Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy

The authors report the outcomes of patients with keloid scars treated with a protocol of extralesional excision and immediate single-fraction adjuvant radiotherapy. The design of the study was a retrospective analysis with up to 5-year outcome data. The setting was a single treatment team, University Teaching Hospital in London, United Kingdom. Participants (n = 80) were treated for 80 keloid scars (59 percent female patients, 76 percent nonwhite), and 44 percent of keloids were located on earlobes. For all patients, prior treatment without radiotherapy had failed. The salvage treatment reported in this article is combined extralesional excision and immediate postoperative external-beam radiotherapy. A 10-Gy dose of superficial 60-kV or 100-kV photon irradiation was given within 24 hours of the operation. The main outcome measure was freedom from recurrence of keloid scars. Results were that all keloid scars were controlled at 4-week follow-up. Probability of relapse at 1 year was 9 percent; at 5 years, probability of relapse was 16 percent. The earlobe showed no greater chance of relapse than other sites on the body. The authors' report shows that extralesional excision of keloid followed by early, single-fraction, postoperative radiotherapy is both simple and effective in preventing recurrence at excision sites.     

N-acetylcysteine for therapy-resistant tobacco use disorder: a pilot study

Abstract

Introduction

N-Acetylcysteine (NAC) may have efficacy in treating tobacco use disorder (TUD) by reducing craving and smoking reward. This study examines whether treatment with NAC may have a clinical efficacy in the treatment of TUD.

Methods

A 12-week double blind randomized controlled trial was conducted to compare the clinical efficacy of NAC 3 g/day versus placebo. We recruited 34 outpatients with therapy resistant TUD concurrently treated with smoking-focused group behavioral therapy. Participants had assessments of daily cigarette use (primary outcome), exhaled carbon monoxide (CO_EXH) (secondary outcome), and quit rates as defined by CO_EXH<6 ppm. Depression was measured with the Hamilton Depression Rating Scale (HDRS). Data were analyzed using conventional and modified intention-to-treat endpoint analyses.

Results

NAC treatment significantly reduced the daily number of cigarettes used (Δ mean±SD = ?10.9 ± 7.9 in the NAC-treated versus ?3.2 ± 6.1 in the placebo group) and CO_EXH (Δ mean± SD = ?10.4 ± 8.6 ppm in the NAC-treated versus ?1.5 ± 4.5 ppm in the placebo group); 47.1% of those treated with NAC versus 21.4% of placebo-treated patients were able to quit smoking as defined by CO_EXH<6 ppm. NAC treatment significantly reduced the HDRS score in patients with tobacco use disorder.

Conclusions

These data show that treatment with NAC may have a clinical efficacy in TUD. NAC combined with appropriate psychotherapy appears to be an efficient treatment option for TUD.     

Radioimmunodetection of melanoma: preliminary results of a prospective study

A prospective study to evaluate the clinical usefulness of radioimmunodetection of melanoma in clinical practice is ongoing at the National Cancer Institute of Milan, Italy. Technical conditions for the application of the method were previously reported. In this trial, 99mTc-labelled F(ab')2 fragments of the 225.28S monoclonal antibody were used against a high molecular weight melanoma associated antigen (HMW-MAA). Retrospective studies on radioimmunodetection of melanoma have already been made by our group and by other Centers in about 300 patients. This study concerns the evaluation of the regional extension of primary melanoma. 23 patients with 32 suspected lymphatic involvements of melanoma on the trunk and arms underwent immunoscintigraphy. No false positive results were observed; 3 false negatives, one corresponding to a micrometastasis, were noticed. Specificity corresponds to 100% and sensitivity to 78.6%.     

Prostaglandin-induced abortion and outcome of subsequent pregnancies: a prospective controlled study

We analysed a prospective series of 204 pregnancies occurring in 168 women after a prostaglandin-induced abortion. The mean (±standard error of mean) interval between abortion and first subsequent conception was 10·4 ± 0·6 months; no patient reported secondary subfertility.Fifty-five of the subsequent pregnancies were terminated, 23 during the second trimester, again using prostaglandins. Of the 149 pregnancies not terminated, 127 were delivered at term, and 19 spontaneously aborted, seven during the second trimester; there was one missed abortion and two ectopic pregnancies. Morbidity in the 127 term pregnancies was infrequent; spontaneous preterm labour occurred in three patients, and four singleton infants weighed less than 2500 g at birth. There was no apparent association between morbidity in the subsequent pregnancies and the period of gestation at the time of the previous abortion, route of prostaglandin administration, or need for post-abortion curettage.The results obtained overall were very similar to a control group of 612 women consecutively admitted for delivery or abortion to the Oxford obstetrical and gynaecological units. There was, however, an increased incidence of spontaneous abortion and placenta praevia after prostaglandin-induced abortion, and the multigravidae in that group had a longer average duration of labour than the control group. Sixty-five per cent of the post-abortion pregnancies were unplanned compared with 36% of the control group.     

Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months

Between 1988 and 2000, 378 cases of keloids were treated in the authors' department, and 147 keloids in 129 patients were selected for this study. Keloids that occurred at a different site in the same patient and keloids that recurred later at the same site were deemed to be different keloids. Those keloids were surgically removed, and the patients were treated postoperatively with 15-Gy electron-beam irradiation and followed for more than 18 months. The therapeutic outcomes were evaluated. Statistical analysis was performed using Fisher's exact probability test or chi-square test. Recurrence occurred in two sites on 14 earlobes (14.3 percent), in two sites on 12 necks (16.7 percent), in 22 sites on 51 anterior chest walls (43.1 percent), in 13 sites in 33 scapular regions (39.4 percent), in four sites on 15 upper limbs (26.7 percent), in four sites in 11 suprapubic regions (36.4 percent), and in one site on 11 lower limbs (9.1 percent). The overall recurrence rate was 32.7 percent. Analysis of the therapeutic outcomes showed that the recurrence rates in the sites with high stretch tension, such as the chest wall, and the scapular and suprapubic regions were statistically higher than in sites without high tension, such as the neck, earlobes, and lower limbs (41.1 percent versus 13.5 percent, p = 0.0017). The results suggested that keloid sites with a high risk of recurrence should be treated with escalated radiation doses and posttreatment self-management.     

Treatment of accidental hypothermia: a prospective clinical study.

A 15-year prospective study was carried out of 44 patients with accidental hypothermia (mean age 60 years) admitted to an intensive therapy unit. The lowest core temperature recorded in each patient ranged from 20.0 to 34.3 degrees C. The precipitating factors were poisoning (by drugs, alcohol, or coal gas) in 25 cases and various illnesses in 19. Rewarming was achieved in 42 patients by applying a radiant heat cradle over the torso, and in two patients by mediastinal irrigation with warmed fluids. Twelve patients died, but only two during the period of rewarming. Thus rewarming may be consistently and safely achieved irrespective of the cause of hypothermia, and normal body temperature may be regained as rapidly as is compatible with adequate tissue perfusion and oxygenation. Surface rewarming of the torso is perhaps the simplest technique available, but internal rewarming procedures may be desirable or essential in the presence of, for example, profound hypothermia, severe hypotension, or ventricular fibrillation. Mortality was attributable to underlying factors or disease and not to hypothermia.     

Impact of genotyping on outcome of prostatic biopsies: a multicenter prospective study

Single nucleotide polymorphisms (SNPs) have been associated with prostate cancer (PCa) risk and tumor aggressiveness in retrospective studies. To assess the value of genotyping in a clinical setting, we evaluated the correlation between three genotypes (rs1447295 and rs6983267[8q24] and rs4054823[17p12]) and prostatic biopsy outcome prospectively in a French population of Caucasian men. Five hundred ninety-eight patients with prostatic-specific antigen (PSA) >4 ng/mL or abnormal digital rectal examination (DRE) participated in this prospective, multicenter study. Age, familial history of PCa, body mass index (BMI), data of DRE, International Prostate Symptom Score (I-PSS) score, PSA value and prostatic volume were collected prospectively before prostatic biopsy. Correlation between genotypes and biopsy outcome (positive or negative) and Gleason score (≤6 or >6) were studied by univariate and multivariable analysis. rs1447295 and rs6983267 risk variants were found to be associated with the presence of PCa in univariate analysis. rs6983267 genotype remained significantly linked to a positive biopsy (odds ratio [OR] = 1.66, 95% confidence interval [CI]: 1.06-2.59, P = 0.026) in multivariable analysis, but rs1447295 genotype did not (OR = 1.47, 95% CI: 0.89-2.43, P = 0.13).When biopsy outcome was stratified according to Gleason score, risk variants of rs1447295 were associated with aggressive disease (Gleason score ≥7) in univariate and multivariable analysis (OR = 2.05 95% CI: 1.10-3.79, P = 0.023). rs6983267 GG genotype was not related to aggressiveness. The results did not reach significance concerning rs4054823 for any analysis. This inaugural prospective evaluation thus confirmed potential usefulness of genotyping PCa assessment. Ongoing clinical evaluation of larger panels of SNPs will detail the actual impact of genetic markers on clinical practice.     

