A Bispecific, Tetravalent Antibody Targeting Inflammatory and Pruritogenic Pathways in Atopic Dermatitis

Inhibition of IL-4/IL-13 signaling has dramatically improved the treatment of atopic dermatitis (AD). However, in many patients, clinical responses are slow to develop and remain modest. Indeed, some symptoms of AD are dependent on IL-31, which is only partially reduced by IL-4/IL-13 inhibition. Thus, there is an unmet need for AD treatments that concomitantly block IL-4/IL-13 and IL-31 pathways. We engineered NM26-2198, a bispecific tetravalent antibody designed to accomplish this task. In reporter cell lines, NM26-2198 concomitantly inhibited IL-4/IL-13 and IL-31 signaling with a potency comparable with that of the combination of an anti-IL-4Rα antibody (dupilumab) and an anti-IL-31 antibody (BMS-981164). In human PBMCs, NM26-2198 inhibited IL-4-induced upregulation of CD23, demonstrating functional binding to FcγRII (CD32). NM26-2198 also inhibited the secretion of the AD biomarker thymus and activation-regulated chemokine (TARC) in blood samples from healthy human donors. In male cynomolgus monkeys, NM26-2198 exhibited favorable pharmacokinetics and significantly inhibited IL-31-induced scratching at a dose of 30 mg/kg. In a repeat-dose, good laboratory practice toxicology study in cynomolgus monkeys, no adverse effects of NM26-2198 were observed at a weekly dose of 125 mg/kg. Together, these results justify the clinical investigation of NM26-2198 as a treatment for moderate-to-severe AD.

An engineered T-cell engager with selectivity for high mesothelin-expressing cells and activity in the presence of soluble mesothelin

Mesothelin (MSLN) is an attractive immuno-oncology target, but the development of MSLN-targeting therapies has been impeded by tumor shedding of soluble MSLN (sMSLN), on-target off-tumor activity, and an immunosuppressive tumor microenvironment. We sought to engineer an antibody-based, MSLN-targeted T-cell engager (αMSLN/αCD3) with enhanced ability to discriminate high MSLN-expressing tumors from normal tissue, and activity in the presence of sMSLN. We also studied the in vivo antitumor efficacy of this molecule (NM28-2746) alone and in combination with the multifunctional checkpoint inhibitor/T-cell co-activator NM21-1480 (αPD-L1/α4-1BB). Cytotoxicity and T-cell activation induced by NM28-2746 were studied in co-cultures of peripheral blood mononuclear cells and cell lines exhibiting different levels of MSLN expression, including in the presence of soluble MSLN. Xenotransplant models of human pancreatic cancer were used to study the inhibition of tumor growth and stimulation of T-cell infiltration into tumors induced by NM28-2746 alone and in combination with NM21-1480. The bivalent αMSLN T-cell engager NM28-2746 potently induced T-cell activation and T-cell mediated cytotoxicity of high MSLN-expressing cells but had much lower potency against low MSLN-expressing cells. A monovalent counterpart of NM28-2746 had much lower ability to discriminate high MSLN-expressing from low MSLN-expressing cells. The bivalent molecule retained this discriminant ability in the presence of high concentrations of sMSLN. In xenograft models, NM28-2746 exhibited significant tumor suppressing activity, which was significantly enhanced by combination therapy with NM21-1480. NM28-2746, alone or in combination with NM21-1480, may overcome shortcomings of previous MSLN-targeted immuno-oncology drugs, exhibiting enhanced discrimination of high MSLN-expressing cell activity in the presence of sMSLN.

Design of antibody variable fragments with reduced reactivity to preexisting anti-drug antibodies

Upon reformatting of an antibody to single-chain variable fragment format, a region in the former variable/constant domain interface of the heavy chain becomes accessible for preexisting (PE) anti-drug antibody (ADA) binding. The region exposed because of this reformatting contains a previously hidden hydrophobic patch. In this study, mutations are introduced in this region to reduce PE ADA reactivity and concomitantly reduce the hydrophobic patch. To enhance our understanding of the importance of individual residues in this region with respect to PE ADA reactivity, a total of 50 molecules for each of two antibodies against different tumor-associated antigens were designed, produced, and characterized by an arsenal of biophysical methods. The aim was to identify suitable mutations that reduce, or completely eliminate, PE ADA reactivity to variable fragments, without compromising biophysical and pharmacodynamic properties. Computational methods were used to pinpoint key residues to mutate and to evaluate designed molecules in silico, in order to reduce the number of molecules to produce and characterize experimentally. Mutation of two threonine residues, Thr101 and Thr146 in the variable heavy domain, proved to be critical to eliminate PE ADA reactivity. This may have important implications in optimizing early drug development for antibody fragment-based therapeutics.

