Cryosurgery versus curettage for intraepidermal carcinoma: A randomized controlled trial.

BACKGROUND: Cryosurgery is a common destructive treatment method for intraepidermal carcinoma (IEC) above the knee. Curettage alone is a simple, non-aggressive and inexpensive treatment method commonly used on benign skin lesions. However, only one study has assessed curettage for treatment of IEC. OBJECTIVE: We aimed to (1) compare the effectiveness of cryosurgery (standard method) to curettage (experimental method) for treatment of IEC in regard to overall clearance rates at 1-year follow-up, and (2) investigate whether wound healing times differed between the treatment groups. METHODS: In this randomized and controlled, non-inferiority trial, adult patients with one or more IEC with a diameter of 5-20 mm, located above the knee and suitable for destructive treatment were recruited from Sahlgrenska University Hospital (Gothenburg, Sweden). Lesions were randomized to treatment with either cryosurgery or curettage. Wound healing was assessed by a nurse after 4-6 weeks and through self-report forms. Overall clearance was assessed by a dermatologist after 1 year. RESULTS: In total, 183 lesions in 147 patients were included, with 93 lesions randomized to cryosurgery and 90 to curettage. Eighty-eight (94.6%) of the lesions in the cryosurgery group and 71 (78.9%) in the curettage group showed an overall clearance at the 1-year follow-up visit (p = 0.002). The non-inferiority analysis was inconclusive. Curettage resulted in both shorter self-reported wound healing times (mean time 3.1 vs. 4.8 weeks, p < 0.001) and a larger proportion of healed wounds after 4-6 weeks (p < 0.001). CONCLUSIONS: Cryosurgery and curettage both result in high clearance rates for treatment of IEC, but cryosurgery is significantly more effective. On the other hand, curettage may result in shorter wound healing times.

Curettage vs. cryosurgery for superficial basal cell carcinoma: a prospective, randomised and controlled trial.

BACKGROUND: Basal cell carcinoma (BCC) is the most common cancer in the world and has a rising incidence. Current guidelines for low-risk BCC including superficial BCC (sBCC) recommend several treatment options including destructive treatment methods, such as cryosurgery with or without prior curettage or curettage and electrodesiccation. Curettage only (i.e. without subsequent cryosurgery or electrodesiccation) is a simple and quick destructive treatment method used for many benign skin lesions but has not been sufficiently evaluated for the treatment of sBCCs. OBJECTIVES: The objective was to compare the effectiveness of curettage vs. cryosurgery for sBCCs in terms of overall clinical clearance rates after 1 year as well as wound healing times. METHODS: A single-centre non-inferiority clinical trial was conducted. Non-facial sBCCs with a diameter of 5-20 mm were randomised to either cryosurgery using one freeze-thaw cycle or curettage. At follow-up visits, treatment areas were evaluated regarding the presence of residual tumour after 3-6 months and recurrence after 1 year. Further, wound healing times were assessed. RESULTS: In total, 228 sBCCs in 97 patients were included in the analysis. At 3-6 months, no residual tumours were seen in any of the treated areas. After 1 year, the clinical clearance rates for curettage and cryosurgery were 95.7% and 100%, respectively (P = 0.060). However, the non-inferiority analysis was inconclusive. Wound healing times were shorter for curettage (4 weeks) compared to cryosurgery (5 weeks; P < 0.0001). Overall, patient satisfaction at 1 year was high. CONCLUSIONS: Both treatment methods showed high clinical clearance rates after 1 year, whilst curettage reduced the wound healing time.

Teledermoscopy images acquired in primary health care and hospital settings - a comparative study of image quality.

