Narrowband ultraviolet B three times per week is more effective in treating vitamin D deficiency than 1600 IU oral vitamin D3 per day: a randomized clinical trial.

BACKGROUND: It is known that narrowband ultraviolet B (NB-UVB) radiation and oral vitamin D(3) supplementation can both improve serum levels of vitamin D, expressed as 25-hydroxyvitamin D(3) [25(OH)D(3) ]. However, surprisingly few studies have compared the effects of the two interventions in treating vitamin D deficiency. OBJECTIVES: To compare the effect of NB-UVB exposure with oral vitamin D(3) supplementation on vitamin D levels in patients with vitamin D deficiency. METHODS: Seventy-three participants with vitamin D deficiency [25(OH)D(3) ≤ 25 nmol L(-1) ] were consecutively enrolled from February 2010 to May 2011, avoiding the summer period (June to September). The participants were randomized into two groups, one receiving full body NB-UVB exposure three times per week, the other receiving 1600 IU (40 µg) oral vitamin D(3) per day together with 1,000 mg calcium. Thirty-two participants completed the 6-week study period, 16 in each group. In both groups blood samples were obtained at baseline and after 3 and 6 weeks. RESULTS: We found a significantly greater increase in 25(OH)D(3) levels (mean) in the NB-UVB treated group (from 19·2 to 75 nmol L(-1) ) compared with the oral vitamin D(3) treated group (from 23·3 to 60·6 nmol L(-1) ) after 6 weeks of treatment (P = 0·02), accompanied by a significant decrease in parathyroid hormone for the whole group (from 5·3 to 4·2 pmol L(-1) , P = 0·028). CONCLUSIONS: Full body NB-UVB three times per week is more effective in treating vitamin D deficiency than prescription of a daily oral intake of 1600 IU (40 µg) vitamin D(3) .

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county.

Patient reported quality of care before vs. after the implementation of a diagnosis related groups (DRG) classification and payment system in one Swedish county. The purpose was to evaluate the effects of a diagnosis related groups (DRG)-intervention on the quality of care as perceived by patients at two surgical clinics in the County Council of Gävleborg, Sweden. The study was planned as a nonequivalent control groups design, but external factors turned it into a prospective longitudinal design. Changes in patient experiences of received care were evaluated for the period 1992-1996. Of the 40 included consecutive patients per year from each hospital, > 85% completed the questionnaire. The selection of patients was defined by diagnoses and surgical treatments, and by geographical area. The results demonstrated a decrease of the quality of care as seen from the patient perspective, especially with respect to treatment by staff. Previously stated DRG goals were partially fulfilled and the DRG-intervention was gradually implemented. Other presumed causal variables were: other reforms, restrained resources, quality assurance activities, organizational and structural changes within the county council. Further studies of the effects of health care reforms would yield more distinct conclusions, provided it would be possible to evaluate interventions prior to full-scale implementation.

Ultrasound investigation of port wine stains.

Congenital capillary malformation, or port wine stains (PWS), have been treated with the pulsed dye laser since the late 1980s. Some studies have shown better results when the malformation has been located on the lateral face, forehead, neck, trunk or shoulder and inferior results, with more treatments required, when it is located on the central face area, dermatome V2 or the extremities. The purpose of this study was to determine the depth of the lesion in various locations. A total of 55 patients with untreated PWS were investigated with a high-resolution 20 MHz ultrasound system. The mean maximum depth of all PWS that were measurable (45 out of 55) was 1.00 mm (+/- 0.50 SD), with a range of 0.2-3.7 mm. Lesions located on the forehead (1.26 +/- 0.44 mm) and on the medial face (1.23 +/- 0.65 mm), were deeper than lesions on the trunk and extremities. PWS involving areas that respond poorly to treatment were on average 0.14 mm deeper than PWS involving areas that responded well. The depth of the PWS, as determined with high-resolution ultrasound, seems to correlate only to some degree with the response to pulsed dye laser treatment. Since this treatment, with its superficial penetration, cannot reach the deeper vessels of a PWS, skin ultrasound could be a good complement in the prognostic investigation as well as for planning treatment.

Patients with port-wine stains and their psychosocial reactions after photothermolytic treatment.