Engineering of a trispecific tumor-targeted immunotherapy incorporating 4-1BB co-stimulation and PD-L1 blockade

Co-stimulatory 4-1BB receptors on tumor-infiltrating T cells are a compelling target for overcoming resistance to immune checkpoint inhibitors, but initial clinical studies of 4-1BB agonist mAbs were accompanied by liver toxicity. We sought to engineer a tri-specific antibody-based molecule that stimulates intratumoral 4-1BB and blocks PD-L1/PD-1 signaling without systemic toxicity and with clinically favorable pharmacokinetics. Recombinant fusion proteins were constructed using scMATCH3 technology and humanized antibody single-chain variable fragments against PD-L1, 4-1BB, and human serum albumin. Paratope affinities were optimized using single amino acid substitutions, leading to design of the drug candidate NM21-1480. Multiple in vitro experiments evaluated pharmacodynamic properties of NM21-1480, and syngeneic mouse tumor models assessed antitumor efficacy and safety of murine analogues. A GLP multiple-dose toxicology study evaluated its safety in non-human primates. NM21-1480 inhibited PD-L1/PD-1 signaling with a potency similar to avelumab, and it potently stimulated 4-1BB signaling only in the presence of PD-L1, while exhibiting an EC₅₀ that was largely independent of PD-L1 density. NM21-1480 exhibited high efficacy for co-activation of pre-stimulated T cells and dendritic cells. In xenograft models in syngeneic mice, NM21-1480 induced tumor regression and tumor infiltration of T cells without causing systemic T-cell activation. A GLP toxicology study revealed no evidence of liver toxicity at doses up to 140 mg/kg, and pharmacokinetic studies in non-human primates suggested a plasma half-life in humans of up to 2 weeks. NM21-1480 has the potential to overcome checkpoint resistance by co-activating tumor-infiltrating lymphocytes without liver toxicity.

Abstract 2871: NM28-2746, a reduced affinity bivalent mesothelin-binding MATCH4 T cell engager, with half-life extension, increases selectivity for killing of mesothelin-overexpressing cells

CD3-based T cell engagers are highly potent therapeutic molecules which enable T cell-mediated cytotoxic activity toward cells expressing selected tumor-associated antigens. Alongside a highly potent anti-tumor activity, is the risk of on-target off-tumor side effects due to low levels of expression of the target antigen in normal tissue. We have sought to overcome this issue with the design and generation of a target-density-dependent activation mechanism. We have generated reduced-affinity antibody fragments to the tumor associated antigen mesothelin and constructed a multi-domain MATCH4 molecule encompassing bivalent mesothelin binding domains, a CD3 binding domain, and a human serum albumin (HSA)-binding domain for half-life extension. Here we report the design of the MATCH4 molecule and the preclinical activity of the molecule in vitro and in vivo. We also report the biochemical characteristics of the therapeutic candidate molecule showing its highly favorable properties for clinical development. We demonstrate that the bivalent mesothelin T cell engager has increased in vitro potency in T cell activation and tumor cell killing in the presence of high mesothelin expressing cells, when compared to a higher-affinity monovalent counterpart. We also demonstrate that the activity on low mesothelin expressing cells, such as healthy mesothelial cells, is reduced for the bivalent molecule compared to the higher affinity monovalent molecule. Due to the shedding of mesothelin from the surface of cancer cells and the high circulating levels of soluble mesothelin in patient sera, we also demonstrate that the bivalent molecule is still highly potent in cytotoxic activity in the presence of concentrations of soluble mesothelin up to 500 ng/ml. We also demonstrate dose dependent anti-tumor activity in in vivo efficacy studies in PBMC-reconstituted mice, and combination therapeutic activity with an anti-PD-L1, anti-4-1BB bispecific molecule (NM21-1480). Collectively, these data demonstrate an increased selectivity to mesothelin-overexpressing cells by this novel MATCH4 reduced affinity bivalent T cell engager. These data indicate the potential of this molecule to increase the therapeutic window by reducing safety concerns on normal tissue where mesothelin expression is low, and yet promote cytotoxicity on mesothelin over-expressing cancer cells.

Citation Format: Bithi Chatterjee, Christian Hess, Daniel Snell, Tea Gunde, Stefan Warmuth, Alexandre Simonin, Matthias Brock, Fabio Spiga, Maria Johansson, Christopher Weinert, Julia Tietz, Niels Kirk, Nicole Bassler, Dana Mahler, Dania Diem, Alessandra Carrella, Noreen Giezendanner, Alessandra Alberti, Giorgio Gambino, Belinda Wickihalder, Bettina Bommer, Simone Muntwiler, Yasemin Yaman, Naomi Flueckiger, Robin Heiz, Sandro Wagen, David Urech. NM28-2746, a reduced affinity bivalent mesothelin-binding MATCH4 T cell engager, with half-life extension, increases selectivity for killing of mesothelin-overexpressing cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2871.

