The practicalities of photodynamic therapy in acne vulgaris.

A staple clinical skill in a dermatologist's repertoire is the ability to treat acne vulgaris effectively. Light-based therapies such as photodynamic therapy (PDT) widen the therapeutic options available for acne. Numerous review articles have agreed on the answer to core questions such as: 'Does PDT work?' and 'Which acne lesions respond best to PDT?' They conclude that PDT is especially useful in inflammatory acne and may be superior to light therapy alone. This literature review seeks to offer guidance regarding treatment-specific queries about the photosensitizer, route of administration, treatment intervals, light sources and patient selection. Ovid Medline, PubMed and EMBASE database searches were executed between January 2007 and March 2008. Due to the scarcity of data, all five randomized trials, four of which were at least investigator blinded and controlled, 12 open clinical studies, two case reports and two abstracts published in English were considered. Four hundred and nineteen patients were recruited. As the quality of the data was suboptimal in a significant number of articles, the conclusions are drawn in very broad strokes: topical short-contact (90 min or less) 5-aminolaevulinic acid or methyl aminolaevulinate using a noncoherent light source at 2-4-week intervals for a total of two to four treatments produces the greatest clinical effect. Papulopustular acne is more responsive and all Fitzpatrick skin types are eligible. However, patients with skin types I-III have a reduced risk of postinflammatory hyperpigmentation seen in darker skin types. These treatment parameters demonstrate a good side-effect profile resulting in acne remission for at least 3 months to a year in a relatively cost-effective manner. Well-designed nonsplit-face randomized controlled trials would offer further guidance, especially for queries surrounding the light source and illumination schemes.

Human African trypanosomiasis: diagnosis, relapse and survival after severe melarsoprol-induced encephalopathy.

We describe a case of human African trypanosomiasis with a number of unusual features. The clinical presentation was subacute, but the infection was shown to be due to Trypanosoma brucei rhodesiense. The infection relapsed twice following treatment and the patient developed a melarsoprol-associated encephalopathy. Magnetic resonance imaging (MRI) findings were suggestive of microhaemorrhages, well described in autopsy studies of encephalopathy but never before shown on MRI. The patient survived severe encephalopathy with a locked-in syndrome. Our decision to provide ongoing life support may be useful to physicians treating similar cases in a setting where intensive care facilities are available.

Evidence for diverse oxidations in the catabolism of toluene by Rhodococcus rhodochrous strain OFS.

Rhodococcus rhodochrous strain OFS grew on toluene as a sole source of carbon and energy with a maximum growth rate of 0.011 h(-1). Initial reaction products were extracted, derivatized and identified by GC-MS. Oxygen consumption studies indicated that OFS grown on an aliphatic substrate required an induction period before oxidizing toluene. OFS grown on toluene transformed an array of aromatic ground water pollutants including styrene, ethylbenzene and chlorobenzene. Products of these transformations were identified. The sole product of chlorobenzene biotransformation was 4-chlorophenol. Products from toluene oxidation included 3- and 4-methylcatechol as well as benzyl alcohol, p-cresol and cis-toluene dihydrodiol. The identification of these and the products of other aromatic substrate conversions affirm that oxidation occurred on the functional group as well as directly on the aromatic nucleus.

Possible Contribution of Prostaglandin E2 to the antiproliferative effect of phosphodiesterase 4 inhibitors in human mononuclear cells.

Phosphodiesterase (PDE) 4, mixed PDE3/4, and non-selective PDE inhibitors have been shown to inhibit the proliferation of human peripheral blood mononuclear cells (HPBM). The aim of the present study was to examine whether endogenous prostaglandins, in particular prostaglandin E2 (PGE2), are involved in mediating the antiproliferative actions of PDE inhibitors, by comparing their effects with drugs which elevate or mimic adenosine 3',5'-cyclic monophosphate (cAMP) through mechanisms other than PDE inhibition. Indomethacin significantly reduced the antiproliferative effects of the PDE4 inhibitors rolipram and CDP840 and the mixed PDE3/4 inhibitor zardaverine, increasing the IC50 values from 2.51 microM to >10 microM, 0.81 microM to 2.82 microM, and 1.58 microM to 4.82 microM, respectively (P < 0.05), but did not alter the effects of theophylline. Forskolin, PGE2, and dibutyryl cAMP also inhibited HPBM proliferation, and in the presence of indomethacin the effects of forskolin and dibutyryl cAMP were reduced (although this was not significant), whereas PGE2 was not affected. Rolipram, CDP840, zardaverine, and dibutyryl cAMP all produced a concentration-related increase in PGE2 production (P < 0.05, ANOVA), but theophylline significantly increased PGE2 production only at the highest concentration examined, 1000 microM. The ability of indomethacin to reduce the antiproliferative effects of rolipram, CDP840, and zardaverine, together with the fact that these drugs can stimulate PGE2 production, suggests that their antiproliferative actions may be mediated in part by stimulation of endogenous PGE2 production. In contrast, it appears that endogenous PGE2 is not critical for the antiproliferative actions of theophylline, forskolin, and dibutyryl cAMP in HPBM. These results establish the importance of co-ordinated regulation of the cAMP phosphodiesterase and cyclooxygenase-PGE2 systems for the regulation of lymphocyte function in man, and have clinical implications for therapeutic approaches to diseases associated with lymphocyte dysregulation.

