Approaches to repigmentation of vitiligo skin: new treatment with ultrasonic abrasion,seed-grafting and psoralen plus ultraviolet A therapy

Vitiligo vulgaris is a common disease throughout the world although its pathogenesis is not yet known. The most frequent treatment used for vitiligo is PUVA (psoralen plus ultraviolet A) and topical steroids but against stable refractory vitiligo, various other surgical techniques have been developed such as autografting, epidermal grafting with suction blisters, epithelial sheet grafting, and transplantation of cultured melanocytes. We have discovered a new method using ultrasonic abrasion, seed-grafting and PUVA therapy. The ultrasonic surgical aspirator abrades only the epidermis of recipient sites. This easily and safely removes only the epidermis, even on spotty lesions or intricate regions which are difficult to remove using a conventional motor-driven grinder or liquid nitrogen. Epidermal seed-grafting can cover more area than sheet-grafting, and subsequent PUVA treatment can enlarge the area of pigmentation with coalescence of adjacent grafts. In this article, we provide a general overview of the current surgical therapies including our method for treating stable refractory vitiligo.     

Approaches to Repigmentation of Vitiligo Skin: New Treatment with Ultrasonic Abrasion,Seed‐Grafting and Psoralen Plus Ultraviolet A Therapy

Vitiligo vulgaris is a common disease throughout the world although its pathogenesis is not yet known. The most frequent treatment used for vitiligo is PUVA (psoralen plus ultraviolet A) and topical steroids but against stable refractory vitiligo, various other surgical techniques have been developed such as autografting, epidermal grafting with suction blisters, epithelial sheet grafting, and transplantation of cultured melanocytes. We have discovered a new method using ultrasonic abrasion, seed‐grafting and PUVA therapy. The ultrasonic surgical aspirator abrades only the epidermis of recipient sites. This easily and safely removes only the epidermis, even on spotty lesions or intricate regions which are difficult to remove using a conventional motor‐driven grinder or liquid nitrogen. Epidermal seed‐grafting can cover more area than sheet‐grafting, and subsequent PUVA treatment can enlarge the area of pigmentation with coalescence of adjacent grafts. In this article, we provide a general overview of the current surgical therapies including our method for treating stable refractory vitiligo.     

Techniques of aortic valve repair

Similar to mitral repair, newer methods of aortic valve reconstruction are achieving excellent outcomes with an 85% to 90% freedom from valve-related complications at 10 years. The goal of this review is to illustrate these newer and more stable techniques of aortic valve repair. Most patients with aortic insufficiency from either trileaflet or bicuspid aortic valves are candidates for repair, in addition to selected patients with mixed aortic stenosis/insufficiency and aortic root aneurysms. Initially, aggressive commissural annuloplasty is performed to reduce measured valve diameter to 19 to 21 mm. Leaflet prolapse is corrected with plication stitches placed in the free edge of each leaflet adjacent to the Nodulus Arantius. In this regard, the leaflet free edge functions as the chorda tendinea of the aortic valve, and shortening with plication stitches raises the leaflet to a proper "effective height." Leaflet defects are augmented with gluteraldehyde-fixed autologous pericardium, and mild-to-moderate strategically placed spicules of calcium are removed with the cavitron ultrasonic surgical aspirator. Using these methods, most insufficient aortic valves, and many with mixed lesions, can be satisfactorily repaired. Six cases are illustrated in this review, spanning the spectrum of pathologies from annular dilatation without leaflet defects, to standard congenital bicuspid valve with prolapse, to trileaflet prolapse, to unusual bicuspid pathology with calcification, to a moderately calcified trileaflet valve with mixed lesions, and to aortic root aneurysms with severe aortic insufficiency. All valves were repaired using the techniques described above with trivial residual leak and minimal gradients. All repairs have been followed with yearly echocardiography, and valve reconstruction with these methods is now quite stable with excellent late outcomes. Most insufficient aortic valves now can undergo stable repair with minimal late valve-related complications. Greater application of aortic valve repair seems indicated.     

Histopathological Changes and Clinical Responses of Buruli Ulcer Plaque Lesions during Chemotherapy: A Role for Surgical Removal of Necrotic Tissue?

Background

Buruli ulcer (BU) caused by Mycobacterium ulcerans is a necrotizing skin disease usually starting with a subcutaneous nodule or plaque, which may ulcerate and progress, if untreated, over months and years. During the currently recommended antibiotic treatment with rifampicin/streptomycin plaque lesions tend to ulcerate, often associated with retarded wound healing and prolonged hospital stays.