BACKGROUND: Since the pulsed dye laser (PDL) was introduced in the late 1980s the question has been raised whether one should treat congenital capillary malformations, commonly called port-wine stains (PWSs), early or not. OBJECTIVE: There are pros and cons, but studies have mainly emphasized the clinical treatment results. The psychosocial importance of an early treatment needs also to be clarified. METHODS: This retrospective study includes 163 patients with PWS treated with the PDL until there was either total clearing or until there was no further improvement. When a period from a few months to 8 years had elapsed after the treatments, the patients were given a questionnaire, which had been developed in cooperation with a psychiatrist, in order to evaluate the psychosocial implications of the PWS and the consequences of treatment. RESULTS: . Eighty percent of the patients more than 7 years of age had not fully accepted their PWS with increasing age and 80% thought that their life would change for the better if their PWS could be eliminated. Eighty-five percent thought their PWS influenced their life in some negative way. Forty-five percent of the patients considered themselves to have a lower self-esteem than their own age group. The majority of the patients considered themselves negatively influenced by their PWS. Most psychosocial parameters, such as self-esteem, contact with the opposite sex, social relationships, school contacts, the need to cover their PWS with make-up or clothes, and meeting new people, improved significantly after PDL treatment. Older patients had higher negative scores than the younger ones, indicating the advantage of early treatment. Patients who were treated earlier with other methods producing less favorable results scored unfavorably compared to previously untreated patients. CONCLUSION: Patients with PWS treated at our clinic consider their psychosocial status to be improved after treatment. An early treatment seems to be favorable for these patients.

PUVA and cancer risk: the Swedish follow-up study.

There is concern about the long-term carcinogenic effects of psoralen and ultraviolet A radiation (PUVA) for treatment of skin disorders. Many authors have found an increased risk for cutaneous squamous cell carcinoma (SCC). Except in anecdotal reports, malignant melanoma had not been observed in patients treated with PUVA until recently. In the U.S.A., a 16-centre prospective study of 1380 patients showed for the first time that there might also be an increased risk for malignant melanoma in patients treated with high cumulative dosages of PUVA. We have therefore followed up the Swedish PUVA cohort until 1994. This cohort had previously been followed up until 1985. Information from 4799 Swedish patients (2343 men, 2456 women) who had received PUVA between 1974 and 1985 was linked to the compulsory Swedish Cancer Registry in order to identify individuals with cancer. The average follow-up period was 15.9 years for men and 16.2 for women. We did not find any increased risk for malignant melanoma in our total cohort of 4799 patients treated with PUVA or in a subcohort comprising 1867 patients followed for 15-21 years. For cutaneous SCC there was an increase in the risk: the relative risk was 5.6 (95% confidence interval, CI 4. 4-7.1) for men and 3.6 (95% CI 2.1-5.8) for women. Significant (P < 0.05) increases were also found in the incidence of respiratory cancer in men and women and of kidney cancer in women. In conclusion, we did not find any increased risk for malignant melanoma in our patients treated with high doses of PUVA and followed up for a long time. We confirm previous reports of an increase in the incidence of cutaneous SCC in patients treated with PUVA, and recommend that patients should be carefully selected for PUVA and rigorously followed up.

Potential psychological benefits from early treatment of port-wine stains in children.

There is a commonly held conception among referring doctors that very small children with congenital capillary malformations, so-called port-wine stains (PWS), should not be treated until they are older. Our experience leads us to believe that the flashlamp pulsed dye laser is a safe and effective treatment even for infants. We have not encountered any persistent pigmentation changes, post-treatment scarring or other adverse effects. It is important to quantify the psychological disabilities associated with this disorder to assess the need for and the benefits of treatment. Questionnaires were distributed to 259 patients and their families who visited our clinic because of their PWS. Patients who were on the waiting list for laser treatment, undergoing treatment or had completed their treatment received different questionnaires. The response rate was 89%. High emotional distress was encountered. During the age period 10-20 years, 73% (125 patients) were most disturbed by their PWS. That the PWS influenced their life negatively was experienced by 75% (171 patients), and 62% (106 patients) were convinced that their life would change radically if their PWS could be eliminated. Suffering from low self-esteem (in comparison with the same age group) was reported by 47% (87% patients). The PWS made their school life and education more difficult according to 28% (51 patients) of the sample. Of the families of patients, 76% (106 relatives) considered the patient to be negatively affected in some way by the PWS. After the laser treatment, all of these distress parameters were significantly relieved, together with a need to cover their PWS, their fear of going into conflict or quarrels, their social relationships, problems with the opposite sex, rage attacks, depressions and abnormal reactions from their peers. We believe there is potential psychological benefit in starting the treatments of PWS (including non-facial) at as early an age as possible.