No need for preoperative antiseptics in elective outpatient plastic surgical operations: a prospective study

The development of antisepsis in the late nineteenth and early twentieth centuries revolutionized health care. The time-honored technique of skin preparation is to scrub the entire operative area of the patient for 5 to 7 minutes with a germicidal detergent solution and then paint the region with an antimicrobial solution of either tincture of povidone-iodine (Betadine) or chlorhexidine. Although antiseptics result in lower colony counts on the skin, they have side effects and higher cost in relation to normal saline. The authors have prepared patients by showering the surgical site with soap and water and rinsing it with normal saline, in 905 cases of outpatient, clean-wound plastic surgery. In another 905 cases that served as the control group, the traditional method of preoperative shower and scrub with chlorhexidine or Betadine was used. In both groups, there was no incidence of wound infection.     

Sequential adjuvant hormone therapy in postmenopausal breast cancer: rationale and clinical results

For the past 15 years tamoxifen has been the standard adjuvant hormone therapy for women with early-stage breast cancer and estrogen receptor (ER)-positive tumors, irrespective of nodal status and other clinicopathological parameters. Recent studies provided evidence that the optimal duration of tamoxifen treatment is 5 years. Based on the positive clinical results obtained with the administration of aromatase inhibitors (AIs) in the metastatic setting, several controlled clinical trials have evaluated the efficacy and side effects of AIs versus standard tamoxifen also as adjuvant therapy in postmenopausal breast cancer patients. The results of the above studies, suggest a therapeutic advantage of AIs over tamoxifen with regard to relapse-free survival and the risk of metachronous contralateral breast cancer. We review the rationale and the available clinical data on initial or sequential hormone treatment with AIs and we propose a novel scenario for possible therapeutic strategies based on the clinicopathological characteristics of the patients and on the biology of each single tumor.     

Causes of atypical pneumonia: results of a 1-year prospective study.

In a protocol study of cases of atypical pneumonia over a 1-year period an etiologic agent was established in 16 cases: Legionella pneumophila in 8, Coxiella burnetii in 3, Chlamydia trachomatis in 2, Mycoplasma pneumoniae in 1, para-influenza 3 virus in 1 and cytomegalovirus in 1. In the remaining 11 cases no agent was identified; the illnesses in these cases tended to be less severe. The pneumonia took much longer to resolve in the patients with Legionnaires'' disease than in all the other patients (mean interval from onset of symptoms to clearing of the chest roentgenogram: 69 days v. an average of 16 days). However, the length of stay in hospital was similar for the three groups: those with Legionnaires'' disease, those with atypical pneumonia of unknown cause and those with atypical pneumonia of various other established causes. L. pneumophila infection may explain a proportion of atypical pneumonias that previously could not be diagnosed, although in this series the cause of 41% of the pneumonias remained unexplained.     

False positive results of tests for syphilis and outcome of pregnancy: a retrospective case-control study.

In a retrospective case-control study 64 women yielding a false positive result to a test for syphilis in pregnancy were compared with 128 controls individually matched for age, parity, hospital of delivery, and year of delivery. There were significantly more unsuccessful pregnancies, mainly spontaneous abortions during the first and second trimesters, among women with persistent false positive results. There was no significant difference between groups in the mean birth weights of liveborn infants. The antibodies responsible for the false positive result may indicate the presence of an immunological disturbance. Women who give a false positive result should be carefully managed throughout their pregnancy.     

Pregnancy outcome after gestational exposure to metronidazole: a prospective controlled cohort study

BACKGROUND: Metronidazole is an important antibacterial agent commonly used in women of reproductive age. Its use in pregnancy is a reason for concern for women and their health care providers. The objective was to examine the fetal safety of metronidazole. METHODS: The Israeli Teratogen Information Service prospectively collected and followed up 228 women exposed to metronidazole in pregnancy, 86.2% of whom with first-trimester exposure. Pregnancy outcome was compared with that of a control group, who were counseled during the same period for nonteratogenic exposure. RESULTS: There was no difference in the rate of major malformations between the groups (3/190; 1.6% [metronidazole] vs. 8/575; 1.4% [control], P = 0.739). The rate of major malformations did not differ between the groups even after including elective terminations of pregnancy due to prenatally diagnosed malformations (5/192; 2.6% [metronidazole] vs. 12/579; 2.1% [control], P = 0.777). A reduced neonatal birth weight was found in the metronidazole group compared with controls without significant differences in the rate of prematurity or in gestational age at delivery. The mean birth weight was lower in the metronidazole group when comparing the subgroup of term infants. CONCLUSIONS: This study confirms that metronidazole does not represent a major teratogenic risk in humans when used in the recommended doses.