Treatment of psoriasis with light and heat energy (LHE): a preliminary study.

In psoriasis the earliest observable electron microscopic changes are in the papillary dermis vasculature. Selective photothermolysis of the dermal vasculature using a 585-nm pulsed-dye laser (PDL) for the treatment of psoriasis was reported more than a decade ago. Although clinically effective, the pulsed-dye laser has limited practicality because of small spot size (5-10 mm) and lack of cost effectiveness. The objective of this study is to evaluate the safety and efficacy of a novel Light and Heat Energy (LHE) selective-photothermolysis system for the treatment of psoriasis. This system delivers controlled heat simultaneously with the light pulse; it has a large beam spot (55 x 22 mm) and is sufficiently cost effective to be widely used. Thirteen patients, seven with plaque psoriasis, five with palmoplantar psoriasis, and one with guttate psoriasis participated in a controlled study. Patients received two therapy regimens in parallel: LHE plus salicylic acid or salicylic-acid cream alone as control. Treatments were applied twice weekly spread evenly over 4-6 weeks. In most cases a fluence of 8.6 J/cm2 was applied. Efficacy of the treatment was assessed using the psoriasis-severity index (PSI) calculated from the investigator's overall assessment of the plaque's erythema, scaling, and induration. PSI was evaluated at baseline, at every other treatment visit, and during two follow-up visits scheduled 1 and 5 weeks following the last treatment. In eleven patients who completed the treatment regimen, the average global PSI score for the treated sites was reduced by 65 percent. In contrast, the control sites average global PSI score was reduced by only 7.4 percent. Six patients (55 %) had a significant improvement of 70-percent reduction or above in their PSI score, ten patients (91 %) had a 50 percent or above reduction; only one patient had a poor response (12.5 % reduction in global PSI). Erythema was reported in all cases and resolved within 24-48 hours. Six cases of burns were resolved within 2 days to 2 weeks following appropriate remedy. No cases of dyspigmentation were encountered. Light and Heat Energy (LHE) selective photothermolysis combined with salicylic acid appears to be a practical modality for the treatment of mild to moderate psoriasis. Patients experience discomfort that is only mild. There is no convalescence downtime. Clinical results obtained are similar to those reported with the pulsed-dye laser; however, this new system seems more suitable to be widely adopted as a treatment modality. Further followup is required to determine whether remission periods will be as long as those reported for treatment with the pulsed-dye laser.

Laser soldering of rat skin, using fiberoptic temperature controlled system.

BACKGROUND AND OBJECTIVE: Laser soldering of tissues is based on the application of a biological solder on the approximated edges of a cut. Our goal was to use laser soldering for sealing cuts in skin under temperature feedback control and compare the results with ones obtained using standard sutures. STUDY DESIGN/MATERIALS AND METHODS: Albumin solder was applied onto the approximated edges of cuts created in rat skin. A fiberoptic system was used to deliver the radiation of a CO(2) laser, to heat a spot near the cut edges, and to control the temperature. Laser soldering was carried out, spot by spot, where the temperature at each spot was kept at 65-70 degrees C for 10 sec. RESULTS: The tensile strength of laser-soldered cuts was measured after 3-28 days postoperatively and was found comparable to that of sutured cuts. Histopathological studies showed no thermal damage and less inflammatory reaction than that caused by standard sutures (P = 0.04). CONCLUSIONS: Temperature controlled laser soldering of cuts in rat skin gave strong bonding. The cosmetic and histological results were very good, in comparison to those of standard sutures.

Pectoralis major muscle flap for deep sternal wound infection in neonates.

BACKGROUND: Deep sternotomy wound infections during the neonatal period, their management utilizing the pectoralis major muscle flap (PMF), and their follow-up are reported. METHODS: Seven hundred-twenty consecutive pediatric cardiac operations performed from 1995 to mid 1998 in 108 neonates and 612 infants are reviewed. Nine children (1.25%), 6 neonates and 3 infants, developed deep sternotomy wound infections and underwent PMF reconstruction. The 6 neonates are reviewed. Their follow-up includes growth and development reports, physical examination, and computerized tomographic scans of the chest. RESULTS: The incidence of sternal wound complications in our neonatal patients (5.5%, 6 of 108) was significantly higher than in the infantile group (0.5%, 3 of 612), (p = 0.0001, odds ratio = 11.94). Five neonates were treated with a unilateral, turnover PMF reconstruction. One patient was treated by a bilateral rotational PMF. All sternal wounds healed successfully, and all patients survived. In a follow-up period, ranging from 6 to 31 months (mean 16.5 months), the growth and development of all operated neonates was as expected for their age. There were no signs of chronic sternal infection in any of them. CONCLUSIONS: Early recognition of sternal wound complications should facilitate surgical treatment. Utilizing the PMF promotes rapid wound healing and preservation of life in these severely ill neonates, with minimal developmental problems.

Screening for mutations in candidate genes for hypospadias.