Evaluation of port wine stains by laser Doppler perfusion imaging and reflectance photometry before and after pulsed dye laser treatment.

Treatment of choice for congenital capillary malformations of the port wine stain type is presently the pulsed dye laser. Although treatment results have usually been excellent or good, a few patients respond less well. Looking for a tool to predict and monitor the treatment we used laser Doppler perfusion imaging and reflectance photometry. Measurements with laser Doppler perfusion imaging were performed in 19 patients initially and after 1-3 treatments and with reflectance photometry initially and after 1-6 treatments. Before treatment, 15 of the patients had an increased bloodflow within the port wine stain in comparison with normal contralateral skin. After the laser treatments, 15 of 18 patients had decreased bloodflow within the lesion and all 18 had surrounding hyperemia. Reflectance photometry showed a successive increase in blanching and predicted within 6 weeks of the first treatment the eventual clinical result. The bloodflow, as measured with laser Doppler perfusion imaging, did not correlate well with the photometrically registered erythema. Reflectance photometry is a useful objective tool, which early in the treatment course indicates whether laser therapy will be successful. Laser Doppler perfusion imaging is less helpful in monitoring patients but may be of use in the study of port wine stain pathophysiology.

Can ultraviolet erythema be used to identify the basal cell carcinoma phenotype?

Since a prolonged duration of a strong UVB erythema has been suggested as a marker for propensity to develop skin cancer, we objectively followed the duration and intensity of erythemas induced by UVB and UVA radiation for 28 days in 18 patients with basal cell carcinoma (BCC), and in 15 healthy controls using reflectance spectrophotometry. The erythema index, defined as the difference in redness between UV-exposed skin and normal, adjacent skin on the lower abdomen, did not differ significantly between the two groups at 24 h, when the reaction was maximal, following a dose of 6 MED of UVB. Erythema values after 7 and 14 days were slightly higher in the BCC group, but this difference did not reach statistical significance. At day 7 some patients in the BCC group showed very strong erythemas. At days 21 and 28 the two groups had almost identical erythemal reactions. Following a standard dose of UVA of 100 J/cm2, patients with BCC and healthy controls both showed weak erythemal reactions, which declined somewhat over the study period. No significant differences in pigmentary response were noted between the BCC and the control group, neither following UVB nor UVA. Although individual patients with BCC deviate from the normal erythemal curve for UVB, the UVB response is not a suitable predictive instrument in screening patients with the basal cell carcinoma phenotype.

Reflectance spectrophotometry in the objective assessment of dye laser-treated port-wine stains.

At present, the treatment of choice for congenital capillary malformations of the port-wine stain type (PWS) is the flashlamp pulsed dye laser. Good results can be obtained in the majority of patients with this technique, but there is a group of poor responders. In the search for predictive tools to determine the therapeutic outcome, we have used a new photoelectric reflectance instrument. Sixty-six patients with PWS, mainly on the face, were treated with a pulsed dye laser during a 21-month period. Using a hand-held reflectance photometer, erythema indices were obtained for the PWS and normal skin. Based on these indices, a relative blanching effect could be calculated. The therapeutic result was judged to be excellent in 19, good in 20, fair in 14 and poor in 13 patients. There was a good correlation (r = 0.844) between the degree of blanching and the therapeutic result. In the 'excellent' category, an average blanching effect of 47% was present after the first treatment, and this increased to between 75 and 100% after successive treatments. In the 'poor' category, the blanching effect after one treatment averaged 14%, increasing to only 40% after up to six treatments. It thus seems to be possible to predict the outcome of therapy, which is of considerable help in treatment planning. Reflectance measurements, an objective estimate of blanching, correlate well with the clinical results, and are helpful in monitoring and predicting the therapeutic outcome in dye laser-treated PWS.