Methodology/Principal Findings

Included in this study were twelve laboratory reconfirmed, HIV negative BU patients presenting with plaque lesions at the CDTUB in Allada, Benin. Punch biopsies for histopathological and immunohistochemical analysis were taken before start of treatment and after four to five weeks of treatment. Where excision or wound debridement was clinically indicated, the removed tissue was also analyzed. Based on clinical judgment, nine of the twelve patients enrolled in this study received limited surgical excision seven to 39 days after completion of chemotherapy, followed by skin grafting. Lesions of three patients healed without further intervention. Before treatment, plaque lesions were characterized by a destroyed subcutis with extensive necrosis without major signs of infiltration. After completion of antibiotic treatment partial infiltration of the affected tissue was observed, but large necrotic areas remained unchanged.

Conclusion/Significance

Our histopathological analyses show that ulceration of plaque lesions during antibiotic treatment do not represent a failure to respond to antimycobacterial treatment. Based on our results we suggest formal testing in a controlled clinical trial setting whether limited surgical excision of necrotic tissue favours wound healing and can reduce the duration of hospital stays.     

Treatment of Malignant Pheochromocytoma

Pheochromocytoma is a tumor derived from chromaffin tissue, which secretes catecholamines. Today, about 90 percent of patients with this tumor are cured by surgical procedures. In 8 to 15 percent of patients with this tumor there is unresectable, recurrent or metastatic disease, which causes significant morbidity and mortality. The natural history of metastatic disease includes long-term survivors; many, however, die early of disseminated disease. The most common site of metastatic lesions is the skeleton. Palliation for these lesions can often be achieved with the use of radiation therapy. Other sites are, in general, less responsive to radiation therapy. Chemotherapy has been used in combination with radiation therapy, but the results generally have been disappointing. Chemotherapy with doxorubicin hydrochloride and cyclophosphamide in combination with radiation therapy has provided good palliation for skeletal disease for about five months, when disease progression was again noted. Further information is needed concerning the optimal chemotherapeutic treatment of this unusual tumor.     

Arsenic concentration in the urine of patients with Blackfoot disease and Bowen’s disease

Extensive epidemiological study implicates that high arsenic content in artesian well water is the causal factor responsible for Blackfoot disease. We determine the arsenic concentration in urine samples of patients with Blackfoot and Bowen’s diseases and examine whether there exists any discrepancy of urinary arsenic concentrations among patients and the normal population. The analyses were made by hydride atomic absorption spectrophotometry (AAS) and the analytical reliability of the method was checked with a standard urine sample (ORTHO Bi-Level Urine Metal Control). The results show that the mean urinary arsenic concentration in 100 healthy adults is 63.4±29.7 μg/L, and those means for 23 and 11 patients with Blackfoot disease and Bowen’s disease are 75.7±39.1 μg/L (P vs controls >0.05) and 201±58 μg/L (P vs controls <0.001), respectively. From the analytical results obtained, we cannot conclude that urinary arsenic is associated with Blackfoot disease, as was disclosed from the epidemiological studies. However, urinary arsenic concentrations are possibly very closely associated with Bowen’s disease.     

甲状腺结节数对钙化甲状腺病变良恶性的鉴别价值

目的:通过甲状腺病变术前超声声像图与术后病理间的对照,分析结节单发或多发在鉴别伴钙化甲状腺病变良恶性中的意义。方法:回顾性分析我院2010年1月至2013年12月收治的218例甲状腺病变患者的临床资料,将患者术前超声声像图与术后病理结果进行对比。结果:术前超声探及甲状腺单发结节伴钙化其术后病理恶性比例显著高于多发结节伴钙化,差异具有统计学意义(P0.05);多发结节伴钙化其术后病理恶性比例显著高于多发结节不伴钙化,差异具有统计学意义(P0.05)。结论:术前超声探及甲状腺单发结节伴钙化其术后病理恶性比例较高,应积极手术治疗,多发结节伴钙化因其术后病理恶性病理较低,不宜作为手术治疗甲状腺病变的绝对指征。     

New diagnostic and therapeutic tools in stereotaxy

A definitive pathoanatomic diagnosis was achieved in 14 biopsies of deep cerebral tumors in which the Laitinen CT adapter was utilized. In 5 patients, a third-ventricular colloid cyst was aspirated or resected by stereotactic endoscopy, with excellent results after a mean follow-up time of 2.5 years. Several instruments, including a diagnostic ultrasound probe, an ultrasonic aspirator, a combination laser and an endoscope can be used stereotactically when mounted on a special instrument carrier. Integration of the Laitinen stereotactic device and the CT adapter was developed to allow noninvasive stereotactic radiotherapy in a conventional fractionation schedule by a standard linear accelerator. Technical experiences using this radiosurgical system in over 30 sessions for treating inoperable cerebral arteriovenous malformations are promising, but the follow-up time is too short for evaluating the clinical effect.     