BACKGROUND: The incidence of melanoma and non-melanoma skin cancer is increasing, which has also lead to an increase in referrals between primary health care (PHC) and dermatology departments, putting a strain on healthcare services. Teledermoscopy (TDS) referrals from PHC can improve the triage process for patients with suspicious skin tumours, but the quality of the images included could potentially affect its usefulness. OBJECTIVE: To critically appraise the quality of the dermoscopic images of a smartphone TDS system, by comparing the TDS referral images with images of the same tumours acquired at the department of dermatology. METHODS: Two dermatologists rated the image quality of two image sets from 172 skin tumours separately. The dermatologists also decided on a main diagnosis, differential diagnoses and described the visible dermoscopic structures. RESULTS: The images acquired in PHC were rated as having slightly lower quality, but there was no significant difference. PHC images and dermatology images were of intermediate-to-high quality in 95.5%-97.7% and 96.5%-98.8%, respectively. There was no difference in agreement between the TDS diagnosis based on the two image sets with the final clinical or histopathological diagnosis. Most image pairs (81.4% and 83.7%) received the same main diagnosis by the two evaluators. When this was not the case, the most common reasons were poor focus, excessive pressure applied when acquiring the image or inadequate amount of zoom. CONCLUSION: TDS performed in PHC with a smartphone-based system does not seem to negatively affect the usefulness of TDS referrals. Thus, physicians at PHC do not necessarily need to be trained photographers to ensure adequate TDS image quality. Knowledge about technical difficulties could however be used when training PHC staff, to improve the image quality further.

Safety of midazolam for sedation of HIV-positive patients undergoing colonoscopy.

OBJECTIVES: Because of concerns regarding interactions between midazolam and antiretroviral therapy (ART), alternative sedatives are sometimes used during procedural sedation. Our objective was to compare outcomes in patients on ART who received intravenous (iv) midazolam vs. iv diazepam, a second-line agent, during colonoscopy. METHODS: We conducted a retrospective analysis of adult HIV-positive patients who underwent colonoscopy over a 3.5-year period. Primary outcomes were sedation duration, nadir systolic blood pressure (SBP), nadir oxygen saturation, abnormal cardiac rhythm, and change in level of consciousness using a standardized scale. We calculated rates of adverse events according to benzodiazepine use and identified risk factors for complications using univariate and multivariate analyses. RESULTS: We identified 136 patients for this analysis: 70 received midazolam-based sedation and 66 received a diazepam-based regimen. There were no significant differences between the two groups with respect to sedation duration (mean 48.0 vs. 45.7 minutes for the midazolam and diazepam groups, respectively; P = 0.68), nadir SBP (mean 97.0 vs. 101.6 mmHg; P = 0.06), nadir oxygen saturation (mean 94.6 vs. 94.8%; P = 0.72) or rate of abnormal cardiac rhythm (11.4 vs. 19.7%; P = 0.18). More patients in the midazolam group experienced a depressed level of consciousness (91% vs. 74% in the diazepam group; P = 0.0075), but no patient required reversal of sedation or became unresponsive. CONCLUSIONS: We did not find evidence that patients who received midazolam for procedural sedation had clinical outcomes statistically different from those who received diazepam. These findings should be confirmed in prospective studies or in a randomized controlled trial.

Poster - Thurs Eve-33: Initial implementation of a novel, measurement-based IMRT QA method.

Current measurement-based QA for IMRT typically involves a composite dose delivery to a phantom. However, this approach does not allow a direct dosimetric evaluation of the delivered treatment with respect to the patient anatomy. In this work we implement a novel, measurement-based IMRT QA method which provides an accurate reconstruction of the 3D-dose distribution in the patient model. The RPC Head&Neck phantom and two clinical prostate cases have been examined to date. Step & shoot plans were developed satisfying required dose metrics. A 2D-array of dose chambers (MatriXX, IBA Dosimetry) was mounted on a linear accelerator to capture delivered fluence. The measurement data were read directly by the control software (COMPASS, IBA Dosimetry), which also provides the ability to import patient plan data from the TPS. The COMPASS software also includes a dose calculation engine and head fluence model and requires beam commissioning procedures analogous to those of a TPS. Reconstructed doses and DVHs were compared to those calculated by the TPS. The beam model in the COMPASS software was able to predict percentage depth dose and X and Y profiles for MLC-defined apertures ranging from 1×1-20×20 cm∧2 to within 1.5% (depth-dose), 2.0% (in-field profiles), and 2.5% (out-of-field profiles). Reconstructed doses in the test plans were mostly within 2% of those in the TPS. DVHs compared to <1.2%. Reconstructed doses were overlaid on CT data and contoured structures, to enable a clinically useful understanding of discrepancies as compared to the TPS plan. Research partially sponsored by IBA Dosimetry.