Hans Sølling: Danish pioneer neurosurgeon.

Hans Adolf Sølling (1879-1945), working completely on his own in the small town of Horsens, was Denmark's first neurosurgeon. Sølling was an admirable and talented man who performed major intracranial operations on more than 130 patients suffering from trigeminal neuralgia, as well as treating epilepsy, craniotrauma, brain tumors, glossopharyngeal neuralgia, and myelomeningoceles. Although not in the same league as Harvey Cushing (1869-1939), Vilhelm Magnus in Norway (1871-1929), and Herbert Olivecrona in Sweden (1891-1980), Sølling was a true Danish pioneer.

Quinine and quinidine photoproducts can be identical.

Quinine and its d-isomer quinidine can both cause contact allergy as well as photoallergy. Contact allergic cross-reactions between quinine and quinidine are uncommon. In allergic photosensitization the two isomers cross-react, suggesting the possibility that quinine and quinidine after UV exposure are converted to one or more common sensitizing photoproducts. Solutions of quinine and quinidine at 0.1% in ethanol 99.5% were exposed to UVA for 14 h (total dose 201.6 J/cm2). Using thin-layer chromatography, we identified 8 and 6 photoproducts from irradiated quinine and quinidine, respectively. Five of these photoproducts were seen in both chromatograms. An identical pattern with four photoproducts was found for both irradiated solutions when these were subjected to analysis in a high-performance liquid chromatography system. This study indicates that photoproducts from irradiated quinine and quinidine can be identical. This would explain the differences in the cross-reactivity pattern between contact and photocontact sensitization clinically.

Differences in phototoxic potency should be considered when tetracyclines are prescribed during summer-time. A study on doxycycline and lymecycline in human volunteers, using an objective method for recording erythema.

In order to test the phototoxic potency of the two tetracyclines most frequently prescribed in Sweden, a double-blind cross-over study using a double-dummy technique with doxycycline 0.1 g twice daily, lymecycline 0.6 g twice daily, and placebo, was performed in 15 healthy volunteers. Drugs were given for 3 consecutive days, and on the third day volunteers were tested with 25, 50, 75 and 100 J/cm2 of artificial long-wave ultraviolet radiation (UVA), and assessed 6 h later for erythematous photoreactions. Objective readings were made using skin reflectance spectrophotometry. All three substances were tested in each individual at weekly intervals. Within 50, 75 and 100 J/cm2 of UVA, lymecycline showed a slight increase in erythema compared with placebo, but this was not significant (50 and 100 J/cm2), or was of low significance (75 J/cm2). However, with the same doses, doxycycline showed a substantial increase in erythema compared with placebo, which was highly significant. We conclude that doxycycline has a higher phototoxic potency than lymecycline, and this is in agreement with earlier in vitro experimental data. We recommend that therapy with doxycycline is avoided during summer-time, and during holidays in a sunny climate.

Herbert Olivecrona: founder of Swedish neurosurgery.

Herbert Olivecrona (1891-1980) singlehandedly founded Swedish neurosurgery. At the International Congress in Neurology in Bern in August, 1931, Harvey Cushing invited the cream of the world's medical society to a private banquet. Among the 28 specially invited guests was Herbert Olivecrona. At 40 years old, Olivecrona took his seat with pioneers such as Otfrid Foerster, Percival Bailey, Hugh Cairns, Geoffrey Jefferson, and Sir Charles Sherrington. This suggests that Cushing was impressed by the Swedish aristocrat's didactic deeds when he visited the Serafimer Hospital in Stockholm 2 years earlier. During the mid-1920's, the radiologist Erik Lysholm greatly improved the technique of ventriculography and, challenged by Olivecrona, his diagnostic neuroradiology became of superior quality. In the early 1930's, utilizing technical innovations of his own, Lysholm became a master at demonstrating and localizing posterior fossa tumors, which Olivecrona then operated on. Olivecrona's clinic became the mecca to which many scholars, thirsting for more knowledge, went on a pilgrimage. The international reputation of the clinic was founded, not on epoch-making discoveries, but by the resolute and practical application of methods already launched elsewhere and the exemplary organization that Olivecrona had established in collaboration with Lysholm. In spite of hardships and primitive working conditions, the clinic at the Serafimer Hospital gradually developed into the ideal prototype for a modern neurosurgical department. Olivecrona trained many colorful personalities who later were to lay the foundation for neurosurgery in their home countries; these included Wilhelm Tönnis of Germany, Edvard Busch of Denmark, and Aarno Snellman of Finland. Olivecrona was a true pioneer who made major contributions in practically all fields of conventional neurosurgery.