Fine Needle Aspiration Cytology of the Breast: Factors Affecting Sensitivity

At Northampton General Hospital a pathologist takes, stains and immediately reports aspirates at a fine needle aspiration clinic which is run in conjunction with a busy surgical breast clinic. the effect of various factors on the sensitivity of the technique have been quantified. Small tumour size, certain types of tumour and lesions difficult to palpate are causes of reduced sensitivity. Acellular samples had little effect on sensitivity. In this clinic trainee aspirators achieved good results early in their experience. After one year each had improved to the level of an experienced aspirator.     

CEREBRAL ANGIOGRAPHY—Its Use in Acute Head Injuries and Undiagnosed Coma

One of the major factors in treating a patient with acute alteration of consciousness is to determine if progressive intracranial hemorrhage is present. Similar problems are encountered in cases of cerebrovascular disease where increasingly effective medical and surgical methods of treatment are available. Progressive cerebral thrombosis can be arrested by anticoagulants, intracranial hemorrhage can be controlled and atheromatous occlusion of a major artery can be corrected. Intracranial mass lesions can be detected when the history is not available or is misleading.Cerebral angiography is a relatively safe diagnostic test that is certainly preferable to delayed or haphazard treatment when an exact diagnosis is uncertain in an unconscious patient.     

绿洲荒漠过渡带风况对波文比和蒸散发的影响

波文比-能量平衡法是目前蒸散发研究常用的方法之一。在利用波文比-能量平衡法对荒漠地区,尤其对绿洲荒漠过渡带的蒸散发进行研究时,发现有波文比波动大、蒸散发结果准确性不高等问题。如何提高波文比-能量平衡法在绿洲荒漠过渡带的准确性成为荒漠干旱区精确研究水分收支急需解决的问题。在以前的研究基础上,发现绿洲荒漠过渡带的不同风况对波文比有不同影响,这可能是造成波文比-能量平衡法在绿洲荒漠过渡带精度不高的主要原因。为了证明这个假设,于2010—2012年在西北民勤绿洲荒漠过渡带进行了野外连续观测,观测了不同风况条件下波文比、不同高度的温度差、湿度差以及蒸散发的变化规律,分析了它们的特征及其影响因素。结果表明,研究区观测期内波文比值在-17.3—16.2范围内变化,波动较大,呈"U"型变化,生长季中期波文比值低于初期和末期;在无风天气,绿洲荒漠过渡带温度、湿度梯度不受水平气流的影响,波文比波动小,异常值少,波文比方法测算出的蒸散量较为准确,能够代表实际蒸散量,所测得民勤绿洲荒漠过渡带波文比日均值为0.07,日蒸散量为1.6mm/d;在绿洲风和荒漠风天气,绿洲荒漠过渡带空气温度、湿度结构发生明显改变,波文比波动大,不同风况使得大气处于逆温或逆湿的状态,波文比-能量平衡法所测得的蒸散量负值增多,适用性降低。因而在应用波文比-能量平衡法估算绿洲荒漠过渡带的蒸散发时应该选择合适的天气和观测点,避开风况对观测结果的影响。     

Medical Grand Rounds: refractory hypertension and renal insufficiency in a patient with renal artery stenosis.