Hypocholesterolaemic effects of dietary propionate: studies in whole animals and perfused rat liver.

In adult male rats fed a non-purified diet supplemented with 5% sodium propionate, plasma cholesterol concentrations were significantly depressed. Although liver cholesterol was increased by feeding propionate, rates of hepatic cholesterol and fatty acid synthesis were unchanged. Tissue concentrations and rates of synthesis of cholesterol were also unaffected by dietary propionate in stomach, small intestine and caecum. Concentrations of propionate in hepatic portal venous plasma were raised by feeding the supplemented diet but the increase was low in comparison to the dietary intake. Examination of the gut contents revealed concentrations of total volatile fatty acids (VFA) of 19 mumol/ml in the stomach contents of control rats and 148 mumol/ml (of which propionate contributed 116 mumol/ml) in those fed the supplemented diet. Duodenal and ileal concentrations of VFA were very low and were only slightly raised in the propionate-fed rats while caecal VFA were the same in both groups with a combined mean of 159 mumol/ml. These data indicate that in the rat, the absorption of dietary propionate appears to occur in the stomach. In pigs fed a standard ration hepatic portal venous VFA remained low for the first 4 h after feeding but then rose with the onset of large bowel fermentation. Feeding the diet supplemented with propionate caused hepatic portal venous plasma concentrations to rise by approximately 0.4 mumol/ml. This increase was apparent 30 min after feeding and was sustained for 3 h but subsequently there was no difference to controls. As in the rat, the absorption of dietary propionate appeared to occur in the upper gastrointestinal tract. The transport of propionate via the porcine hepatic portal vein also appeared insufficient to account for the dietary intake and suggests metabolism of the acid by the upper gastrointestinal tract. Further studies with perfused livers from fed rats indicated that propionate at a concentration of 1 mumol/ml did not alter cholesterol synthesis but that inhibition occurred at 18 mumol of propionate/ml. It appears that a redistribution of cholesterol from the plasma to the liver, rather than inhibition of hepatic and intestinal cholesterol synthesis, is responsible for the hypocholesterolaemic effects of dietary propionate. Because the absorption and transport of dietary propionate appears to follow a time course which differs considerably to that of the acid produced by the large bowel microflora, we conclude also that VFA produced by such fermentation would not seem to be responsible for the hypocholesterolaemic effects of certain water-soluble plant fibres.

Effects of wheat bran and porridge oats on hepatic portal venous volatile fatty acids in the pig.

Adult male pigs (40-60 kg of body weight) of the Kangaroo Island strain were surgically implanted with chronic indwelling hepatic portal venous cannulae. After a 24-hour fast the animals were given meals containing 500 g of either wheat bran or porridge oats and 200 g of sucrose and 2 litres of milk. With both cereal preparations plasma volatile fatty acids rose in the hepatic portal vein but the increase was significantly greater with wheat bran. Omission of sucrose and milk did not alter the response to porridge oats but diminished the response to wheat bran. These changes in plasma volatile fatty acids were unaffected by prior cooking of the cereals with hot water. With all test meals acetate and propionate were the major acids found, with butyrate contributing less than 8% of the total. This compositional profile was also found when the pigs were fed a commercial ration. The absence of butyrate differed from observations in the rat and reflected low concentrations of this acid in large bowel digesta. The difference in the response of the concentration of volatile fatty acids to feeding porridge oats and wheat bran in the pig was also the reverse of that found in the rat. These species differences may be of significance in relation to the choice of animal models for human fibre metabolism.

Disseminated histoplasmosis associated with the acquired immune deficiency syndrome.

Disseminated histoplasmosis developed in a previously healthy man as the initial manifestation of the acquired immune deficiency syndrome. Following apparently successful therapy with intravenous amphotericin B, he presented two months later with a subacute pneumonitis syndrome diagnosed by bronchoscopy as Pneumocystis carinii pneumonia. He showed response to intravenous trimethoprim/sulfamethoxazole with resolution of his symptoms and clearing of chest radiographic findings. While he was receiving antibiotics, oral candidiasis developed and has persisted for more than two months despite topical therapy and discontinuation of all antibiotics.