Abstract 2870: Dose selection investigations and combination strategies of NM21-1480, a PD-L1/4-1BB/HSA trispecific MATCH3 therapeutic clinical candidate

Antagonistic molecules targeting the PD-1/PD-L1 axis have shown excellent activity in the clinic. However, the majority of patients do not respond to the therapy due to multifaceted reasons implicating a non-effective activation of the immune system in those patients. The co-stimulatory molecule 4-1BB has been shown to be a key signalling component of T cells and the combination of 4-1BB activation and PD-1/PD-L1 antagonism has been shown to be highly active in preclinical models. Systemic application of first-generation anti-4-1BB antibodies however have resulted in dose limiting hepatic toxicities. We have generated and are currently clinically investigating a novel 4-1BB/PD-L1/HSA trispecific MATCH3 immunomodulatory drug candidate (NM21-1480) that agonizes 4-1BB conditionally upon PD-L1 binding and concomitantly blocks the interaction between PD-1 and PD-L1. Here we investigate the impact of dose dependency in vitro and the translation of this to in vivo studies to aid the selection of optimal doses for our ongoing clinical study of NM21-1480 in cancer patients. In human PD-L1 tumor bearing mice, triple knock-in for human PD-1, human PD-L1 and human 4-1BB, we have investigated the impact of dose titrations of NM21-1480. We observe a dose dependent effect of NM21-1480 on tumor growth, systemic exposure, tumor exposure and pharmacodynamic biomarkers of immune cell activation. We also demonstrate the formation of a memory response in treated mice through rechallenge of the mice with tumor. We also investigate the effect of combination therapy of NM21-1480 with immune-oncology targeted therapeutics both in vitro and in vivo. In particular, we demonstrate that the combination of NM21-1480 with anti-CD3 T cell engagers is highly effective in T cell activation and tumor control. These data highlight the potential of NM21-1480 for the treatment of cancer patients and enable greater understanding of the relationship between dose, tumor exposure, immune activation and tumor growth inhibition.

Citation Format: Daniel Snell, Tea Gunde, Stefan Warmuth, Peter Lichtlen, Linlin Liu, Shu-wen Teng, Lan Zhang, ChaoHsuan Pan, Peiqi Li, Julia Tietz, Matthias Brock, Alexandre Simonim, Christian Hess, Christopher Weinert, Maria Johansson, Bithi Chatterjeee, Nicole Bassler, Niels Kirk, Catia Mendes, Robin Heiz, Naomi Flueckiger, Dania Diem, Dana Mahler, Belinda Wickihalder, Simone Muntwiler, Sandro Wagen, Elmar vom Baur, Archie N. Tse, David Urech. Dose selection investigations and combination strategies of NM21-1480, a PD-L1/4-1BB/HSA trispecific MATCH3 therapeutic clinical candidate [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2870.

844 A trispecific ROR1 x CD3 T cell engager mediates in vitro tumor cell killing and in vivo tumor eradication

Background

Receptor tyrosine kinase-like orphan receptor 1 (ROR1) is expressed on a variety of difficult to treat solid and hematological malignancies. Several therapeutic concepts targeting ROR1 are currently in clinical studies, including antibody-drug conjugates (ADCs), chimeric antigen receptor engineered T cells, as well as a bispecific T cell engager. In contrast to ADCs, T cell engagers have the capacity to induce tumor cell depletion irrespective of tumor cell mitotic activity. For the therapy of ROR1 expressing tumors, we engineered a T cell engager with prolonged half-life to support convenient administration schemes.

Methods

NM32-2668, a ROR1-targeting T cell engager with prolonged serum half-life was engineered by joining three humanized rabbit antibody variable region (Fv) fragments specific for ROR1, CD3ɛ, and serum albumin, into our tri-specific scMATCHTM3 format. Each Fv fragment was stabilized using the ʎ-capTM technology. NM32-2668 was tested in assays for specific tumor lysis, induction of T cell proliferation, and cytokine release. These studies were performed using human T cells co-cultured with tumor cell lines and human tumor samples expressing various levels of ROR1. In vivo xenograft mouse studies were conducted using a human mantle cell lymphoma model in NCG mice engrafted with human PBMCs.

Results

Here we report the design and the promising preclinical activity of the scMATCHTM3 ROR1/CD3/hSA T cell engager NM32-2668 in vitro and in vivo. Importantly, we demonstrate potent and specific cytotoxic activity in the sub-nanomolar range on tumor cell lines expressing different levels of ROR1. NM32-2668 also mediates ROR1 dependent T cell activation and cytokine release. We observe robust tumor cell killing activity of NM32-2668 over an extended time period and at multiple ratios of effectors to targets in a real time imaging-based cytotoxicity assay. This molecule also mediates T cell proliferation in response to target cell binding. NM32-2668 mediates in vitro lysis of CLL patient tumor cells, T cell activation, and cytokine release, with minimal IL-6 involvement. In an in vivo mantle cell lymphoma model (Jeko-1) engrafted with human PBMCs, we observe tumor regression and eradication.

