 7, was reduced from a mean (±SD) of 53.5 ± 13.7 to 19.3 ± 12.2 after leech therapy compared with 51.5 ± 16.8 to 42.4 ± 19.7 with topical diclofenac (estimated group difference, –23.9 [95% CI, –32.8 to –15.1]; P < 0.001). Although the difference between group pain scores was no longer significant after day 7, differences for function, stiffness, and total symptoms remained significant in favor of leech therapy until the end of study and for quality of life until day 28. Results were not affected by outcome expectation.
    Conclusions: Leech therapy helps relieve symptoms in patients with osteoarthritis of the knee. The potential of leech therapy for treating osteoarthritis and the pharmacologic properties of leech saliva remain to be clarified.


    Editors' Notes


    Context
    • Osteoarthritis causes pain and disability, but conventional therapies offer limited relief for many patients. Leech saliva contains anti-inflammatory substances, and leeches showed promise as an osteoarthritis therapy in a nonrandomized study.

    Contribution
    • This randomized trial compared a single application of 4 to 6 leeches to the affected knee with 28 days of topical diclofenac treatment. Patients with leech therapy had less pain through day 7 than those receiving diclofenac. The leech therapy group showed benefits in function, stiffness, and total arthritis symptoms through the 91 days of follow-up.

    Cautions
    • Future studies should evaluate leeches and the substances in their saliva against various conventional therapies in blinded studies with long-term follow-up.

    –The Editors



    Author and Article Information

    From the Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, Karl and Veronica Carstens Foundation, and Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany.
    Grant Support: By a research grant from the Karl and Veronica Carstens Foundation, Essen, Germany.
    Potential Financial Conflicts of Interest: None disclosed.
    Requests for Single Reprints: Gustav J. Dobos, MD, Kliniken Essen-Mitte, Department of Internal Medicine V, Am Deimelsberg 34 a, 45276 Essen, Germany; e-mail,
    gustav.dobos@uni-essen.de .
    Current Author Addresses: Drs. Michalsen, Spahn, and Dobos and Ms. Klotz: Kliniken Essen-Mitte, Department of Internal Medicine V, Am Deimelsberg 34 a, 45276 Essen, Germany.
    Dr. Lüdtke: Karl and Veronica Carstens Foundation, Am Deimelsberg 36, 45276 Essen, Germany.
    Dr. Moebus: Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University of Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
    Author Contributions: Conception and design: A. Michalsen, R. Lüdtke, G.J. Dobos.
    Analysis and interpretation of the data: A. Michalsen, R. Lüdtke, S. Moebus, G.J. Dobos.
    Drafting of the article: A. Michalsen, G. Spahn.
    Critical revision of the article for important intellectual content: S. Moebus, G. Spahn, G.J. Dobos.
    Final approval of the article: A. Michalsen, G.J. Dobos.
    Statistical expertise: R. Lüdtke.
    Obtaining of funding: G.J. Dobos.
    Administrative, technical, or logistic support: A. Michalsen, S. Klotz, G. Spahn.
    Collection and assembly of data: S. Klotz, S. Moebus.


    Related articles in Annals:
    Editorials
    Multidisciplinary Integrative Approach to Treating Knee Pain in Patients with Osteoarthritis
    Marc C. Hochberg
    Annals 2003 139: 781-783. [Full Text]
    Summaries for Patients
    Leeches To Treat Knee Osteoarthritis
    Annals 2003 139: I-22. [Full Text]

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