Pneumococcal pneumonia in patients requiring hospitalization: effects of bacteremia and HIV seropositivity on radiographic appearance.

OBJECTIVE: Our purpose was to establish the incidence of lobar versus bronchopneumonia patterns in patients hospitalized for pneumococcal pneumonia and to determine whether bacteremia or HIV status affects the radiographic appearance. MATERIALS AND METHODS: Eighty-one patients with community-acquired pneumococcal pneumonia and positive findings on admission chest radiographs were selected from a group of 105 patients with positive findings for Streptococcus pneumoniae from sputum or blood cultures. Patients less than 16 years old and those with nosocomial pneumonia, aspiration pneumonia, or coexistent lung disease were excluded. The dominant pattern was classified as lobar or lobular bronchopneumonia by two radiologists who were unaware of results from blood cultures and HIV testing. RESULTS: Forty-three females and 38 males, with a mean age of 48 years (age range, 16-92 years), required admission for pneumococcal pneumonia. Fifty-nine (73%) of the 81 patients were bacteremic and 20 (25%) of the 81 patients were HIV-positive, including 14 patients (17%) who were both bacteremic and HIV-positive. Among all the patients, focal lobar consolidation was the most common pattern, observed in 48%. Multifocal lobar consolidation was the next most frequent pattern, occurring in 33%. Multifocal and focal bronchopneumonia patterns were seen in 16% and 2% of the patients, respectively. Overall, multifocal consolidation occurred in 49%. The dominant radiographic pattern and incidence of multicentric disease were not affected by HIV seropositivity (p = 0. 61) or bacteremia (p = 0.17). CONCLUSION: Lobar consolidation, involving single or multiple lobes, is the most common radiographic pattern of community-acquired pneumococcal pneumonia in patients requiring hospitalization. The pattern of consolidation is not influenced by bacteremia or HIV status.

Comparison of resistive index versus pulsatility index in assessing the benign etiology of adnexal masses.

Retrospective analysis of pelvic sonograms with colorguided spectral Doppler evaluation of 189 adnexal masses yielded four malignancies, 20 benign neoplasms, 32 cysts, and 14 endometriomas. Fifty-eight masses were presumed benign on additional imaging. Pulsatility index (PI) < 1.0 was seen in 70% neoplasms, 63% benign cysts and 50% endometriomas. Thirteen percent of benign cysts and no neoplasms had resistive index (RI) < 0.4. Fifty percent malignancies had PI < 1.0. None had RI < 0.4. Both thresholds lack sufficient sensitivity and specificity for distinguishing benign and malignant lesions.

Iliopsoas myositis mimicking appendicitis: MRI diagnosis.

Myositis of the truncal muscles can closely mimic acute appendicitis. Myositis is the early stage of muscular infection. It is characterized by diffuse muscular pain and swelling without a distinct mass. Early diagnosis of myositis improves the outcome and surgical debridement is usually avoided. Pyomyositis, the advanced stage of the disease, can be diagnosed by MRI examination. We present a case of early bacterial myositis that was diagnosed by MRI.

Chronic regional muscular pain in women with precise manipulation work. A study of pain characteristics, muscle function, and impact on daily activities.

Pain characteristics, muscle function and impact on daily activities were studied in 39 women with chronic regional muscular pain (RMP). They were all blue-collar workers in work involving precise manipulations. The main location of the pain was in the neck-shoulder region. Nineteen age-matched women with fibromyalgia (FM) were studied in the same way as the RMP patients. Thirty-seven women with no pain and with the same age and weight as the RMP patients served as reference group with respect to muscle strength and endurance. A follow-up study was done with respect to pain distribution and other pain characteristics 20 months after the initial examination. The findings were of the same nature in the RMP and the FM groups. The intensity of pain, the lowering of pain threshold for pressure, and the degree of sleep disturbance were greater in the FM than in the RMP group. Isometric muscle strength and static muscular endurance were reduced in both FM and RMP compared to reference values. The reduction in strength and endurance was greater in FM than in RMP. Even if the impact on everyday activities were greater in FM than in RMP, the impact was substantial in RMP patients also, for example with regard to work capacity. There were no transitions from RMP to FM during the 20 months to follow-up. Three FM patients, however, did not meet the ACR criteria for FM at follow-up.