Conclusions

Collectively, these data demonstrate robust anti-tumor efficacy by NM32-2668, a scMATCHTM3 ROR1/CD3/hSA. Our results demonstrate that NM32-2668 promotes ROR1 dependent T cell activation and proliferation, as well as T cell-mediated tumor cell lysis. The activity of NM32-2668 has the potential to provide significant benefit to patients with ROR1+ malignancies on a convenient dosing schedule. We intend to rapidly progress NM32-2668 to clinical development.

Abstract 2276: Preclinical development and mechanism of action studies of NM21-1480, a PD-L1/4-1BB/HSA trispecific MATCH3 therapeutic clinical candidate

Antagonistic molecules targeting the PD-1/PD-L1 axis have shown excellent activity in the clinic. However the majority of patients do not respond to the therapy due to multifaceted reasons implicating a non-effective activation of the immune system in those patients. The co-stimulatory molecule 4-1BB has been shown to be a key signalling component of T cells and the combination of 4-1BB activation and PD-1/PD-L1 antagonism has been shown to be highly active in preclinical models. Systemic application of first generation anti-4-1BB antibodies however have resulted in dose limiting hepatic toxicities. We have generated a novel 4-1BB/PD-L1/HSA trispecific MATCH3 immunomodulatory drug candidate (NM21-1480) that agonizes 4-1BB conditionally upon PD-L1 binding / blockade. Here we show the preclinical development data package for NM21-1480 demonstrating exquisite tumour-specific T cell activation associated with both 4-1BB agonism as well as PD-L1/PD-1 antagonism. We also demonstrate tumour specific localisation and accumulation of NM21-1480 in a mouse xenograft model. We report on the toxicity profile and pharmacokinetic properties of the molecule in non-human primates. We plan to initiate a first-in-human clinical study in the second half of 2020 to determine the safety, tolerability and first signs of clinical activity of the molecule.

Citation Format: Daniel Snell, Tea Gunde, Stefan Warmuth, Peter Lichtlen, Julia Tietz, Matthias Brock, Alexandre Simonin, Christian Hess, Weinert Christopher, Robin Heiz, Naomi Flueckiger, Julia Zeberer, Dania Diem, Dana Mahler, Diego Morenzoni, Belinda Wickihalder, Simone Muntwiler, Antonia Poelderl, Benjamin Kuettner, Sandro Wagen, Sebastian Meyer, Timothy Egan, David Urech. Preclinical development and mechanism of action studies of NM21-1480, a PD-L1/4-1BB/HSA trispecific MATCH3 therapeutic clinical candidate [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2276.

Abstract 1532: A novel, monovalent tri-specific antibody-based molecule that simultaneously modulates PD-L1 and 4-1BB exhibits potent anti-tumoral activity in vivo

The combined immunomodulation of PD-L1/PD-1 and 4-1BB is considered a promising strategy to increase response rates among cancer patients who are eligible to receive PD-L1/PD-1 inhibitors. Unfortunately, encouraging pre-clinical results achieved with such regimens have not yet translated into durable clinical success, due to addition of 4-1BB-agonistic antibodies being either intolerable at effective doses or ineffective, despite tolerability, at all doses. To eliminate this safety/efficacy tradeoff, we engineered a novel, tri-specific immunomodulatory drug candidate. The molecule consists of three monovalent antibody Fvs - specific for PD-L1, serum albumin (SA) and 4-1BB - fused in a single chain (a PD-L1/4-1BB/SA tri-specific scDb-scFv). The monovalent and Fc-less structure of the molecule ensures that 4-1BB agonism is conditional upon drug-mediated formation of an immunological synapse between PD-L1+ cells and 4-1BB+ cells, thereby restricting costimulation of 4-1BB+ cells to the tumor microenvironment (TME). Therefore, the scDb-scFv molecule avoids the extratumoral costimulation of immune cells that is believed to cause the dose-limiting toxicities that arise from therapeutic 4-1BB agonism. Meanwhile, the αSA domain extends the molecule’s serum half-life and is expected to promote delivery to the TME. In the present study, we demonstrate that a novel PD-L1/4-1BB/SA tri-specific scDb-scFv potently blocks PD-L1/PD-1 signaling and elicits T cell costimulation solely in the presence of PD-L1+ cells. In in vitro experiments, the scDb-scFv molecule exhibits a greater capacity to costimulate T cells than combinations of clinical stage α4-1BB and αPD-L1/PD-1 IgGs. Moreover, in contrast to ADCC-enabled αPD-L1 IgGs, the Fc-less scDb-scFv spared CD11c+ monocytes from depletion. We also demonstrate that the carefully balanced relative affinity between the molecule’s component αPD-L1 and α4-1BB Fvs maximizes its pharmacological activity and avoids bell-shaped dose-response curves. Next, in vivo efficacy was demonstrated in two xenograft models - HCC827 NCSLC and HCC1954 breast carcinoma - using humanized mice. While equally effective at slowing tumor progression in vivo, the PD-L1/4-1BB/SA tri-specific scDb-scFv was better tolerated, and was more pro-proliferative vis-à-vis intratumoral CD8+ T cells, than combined αPD-L1 and α4-1BB IgGs. In PK/PD studies in cynomologus monkeys, we confirmed the tolerability, pharmacological activity and extended serum half-life of the scDb-scFv molecule. Finally, the molecule was produced from stable CHO cells at high titers (comparable to IgGs) and exhibits outstanding stability characteristics. In conclusion, our data confirm the successful development of a novel therapeutic that is designed to unlock the full potential of combined immunomodulation and overcome its present limitations.