Functional recovery after near complete traumatic deficit of the cervical cord lasting more than 24 h.

Two young men presented with a complete cervical cord deficit associated with bilateral C4-C5 dislocation and 11 mm encroachment (sagittal narrowing) of the spinal canal in one case and near complete cervical cord deficit due to a crush fracture of the C7 vertebral body with 9 mm axial compression and 50% antero-posterior encroachment of the canal in the other case. There was no improvement within the first 24 h. Both patients left the hospital walking after open surgical realignment and complete cord decompression.

Evaluation of port wine stain perfusion by laser Doppler imaging and thermography before and after argon laser treatment.

Thirteen patients with port wine stains (PWS) were treated with argon laser therapy. Before and at different points in time following treatment, skin blood perfusion and temperature were mapped with laser Doppler imaging and thermography. In nine patients no elevation in blood perfusion was observed in the PWS in comparison with the surrounding normal skin before treatment. In the remaining four patients a significantly (p less than 0.01) higher blood flow was recorded within the PWS. Immediately after treatment nine patients showed elevated perfusion within the PWS. During the first two days following treatment, all patients showed a gradually decreasing hyperperfusion in the borderline between the PWS lesion and surrounding skin. Immediately after treatment 10 patients had a significantly (p less than 0.01) higher temperature in the PWS than in normal skin. During the first 24 h following treatment, an elevated perfusion was in general accompanied by a tissue temperature increase. Three and a half months after argon laser treatment, three patients showed excellent clinical results with no remaining PWS spots or scarring. Two of these patients had had both elevated perfusion and temperature in the PWS prior to treatment.

Systemic quinine photosensitivity with photoepicutaneous cross-reactivity to quinidine.

A 75-year-old man developed an eczematous eruption on the face and dorsal aspects of the hands one July after 3 weeks' treatment with quinine, 0.25 g nightly, for nocturnal leg cramps. The photoreaction cleared within a week of quinine being stopped. UVA and UVB erythema threshold determinations, after the acute episode had subsided, were normal. A photopatch test was positive for irradiated quinine down to a concentration of 0.01% and for unirradiated quinine to 0.5%. The test with the isomer quinidine was positive only when irradiated, down to a concentration of 0.01%. Preirradiated samples of quinine and quinidine were negative. Whereas in contact allergy quinine and quinidine usually do not cross-react, after systemic photosensitization, the 2 isomers probably form a common photoproduct, accounting for the cross-reactivity.

Ultraviolet B irradiation inhibits the induction of photoallergy to systemically administered quinidine in the mouse.

In albino mice photosensitized to quinidine, 100 mg/kg by intraperitoneal injection, pretreatment of the induction area with ultraviolet B (UVB) on 3 consecutive days was shown to significantly reduce the inflammatory response when the mice were challenged at a distant site 1 week later. Mice controlled for phototoxicity did not react. The inhibition was dose-dependent within the UVB dose range tested (0.05-1.0 J/cm2 x 3), being almost complete with the highest doses. Inhibition, although somewhat less pronounced, was also seen when an area on the back, distant from the induction site, was preirradiated following a similar protocol. The reduced response at elicitation persisted when the time to challenge was increased up to 4 weeks. At 5 weeks, a second attempt to photosensitize the previously inhibited animals failed, suggesting that a state of tolerance had been acquired. The timing of the UV exposure in relation to the photoactive chemical is critically important in determining whether an exposure promotes or inhibits photoallergic sensitization.