Muscle function in juvenile chronic arthritis.

OBJECTIVE: Muscle strength and thickness were studied in children with juvenile chronic arthritis (JCA) to evaluate their muscle function. METHODS: We studied voluntary isometric, isokinetic, and nonvoluntary isometric muscle strength, as well as muscle thickness, in 20 children with JCA. Thickness of the quadriceps muscle was measured by ultrasound. Results were compared with reference values for healthy children and a matched control group. RESULTS: Isometric muscle strength in knee extensors, elbow flexors, and wrist dorsiflexors was reduced in children with JCA. In muscles near an inflamed joint, the strength was 45-65% of expected value. In muscles without adjacent arthritis, the strength was slightly decreased (80-90% of expected value). Isometric and isokinetic strength in ankle dorsiflexors was reduced only in children with ankle arthritis. Nonvoluntary muscle strength in thumb adductors during electrical stimulation of the ulnar nerve was reduced in children with arthritis in the hand. Thickness of the quadriceps muscle was reduced both in children with and without knee arthritis (75 and 90% of expected). CONCLUSION: Children with JCA have reduced muscle strength and thickness, which is most pronounced in muscles near an inflamed joint.

Isometric muscle strength and muscular endurance in normal persons aged between 17 and 70 years.

Isometric muscle strength was measured in 63 women and 65 men, randomly selected, aged 17-70 years, using Penny & Giles' hand-held dynamometer. Eight muscle groups as well as the hand grip strength were tested bilaterally. The muscular endurance was measured as time to exhaustion in the abductors of the shoulder and the flexors of the hip. Reference values for muscle strength and muscular endurance are given in the age groups 17-18, 20-29, 30-39, 40-49, 50-59 and 60-70 years of age. The mean strength of females was about 65-70% of that of the men, but when the results were related to weight, the differences almost disappeared. Both men and women seem to have the greatest muscle strength at the age of about 17-18. The strength is rather constant up to the age of about 40 years, after which a discrete decline is seen up to about 60, from where the decline is more obvious. Muscular endurance showed great variability between individuals. However, no decrease in endurance was seen in older ages. For both sexes, lower reference limits of endurance, with the methods used, for arm abductors are suggested as being 3 minutes and for hip flexors, 90 seconds.

Phospholipase A2 activity in dystrophinopathies.

Phospholipase A2 activity in human muscle with or without dystrophin abnormality was studied. The results showed an increased phospholipase A2 activity in Duchenne muscular dystrophy (DMD) patients (1160 +/- 160, P < 0.01) compared to controls (< 200 U mg-1). DMD fetal muscle showed normal levels, but levels then increased dramatically postnatally. Highest levels were found at 5 yr of age (10 times normal) and then declined to 1.5-2 times normal by age 10. Steroid treatment did not change the phospholipase A2 levels significantly. In patients with abnormal dystrophin, i.e. Becker muscular dystrophy, phospholipase A2 activity was increased in the age group 3-15 (920 +/- 230 U mg-1, P < 0.01), while older patients (17-49) showed a non-significant (220 +/- 60 U mg-1) increase. The lack of phospholipase A2 activation in fetuses with DMD, indicates that activation is not a direct consequence of dystrophin deficiency. Phospholipase A2 activity has been shown to be connected to the formation of several inflammatory mediators such as prostaglandins, leukotriens, platelet activating factor and lysophospholipids. Phospholipase A2 activation may therefore play an important role in the development of inflammation and necrosis, with subsequent fibrosis and massive loss of muscle function, which develops in Duchenne and Becker muscular dystrophy.

Low-dose prednisolone treatment in Duchenne and Becker muscular dystrophy.

Forty-one boys, aged 4.0-19.4 yr, with Duchenne or Becker muscular dystrophy, took part in a 12-month randomized, double-blind cross-over trial in which the patients received 0.35 mg kg-1 day-1 prednisolone for six months and placebo for six months. One patient stopped the treatment because of excessive weight gain. The boys were assessed every third month with a comprehensive test battery of muscle force and function. The results support earlier reports that prednisolone treatment can either improve muscle force and function or diminish the deterioration of muscle function in both Becker and Duchenne muscular dystrophy.

Pain analysis in patients with fibromyalgia. Effects of intravenous morphine, lidocaine, and ketamine.