Citation Format: Tea Gunde, Matthias Brock, Stefan Warmuth, Alexandre Simonin, Christian Hess, Eva Oswald, Julia Tietz, Julia Zeberer, Dana Mahler, Simone Muntwiler, Benjamin Küttner, Belinda Wickihalder, Antonia Pölderl, Dania Diem, Teddy Beltrametti, Robin Heiz, Sebastian Meyer, Timothy Egan, David Urech. A novel, monovalent tri-specific antibody-based molecule that simultaneously modulates PD-L1 and 4-1BB exhibits potent anti-tumoral activity in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1532.

Using the PerioChip in treating adult periodontitis: an interim report

Multicenter clinical trials have established that the adjunctive use of the subgingival controlled release of chlorhexidine, in the form of the PerioChip, significantly reduces pocket probing depth, improves probing attachment levels, and reduces bleeding on probing compared to scaling and root planing alone, for periods up to 9 months. The purpose of the present study was to report on the adjunctive use of the PerioChip for the long-term management of adult periodontitis for 2 years. A total of 836 patients with adult periodontitis from private dental offices were recruited into the trial. This interim report is on the first 72 patients to have completed the 2-year study. Treatments included initial definitive therapy followed by PerioChip placement in pocket sites with a pocket probing depth of > or = 5 mm after 1 month. Subsequently, the patients received routine periodontal maintenance therapy together with the placement of a PerioChip in pockets with pocket probing depths > or = 5 mm every 3 months. Results indicated that there was a continuous decrease in pocket probing depth over the 2 years (1.26 +/- 0.77 mm). This decrease in pocket probing depth was marked over the first 9 to 12 months, and then appeared to be less marked over the next 12 months. At 2 years, 60% of the patients had at least 2 pockets showing a reduction of 2 mm or more, and only 10% of the patients showed no change or increased pocket probing depth. The results indicate that adjunctive PerioChip use is a clinically effective treatment option for dental professionals and their patients for the long-term management of adult periodontitis.

Anal stenosis with megarectum: an unusual complication of a perineal burn

A case of a 3-year-old boy with anal stricture and megarectum is described. Overflow incontinence and soiling were corrected by local flaps and skin graft and were maintained by frequent dilatations after downward traction of the whole anus was performed. The options of immediate and late treatment of such burns and the colostomy procedure are discussed.

Burns during pregnancy: our experience

Although few women sustain thermal injuries during pregnancy, when pregnancy is complicated by thermal injury a clear management scheme plus a team approach is needed to provide optimal care both to the foetus and mother. The clinical course of eight pregnant women treated in our burn unit is presented. The relationship between the burn area, gestational age at treatment and prognosis is analysed. Active surgical treatment is advocated.

Dermodress: a temporary skin substitute for coverage of exposed vital structures in the hand

A chemically treated bovine skin, Dermodress, is presented as a new type of biological dressing for exposed tendons, bones, and nerves following extensive thermal or severe soft-tissue injuries to the hand. Its use enables the surgeon to postpone closure of defects with grafts or flaps until the presence of healthy, viable tissue is secured. The vital structures underneath the covering are kept moist, thus preventing necrosis and desiccation. Because of its adherence properties, Dermodress use also allows early mobilization and bathing, thereby accelerating rapid return of function.

New ideas in splinting of burns

Splinting in burns is by no means a new subject, but this paper tries to demonstrate a new approach using new materials and sometimes humour. Conventional burn splints, dynamic and static, have been described in the past. All the following splints are made either with Mediplast, a new Israeli product, or Hexcelite.

Treatment of the burned hand: early surgical treatment (1975-85) vs. conservative treatment (1964-74). A comparative study

Our experience with early tangential excision and grafting for burns of the hands is presented. The advantages of the early surgical approach are proven by comparing this technique with the 'old' conservative treatment in two different populations. It is clearly concluded that early excision and grafting, combined with adequate physiotherapy and pressure garments, offer favourable results for the burned hand. Early excision of the burn eschar, before the appearance of contamination, may prevent infection, long and unfavourable delay in healing, scar formation with its incapacitating sequellae and a non-aesthetic appearance. Such a delay was characteristic of the 'conservative period', which was dominated by 'fibroblast', 'good granulation tissue', and hypertrophic scarring. Early surgery, as described and advocated here, shortens the healing time, lessens the hospital stay, minimizes reconstructive surgery and leads to a good functioning hand with a reasonable aesthetic appearance, enabling the affected patient to return quickly to work and normal routine life.