Renal artery stenosis has become increasingly common as a cause of refractory hypertension and renal insufficiency. There is a high prevalence of bilateral disease and the lesions tend to progress over time. Newer, less invasive, imaging modalities such as doppler ultrasound, magnetic resonance angiography, and spiral CT scanning are evolving technologies in the diagnosis of renal artery stenosis. Advances in surgical technique, particularly the development of extra-anatomical procedures such as spleno-renal and hepato-renal by pass, have significantly lowered surgical morbidity and mortality and provides revascularization options for patients with complex vascular disease that would previously not have been considered because of their high surgical risk. Improvements in angioplasty technique and the use of stents are broadening the types of lesions that can be successfully approached with these techniques and may be particularly helpful for patients with more severe cardiac or cerebrovascular disease. The benefits of revascularization may be even greater for preservation of renal function than for control of blood pressure in properly selected patients. It is difficult to predict which patients will benefit from surgical revascularization versus medical management of RAS. Knowledge of the progressive nature of RAS, the high prevalence of bilateral disease, and the clinical characteristics that correlate with progression (e.g., decreasing renal size) are helpful in guiding clinical decisions regarding intervention. Additional studies to determine the predictive value of non-invasive tests such as CRS, doppler ultrasound before and after administration of angiotensin converting enzyme inhibitors, and other tests, are needed to assist the clinician in identifying who will benefit most from revascularization both in terms of renal function and blood pressure control.     

Pituitary Adenoma: A Clinician’S Perspective

ObjectiveTo review the underlying causes of pituitary lesions, a rational approach to their diagnosis, and therapeutic options.MethodsThe types of pituitary lesions and their clinical manifestations are reviewed, and treatment strategies and long-term follow-up are discussed.ResultsA pituitary adenoma is quite common and poses a challenge to the clinician to determine the clinical significance, the appropriate diagnosis, the need for treatment, and the appropriate therapy or therapies. The treatment of a pituitary adenoma depends on the type of tumor; a prolactinoma is treated medically with a dopamine agonist drug, and other lesions are usually treated by transsphenoidal surgical removal. Replacement of a deficient hormone or hormones is necessary for optimal functioning. Some patients require more than one treatment, including surgical intervention, replacement of a hormone or hormones, medications to lower hormone hypersecretion to normal (for prolactinoma, acromegaly, or Cushing disease), pituitary radiation therapy (optimally with focused irradiation such as the Gamma Knife or LINEAC), and, in the situation of persistent Cushing disease, bilateral adrenalectomy as a last resort. Lifelong monitoring is necessary for all these patients.ConclusionThe goal is to decrease the mass effect of the adenoma, to restore normal pituitary function, and to suppress hormone hypersecretion. Achievement of this goal necessitates the cooperation and interdisciplinary efforts of several medical specialties. (Endocr Pract. 2008;14:757-763)     

The role of monopolar stimulation during computed-tomography-guided stereotactic biopsies

44 patients underwent intraoperative stimulation with a monopolar electrode prior to computed tomography (CT)-guided stereotactic biopsy. Stimulation at 2-100 Hz resulted in functional responses in 6/21 patients with subcortical or callosal lesions, 4/6 with basal ganglion lesions, 8/10 with thalamic and 4/4 with brainstem lesions. In all but 2 patients with mesencephalic lesions, where limited biopsy sites were available, an alternative biopsy site was used if a functional response was obtained. No morbidity was seen among these patients, although postbiopsy CT scans demonstrated small 3- to 7-mm hematomas in 5/11 patients. Retrospective review of 79 patients who underwent biopsies without stimulation demonstrated hematomas in 6/10 patients and a 3.3% transient surgical morbidity. These data indicate that postbiopsy hematomas are a relatively common occurrence, that intraoperative electrical stimulation within abnormal lesions can identify functional potential, and that avoidance of biopsies within these functional areas may be associated with reduced morbidity.     

Congenital cardiology: recent advances emphasise the need for collaboration

The population of adult patients with congenital heart disease is steadily growing, due to the developments in cardiac surgery and thereby decreased mortality. However, morbidity in these patients is substantial. Patients with repaired lesions often need reoperations later in life. Most congenital heart defects, operated or not, have the potential to lead to clinical heart failure. Arrhythmias affect up to 50% of patients with congenital heart disease. The prevalence of pulmonary hypertension due to a left-to-right shunt among patients with a congenital heart defect is estimated at 4 to 10%. Advances in diagnostics, interventional and surgical therapy will result in new populations of adult survivors with even more complex disease. Collaboration of cardiologists with expertise in different areas of modern cardiology, such as electrophysiology, imaging and percutaneous interventions, is necessary for optimal care and management of these patients.     