Pain intensity, muscle strength, static muscle endurance, pressure pain threshold, and pain tolerance at tender points and control points were assessed in 31 patients with fibromyalgia (FM), before and after intravenous administration of morphine (9 patients), lidocaine (11 patients), and ketamine (11 patients). The three different studies were double-blind and placebo-controlled. The patients were classified as placebo-responders, responders (decrease in pain intensity by > 50%) and non-responders. The morphine test did not show any significant changes. The lidocaine test showed a pain decrease during and after the infusion. The ketamine test showed a significant reduction in pain intensity during and after the test period. Tenderness at tender points decreased and endurance increased significantly, while muscle strength remained unchanged. The present results support the hypothesis that the NMDA receptors are involved in pain mechanisms in fibromyalgia. These findings also suggest that central sensitization is present in FM and that tender points represent secondary hyperalgesia.

Renal impairment after acute diclofenac, naproxen, and sulindac overdoses.

Acute renal dysfunction has been described as a feature of acute overdoses of the nonsteroidal anti-inflammatory drugs benoxaprofen, fenoprofen, ibuprofen, mefenamic acid, piroxicam, suprofen, and zomepirac. The cases reported here include renal impairment after acute overdoses of another three nonsteroidal anti-inflammatory drugs: diclofenac (one case), naproxen (two cases), and sulindac (five cases). The eight patients presented with lumbar pain and oliguria and had protein and erythrocytes in the urine. Serum creatinine was increased to a maximum of 190-932 mumol/L. Renal impairment was generally transient but in one case was treated by hemodialysis and one by continuous arterio-venous hemofiltration dialysis. In all cases of significant acute overdose of nonsteroidal anti-inflammatory drugs, the risk of acute renal dysfunction must be considered.

The heart in Duchenne muscular dystrophy: a non-invasive longitudinal study.

Sixteen boys with Duchenne muscular dystrophy (DMD) underwent serial investigations of echocardiographic left ventricular dimensions, systolic time intervals (STI), ECG and vectorcardiography (VCG). Spirometry with measurement of vital capacity and forced expiratory volume was also performed, as well as tests of muscle function. ECG was abnormal with high right precordial R-amplitudes even in the youngest patients. In contrast, VCG QRS area progressively diminished with age. STI and echocardiographic contractility indices decreased with increasing age. There was no clinically useful relationship between the various non-invasive variables on the one hand and results from skeletal muscle tests or lung function tests on the other, or between the different cardiac investigation methods. It is concluded that several non-invasive tests are needed during follow-up studies of Duchenne patients to evaluate the effects of treatment or assess prognosis.

Characteristics of tetanic muscle contraction in Parkinson patients.

The aim of this study was to examine contraction characteristics in striated muscles from Parkinson patients and to measure any changes in characteristics based on changes in medication. Fifteen patients, 9 men and 6 women, mean age 61.6 (range 43-70) with mild to moderate parkinsonism, (Hoehn and Yahr I-III) were investigated, and the results were compared with a group of 8 normal controls (mean age 59.6, range 50-70). Twelve of the patients (7 men and 5 women) were also tested after a 24-h period without medication. Using supramaximal electrical stimulation of the ulnary nerve at the wrist contraction, characteristics in the m. adductor pollicis muscle can be recorded. Stimulation results were printed on a fast paper writer. The following characteristics were recorded: 1) electromechanical delay of contraction EMDc; 2) contraction time to half tetanus CTT1/2; 3) electromechanical delay of relaxation EMDr; 4) relaxation rate RR for 10 ms RR-10; 5) the force produced in the tetanic contraction at stimulus frequencies 5, 10, 20, 50 Hz. The results showed that the in initiation of contraction (EMDc) was normal compared with controls. CTT1/2 was shorter (p less than 0.001) in the group of Parkinson patients compared with normals. EMDr was not changed when compared with normals, but RR-10 was increased, p less than 0.05. Force levels at the different stimulation rates were not significantly changed. After withdrawal of medication all parameters were unchanged. Muscle contraction characteristics in tetanic contraction were found to be abnormal indicating either a possible preactivation in the muscle contraction or a secondary change in the muscles of patients with Parkinson's disease.