A ten-year-old boy with dermatofibrosarcoma protuberans of the face

A rare case of dermatofibrosarcoma protuberans on the face of a 10-year-old boy is presented. The patient's young age and the localization of the tumor led to limited excisions that resulted in two local recurrences. Primary wide excision with 2.5 cm of free margins is recommended to avoid local recurrences that are otherwise frequent.

The correction of the prominent ear

The prominent ear was first noted in the medical literature to be a social and psychological disturbance in 1881, when Ely suggested the first technique for the correction of this condition. Since Ely many surgeons have tried to find the best solution for this deformity; however, because of the specific cartilagenous architecture of the auricle, no one has yet designed an acceptable and secure technique. The successful reconstructured auricle should be the result of tackling all components of the deformity, namely, the absence of the antihelix and the aloofing of the concha from the mastoid. Mustarde's technique and the various anterior scoring methods do not deal with the conchal component of the protruded ear, nor do they give a fully satisfactory formation of the antihelix when one of these methods is used alone. This article presents the author's preferred technique for reconstructing the auricle, simultaneously using Mustarde's mattress sutures, Cochrane's anterior scoring of the antihelix, and the approximating of the concha to the mastoid.

Securing of the nasal skin under the cast in rhinoplasty

The author suggests a method to protect the skin of the nose from vascular impairment, bruising, necrosis, and other complications by interposing between the nasal skin and the overlying splint or cast a protective layer of a soft delicate material such as Telfa or Scrylin.

The role of turbinectomy in rhinoplasty

Turbinectomy, in cases of inferior or middle turbinate hypertrophy, is one of the solutions for nasal breathing difficulties. For many decades, this procedure was controversial owing to the severe complications believed to occur after such an operation. Its performance was held to be within the responsibility of otolaryngologists. However, eventually most of these complications were found to be nonexistent, and the performance of turbinectomy became a simple surgical procedure. The turbinate hypertrophy, which often exists on the contralateral side of the deviated septum, blocks the correct reposition of the septum with the consequent nasal bone, and thus prevents the plastic surgeon from achieving a straight nose. Therefore, proper handling of both septal deviation and turbinate hypertrophy is an important aid for the plastic surgeon. This article is dealing with the various aspects of turbinate hypertrophy and its surgical handling.

Quintuplets with clefts: follow-up at 5 years

Follow-up observations are presented of a set of quintuplets at 5 years of age. Three of the children were born with different degrees of oral clefting. Height and weight comparisons between siblings with clefts and those without reveal that the most severely affected children lagged in their height measurements at the age of 5 years. This may indicate need for special awareness when caring for such children. A relative constriction of the anterior segment of the maxillary dental arch in two of the affected siblings may reflect a possible effect from previous surgical intervention.

Burns caused by bromine and some of its compounds

Our experience with infrequent and unfamiliar types of injury caused by various compounds of bromine are described and discussed. While bromine containing compounds share some of the characteristics of other common causes of chemical burns, they also have a specific, exclusive mode of affecting the skin. The delay in the appearance of clinical signs and symptoms is an important factor to be considered by those who treat injuries caused by bromine or some of its compounds, or by those who may be the first to see persons who are injured by these agents. As most of the injuries occur at work (92 per cent) it is in these industrial premises that considerable stress should be made of the importance of wearing protective clothing in order to reduce local damage and prevent systemic effects. Prompt first aid, by thorough washing with large volumes of water reduces the extent and depth of the injury.

Dermodress: a new, temporary skin substitute for extensive deep burn coverage

A chemically treated bovine skin, Dermodress, is presented as a long-term skin substitute. Dermodress was applied over denuded surfaces of debrided deep burns and was kept in place for up to 56 days. Dermodress adheres to all contours of the debrided surfaces, has hemostatic effect and does not present any signs of infection or rejection. Dermodress can be removed in stages according to the availability of autografts, which may be applied immediately, since the exposed areas are clean and suitable for immediate grafting. Our clinical experience shows that Dermodress has most of the required properties of a long-term temporary skin substitute.

Plantar ulcers in hereditary sensory neuropathy. A plea for conservative treatment

Hereditary sensory neuropathy is a rare syndrome characterized by the occurrence, in childhood or early adult life, of perforating ulcers of the feet, lightning pains, and loss of cutaneous sensation and tendon reflexes in the lower extremities. Three patients with hereditary sensory neuropathy were family members. Trophic ulcers may be caused by diseases other than diabetes, syphilis, and leprosy.

