New and emerging therapies for diseases of the oral cavity.

It is obvious from the review of the literature that most treatments for oral diseases such as lichen planus, pemphigoid, and pemphigus are based on case reports, anecdotes, and small uncontrolled studies. Efforts must be made to perform more controlled studies to evaluate the efficacy of new treatments. Small numbers of patients at each site and multiple-drug therapy make this task difficult. Dermatologists should familiarize themselves with the newer immunosuppressive agents available. Use of these drugs requires knowledge of their pharmacokinetics and potential side effects, so that they may be used effectively and safely. Relatively low doses of azathioprine, cyclophosphamide, and cyclosporine should then be added to the dermatologist's armamentarium for the treatment of severe or recalcitrant diseases. Old drugs are resurfacing with new (but often off-label) uses as the underlying mechanisms of disease become understood. Thalidomide and mycophenolate mofetil are two examples of promising drugs for the future of dermatology.

Perforations of the esophagus from gunshot wounds.

Fifteen cases of gunshot wounds of the esophagus seen between the years 1970 and 1978 were reviewed, eight involving the cervical esophagus and seven involving the thoracic portion. Most common symptoms were pain, neck tenderness, dyspnea, and dysphagia. Signs observed were subcutaneous emphysema, crepitations, fever, and leukocytosis. Plain X-rays showed pneumomediastinum, hydrothorax, and pneumothorax. Perforations were confirmed by barium studies in 12 patients. Injuries in the cervical portion were treated by prompt exploration, closure of the defect, and drainage. There were no deaths in this group. Thoracic injuries were treated by prompt thoracotomy except in one patient, for whom the diagnosis was not made until 22 hours after the injury; his was the only death in this series. Because of the extensive tissue involvement in gunshot wounds, primary repairs of thoracic esophageal perforations have a high incidence of failure. Defunctionalization of the esophagus, through ligation of the distal esophagus, gastrostomy, and cervical esophagostomy, has provided a safer method. Use of a double strand of absorbable Dexon to ligate the distal esophagus made a second thoracotomy for removal of the ligature unnecessary. We have adopted routine use of hyperalimentation, avoiding the need for feeding jejunostomy.

Esophagogastrostomy in continuity for carcinoma of the esophagus. Its use for unresectable tumors of the lower third of the esophagus and cardia.

Esophagogastrostomy in continuity without removal of the tumor was performed on six patients with carcinoma of the lower third of the esophagus and cardia found to be unresectable at the time of surgery. There was no operative morbidity or mortality. Satisfactory palliation, with restoration of the swallowing mechanism, was achieved in all six cases. Average survival time after surgery was 7 1/2 months. This compares satisfactorily with other palliative procedures for far-advanced tumors in this area.

Infected prosthetic grafts. Local therapy with graft preservation.

Three cases of infected vascular prosthesis in the groin were treated successfully with antibiotics, local debridement, and continuous irrigation of the area with the appropriate antibiotic solution. We describe a system developed to permit steady instillation of antibiotic solution and complete drainage by suction to remove serous and necrotic material. In selected cases of infected vascular grafts, when they have not thrombosed, aggressive local and systemic therapy may control the infection and permit salvage of the prosthesis.

Parasitic, amoeboid dinoflagellates.

SEXUAL reproduction has so far been unknown among the Dinococcales, unicellular brown algae belonging to the Dinophyceae (dinoflagellates). As we report here, however, the life cycles of two members of this group, Stylodinium sphaera and Cystodinedria inermis, include a parasitic amoeboid stage which brings about vegetative reproduction and also possibly sexual reproduction. We believe that the two amoeboid forms have previously been identified mistakenly as a separate taxon of protozoon.

Extraluminal or intraluminal inferior vena cava occlusion in pulmonary embolism.

Twenty-five cases of extraluminal and 47 of intraluminal inferior vena caval (IVC) occlusion for management of pulmonary embolism were reviewed. A comparison of results obtained with both methods suggests that the IVC umbrella filter provides the safer, more reliable means of IVC interruption in patients whose condition fulfills the criteria for caval occlusion. The simplicity of this technique and the fact that it can be performed under local anesthesia justify its consideration as the procedure of choice for IVC occlusion and permit its use in severely ill patients. On the basis of our positive findings, we now recommend that extraluminal occlusion be reserved for patients in whom insertion of the IVC umbrella is technically impossible.

Gunshot wounds of the esophagus.

During a 4 year period between 1970 and 1974 there were eleven esophageal gunshot wounds representing 52 per cent of the total esophageal perforations. The increased incidence of esophageal gunshot wounds reflects the higher rate of civilian gunshot injuries. There were six perforations in the cervical portion of the esophagus and five in the thoracic portion, with three located above the aortic arch, one in the midesophagus, and one in the lower third. Symptoms are less diagnostic than in esophageal perforations from other causes because the gunshot wound tends to mask the complaints related to mediastinitis. The signs are similar. In 9 patients free air was present in the neck or mediastinum and in 10 patients the diagnosis was confirmed by barium swallow. Of the 2 patients without free air, one had a lateral thoracic wound and esophageal injury was not suspected; the diagnosis was made by drainage of oral feeding through a thoracostomy and confirmed by barium swallow. In the other patient the perforation was found during surgery for hemothorax. Primary repair with drainage was done in the group with cervical injuries. All survived with no serious complications. In the group with thoracic injuries, fistulas developed in 2 of 3 patients who had primary repair with drainage. Two patients with extensive injuries of the esophagus treated by defunctionalization did well but required a second procedure. It is concluded that gunshot wounds of the cervical esophagus, if treated promptly by suture and drainage, will do well. Thoracic injuries represent a more difficult problem and it is suggested that defunctionalization of the esophagus is the safest procedure, particularly if damage is extensive.

Bypass of thoracic aorta using axillofemoral shunt.

A left thoracotomy was performed and the thoracic aorta was occluded for 1 hr. in 7 dogs following placement of an 8 mm. right axillary-to-femoral artery shunt. Postop serial blood urea nitrogen and creatinine levels showed no significant changes and pathological examination of the kidneys at 2 weeks showed no abnormalities. Neurological deficits were not observed, suggesting that an axillary-to-femoral bypass will maintain adequate perfusion to the lower body during cross-clamping of the thoracic aorta.