Hypospadias. a condition with a frontally placed urethral orifice on the penis, is the most common malformation in males. During fetal development several components are necessary for normal male genital development. Testosterone and dihydrotestosterone act via the androgen receptor but a defective receptor function results in different degrees of genital malformations. Testosterone-5alpha-reductase converts testosterone to dihydrotestosterone, which is crucial for normal differentiation, and a total lack of this enzyme results, in syndromes with hypospadias. The Wilms' tumour 1 (WT1) gene is expressed in the fetal gonad and genital malformations can occur due to WT1 gene mutations. These genes are therefore strong candidate genes for hypospadias. We have analysed 35 boys with hypopadias and one girl diagnosed as with complete androgen insensitivity syndrome, using exon by exon polymerase chain reaction (PCR) amplification of the AR, WTI and 5alpha-reductase genes and screened for point mutations and performed subsequent DNA sequencing. No mutations in any of these genes were found in the 26 patients with isolated hypospadias. Two patients with severe hypospadias with cryptorchidism were found to carry mutations in the androgen receptor gene. Also the girl with clinically diagnosed complete androgen insensitivity was found to be homozygous for a splice mutation in the 5alpha-reductase gene. In summary, mutations in the WT1, AR and 5alpha-reductase genes are not common causes of isolated hypospadias.

Expression of rasGTPase activating protein in basal cell carcinoma of the skin.

The ras proto-oncogene, a key component in the signal transduction cascade of activated growth factors, is involved in multiple tumor types, including basal cell carcinoma (BCC). rasGTPase activating protein (rasGAP), is a dual function protein in the ras signaling pathway, i.e., it downregulates activated ras via its catalytic domain, and it also participates in the downstream effector signaling pathway by mediating protein-protein interaction. Missense mutations presumably leading to rasGAP activation were previously detected in this gene, in a subset of BCCs. To assess the role of rasP21 and rasGAP in BCC tumorigenesis, we performed an immunohistochemical analysis of 48 BCCs, of which 45 were of the circumscribed variant (indolent-growth tumors) and the remaining 3 (2 morpheaform, 1 infiltrative), were aggressive-growth variants. rasGAP overexpression was demonstrated in 7 of 48 BCC cases, i.e., in 4 (8.8%) of 45 indolent-growth cases and in all of the 3 aggressive-growth cases. We detected tumor-specific reduction of rasP21 levels in 5 (11.1%) of 45 cases. There was no overlap between the tumors displaying rasGAP and rasP21 alternations and a high proliferation index, as assessed by Ki-67 staining, except for one case of aggressive-growth variant. We conclude that rasGAP overexpression is associated with BCC tumorigenesis in a ras-independent manner, is not reflective of the proliferation status of the tumor, and is more characteristic of aggressive-growth BCCs.

Extensive necrotizing soft tissue infection of the perineum.

Synergistic necrotizing fasciitis of the penis and scrotum was first described by Fournier, and remains a rare, but life-threatening disease. The reported mortality rates in different series range between 22 and 60%. We present a study of 20 patients treated over a 9 year period by early aggressive excision. Four of the treated patients (20%) died. A high index of suspicion, combined with early radical surgical intervention, is the key to effective treatment. Delayed diagnosis and treatment were the primary factors responsible for death.

Epithelioid sarcoma of the penis.

A case of epithelioid sarcoma of the penis is reported with a review of the current treatment modalities. A new method of reconstructing the penis involved with malignancy is presented. Pertinent literature is cited. Cases of epithelioid sarcoma should be published to improve the understanding of the potential of different treatments available. This case represents the fifth epithelioid sarcoma of the penis reported in the literature.

Late results of surgery for congenital esotropia.

In a retrospective study we have evaluated the surgical outcome in 46 children with congenital esotropia who were followed up for at least two years. The results support the concept of early operation for congenital esotropia. Evaluation of the effect of simultaneous weakening of the inferior obliques proved statistically that this reduced the effect of recession-resection of the horizontal recti.

Late results of surgery for congenital esotropia.

In a retrospective study we evaluated the surgical outcome in 46 children with congenital estropia who were followed up for at least two years. The results support the concept of early operation for congenital estropia. Evaluation of the effect of simultaneous weakening of the inferior obliques proved statistically that this reduced the effect of recession-resection of the horizontal recti.

Alpha-adrenergic blocker for posthernioplasty urinary retention. Prevention and treatment.

In a prospective, randomized study, 102 patients over the age of 60 years underwent inguinal hernioplasty. We compared a group of 58 patients who received phenoxybenzamine hydrochloride with a control group of 44 patients. The phenolsulfonphthalein test was performed in all patients. Twenty-six (25.5%) of the 102 patients developed acute urinary retention after the hernioplasty; all of them were in the control group. All of these 26 patients had pathological phenolsulfonphthalein test. In 21 of these 26 patients, urinary retention disappeared within 48 hours following phenoxybenzamine administration.

Common bile duct stone caused by a foreign body.

Foreign bodies are very rare in the common bile duct. We report a patient with incomplete obstruction of the common duct, due to stone formation around an ingested fish bone.