After aesthetic rhinoplasty: new looks and psychological outlooks on post-surgical satisfaction

Thirty-four female patients who underwent rhinoplasty were followed through assessment of post-surgical satisfaction (pss), perception of subjective improvement, objective improvement (surgeon's ratings), and objective post-surgical nasal deformity. Assessments of pss and subjective improvement were obtained on 3 occasions: T1, 1 week after surgery, on cast removal; T2, 1 month after cast removal; and T3, 3 months after cast removal. The investigation was aimed at examination of the relationship of patients' subjective post-surgical appraisals of the operation with objective indices of outcome of rhinoplasty. Results indicated that at T1, pss is totally dissociated from objective outcome or its appraisal by the patient. At T2 an association between objective outcome and pss and subjective appraisal of outcome is evident, but seems to reflect the total reliance of the patients' judgment on surgeons' appraisals. At T3 a paradoxical trend is indicated: slim objective favorable outcomes correlate with high pss, while a considerable share of patients with whom a highly favorable outcome has been attained express relatively low pss. This paradoxical trend may be well understood when applying Cognitive Dissonance Theory. The whole pattern of results point again at highly complex and powerful psychological processes, some of them seemingly irrational, operating within patients when relating to rhinoplasty, a simple superficial surgical procedure.

Bilateral nasal glandular cysts: an occasional finding in rhinoplasty

Clinical and pathological aspects of an unusual case of bilateral, multiple glandular cysts of the nasal mucosa, originating from both inferior turbinates, are herewith described, as an occasional finding in rhinoplasty. Although cystic structures are common in the upper respiratory tract, the development of a mucous cyst in the nasal cavity is a very rare occurrence. The differential diagnosis of nasal glandular cysts from other cystic conditions appearing in the nasal cavity is discussed.

Noninvasive diagnosis of pulmonary arterial hypertension in chronic obstructive pulmonary disease: right ventricular ejection fraction at rest

Because right ventricular ejection fraction (RVEF) depends on impedance to RV ejection, the hypothesis was tested that an abnormality in radionuclide-determined RVEF would be a useful noninvasive predictor of pulmonary artery (PA) hypertension in patients with chronic obstructive pulmonary disease (COPD). Simultaneous measurements of resting RVEF and PA pressure were made in 30 patients with COPD. All were stable and without clinical evidence of respiratory decompensation or congestive heart failure. Eleven patients had normal (less than 20 mm Hg) mean PA pressure and 19 patients had PA hypertension. The average RVEF was 41 +/- 7% (range 29 to 60%). Five patients had normal (greater than 45%) and 25 patients depressed RVEF. An inverse linear relation between mean PA pressure and RVEF was present (r = -0.74). In the group with normal PA pressure, RVEF averaged 48% (range 42 to 60%). In the group with PA hypertension, RVEF averaged 36% (range 29 to 44%). RVEF was significantly higher in the group with PA hypertension. Using RVEF less than 45% as an indicator of PA hypertension, the sensitivity was 100%, the specificity 55%, and the predictive accuracy of a positive result 79%. Using RVEF less than or equal to 40% as an indicator of PA hypertension, the sensitivity was 75%, the specificity 100%, and the predictive accuracy of a positive study 100%. Thus, radionuclide-determined RVEF using the first-pass technique and a multicrystal camera is a useful noninvasive test for diagnosing PA hypertension in patients with advanced COPD.

Pressure garments in the control of hypertrophic scarring and rehabilitation of the burn patient: an occupational therapy approach

During the first 2 years of its existence, the Jobst Service of the Soroka Medical Center treated 150 patients, including 29 casualties of the Lebanon War, 1982, for postburn hypertrophic scarring. The Jobst pressure-gradient burn garments were successful in the control of hypertrophic scars, and in shortening the patient's rehabilitation time. The discussion stems from the perspective of the occupational therapist for treatment planning, paying special attention to the physical and psychosocial problems that confront the thermally injured patient, and to the need for total patient care.

Late sequelae of deep venous thrombosis. Diagnostic and therapeutic considerations

The efficacy of heparin, sodium warfarin, and elastic stockings in preventing the late leg sequelae of deep venous thrombosis was evaluated by reexamining 15 patients with previous acute deep venous thrombosis so treated. All 5 patients with iliocommon femoral disease and only 5 of 10 patients with distal disease had evidence of postphlebitic syndrome. Venous Doppler and strain gauge plethysmography confirmed these clinical findings. The most striking and consistent laboratory abnormalities were in the patients with proximal disease. Treatment of acute deep venous thrombosis by traditional means does not prevent the clinical and laboratory late leg sequelae. In light of these findings, serious investigation of new therapeutic modalities is strongly suggested.

A measuring scale for objective evaluation of the nasal shape

Evaluating preoperative expectations and post-operative results of the physical aspects of a rhinoplasty is a challenge. Using a graphic scale of 4 aspects of the nose--length, width, hump, and tip--can enable almost anyone to achieve a more or less objective evaluation of nasal characteristics. The scale ranges from 1, being the "nicest," to 7, being the "worst." The scales can be prepared on translucent sheets suitable for superimposing on pre- and postoperative photographs, and the differences in scores give a value to the result.