Surgical Management of Regional Enteritis

The present-day concepts concerning the surgical management of regional enteritis are reviewed and the multitude of problems that may arise in surgical treatment are discussed. The primary treatment of regional enteritis remains medical. Surgical intervention is necessary only for the complications of intractability, obstruction, fistula, abscess formation, anal and rectal complications, massive hemorrhage and perforation. To ensure the best possible results, medical treatment should continue after surgery. A perfect operation for this disease does not exist. Operations for regional enteritis can now be performed with a mortality rate of less than 2%, and although the recurrence rate following surgery averages approximately 30%, the disease is well controlled in the majority of patients with medical and/or surgical treatment.     

Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults

Background

The management of brachial plexus injuries due to gunshot wounds is a surgical challenge. Better surgical strategies based on clinical and electrophysiological patterns are needed. The aim of this study is to clarify the factors which may influence the surgical technique and outcome of the brachial plexus lesions caused by gunshot injuries.

Methods

Two hundred and sixty five patients who had brachial plexus lesions caused by gunshot injuries were included in this study. All of them were male with a mean age of 22 years. Twenty-three patients were improved with conservative treatment while the others underwent surgical treatment. The patients were classified and managed according to the locations, clinical and electrophysiological findings, and coexisting lesions.

Results

The wounding agent was shrapnel in 106 patients and bullet in 159 patients. Surgical procedures were performed from 6 weeks to 10 months after the injury. The majority of the lesions were repaired within 4 months were improved successfully. Good results were obtained in upper trunk and lateral cord lesions. The outcome was satisfactory if the nerve was intact and only compressed by fibrosis or the nerve was in-contunuity with neuroma or fibrosis.

Conclusion

Appropriate surgical techniques help the recovery from the lesions, especially in patients with complete functional loss. Intraoperative nerve status and the type of surgery significantly affect the final clinical outcome of the patients.     

Individual Management of Recurrent Intracranial Aneurysms: The Wuxi Experience

Recurrent intracranial aneurysms can occur after either surgical clipping or endovascular therapy. In this article, we present a consecutive series of 18 patients who underwent individual treatment for recurrent aneurysms after primary coil embolization or surgical clipping. During an 8-year period between May 1997 and December 2005, 18 patients underwent individual treatment for recurrent aneurysms. Clinical data and imaging studies of the patients were analyzed retrospectively. Out of the 18 patients, 13 had recurrent aneurysms located in the anterior circulation, and 5 had aneurysms of the posterior circulation. Treatment consisted of coiling in 16 patients and clipping in two patients. Of the 18 patients, 15 achieved a good or excellent recovery, two were paralyzed, and one died post-treatment. Both the surgical clipping and endovascular embolization for the treatment of recurrent intracranial aneurysms can achieve very good radiological results with low mortality rates. One of the key points for the successful treatment of this kind of lesions is the proper, individual, and interdisciplinary patient selection.     

Suction lipoplasty: biohazardous aerosols and exhaust mist--the clouded issue

With the increased popularity of suction lipoplasty procedures, attention has been focused on their safety. One significant concern involves the rotary vane aspirators used to provide the suction required for the procedure. A series of experiments was carried out to determine whether aerosols are produced during the use of a rotary vane aspirator, since aerosols are known to be hazardous under appropriate conditions. Using a viable strain of Pseudomonas aeruginosa, we challenged the system through the suction port, and the exhaust from the aspirator was then cultured in a particle sampler. Results indicate that viable pathogens are released from the exhaust in physiologically significant particles capable of penetrating to the level of the alveolus in the normal human lung. These infectious particles were produced for 3 hours after the initial challenge. When an appropriate filtration device was attached to the aspirator outflow, the aspirator pump and environment were protected. In the absence of an appropriate filtration device, the aerosolized particles may constitute a hazard to patients or medical workers in the vicinity of the aspirator.     

Testicular Biopsy in Evaluation of Male Infertility

Testicular biopsy findings in 100 infertile men were correlated with the clinical findings. Mild or moderately severe tubular lesions were seen in 57 cases and severe changes in 43. Clinical examination and semen analysis were no guide to the severity of the testicular lesion. Though patients with normal sized testes more commonly had mild tubular lesions, many were severe. Patients with small testes more often had severe lesions but some had only mild tubular changes. Biopsy findings in both aspermic and oligospermic patients ranged from normal to a complete loss of germinal tissue.Testicular biopsy is advocated in infertile men for the complete assessment of the case and for identifying those which are potentially treatable. Patients with a severe lesion can be spared further investigations. The choice and results of treatment are discussed, particularly the surgical treatment of varicocele or obstruction. Only patients with a mild or moderate testicular tubular lesion should participate in future trials with drugs for male infertility.