Durability of carotid endarterectomy

Carotid endarterectomy is the preferred treatment for patients with transient ischemic attacks and carotid stenosis. Although clinically these patients do well, the long-term fate of the operated carotid artery has not been well documented. To address this question, repeated noninvasive testing has been employed to follow our carotid endarterectomy patients since 1976. Supraorbital Doppler examination, oculoplethysmography-Kartchner, carotid phonoangiography and, later in this series, spectral analysis of the carotid Doppler velocities were performed after 193 endarterectomies. One hundred fifty-eight patients were initially tested within 3 months of operation, and 35 were initially tested 3 or more months after operation. Twenty-four arteries, four of which were symptomatic, had an initial abnormal test and are excluded from this study of carotid artery durability. Of the 169 patients with normal carotid tests, 36 had no further evaluation. Among the 133 patients who returned for serial testing from 1 to 60 months (mean 20 months), 115 carotid arteries continued to test normal at late follow-up but 18 subsequently developed test abnormalities. Ten had more than 75% stenosis, eight had 50% to 75% stenosis. Eight of these patients had contrast studies: three had normal findings; the five that had abnormal findings underwent reoperation. Interestingly, only two patients presented with symptoms appropriate to the abnormal test. The findings suggest that carotid endarterectomy is a reasonably durable operation. Recurrent stenosis was presumed or proven in 10% of 133 serially tested carotid arteries. This threat of restenosis makes long-term follow-up of these patients mandatory.

Mental health correlates of valid perception of nasal deformity in female applicants for aesthetic rhinoplasty

Thirty-four female applicants for rhinoplasty were assessed prior to undergoing surgery by means of a measuring scale for objective evaluation of the nasal shape. This scale yields an objective nasal deformity score as well as a measure of validity of subjective perception of nasal shape (nose image) and deformity. Subjects were assessed also for identity integration by a short measure of Eriksonian identity, and for psychological well-being and self-acceptance by means of the appropriate California Psychological Inventory (CPI) scales. Degree of nasal objective deformity was found to correlate with various aspects of positive mental health, namely, identity integration, psychological well-being, and self-acceptance. Validity of nose image was also correlated with identity integration. Findings are in accord with former investigations and call attention to the need for careful selection and management of patients for rhinoplasty, especially when deformity is mild.

Contrasting acute effects of vasodilators (nitroglycerin, nitroprusside, and hydralazine) on right ventricular performance in patients with chronic obstructive pulmonary disease and pulmonary hypertension: a combined radionuclide-hemodynamic study

Fourteen patients with chronic obstructive pulmonary disease, mild to moderate pulmonary hypertension, and diminished right ventricular (RV) ejection fraction were studied acutely with use of a combined radionuclide-hemodynamic approach to assess and contrast the effects of 3 vasodilators on RV performance and central hemodynamic function. Nitroglycerin significantly decreased mean right atrial pressure, RV end-diastolic volume index, mean pulmonary artery pressure, cardiac index, and arterial oxygen tension, but did not affect pulmonary vascular resistance index and increased RV ejection fraction. Nitroprusside had similar effects on mean right atrial pressure, RV end-diastolic volume index, mean pulmonary artery pressure, cardiac index, and arterial oxygen tension, but also mildly decreased pulmonary vascular resistance index and did not alter RV ejection fraction. In contrast, hydralazine decreased pulmonary vascular resistance index and increased cardiac index and RV ejection fraction. The increase in ejection fraction correlated well with the decrease in pulmonary vascular resistance. These data suggest that in patients with mild to moderate secondary pulmonary hypertension, acute administration of hydralazine results in a substantial improvement in RV performance by virtue of decreasing pulmonary vascular resistance. In contrast, nitroglycerin and nitroprusside demonstrate predominant effects that reduce preload, cardiac index, and arterial oxygen tension. Based on these data, afterload reduction with vasodilators such as hydralazine may be potentially useful in selected patients with pulmonary disease and secondary pulmonary hypertension and appear preferable to agents that primarily reduce preload. Further long-term studies are necessary to establish therapeutic efficacy.

A nail Island flap for treatment of macrodactyly

A case of macrodactyly of the middle finger is presented. An easy and versatile one stage surgical method, using an Island axial nail flap is proposed. This method eliminated the need for secondary intervention.

A simple method for the correction of the inverted nipple

A procedure is described in which a direct approach to the underlying pathology of the inverted nipple is undertaken. The inverted nipple is raised as desired by freeing it from the surrounding tissue by vertical and horizontal undermining and then is stabilized by purse-string suture. It can be performed as an office procedure under local anesthesia. This procedure is simple, reliable, not time-consuming, leaves no visible scars, and requires no special or bulky dressing.

The retropectoral route for breast augmentation

The subpectoral approach, better called retropectoral, in breast augmentation procedures has been used in 52 patients with either hypoplastic or ptoticatrophied breasts, with excellent results. Breasts remained soft in all but 1 patient (who disregarded instructions regarding arm activity). Capsular formation was avoided and no lateral displacement when the arms were elevated has been observed. Postoperatively there is a superior bulging of the breast, but this subsides within 4 to 6 weeks and the breast assumes a normal, pleasant contour.